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Typically the diagnosis of valvular disease and dysfunction has been previously established but emergency physicians must be alert to the presenting signs and symptoms to aid the undiagnosed patient, and with bedside echocardiography becoming more common, initial diagnosis will occur more commonly in the ED.

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Clinical Features

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As with all valvular diseases, exertional dyspnea is the most common presenting symptom (80% of patients with mitral stenosis). In the past, hemoptysis was the second most common presenting symptom, but it is less common now with earlier recognition and treatment. Systemic emboli may occur and result in myocardial, kidney, central nervous system, or peripheral infarction. Most patients eventually develop atrial fibrillation because of progressive dilation of the atria. The classic murmur of mitral stenosis and associated signs are listed in Table 23-1.

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Table Graphic Jump Location
Table 23-1 Comparison of Heart Murmurs, Sounds, and Signs
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Diagnosis and Differential

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The electrocardiogram (ECG) may demonstrate notched or diphasic P waves and right axis deviation. On the chest radiograph, straightening of the left heart border, indicating left atrial enlargement, is a typical early radiographic finding. Eventually, findings of pulmonary congestion are noted: redistribution of flow to the upper lung fields, Kerley B lines, and an increase in vascular markings. The diagnosis of mitral stenosis should be confirmed with echocardiography or consultation with a cardiologist. The urgency for an accurate diagnosis and appropriate referral depends on the severity of symptoms.

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Emergency Department Care and Disposition

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  1. The medical management of mitral stenosis includes intermittent diuretics, such as furosemide 40 milligrams intravenously (IV), to alleviate pulmonary congestion, the treatment of atrial fibrillation (see Chapter 2), and anticoagulation (international normalized ratio [INR] goal of 2:3) for patients at risk for arterial embolic events.

  2. Frank hemoptysis ...

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