Physical Examination
Upon auscultation of an individual with mitral stenosis, the first heart sound is unusually loud and may be palpable (tapping apex beat) because of increased force in closing the mitral valve. The first heart sound is made by the mitral and tricuspid heart valves closing. These are normally synchronous, and the sounds are termed M1 and T1 respectively. M1 becomes louder in mitral stenosis. It may be the most prominent sign.
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 with presystolic accentuation 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 is heard best with the bell of the stethoscope. Its duration increases with worsening disease. 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 precordium.
Advanced disease may present with signs of right-sided heart failure such as parasternal heave, jugular venous distension, hepatomegaly, ascites and/or pulmonary hypertension, the latter often presenting with a loud P2.
Almost all signs increase with exercise and pregnancy.
Other peripheral signs include:
- Malar flush - due to back pressure and build up of carbon dioxide (CO2). CO2 is a natural vasodilator.
- 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
Medical signs of atrial fibrillation include:
Heart rate is about 100-150/min. Irregularly irregular pulse with a pulse deficit>10. varying first heart sound intensity. Opening snap is not heard sometimes. Absent a waves in the neck veins. Presystolic accentuation of diastolic murmur disappears. Embolic manifestations may appear.
Read more about this topic: Mitral Valvuloplasty, Diagnosis
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