Clinical Features
The main clinical presentations are:
- Exertional breathlessness, orthopnoea and PND. Breathlessness on exertion is often the first symptom noticed
- Acute pulmonary oedema Hyperdynamic states with an associated tachycardia such as pregnancy, infection, uncontrolled AF and anaemia may result in a worsening of symptoms
- Atrial fibrillation (Fig 1) Onset is associated with a marked deterioration of the patients clinical state. Risk of left atrial thrombus and systemic embolism
Learning Bite
A patient may first present with symptomatic mitral stenosis when she becomes pregnant because of the hyperdynamic state of the circulation. Balloon valvuloplasty may be needed to get through the pregnancy.
- Haemoptysis This used to be the second most common presentation but is rarer now that the disease is recognised sooner
- Fatigue (due to reduced cardiac output)
Clinical, ECG and CXR findings associated with mitral stenosis are to be found in Table 1.
| Pulse | Small volume, irregular (usually AF) |
| Cardiac impulse | Tapping apex due to palpable first heart sound (S1) |
| Auscultation | Loud first heart sound (S1) (in sinus rhythm), opening snap and rumbling mid-diastolic murmur. Early diastolic murmur of pulmonary regurgitation (Graham Steell murmur due to secondary pulmonary hypertension) |
| ECG | Broad or biphasic p wave best seen in Lead 2 indicating LA hypertrophy. R axis deviation. AF common, RV hypertrophy in later stages |
| CXR | Straightening of the left heart border indicating a dilated LA (double atrial shadow). Pulmonary congestion |
| Other features | Mitral facies: peripheral cyanosis of the cheeks |