Mitral stenosis physical examination: Difference between revisions
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==Overview== | ==Overview== | ||
Mitral stenosis is associated with a rumbling diastolic murmur | 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]]. | ||
==Vitals== | ==Physical Examination== | ||
* Tachycardia may be present if there is a reduction in [[cardiac output]] | The physical examination findings of mitral stenosis include:<ref name="pmid16027271">{{cite journal| author=Carabello BA| title=Modern management of mitral stenosis. | journal=Circulation | year= 2005 | volume= 112 | issue= 3 | pages= 432-7 | pmid=16027271 | doi=10.1161/CIRCULATIONAHA.104.532498 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16027271 }} </ref><ref name="pmid20435842">{{cite journal| author=Maganti K, Rigolin VH, Sarano ME, Bonow RO| title=Valvular heart disease: diagnosis and management. | journal=Mayo Clin Proc | year= 2010 | volume= 85 | issue= 5 | pages= 483-500 | pmid=20435842 | doi=10.4065/mcp.2009.0706 | pmc=2861980 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20435842 }} </ref><ref name="pmid9798818">{{cite journal| author=Etchells E, Glenns V, Shadowitz S, Bell C, Siu S| title=A bedside clinical prediction rule for detecting moderate or severe aortic stenosis. | journal=J Gen Intern Med | year= 1998 | volume= 13 | issue= 10 | pages= 699-704 | pmid=9798818 | doi= | pmc=1500900 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9798818 }} </ref> | ||
=== 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]] | * The pulse may be irregularly irregular with the onset of [[atrial fibrillation]] | ||
* Due to the decreased [[stroke volume]], arterial pulses are reduced in volume | * Due to the decreased [[stroke volume]], arterial pulses are reduced in volume | ||
==Head== | === 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 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. | * There may be a malar flush. | ||
==Neck== | === Neck === | ||
* [[Jugular venous distension]] is present. | * [[Jugular venous distension]] is present. | ||
* Prominent "[[a wave]]" is present indicating increased right atrial pressure from pulmonary hypertension and right ventricular failure. | * 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. | * 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. | * Prominent "c-v wave" is present with [[tricuspid regurgitation]], indicating regurgitation of blood into the right atrium. | ||
==Heart | === Heart === | ||
* Left parasternal [[heave]] is palpable if [[right ventricular hypertrophy]] is present due to [[pulmonary hypertension]] | * Left parasternal [[heave]] is palpable if [[right ventricular hypertrophy]] is present due to [[pulmonary hypertension]] | ||
* Due to the underfilling of the left ventricle, the [[PMI]] may not be palpable or displaced | * Due to the underfilling of the left ventricle, the [[PMI|point of maximal impulse]] may not be palpable or displaced | ||
* A diastolic thrill may be palpated rarely | * A [[diastolic]] [[thrill]] may be palpated rarely | ||
* A [[P2]] may be palpable in the | * A [[P2]] may be palpable in the 2<sup>nd</sup> left intercostal space | ||
* A right ventricular [[lift]] may be present | * A right ventricular [[lift]] may be present | ||
===Auscultation=== | ==== Auscultation ==== | ||
====Heart | ===== 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. | * [[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]] ( | * [[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. | * [[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 regurgitation|aortic]] or [[mitral regurgitation]]. | ||
* [[S4]]: A patient in sinus rhythm with hypertrophied and dilated right ventricle may produce a fourth heart sound, S4. | * [[S4]]: A patient in [[sinus rhythm]] with hypertrophied and dilated right ventricle may produce a fourth heart sound, S4. | ||
* Opening Snap | * 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 A<sub>2</sub> (aortic) component of the second heart sound (S<sub>2</sub>), which correlates to the forceful opening of the mitral valve. | ** 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 A<sub>2</sub> (aortic) component of the second heart sound (S<sub>2</sub>), which correlates to the forceful opening of the mitral valve. | ||
** It is best heard at the cardiac apex and lower left sternal border. | ** 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]]. | ** 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 A<sub>2</sub> (aortic) component of the second heart sound (S<sub>2</sub>) as the disease progresses and left atrial pressure rises. | ** Opening snap occurs earlier after A<sub>2</sub> (aortic) component of the second heart sound (S<sub>2</sub>) as the disease progresses and left atrial pressure rises. | ||
** Thus, the shorter the A2 - Opening Snap interval, the more severe the mitral stenosis. | ** Thus, the shorter the A2 - Opening Snap interval, the more severe the mitral stenosis. | ||
** Mild: >110 msec | |||
** Moderate: 70-110 msec | |||
** Severe: <70 msec | |||
{{#ev:youtube|E0fDFsmVQfY}} | {{#ev:youtube|E0fDFsmVQfY}} | ||
====Murmur==== | ===== Murmur ===== | ||
* A mid-diastolic rumbling murmur heard after the opening snap is present. | * 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. | * 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. | * 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. | * 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. | * The duration of the murmur and not the intensity of the murmur correlates with the severity of mitral stenosis. | ||
{{#ev:youtube|HW2pk1icYdM}} | |||
* In presence of [[pulmonary hypertension]]: | * In presence of [[pulmonary hypertension]]: | ||
** A pulmonary ejection sound, which diminishes with inspiration is present. | ** 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 [[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. | ** 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]] when there is [[right heart failure]] | * Ankle/sacral [[edema]] is present when there is a [[right heart failure]]. | ||
==References== | ==References== | ||
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Latest revision as of 20:33, 7 December 2016
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Mitral Stenosis Microchapters |
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Mitral stenosis physical examination On the Web |
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American Roentgen Ray Society Images of Mitral stenosis physical examination |
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Risk calculators and risk factors for Mitral stenosis physical examination |
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:[1][2][3]
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 2nd 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
{{#ev:youtube|E0fDFsmVQfY}}
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.
{{#ev:youtube|HW2pk1icYdM}}
- 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.
References
- ↑ Carabello BA (2005). "Modern management of mitral stenosis". Circulation. 112 (3): 432–7. doi:10.1161/CIRCULATIONAHA.104.532498. PMID 16027271.
- ↑ 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.
- ↑ 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.