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Mitral Valve Prolapse: Treatment & Medication
Updated: Dec 22, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
The prehospital treatment of patients with chest pain, dyspnea, palpitations, a neurologic deficit, or syncope should include cardiac monitoring, supplemental oxygen, and intravenous catheter placement.
Emergency Department Care
- Patients with symptoms of chest pain, dyspnea, palpitations, a neurologic deficit, or syncope should be placed on oxygen, put in a supine or Fowler position, and monitored.
- Pulse oximetry
- Cardiac monitoring
- Frequent vital signs, including one set of orthostatic vital signs when possible
- Anxious patients should be reassured regarding their status, and many may benefit from psychosocial intervention.
Consultations
- Consult a cardiologist in cases of diagnostic uncertainty, ventricular dysrhythmia, or risk of sudden death as well as when symptoms of severe MR are present.
- Consider consulting a cardiothoracic surgeon in patients with significant exertional dyspnea and congestive heart failure that is related to MR.
Medication
Medications generally are not necessary. Beta-blockers may be helpful if palpitations are severe.
Antiplatelet agents such as aspirin, aspirin with extended-release dipyridamole (Aggrenox), or clopidogrel (Plavix) are indicated for patients with transient ischemic attack or stroke.17 Some authors recommend prophylaxis with antiplatelet agents in all patients with mitral valve prolapse (MVP) and murmur because of a small but significant increase in risk of stroke (10%).18
Orthostatic hypotension and presyncope symptoms may be treated with sodium chloride tablets; however, if this treatment is not successful, fludrocortisone 0.05-0.10 mg/d PO may be used.
Magnesium supplementation may improve symptoms of the classic MVP syndrome.5
Significant mitral regurgitation (MR) in the setting of hypertension (systolic blood pressure >140 mm Hg) may be improved with the use of angiotensin-converting enzyme inhibitors. No evidence exists as yet to support the use of these medications to halt the progression of MVP to MR.
Antibiotics
Antibiotic prophylaxis to prevent infective endocarditis is no longer recommended prior to dental or surgical procedures for any patient with MVP (even those with a murmur or nontrivial MR on echo and men older than 45 years with valve thickening) unless there is a history of endocarditis.19 Antibiotic prophylaxis to prevent infective endocarditis is no longer recommended prior to genitourinary or gastrointestinal procedures, even with a history of endocarditis.19,20
Patients with MVP with prior endocarditis who are undergoing a dental, respiratory tract, infected skin, or musculoskeletal tissue procedure (eg, contaminated wound repair or abscess incision and drainage) should receive prophylaxis for infective endocarditis with amoxicillin 2 g (50 mg/kg) PO 1 hour prior to the procedure. Patients with MVP with prior endocarditis who are unable to take oral medications may be treated with ampicillin 2 g (50 mg/kg) IM or IV, or cefazolin or ceftriaxone 1 g (50 mg/kg) IM or IV 1 hour prior to the procedure.
Patients with MVP with prior endocarditis who are allergic to penicillin may be treated 1 hour before the procedure with cephalexin 2 g (50 mg/kg) PO, clindamycin 600 mg (20 mg/kg) PO, or azithromycin or clarithromycin 500 mg (15 mg/kg) PO. Clindamycin 600 mg (20 mg/kg), or cefazolin or ceftriaxone 1 g (50 mg/kg), may be administered IM or IV 30 minutes before the procedure, as an alternative to the PO route.
Amoxicillin (Amoxil, Biomox, Polymox)
DOC; interferes with the synthesis of cell wall mucopeptide during active multiplication, resulting in a bactericidal activity against susceptible bacteria.
Adult
2 g PO 1 h before the procedure; alternatively, 3 g PO 1 h before the procedure, followed by 1.5 g PO 6 h after the initial dose
Pediatric
50 mg/kg PO 1 h before procedure
May reduce efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; may enhance chance of candidiasis
Ampicillin (Marcillin, Omnipen)
Alternative parenteral agent. Interferes with bacterial cell wall synthesis during active multiplication, causing bactericidal activity against susceptible organisms. Given in place of amoxicillin in patients who are unable to take medication orally.
Adult
2 g IV/IM 30 min before the procedure
Pediatric
50 mg/kg IV/IM 30 min before the procedure
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Beta-blockers
Blood pressure control may prevent chordal rupture and the progression of MVP to severe MR. Clonidine has been shown to diminish symptoms of the classic (disputed) MVP syndrome. Beta-blocking agents (eg, propranolol, atenolol, pindolol) may also be effective in those with neurocardiogenic syncope.
Atenolol (Tenormin)
Selectively blocks beta1-receptors with little or no effect on beta2 types.
Adult
50 mg PO qd, increase to 100 mg/d
Pediatric
Not established; 1-2 mg/kg/dose PO qd suggested
Coadministration with aluminum salts, barbiturates, calcium salts, cholestyramine, NSAIDs, penicillins, and rifampin may decrease effects; haloperidol, hydralazine, loop diuretics, and MAOIs may increase toxicity of atenolol
Documented hypersensitivity; congestive heart failure; pulmonary edema; cardiogenic shock; AV conduction abnormalities and heart block (without a pacemaker)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Beta-adrenergic blockade may reduce symptoms of acute hypoglycemia and mask signs of hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism and cause thyroid storm; monitor patients closely and withdraw drug
Antiarrhythmics
Digoxin has been effective in treating supraventricular tachycardia and in the prevention of symptoms of classic MVP syndrome (eg, chest pain, fatigue).
Digoxin (Lanoxin)
Cardiac glycoside with direct inotropic effects in addition to indirect effects on the cardiovascular system. Effects on the myocardium involve both a direct action on cardiac muscle that increases myocardial systolic contractions and indirect actions that result in increased carotid sinus nerve activity and enhanced sympathetic withdrawal for any given increase in mean arterial pressure.
Adult
0.125-0.375 mg PO qd; digitalization must be individualized
Pediatric
5-10 years: 20-35 mcg/kg PO divided bid
>10 years: 10-15 mcg/kg PO qd
Maintenance dose: 25-35% of PO loading dose
Digitalization must be individualized
Medications that may increase digoxin levels include alprazolam, benzodiazepines, bepridil, captopril, cyclosporine, propafenone, propantheline, quinidine, diltiazem, aminoglycosides, oral amiodarone, anticholinergics, diphenoxylate, erythromycin, felodipine, flecainide, hydroxychloroquine, itraconazole, nifedipine, omeprazole, quinine, ibuprofen, indomethacin, esmolol, tetracycline, tolbutamide, and verapamil
Medications that may decrease serum digoxin levels include aminoglutethimide, antihistamines, cholestyramine, neomycin, penicillamine, aminoglycosides, oral colestipol, hydantoins, hypoglycemic agents, antineoplastic treatment combinations (including carmustine, bleomycin, methotrexate, cytarabine, doxorubicin, cyclophosphamide, vincristine, procarbazine), aluminum or magnesium antacids, rifampin, sucralfate, sulfasalazine, barbiturates, kaolin/pectin, and aminosalicylic acid
Documented hypersensitivity; beriberi heart disease; idiopathic hypertrophic subaortic stenosis; constrictive pericarditis; carotid sinus syndrome
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hypokalemia may reduce positive inotropic effect of digitalis; IV calcium may produce arrhythmias in digitalized patients; hypercalcemia predisposes patient to digitalis toxicity, and hypocalcemia can make digoxin ineffective until serum calcium levels are normal; magnesium replacement therapy must be instituted in patients with hypomagnesemia to prevent digitalis toxicity; patients diagnosed with incomplete AV block may progress to complete block when treated with digoxin; exercise caution in hypothyroidism, hypoxia, and acute myocarditis
More on Mitral Valve Prolapse |
| Overview: Mitral Valve Prolapse |
| Differential Diagnoses & Workup: Mitral Valve Prolapse |
 Treatment & Medication: Mitral Valve Prolapse |
| Follow-up: Mitral Valve Prolapse |
| Multimedia: Mitral Valve Prolapse |
| References |
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References
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Further Reading
Keywords
mitral valve prolapse, MVP, endocarditis, bacterial endocarditis, stroke, mitral valve surgery, sudden death, supraventricular arrhythmias, palpitations, mitral regurgitation, MR, syncope, Marfan syndrome, polyarteritis nodosa, relapsing polychondritis, systemic lupus erythematosus, Stickler syndrome, pseudoxanthoma elasticum, osteogenesis imperfecta, Ehlers-Danlos syndrome type I, Ehlers-Danlos syndrome type II, Ehlers-Danlos syndrome type IV, polycystic kidney disease, Duchenne muscular dystrophy, fragile X syndrome, mucopolysaccharidoses, myotonic dystrophy, atrial septal defect, Ebstein anomaly, papillary muscle dysfunction, cardiac trauma, post mitral valve surgery, rheumatic endocarditis, Wolff-Parkinson-White syndrome, Von Willebrand disease
