Assessment

HISTORY. Because patients generally have a history of either rheumatic fever or a genetic predisposition to valvular heart disease, ask about specific dates and treatments related to the initial episode of rheumatic fever. Note the use of prophylactic antibiotics against the recurrence of rheumatic fever.

Patients may remain asymptomatic for a period of 10 to 15 years after the diagnosis. Once the valve orifice decreases to less than 2.5 cm2, however, any physiological state that causes an increase in cardiac output (exercise, fever, anxiety, pain, pregnancy) or a decrease in diastolic filling time (tachycardias, atrial fibrillation) may cause the patient to complain of excessive fatigue, malaise, decreased tolerance to exercise, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and dry cough.

PHYSICAL EXAMINATION. As the valve orifice becomes increasingly narrowed, symptoms of right-sided heart failure may occur. Inspect the patient for neck vein distension and pitting peripheral edema. Pulmonary edema may also occur and lead to orthopnea, tachypnea, diaphoresis, pallor, cyanosis, and pink frothy sputum. Palpate the patient's abdomen for hepatomegaly, and auscultate the patient's lungs for crackles.

You may note a normal apical pulse or an irregular rate associated with atrial fibrillation when the heart is auscultated. There are four principal findings: (1) a loud apical first heart sound (closure of the stenotic mitral valve); (2) an opening snap (the snapping of the stenotic mitral valve); (3) a rumbling, apical diastolic low-frequency murmur (blood flowing with difficulty and under increased pressure through the stenotic mitral valve); and (4) an increased pulmonic second sound associated with pulmonary hypertension.

618 Mitral Stenosis

PSYCHOSOCIAL. Often, patients have been living with the diagnosis for more than 10 years. The possibility of open-heart surgery presents a crisis for patients who fear for their lives. In addition, their symptoms may interfere with activities of daily living. Assess the patient's degree of anxiety and ability to cope with the disease.

Diagnostic Highlights

Test

Normal Result

Abnormality with Condition

Explanation

Transesophageal echocardiogram

Normal mitral valve

Stenotic mitral valve, left atrial enlargement

Opening of mitral valve is narrow, which elevates left atrial pressure and leads to left atrial hypertrophy and right ventricular hypertrophy

Cardiac catheterization

Normal mitral valve

Stenotic mitral valve; elevation of left atrial pressure, elevation of pulmonary capillary pressures and venous pressures, left atrial enlargement

Same as above

Doppler echocardiography

Normal mitral valve

Stenotic mitral valve; left atrial enlargement

Same as above

Other Tests: Electrocardiogram (ECG) may show atrial fibrillation, chest radiography, prothrombin time, activated partial thromboplastin time (APPT)

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