Clinical manifestations and diagnosis of mitral stenosis
- Catherine M Otto, MD
Catherine M Otto, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Evaluation; Valvular Disease
- Professor of Medicine
- University of Washington
Mitral stenosis (MS) causes an obstruction to blood flow from the left atrium to left ventricle. As a result, there is an increase in pressure within the left atrium, pulmonary vasculature, and right side of the heart, while the left ventricle is unaffected in isolated MS. Nearly all cases of MS are caused by rheumatic heart disease with mitral commissural adhesion; thickened, immobile mitral valve leaflets; and fibrosis, thickening, shortening, fusion, and calcification of the chordae tendineae. Infrequent causes of MS include mitral annular calcification and congenital mitral stenosis (including parachute mitral valve). (See "Pathophysiology and natural history of mitral stenosis".)
This topic will review the clinical features and evaluation of MS . Other issues related to MS, such as the pathophysiology, natural history, medical and surgical therapy, and use of percutaneous balloon valvotomy are discussed separately. (See "Pathophysiology and natural history of mitral stenosis" and "Medical management and indications for intervention for mitral stenosis" and "Surgical management of mitral stenosis" and "Percutaneous mitral balloon valvotomy for mitral stenosis".)
Clinical presentation — Mitral stenosis (MS) usually presents with exertional dyspnea and/or decreased exercise tolerance . These symptoms are primarily related to the severity of the valvular stenosis, as it impacts the left atrial pressure, pulmonary pressures, pulmonary vascular resistance, and cardiac output. However, many patients with severe MS do not recognize symptoms because slow progression of disease is accompanied by a gradual reduction in activity. As a result, a careful history regarding exercise tolerance is often required to document a slow decline in functional status. (See 'Staging' below.)
Less common clinical presentations include hemoptysis, chest pain (often due to pulmonary hypertension), fatigue (which may be associated with low forward flow and a low transmitral gradient), ascites and lower extremity edema associated with right heart failure (particularly in patients with severe pulmonary arterial hypertension), stroke or other thromboembolic event (particularly in patients with atrial fibrillation), hoarseness, and infective endocarditis .
Dyspnea — The most common and often the only symptom of MS is dyspnea, which occurs in up to 70 percent of symptomatic patients . Dyspnea usually results from the elevation in left atrial pressure, and pulmonary venous hypertension, which leads to reduced compliance of the lungs and a decrease in vital capacity. Dyspnea also may be related to an inability to increase the cardiac output with increased metabolic demands.
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- CLINICAL MANIFESTATIONS
- Clinical presentation
- - Dyspnea
- - Hemoptysis
- - Atrial fibrillation
- - Thromboembolism
- - Chest pain
- - Right-sided heart failure
- - Hoarseness
- - Infective endocarditis
- Precipitants of symptoms
- Physical examination
- - General examination
- - Cardiovascular examination
- Pulse examination
- Cardiac auscultation
- - Heart sounds
- - Opening snap
- - Diastolic murmur
- Test results
- - Electrocardiogram
- - Chest radiograph
- Approach to diagnosis
- Stress testing
- Cardiac catheterization and angiography
- DIFFERENTIAL DIAGNOSIS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS