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 diastolic murmur and an opening snap. Later in the course of the disease there are signs of right heart failure such as pedal edema, ascites, and congestive hepatopathy.

Vitals

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

Heart

Palpation

Auscultation

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.

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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.

Periphery

References

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