Mitral stenosis physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Mitral stenosis is associated with a rumbling mid-diastolic murmur that is associated with an opening snap, best heard at the cardiac apex, and radiating to the axilla. While the murmur increases when lying down, raising the legs, and with exercise, it decreases upon performing the valsalva maneuver. The pulse pressure might be decreased among patients with mitral stenosis. Later in the course of the disease there may be signs of right heart failure such as pedal edema, ascites, and congestive hepatopathy.

Physical Examination

The physical examination findings of mitral stenosis include:

Vitals

• Tachycardia may be present if there is a reduction in cardiac output
• The pulse may be irregularly irregular with the onset of atrial fibrillation
• Due to the decreased stroke volume, arterial pulses are reduced in volume

Head

• There is sometimes presence of mitral facies with patches of pink and purple on the cheeks due to reduced cardiac output and peripheral vasoconstriction.
• There may be a malar flush.

Neck

• Jugular venous distension is present.
• Prominent "a wave" is present indicating increased right atrial pressure from pulmonary hypertension and right ventricular failure.
• With the onset of atrial fibrillation, "a wave" is lost and only a prominent "v wave" is visible.
• Prominent "c-v wave" is present with tricuspid regurgitation, indicating regurgitation of blood into the right atrium.

Heart

• Left parasternal heave is palpable if right ventricular hypertrophy is present due to pulmonary hypertension
• Due to the underfilling of the left ventricle, the point of maximal impulse may not be palpable or displaced
• A diastolic thrill may be palpated rarely
• A P2 may be palpable in the 2^nd left intercostal space
• A right ventricular lift may be present

Auscultation

Heart Sounds

• S1: The first heart sound is unusually loud and may be palpable due to the increased force of the closing of the mitral valve.
• S2: If pulmonary hypertension secondary to mitral stenosis is severe, the P2 (pulmonic component of the second heart sound) will become loud. When pulmonary hypertension develops, murmurs of pulmonary regurgitation (Graham-Steell murmur), tricuspid regurgitation and a right sided S3 can be heard.
• S3: Flow of blood into the heart during rapid filling is not normally heard in pure mitral stenosis except in certain pathological conditions where there is a coexisting aortic or mitral regurgitation.
• S4: A patient in sinus rhythm with hypertrophied and dilated right ventricle may produce a fourth heart sound, S4.

• Opening Snap
  • The closing of the mitral valve and the tricuspid valve constitutes the first heart sound (S1). It is not actually the valve closure which produces a sound but rather the sudden cessation of blood flow caused by the closure of the mitral and tricuspid valves. The mitral valve opening is normally not heard except in mitral stenosis as the opening snap. As the severity of the mitral stenosis increases, the pressure in the left atrium increases, and the mitral valve opens earlier and more abruptly in ventricular diastole. An opening snap which is a high pitched additional sound may be heard after the A₂ (aortic) component of the second heart sound (S₂), which correlates to the forceful opening of the mitral valve.
  • It is best heard at the cardiac apex and lower left sternal border.
  • Initially, an opening snap is heard loud because there is an increased gradient between the left atrium and the left ventricle and S1. As the valve calcifies and left atrial pressure increases, S1 becomes softer and the opening snap moves closer to S2.
  • Opening snap occurs earlier after A₂ (aortic) component of the second heart sound (S₂) as the disease progresses and left atrial pressure rises.
  • Thus, the shorter the A2 - Opening Snap interval, the more severe the mitral stenosis.
  • Mild: >110 msec
  • Moderate: 70-110 msec
  • Severe: <70 msec

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Murmur

• A mid-diastolic rumbling murmur heard after the opening snap is present.
• The murmur is best heard at the apical region and is not radiated. Since it is low-pitched it should be picked up by the bell of the stethoscope.
• Rolling the patient towards left, as well as isometric exercise will accentuate the murmur.
• If the patient is in normal sinus rhythm, there will be a “presystolic accentuation” of the murmur due to increased flow across the valve with normal atrial contraction.
• The duration of the murmur and not the intensity of the murmur correlates with the severity of mitral stenosis.

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• In presence of pulmonary hypertension:
  • A pulmonary ejection sound, which diminishes with inspiration is present.
  • A holosystolic murmur best heard along the right sternal border which increases with inspiration indicating tricuspid regurgitation due to right ventricular dilation may be present.
  • A high-pitched decrescendo diastolic murmur secondary to pulmonary regurgitation (Graham Steell murmur) best heard at the upper sternal border may be audible.

Extremities

• Ankle/sacral edema is present when there is a right heart failure.