Clinical Features

Acute mitral incompetence presents with dyspnea, tachycardia, and pulmonary edema. Usually an S3 and S4 will be heard. Acutely, the harsh apical systolic murmur starts with S-, and may end before S2. Patients may quickly deteriorate to cardiogenic shock or cardiac arrest. Intermittent mitral incompetence usually presents with acute episodes of respiratory distress due to pulmonary edema and can be asymptomatic between attacks. The pronounced dyspnea may mask angina that accompanies the ischemia. Patients may have an active apical impulse, systolic thrust, and thrill at the apex. Jugular venous distention may be seen, with a prominent a wave and a left parasternal lift. The eCg may show evidence of acute inferior wall infarction (more common than anterior wall infarction in this setting). On the chest radiograph, acute mitral incompetence from papillary muscle rupture may result in a minimally enlarged left atrium and pulmonary edema, with less cardiac enlargement than expected.

Chronic mitral incompetence may be tolerated for years or even decades. The first symptom is usually exertional dyspnea, sometimes prompted by atrial fibrillation. If patients are not anticoagulated, systemic emboli occur in 20 percent and are often asymptomatic. Endocarditis is still a feared complication. Signs of chronic mitral incompetence include a late systolic left parasternal lift. There is a high-pitched holosystolic murmur that is best heard in the fifth intercostal space, mid left thorax, which radiates to the axilla. The first heart sound is soft and often obscured by the murmur. An S 3 is usually heard and is followed by a short diastolic rumble, indicating increased flow into the left ventricle. The ECG may demonstrate findings of left atrial and left ventricular hypertrophy (LVH). On the chest radiograph, chronic mitral incompetence produces left ventricular and atrial enlargement that is proportional to the severity of the regurgitant volume.

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