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Mitral Stenosis in Emergency Medicine Treatment & Management

  • Author: Ethan S Brandler, MD, MPH; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
Updated: Dec 28, 2015

Prehospital Care

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:

  • Metoprolol
  • Esmolol
  • Diltiazem
  • Digoxin

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
Contributor Information and Disclosures

Ethan S Brandler, MD, MPH Clinical Assistant Professor, Attending Physician, Departments of Emergency Medicine and Internal Medicine, University Hospital of Brooklyn, Kings County Hospital

Ethan S Brandler, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


Eric M Suess, MD Clinical Assistant Instructor, Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center

Eric M Suess, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Paul Blackburn, DO, FACOEP, FACEP Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, Arizona Medical Association, American College of Osteopathic Emergency Physicians, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Robert M McNamara, MD, FAAEM Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine

Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors, Yiju Teresa Liu, MD, and Richard H Sinert, DO, to the development and writing of this article.

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Mitral stenosis.
Echocardiography of mitral stenosis. Courtesy of Michael B. Stone, MD, RDMS.
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