Mitral Valve Prolapse in Emergency Medicine Clinical Presentation

  • Author: Michael C Plewa, MD; Chief Editor: David FM Brown, MD   more...
 
Updated: Jun 27, 2011
 

History

  • Mitral valve prolapse (MVP) usually is asymptomatic, nonprogressive, and benign.
  • Palpitations occur in 40% of MVP cases. This percentage excludes palpitations due to withdrawal syndromes (eg, alcohol, sedatives), intoxications (eg, cocaine, amphetamine, phencyclidine), or medication exposures (eg, caffeine, sympathomimetic, anticholinergic).
  • Chest pain and dyspnea previously were considered part of the MVP syndrome, but they are now felt to be no more common in cases of MVP than they are in the general population.[18, 2]
  • Although controversial, anxiety and panic disorders may be more common in patients with MVP than the general population.[19]
  • Fatigue
  • Syncope/presyncope[18]
  • Orthostasis[18]
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Physical

  • Thin aesthetic body habitus with narrow anteroposterior diameter[20]
  • Skeletal abnormalities (ie, pectus excavatum, straight back, kyphoscoliosis)
  • Supernumerary nipples in Asian Indians
  • Resting bradycardia and orthostatic hypotension
  • Cardiac auscultation
    • Apical, single or multiple, mid-to-late systolic clicks, which result from the tightening of the chordae tendineae or the redundant valve, can be heard.
    • An apical mid-to-late systolic murmur of crescendo, decrescendo, or constant nature can be heard, and the murmur continues to be heard in S2.
    • The click and the murmur change as the position changes (closer to S1 with diminished LV volume; closer to S2 with increased LV volume)
    • In the supine position, the click is late (ie, close to S2), and the murmur is brief.
    • In the standing position and during the Valsalva maneuver, the click is earlier (ie, close to S1), and the murmur is longer. This may identify a murmur that previously was not noted.
    • In the squatting position, the click is later (ie, closer to S2), and the murmur is shorter. The click and the murmur may even disappear.
    • The isometric handgrip exercise increases the intensity (ie, loudness) of the murmur without affecting the position.
    • The murmur should be distinguished from that of aortic stenosis (ie, early systolic, at base); pulmonic flow murmur (ie, short and early systolic, diminishes with Valsalva maneuver); hypertrophic cardiomyopathy (ie, diminishes with squatting and intensifies with standing and Valsalva maneuver); and mitral regurgitation (ie, holosystolic murmur with S3, enlarged and displaced point of maximal intensity [PMI]).
  • Mitral regurgitation
  • Autonomic dysfunction - Decreased heart rate variability and parasympathetic tone[21, 22]
  • Neuroendocrine dysfunction
  • Ehlers-Danlos syndrome findings (eg, joint hypermobility, abnormal striae, bruising, distensibility of skin)
  • Osteogenesis imperfecta findings (eg, blue sclera)
  • Marfan syndrome findings (eg, scoliosis, straight back, pectus excavatum, arachnodactyly, arm span greater than body height)
  • Stickler syndrome findings (eg, kyphosis, scoliosis, mandibular hypoplasia, retinal detachment). Whether Stickler syndrome is associated with MVP is debatable.
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Causes

Most cases of mitral valve prolapse are primary, idiopathic in nature, and expressed as an autosomal dominant trait that exhibits both sex- and age-dependent penetrance.[23]

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Contributor Information and Disclosures
Author

Michael C Plewa, MD  Research Coordinator, Consulting Staff, Department of Emergency Medicine, Lucas County Emergency Physicians, Inc, and Mercy Saint Vincent Medical Center

Michael C Plewa, MD, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Physicians for Social Responsibility, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Richard Worthington  MD, Department of Emergency Medicine, Wood County Hospital

Richard Worthington is a member of the following medical societies: American College of Emergency Physicians, Ohio State Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Filho AS, Maciel BC, Martín-Santos R, Romano MM, Crippa JA. Does the association between mitral valve prolapse and panic disorder really exist?. Prim Care Companion J Clin Psychiatry. 2008;10(1):38-47. [Medline]. [Full Text].

  2. Freed LA, Levy D, Levine RA, et al. Prevalence and clinical outcome of mitral-valve prolapse. N Engl J Med. Jul 1 1999;341(1):1-7. [Medline].

  3. Avierinos JF, Brown RD, Foley DA. Cerebral ischemic events after diagnosis of mitral valve prolapse: a community-based study of incidence and predictive factors. Stroke. Jun 2003;34(6):1339-44. [Medline].

  4. Singh RG, Cappucci R, Kramer-Fox R, et al. Severe mitral regurgitation due to mitral valve prolapse: risk factors for development, progression, and need for mitral valve surgery. Am J Cardiol. Jan 15 2000;85(2):193-8. [Medline].

  5. Termine C, Trotti R, Ondei P, Gamba G, Montani N, Gamba A, et al. Mitral valve prolapse and abnormalities of haemostasis in children and adolescents with migraine with aura and other idiopathic headaches: a pilot study. Acta Neurol Scand. Oct 5 2009;[Medline].

  6. Evangelopoulos ME, Toumanidis S, Sotou D, Evangelopoulos C, Mavrikakis M, Alevizaki M, et al. Mitral valve prolapse in young healthy individuals. An early index of autoimmunity?. Lupus. Apr 2009;18(5):436-40. [Medline].

  7. Vazquez R, Solanellas J, Alfageme I, Valenzuela-García LF, Pavon R, Leal J, et al. Mitral valve prolapse and sudden deafness. Int J Cardiol. Mar 14 2008;124(3):370-1. [Medline].

  8. Chou HT, Shi YR, Hsu Y. Association between fibrillin-1 gene exon 15 and 27 polymorphisms and risk of mitral valve prolapse. J Heart Valve Dis. Jul 2003;12(4):475-81. [Medline].

  9. Cavenaghi S, Marino LH, Oliveira PP, Lamari NM. Joint hypermobility in patients with mitral valve prolapse. Arq Bras Cardiol. Sep 2009;93(3):307-11. [Medline].

  10. Lichodziejewska B, Klos J, Rezler J, et al. Clinical symptoms of mitral valve prolapse are related to hypomagnesemia and attenuated by magnesium supplementation. Am J Cardiol. Mar 15 1997;79(6):768-72. [Medline].

  11. Scordo KA. Mitral valve prolapse syndrome: interventions for symptom control. Dimens Crit Care Nurs. Jul-Aug 1998;17(4):177-86. [Medline].

  12. Fontana ME, Sparks EA, Boudoulas H, Wooley CF. Mitral valve prolapse and the mitral valve prolapse syndrome. Curr Probl Cardiol. May 1991;16(5):309-75. [Medline].

  13. Kao CH, Tsai SC, Hsieh JF, et al. Radionuclide esophageal transit test to detect esophageal disorders in patients with mitral valve prolapse. Nuklearmedizin. 2000;39(4):92-6. [Medline].

  14. Avierinos JF, Detaint D, Messika-Zeitoun D, Mohty D, Enriquez-Sarano M. Risk, determinants, and outcome implications of progression of mitral regurgitation after diagnosis of mitral valve prolapse in a single community. Am J Cardiol. Mar 1 2008;101(5):662-7. [Medline].

  15. Ahmed MI, Sanagala T, Denney T, Inusah S, McGiffin D, Knowlan D, et al. Mitral valve prolapse with a late-systolic regurgitant murmur may be associated with significant hemodynamic consequences. Am J Med Sci. Aug 2009;338(2):113-5. [Medline].

  16. Theal M, Sleik K, Anand S. Prevalence of mitral valve prolapse in ethnic groups. Can J Cardiol. Apr 2004;20(5):511-5. [Medline].

  17. Avierinos JF, Inamo J, Grigioni F, Gersh B, Shub C, Enriquez-Sarano M. Sex differences in morphology and outcomes of mitral valve prolapse. Ann Intern Med. Dec 2 2008;149(11):787-95. [Medline].

  18. Devereux RB, Kramer-Fox R, Kligfield P. Mitral valve prolapse: causes, clinical manifestations, and management. Ann Intern Med. Aug 15 1989;111(4):305-17. [Medline].

  19. Tamam L, Ozpoyraz N, San M, Bozkurt A. Association between idiopathic mitral valve prolapse and panic disorder. Croat Med J. Dec 2000;41(4):410-6. [Medline].

  20. Raggi P, Callister TQ, Lippolis NJ, Russo DJ. Is mitral valve prolapse due to cardiac entrapment in the chest Cavity? A CT view. Chest. Mar 2000;117(3):636-42. [Medline].

  21. Han L, Ho TF, Yip WC, Chan KY. Heart rate variability of children with mitral valve prolapse. J Electrocardiol. Jul 2000;33(3):219-24. [Medline].

  22. Kochiadakis GE, Parthenakis FI, Zuridakis EG, et al. Is there increased sympathetic activity in patients with mitral valve prolapse?. Pacing Clin Electrophysiol. Nov 1996;19(11 Pt 2):1872-6. [Medline].

  23. Freed LA, Acierno JS, Dai D. A locus for autosomal dominant mitral valve prolapse on chromosome 11p15.4. Am J Hum Genet. Jun 2003;72(6):1551-9. [Medline].

  24. Cetinkaya M, Semizel E, Bostan O, Cil E. Risk of vasovagal syncope and cardiac arrhythmias in children with mitral valve prolapse. Acta Cardiol. Jun 2008;63(3):395-8. [Medline].

  25. Guven B, Eroglu AG, Babaoglu K, Demir T, Güzeltas A, Oztunc F, et al. QT dispersion and diastolic functions in differential diagnosis of primary mitral valve prolapse and rheumatic mitral valve prolapse. Pediatr Cardiol. Mar 2008;29(2):352-8. [Medline].

  26. Ozkan M, Kaymaz C, Dinckal H, et al. Single-photon emission computed tomographic myocardial perfusion imaging in patients with mitral valve prolapse. Am J Cardiol. Feb 15 2000;85(4):516-8, A11. [Medline].

  27. Han Y, Peters DC, Salton CJ, Bzymek D, Nezafat R, Goddu B, et al. Cardiovascular magnetic resonance characterization of mitral valve prolapse. JACC Cardiovasc Imaging. May 2008;1(3):294-303. [Medline].

  28. Hirata K, Pulerwitz T, Sciacca R, Otsuka R, Oe Y, Fujikura K, et al. Clinical utility of new real time three-dimensional transthoracic echocardiography in assessment of mitral valve prolapse. Echocardiography. May 2008;25(5):482-8. [Medline].

  29. Feuchtner GM, Alkadhi H, Karlo C, Sarwar A, Meier A, Dichtl W, et al. Cardiac CT angiography for the diagnosis of mitral valve prolapse: comparison with echocardiography1. Radiology. Feb 2010;254(2):374-83. [Medline].

  30. [Guideline] Salem DN, O'Gara PT, Madias C, Pauker SG. Valvular and structural heart disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. Jun 2008;133(6 Suppl):593S-629S. [Medline].

  31. Karakurum B, Topcu S, Yildirim T. Silent cerebral infarct in patients with mitral valve prolapse. Int J Neurosci. Nov 2005;115(11):1527-37. [Medline].

  32. [Guideline] Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. Oct 9 2007;116(15):1736-54. [Medline].

  33. [Guideline] Gould FK, Elliott TS, Foweraker J. Guidelines for the prevention of endocarditis: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother. Jun 2006;57(6):1035-42. [Medline].

  34. Berbarie RF, Roberts WC. Frequency of atrial fibrillation in patients having mitral valve repair or replacement for pure mitral regurgitation secondary to mitral valve prolapse. Am J Cardiol. Apr 1 2006;97(7):1039-44. [Medline].

  35. Turker Y, Ozaydin M, Acar G, Ozgul M, Hoscan Y, Varol E, et al. Predictors of atrial arrhythmias in patients with mitral valve prolapse. Acta Cardiol. Dec 2009;64(6):755-60. [Medline].

  36. Turker Y, Ozaydin M, Acar G, Ozgul M, Hoscan Y, Varol E, et al. Predictors of ventricular arrhythmias in patients with mitral valve prolapse. Int J Cardiovasc Imaging. Feb 2010;26(2):139-45. [Medline].

  37. Avierinos JF, Gersh BJ, Melton LJ. Natural history of asymptomatic mitral valve prolapse in the community. Circulation. Sep 10 2002;106(11):1355-61. [Medline].

  38. Bobkowski W, Siwinska A, Zachwieja J. A prospective study to determine the significance of ventricular late potentials in children with mitral valvar prolapse. Cardiol Young. Jul 2002;12(4):333-8. [Medline].

  39. [Guideline] Bonow RO, Carabello B, de Leon AC, et al. ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease. Executive Summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Val. J Heart Valve Dis. Nov 1998;7(6):672-707. [Medline].

  40. Freed LA, Benjamin EJ, Levy D. Mitral valve prolapse in the general population: the benign nature of echocardiographic features in the Framingham Heart Study. J Am Coll Cardiol. Oct 2 2002;40(7):1298-304. [Medline].

  41. Gilon D, Buonanno FS, Joffe MM, et al. Lack of evidence of an association between mitral-valve prolapse and stroke in young patients. N Engl J Med. Jul 1 1999;341(1):8-13. [Medline].

  42. Kitlinski M, Stepniewski M, Nessler J. Is magnesium deficit in lymphocytes a part of the mitral valve prolapse syndrome?. Magnes Res. Mar 2004;17(1):39-45. [Medline].

  43. La Vecchia L, Ometto R, Centofante P, et al. Arrhythmic profile, ventricular function, and histomorphometric findings in patients with idiopathic ventricular tachycardia and mitral valve prolapse: clinical and prognostic evaluation. Clin Cardiol. Oct 1998;21(10):731-5. [Medline].

  44. Leung DY, Dawson IG, Thomas JD, Marwick TH. Accuracy and cost-effectiveness of exercise echocardiography for detection of coronary artery disease in patients with mitral valve prolapse. Am Heart J. Dec 1997;134(6):1052-7. [Medline].

 
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Mitral valve prolapse. A patient with straight back syndrome.
 
 
 
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