Management of MS

Any cause of tachycardia may result in an acute deterioration. Common causes are infection, new onset or uncontrolled atrial fibrillation, exercise or pregnancy. Symptoms will be improved by slowing the heart rate and allowing better ventricular filling during diastole. Atrial fibrillation can precipitate acute heart failure and may be difficult to treat.

There are a number of emergency measures to be undertaken when managing mitral stenosis in the ED, and these are shown below:

Emergency measures for the management of mitral stenosis

• Close attention to fluid balance
• Antipyretics as appropriate
• Find and treat underlying infection if suspected
• Diuretics may be needed to relieve pulmonary congestion but addressing the shortened diastolic filling caused by any tachycardia will be of most benefit in the emergency setting
• Rate control with beta blockers, digoxin or calcium channel blockers will be required for rapid atrial fibrillation. Any consideration of cardioversion must recognise the significant incidence of atrial thrombus and the risks of embolisation
• Acute haemoptysis is relatively rare but can be severe. It is caused by vessel rupture due to venous congestion and may require referral to a cardiothoracic surgeon
• All MS patients in atrial fibrillation should be on long term anticoagulants. There is little benefit to those in sinus rhythm. Systemic embolisation may be due to sub-therapeutic anticoagulation therapy. Patients may also present with complications of over anticoagulation