Mitral Valve Prolapse in Emergency Medicine Clinical Presentation

Updated: Apr 08, 2021
  • Author: Michael C Plewa, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Mitral valve prolapse (MVP) usually is asymptomatic, nonprogressive, and benign.

Palpitations occur in 40% of MVP cases. This percentage excludes palpitations due to withdrawal syndromes (eg, alcohol, sedatives), intoxications (eg, cocaine, amphetamine, phencyclidine), or medication exposures (eg, caffeine, sympathomimetic, anticholinergic).

Chest pain and dyspnea previously were considered part of the MVP syndrome, but they are now thought to be no more common in cases of MVP than they are in the general population. [5, 32]

Although controversial, anxiety and panic disorders may be more common in patients with MVP than the general population. [33]

Other symptoms may include fatigue, syncope/presyncope, [32] and orthostasis. [32]


Physical Examination

Patients may have the following features:

  • Thin aesthetic body habitus with narrow anteroposterior diameter [34]

  • Skeletal abnormalities (ie, pectus excavatum, straight back, kyphoscoliosis)

  • Supernumerary nipples in Asian Indians

  • Resting bradycardia and orthostatic hypotension

  • Mitral regurgitation [35]

  • Autonomic dysfunction - Decreased heart rate variability and parasympathetic tone [36, 37]

  • Neuroendocrine dysfunction

  • Ehlers-Danlos syndrome findings (eg, joint hypermobility, abnormal striae, bruising, distensibility of skin)

  • Osteogenesis imperfecta findings (eg, blue sclera)

  • Marfan syndrome findings (eg, scoliosis, straight back, pectus excavatum, arachnodactyly, arm span greater than body height)

  • Protrusions of subcutaneous fatty tissue (piezogenic pedal papules) on the lateral feet when standing [38]

  • Stickler syndrome findings (eg, kyphosis, scoliosis, mandibular hypoplasia, retinal detachment). Whether Stickler syndrome is associated with mitral valve prolapse is debatable.

Cardiac auscultation

On cardiac evaluation, the following features may be noted:

  • Apical, single or multiple, mid-to-late systolic clicks, which result from the tightening of the chordae tendineae or the redundant valve, can be heard.

  • An apical mid-to-late systolic murmur of crescendo, decrescendo, or constant nature can be heard, and the murmur continues to be heard in S2.

  • The click and the murmur change as the position changes (closer to S1 with diminished LV volume; closer to S2 with increased LV volume)

  • In the supine position, the click is late (ie, close to S2), and the murmur is brief.

  • In the standing position and during the Valsalva maneuver, the click is earlier (ie, close to S1), and the murmur is longer. This may identify a murmur that previously was not noted.

  • In the squatting position, the click is later (ie, closer to S2), and the murmur is shorter. The click and the murmur may even disappear.

  • The isometric handgrip exercise increases the intensity (ie, loudness) of the murmur without affecting the position.

  • The murmur should be distinguished from that of aortic stenosis (ie, early systolic, at base); pulmonic flow murmur (ie, short and early systolic, diminishes with Valsalva maneuver); hypertrophic cardiomyopathy (ie, diminishes with squatting and intensifies with standing and Valsalva maneuver); and mitral regurgitation (ie, holosystolic murmur with S3, enlarged and displaced point of maximal intensity [PMI]).