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]


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:[1][2][3]



  • 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.




Heart Sounds
  • 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


  • 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.




  1. Carabello BA (2005). "Modern management of mitral stenosis". Circulation. 112 (3): 432–7. doi:10.1161/CIRCULATIONAHA.104.532498. PMID 16027271.
  2. Maganti K, Rigolin VH, Sarano ME, Bonow RO (2010). "Valvular heart disease: diagnosis and management". Mayo Clin Proc. 85 (5): 483–500. doi:10.4065/mcp.2009.0706. PMC 2861980. PMID 20435842.
  3. Etchells E, Glenns V, Shadowitz S, Bell C, Siu S (1998). "A bedside clinical prediction rule for detecting moderate or severe aortic stenosis". J Gen Intern Med. 13 (10): 699–704. PMC 1500900. PMID 9798818.

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