Mitral Stenosis in Emergency Medicine Clinical Presentation

Updated: May 12, 2020
  • Author: Ethan S Brandler, MD, MPH; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Presentation

History

Although many patients are otherwise asymptomatic, fever, anemia, emotional upset or excitement, pregnancy, thyroid dysfunction, and exercise may precipitate symptoms.

Patients may present with complications of mitral stenosis (MS) including new onset atrial fibrillation, systemic embolism (including stroke and myocardial infarction), and infective endocarditis.

Inquire about a history of rheumatic fever, scarlet fever, skin infections, or repeated episodes of streptococcal pharyngitis. However, 50-60% of patients do not recall any of these.

Initial presenting complaints often include new exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Frank pulmonary edema is rare but may occur.

Chest pain should prompt consideration of right ventricular ischemia or failure and concomitant coronary atherosclerosis.

Hemoptysis from pulmonary venous hypertension may result from rupture of pulmonary veins or the capillary system.

Patients who complain of hoarseness may be presenting with Ortner syndrome, in which the left recurrent laryngeal nerve is compressed by an enlarged left atrium secondary to the increased valvular pressure gradient in worsening mitral stenosis.

Next:

Physical Examination

A complete physical examination, focusing on not just findings specific to mitral stenosis but also specific to right and/or left ventricular failure is essential.

Inspection

Findings are often unremarkable. Mitral facies, which are patches of pink-purple discoloration on the cheeks, are rare but are traditionally thought to result from elevated venous pressures and right heart failure. Elevated jugular pulse may be seen, but is a nonspecific finding.

Palpation

Neither diastolic thrill nor apical impulse is often appreciated in isolated mitral stenosis; left ventricular function is usually normal, and thrill is absent in mild stenosis.

With proper patient positioning, a peristernal lift may be infrequently felt when elevated pulmonary pressures induce increased right ventricular activity.

All peripheral pulses should be palpated to assess for embolization, especially in the setting of concomitant atrial fibrillation.

Auscultation

The classic murmur of mitral stenosis (ie, a low-pitched, rumbling, diastolic murmur best heard with the bell near the apex) can be accentuated by antecedent exercise and positioning the patient in the left lateral decubitus position. The length of the murmur, as opposed to the intensity, is used as a nonspecific guide to stenosis severity.

The S1 sound is loud and followed by an opening snap (OS), which is heard best with the diaphragm.

Further examination

As noted above, signs of left and/or right failure in general should be assessed.

The complications of mitral stenosis should be looked for when appropriate, including the following:

  • Endocarditis - Fever, changed murmur, Roth spots, Janeway lesions, splinter hemorrhages, and Osler nodes

  • Atrial fibrillation

  • Systemic embolizations

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