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.
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.
Table 23-1 Comparison of Heart Murmurs, Sounds, and Signs ||Download (.pdf)
Table 23-1 Comparison of Heart Murmurs, Sounds, and Signs
|Valve Disorder||Murmur||Heart Sounds and Signs|
|Mitral stenosis||Mid-diastolic rumble, crescendos into S1||Loud snapping S1, apical impulse is small, tapping due to under- filled ventricle|
|Mitral regurgitation||Acute: harsh apical systolic murmur that starts with S1 and may end before S2 Chronic: high-pitched apicalholosystolic murmur that radiates into S2||S3 and S4 may be heard|
|Mitral valve prolapse||Click may be followed by a late systolic murmur that crescendos into S2||Midsystolic click; S2 may be diminished by the late systolic murmur|
|Aortic stenosis||Harsh systolic ejection murmur||Paradoxic splitting of S2; S3 and S4 may be present; pulse of small amplitude; pulse has a slow rise and sustained peak|
|Aortic regurgitation||High-pitched blowing diastolic murmur immediately after S2||S3 may be present; wide pulse pressure|
Diagnosis and Differential
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.
Emergency Department Care and Disposition
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.