Mitral Stenosis in Emergency Medicine Treatment & Management
- Author: Ethan S Brandler, MD, MPH; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
Prehospital care is appropriate for acute pulmonary edema or arrhythmia secondary to mitral stenosis.
Oxygen administration is always indicated for symptomatic patients.
In patients with significant acute dyspnea, appropriately trained personnel may administer agents that promote afterload reduction such as nitrates or ACE inhibitors.
Clinically significant arrhythmias such as atrial fibrillation with rapid ventricular response should be corrected according to local protocols. Medications appropriate for use by prehospital personnel vary according to local protocol but may include diltiazem, amiodarone, esmolol, or metoprolol.
Grossly unstable patients with atrial fibrillation with rapid ventricular response should receive synchronized direct current (DC) cardioversion.
Emergency Department Care
The goal is to control symptoms, to prevent or retard disease progression, and to treat complications.
Treatment of congestive heart failure
Medications to consider include nitroglycerin, ACE inhibitors, and diuretics.
Patients with severe mitral stenosis should maintain an upright posture and avoid strenuous physical activity.
Sodium intake should be restricted, and maintenance doses of oral diuretics should be continued.
The data on beta-blockers are conflicting; beta-blockade may be useful for patients with exertional symptoms if the symptoms occur primarily at high heart rates.
Prevent or retard disease. Primary and/or secondary prophylaxis against streptococci/endocarditis should be administered.
Penicillin is indicated whenever streptococcal infection is suspected in a patient with known rheumatic disease.
Management of atrial fibrillation
Much of the dyspnea related to mitral stenosis is rate related. Control of atrial fibrillation with rapid ventricular response may be considered with any of the following agents:
If the patient is unstable and immediate cardioversion is indicated, then heparin should be administered before, during, and after cardioversion. Otherwise, electrical or chemical cardioversion should be performed after 3 weeks of warfarin anticoagulation. Transesophageal echocardiography prior to elective cardioversion should be considered.
Anticoagulation is necessary in many patients who are unable to maintain normal sinus rhythm. Anticoagulation may also be beneficial for patients with normal sinus rhythm with a prior embolic event or a left atrial dimension greater than 55 mm Hg noted by echocardiography.
A cardiologist and/or cardiothoracic surgeon should be consulted in the following situations:
Known or suspected cases of mitral stenosis with hemodynamic instability, arrhythmia, or embolization
Cases involving a new onset or progression of symptoms
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