Snapshot A 56-year-old man presents to his cardiologist for dyspnea. He previously had dyspnea with exertion. In the past few weeks, he has had dyspnea at rest as well. He also reports easy fatigability. He has a previous history of hypertension and ischemic heart disease. He currently takes statins, metoprolol, captopril, and furosemide. On physical exam, there is a holosystolic murmur heard best at the apex, a systolic thrill, and S3 heart sound. An echocardiogram reveals left ventricular hypertrophy, left atrial enlargement, and mitral regurgitation. Introduction Clinical definition a valvular disorder characterized by mitral valve insufficiency acute or chronic Associated conditions tuberous sclerosis Epidemiology Demographics male > female Risk factors coronary artery disease past myocardial infarction Etiology Acute rupture of chordae tendinae papillary muscle rupture infective endocarditis trauma Chronic rheumatic heart disease (most common in developing countries) mitral valve prolapse (most common in developed countries) infective endocarditis hypertension ischemic heart disease hypertrophic obstructive cardiomyopathy congenital Pathogenesis mitral insufficiency results in blood flow from the left ventricles to the left atrium (LA) instead of into systemic circulation ↑ LA pressure ↑ volume overload and preload ↓ cardiac output as left ventricle empties some of its blood into the low-pressure compartment of LA over time, this results in left ventricular failure Presentation Symptoms heart failure dyspnea orthopnea paroxysmal nocturnal dyspnea fatigue Physical exam cardiac exam downward-displaced left ventricular impulse holosystolic apical murmur radiates to axilla best heart at apex systolic thrill S3 heart sound pulmonary rales peripheral edema Imaging Chest radiography indication initial imaging findings increased pulmonary vasculature cardiomegaly left atrial enlargement Echocardiography indication diagnostic test findings mitral insufficiency left heart enlargement Studies Electrocardiogram findings left ventricular hypertrophy left atrial enlargement Differential Ventricular septal defect (VSD) distinguishing factors also presents with holosystolic murmur may be asymptomatic or may develop heart failure no S3 sound or thrill echo shows VSD Diagnosis Making the diagnosis based on clinical presentation and imaging Treatment Management approach treat heart failure if present Medical vasodilating drugs indication for all patients drugs angiotensin receptor blockers angiotensin-converting enzyme inhibitors hydralazine diuretics indication for patients with heart failure β-blockers indication for patients with heart failure Operative valvular repair or replacement indications ejection fraction ≤ 60% left ventricular end systolic diameter ≥ 40 mm refractory to medical therapy Complications Heart failure Cardiogenic shock Pulmonary hypertension Atrial fibrillation