Mitral stenosis physical examination

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Physical examination

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The cardiac exam reflects the anatomy and hemodynamics. Initially, an OS is heard because there is an increased gradient between the LA and LV and S1 is loud. As the valve calcifies and LA pressure increases, S1 becomes softer and the OS moves closer to S2. When PHTN develops increased P2, pulmonary ejection sounds, murmurs of PI (Graham Steel), TR and right sided congestive heart failure (RVS3) can be heard. The diastolic murmur does not correlate with tee severity of MS but generally occurs throughout diastole in sever cases. Those in NSR (normal sinus rhythm) will have “presystolic accentuation” of the murmur due to atrial contraction.

Heart: The first heart sound is unusually loud and may be palpable due to the increased force of the closing of the mitral valve.

If pulmonary hypertension secondary to mitral stenosis is severe, the P₂ (pulmonic) component of the second heart sound (S₂) will become loud.

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. The mitral valve opens when the pressure in the left atrium is greater than the pressure in the left ventricle. This happens in ventricular diastole (after closure of the aortic valve), when the pressure in the ventricle precipitously drops. In individuals with mitral stenosis, the pressure in the left atrium correlates with the severity of the mitral stenosis. As the severity of the mitral stenosis increases, the pressure in the left atrium increases, and the mitral valve opens earlier in ventricular diastole.

A mid-diastolic rumbling murmur will be heard after the opening snap. 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. A thrill might be present when palpating at the apical region of the praecordium.

Peripheral signs include:

• Malar flush - pulmonary hypertension is prominent in patients with mitral stenosis
• Ankle/sacral edema (oedema) when there is right heart failure
• Atrial fibrillation - irregular pulse and loss of 'a' wave in jugular venous pressure
• Left parasternal heave - presence of right ventricular hypertrophy due to pulmonary hypertension
• Tapping apex beat which is not displaced