Medical Encyclopedia         Diseases

just click the Angel:-))

American Stroke Association

Arrhythmia              Children & Heart Disease              Cholesterol              Diabetes              Heart Attack              Congestive Heart Failure              High Blood Pressure              Other Conditions

Warning Signs

Risk Assessment

Diseases & Conditions

CPR & ECC

Healthy Lifestyle

Advocacy: Take Action

Legislative              Action Center              Legislative Priorities              Advocacy News              Facts & Statistics              Spread the Word              Coalitions

Heart & Stroke Encyclopedia

Publications and Resources

Making Contributions              American Heart Walk              Hoops For Heart              Jump Rope For Heart              Heart to Heart E-Cards

Diet & Nutrition              Cholesterol Low Down              Women & Cardiovascular Disease              Exercise and Fitness              Managing Your Lifestyle My Heart              Watch Heart At Work              How Your Heart Works

Publications              Resources              Statistics

Other sites

Heart Attack          -                 Str

oke -                 Risk Assessment

Oxgen

oxide out

Trachia

Aorta

Pulmonary art

Respiratory          Disorders(new)

Patient          -                 Choose To Move          -                 Cholesterol Low Down

Nutrition          -                 Exercise -                 Children -                 Programs -                 Books

Medical          Forums:

Family          Practice         (new)

Addiction

Gastroenterology

Dermatology

Hepatitis

Heart

Liver          Diseases

Child          Behavioral Health

Mental          Health

Neurology

Neurosurgery

Transplant

Breast          Cancer

HEART ATTACK SYMPTOMS / WARNING SIGNS

Some heart attacks  are sudden and intense -- the "movie heart attack," where no one doubts what's  happening. But most heart attacks start slowly, with mild pain or discomfort.  Often the people affected aren't sure what's wrong and wait too long before  getting help. Here are some of the signs that can mean a heart attack is  happening.

Chest    discomfort. Most heart attacks involve discomfort in the center of the    chest that lasts more than a few minutes, or that goes away and comes back. It    can feel like uncomfortable pressure, squeezing, fullness or pain.

;Discomfort in    other areas of the upper body. Symptoms can include pain or discomfort in    one or both arms, the back, neck, jaw or stomach.

;Shortness of    breath. This feeling often comes along with chest discomfort. But it can    occur before the chest discomfort.

;Other signs.    These may include breaking out in a cold sweat, nausea or lightheadedness.

If you or someone  you're with has chest discomfort, especially with one or more of the other  signs, don't wait longer than a few minutes (no more than 5) before calling for  help. Call 9-1-1?Get to a hospital right away.

Calling 9-1-1 is almost always the fastest way to get lifesaving treatment.  Emergency medical services (EMS) staff can begin treatment when they arrive --  up to an hour sooner than if someone gets to the hospital by car. The staff are  also trained to revive someone whose heart has stopped. You'll also get treated  faster in the hospital if you come by ambulance.

If you can't access the emergency medical services, have someone drive you to  the hospital right away. If you're the one having symptoms, don't drive  yourself, unless you have absolutely no other option.

Related AHA publication(s):

Heart and Stroke Facts Heart Attack and Stroke: Warning Signals    wallet card Heart Attack and Stroke: Signals and Actions    (also in Spanish) Silent Epidemic... Fighting About Heart    Disease and Stroke for Women Ages 25 to 44 Take Charge!... Fighting Heart Disease for    Women Over 35 We're Talking About Women and Heart Attack      (Quick and Easy Reading) (also in Spanish) ;What Are the Warning Signs of Heart Attack?"      in Answers By Heart kit (also in Spanish kit),"What Is a Heart Attack?" in Answers By Heart      ki

SILENT ISCHEMIA AND ISCHEMIC HEART DISEASE

What is ischemia?

Ischemia is a usually temporary shortage of oxygen in a part of the  body. It can occur when an artery bringing blood to that part, such as the  heart, is narrowed by spasm or disease.

What is ischemic heart disease?

Ischemic heart disease includes heart attack and related heart problems  caused by narrowed coronary arteries and thus less blood and oxygen reaching the heart. It's also  called coronary artery disease and coronary heart disease.

What is silent ischemia?

As many as 3 to 4 million Americans may have  ischemic episodes without knowing it. These people, who have ischemia without  pain, have silent ischemia. They may have a heart attack with no prior warning.  In addition, people with angina (chest pain) also may have undiagnosed episodes  of silent ischemia. Various tests, such as an exercise test or a 24-hour  portable monitor of the electrocardiogram (Holter monitor), are used to diagnose silent  ischemia.

EMERGENCIES

If you experience any heart attack or stroke  warning signs, don't wait. Call 9-1-1 or your emergency medical services and get  to a hospital right away!

Be Prepared

Keep a list of emergency rescue service numbers next to the telephone and    in your pocket, wallet or purse. In most areas 9-1-1 is the number to call for    all emergencies.

Take Action

If you have heart attack or stroke symptoms that last more than a few    minutes, don't delay! Immediately call 9-1-1 or the EMS number so an ambulance    (ideally with advanced life support) can quickly be sent for you. If ambulance service isn't available in your area, immediately have    someone drive you to the nearest hospital emergency room (or another facility    offering 24-hour life support). If you're with someone who may be having heart attack or stroke symptoms,    immediately call 9-1-1 or the EMS. Expect the person to protest - denial is    common. Don't take "no" for an answer. Insist on taking prompt action. Give CPR (mouth-to-mouth breathing and chest compression) if it's    necessary and you're properly trained.

What equipment should be on emergency room  crash carts?

The American Heart Association doesn't currently  have an inventory of emergency room crash cart items. However, the Emergency  Cardiovascular Care Committee is developing recommendations for crash cart  contents. See the 1997-99 Handbook of Emergency Cardiovascular Care for  Healthcare Providers (#70?1099).

Mysteries of mitral valve prolapse

Proper treatment requires consideration of all clues

Mahesh S. Mulumudi, MD; Krishnamoorthy Vivekananthan, MD

VOL 110 / NO 2 / AUGUST 2001 / POSTGRADUATE MEDICINE

CME learning objectives

To review signs and symptoms of mitral valve prolapse To understand how echocardiography is used in diagnosis of mitral valve    prolapse To understand the role of infective endocarditis prophylaxis in management    of mitral valve prolapse

The authors disclose no financial interest in this  article.

This is the second of four articles on valvular heart disease.

Preview: Mitral valve prolapse, one of the most common forms of  valvular heart disease in developed nations, can be associated with a variety of  clinical symptoms and rare serious complications--all of which require careful  attention. This article reviews the clinical manifestations of mitral valve  prolapse, outlines use of echocardiography in diagnosis of the condition,  identifies potential complications, and offers guidelines on management. Mulumudi MS, Vivekananthan K. Mysteries of mitral valve prolapse: proper  treatment requires consideration of all clues. Postgrad Med 2001;110(2):43-54

In 1963, Barlow and colleagues (1) used  cineangiography to conclusively identify mitral valves as the origin of  midsystolic clicks and late systolic murmurs and to confirm the clinical entity  of mitral valve prolapse. Since that time, mitral valve prolapse has become the  most common valvular cardiac abnormality in developed countries. It has been  associated with a myriad of clinical symptoms and rare serious complications.

Prolapse is defined as the slipping of a body part from its normal position  in relation to other body parts. In mitral valve prolapse, one or both mitral  leaflets are displaced superiorly from the mitral valve annulus into the left  atrium during systole. Proper management requires an awareness of several  issues: accurate prevalence data and etiologic information, factors involved in  diagnosis, possible complications associated with the condition, and  evidence-based considerations for management and prevention.

Prevalence data

In the past, the reported prevalence of mitral valve prolapse ranged from 5%  to 17%, depending on the population studied (2-4). This range was higher than  recently reported estimates, in part because of (1) ambiguity of the previous  echocardiographic criteria for diagnosis of mitral valve prolapse, which had  yielded a higher number of false-positive cases, and (2) referral bias inherent  in the population studied. In a 1999 study in which the current two-dimensional  echocardiographic criteria were applied (5), the prevalence of mitral valve  prolapse in the general population was estimated to be 2.4%. This percentage  probably reflects the true prevalence, because the study included 1,845 women  and 1,646 men from the general population. Women composed 59.5% of the patients  with mitral valve prolapse and 52.7% of those without prolapse (P=.21).  Patient ages ranged from 26 to 84 years. Hence, mitral valve prolapse does not  affect women or younger individuals more than other members of the general  population.

Etiologic factors

Although the cause of mitral valve prolapse is not entirely known, the  majority of cases are genetically determined (primary) or occur as a sequela of  other conditions that have altered the mitral valve apparatus (secondary).

Primary Most cases of mitral valve prolapse are primary, that is, of autosomal dominant  inheritance. The results of family studies show that the genetic expression of  mitral valve prolapse is affected by both age and sex. Research indicates that  phenotypic expression is low in males, older women, and children of both sexes,  but the genetic defect responsible for primary mitral valve prolapse is not  known. Pathologic studies have shown disruption of collagen bundles in the  leaflets and chordae tendineae of prolapsed mitral valves. Biochemical studies  have shown a spectrum of collagen abnormalities in the prolapsed valves.  However, mitral valve prolapse is not associated with the genetic abnormalities  for collagen types I, III, and V.

During prolapse, the mitral leaflets are displaced superiorly into the left  atrium or displaced posteriorly because of the dynamic systolic expansion of the  mitral valve annulus. There is a strong familial nature to this pattern of  displacement, which might indicate that these two patterns of mitral leaflet  motion are two different genetic entities. By echocardiographic evaluation,  mitral valve prolapse was noted in nearly 57% of patients with Marfan syndrome  (6). It also occurs in types I and III of Ehlers-Danlos syndrome, pseudoxanthoma  elasticum, and osteogenesis imperfecta.

Secondary Mitral valve prolapse can also develop when the size of the left ventricle is  relatively small, resulting in a relatively large and redundant mitral  apparatus. This is called secondary mitral valve prolapse. Ostium ecundum atrial  septal defects, anorexia nervosa, hypertrophic cardiomyopathy, pulmonary  hypertension, dehydration, and straight back syndrome are good examples of  conditions in which ventricular size is reduced, causing secondary mitral valve  prolapse.

Diagnosis

Diagnosis of mitral valve prolapse is based on signs and symptoms, results of  clinical examination including auscultation, and echocardiographic findings.

Signs and symptoms In the past, dyspnea, panic attacks, generalized anxiety disorders, chest pain  not associated with angina, and repolarization abnormalities on the  electrocardiogram were thought to be associated with mitral valve prolapse. As a  result, the term mitral valve prolapse syndrome was coined to bring all  the clinical signs and symptoms under one diagnostic entity (7). Some older  studies (8) and a recent study (5) have shown that the incidence of dyspnea,  chest pain, and electrocardiographic abnormalities in patients with prolapse is  no different than in patients without the disorder. However, thoracic bony  abnormalities, leaner body weight, and palpitations have been shown to be  associated with mitral valve prolapse (8). In fact, the fifth examination of the  offspring cohort of the Framingham Heart Study (5), which is more reflective of  the general population, has shown that leaner body mass index and lower  waist-to-hip ratio are seen in patients with mitral valve prolapse.

Clinical examination Clinical examination plays a major role in the initial screening of patients  with mitral valve prolapse and in their suitability for echocardiography (to  confirm the preliminary diagnosis). Midsystolic click and late systolic murmur  are the hallmarks of mitral valve prolapse on clinical examination. Midsystolic  click shifts in relation to the first heart sound with maneuvers that increase  or decrease the left ventricular size. When the patient sits or stands,  ventricular size in relation to the mitral valve size is reduced, so the click  occurs earlier in systole and the systolic murmur is prolonged. Moreover,  maneuvers that increase ventricular size, such as squatting, make the click  occur later in systole and shorten the systolic murmur. A widely split first  heart sound can be mistaken for a midsystolic click during auscultation. Also, a  midsystolic murmur could be misinterpreted as a late systolic murmur, leading to  a false diagnosis. Patients who are dehydrated at the time of the examination  can have clinical and echocardiographic evidence of mitral valve prolapse that  resolves after they are rehydrated.

Auscultatory findings are highly variable from one physical examination to  another and include fluctuations in the intensity of both the click and the  murmur (9). Frequent examinations are required to determine if a patient has a  murmur, the presence of which has a bearing on management.

Echocardiography Initially, mitral valve prolapse was diagnosed by using cineangiography. The  advent of echocardiography about 30 years ago facilitated the diagnosis of  mitral valve prolapse noninvasively. The parasternal long-axis view is preferred  (10). The apical four-chamber view yields a high number of false-positive  results and thus should not be used for the assessment of mitral valve  prolapse (10). Because of the nonflat, saddle shape of the mitral valve annulus  (11), classic mitral valve prolapse is diagnosed by echocardiography by the  following criteria: systolic displacement of the mitral leaflets by more than 2  mm into the left atrium superior to the mitral annular plane (the line  connecting the annular hinge points of the leaflets) and mitral leaflet  thickness of at least 5 mm during diastole (figures 1 and 2: not shown).  Nonclassic prolapse is defined as displacement by more than 2 mm beyond the  mitral annular plane and a maximal thickness of less than 5 mm. When physical  findings are not suggestive of mitral valve prolapse, screening with routine  echocardiography is not recommended.

Complications

Complications of mitral valve prolapse are rare. When they do develop, they  usually occur in patients with a mitral systolic murmur, thickened redundant  mitral valve leaflets, or an enlarged left atrium or left ventricle.

Mitral regurgitation Mitral regurgitation is the most severe complication of mitral valve prolapse,  and it requires surgery in some cases. In a cross-sectional study of the  offspring of the Framingham Heart Study cohort (5), the degree of mitral  regurgitation in individuals with classic mitral valve prolapse on average was  mild. The degree of mitral regurgitation in those with nonclassic prolapse or no  prolapse was trace. Severe mitral regurgitation occurred in 7% of subjects with  classic mitral valve prolapse compared with 0.5% of those without prolapse and  0% of those with nonclassic prolapse.

According to a study by Singh and colleagues (12), 25% of the mitral valve  surgeries performed in three centers were for severely regurgitant prolapsed  valves; 67% of subjects with severe prolapse were men. Risk factors for the  development of severe mitral regurgitation in subjects with mitral valve  prolapse included male sex, higher body mass index, systemic hypertension, and  older age. Age was the most strongly associated risk factor. The cumulative risk  for valve replacement surgery for severe mitral regurgitation in subjects with  mitral valve prolapse was estimated to be 2.6% in men and 0.8% in women before  age 65. By age 75, the same risk in men and women became 5.5% and 1.4%,  respectively. These calculations were based on a 5% prevalence of mitral valve  prolapse in the general population and the total US population in 1985.

In the previously mentioned study (12), mitral valve prolapse was the  underlying cause in 51% of all mitral valve surgeries done for mitral  regurgitation alone. The intrinsically weaker mitral valve in patients with  prolapse tends to develop regurgitation because of increased hemodynamic burden  imposed on the valve by systemic hypertension and by a higher body mass index.

Infective endocarditis It is generally agreed that patients with mitral valve prolapse have an  increased risk of endocarditis. Estimated relative risk of endocarditis among  all patients with mitral valve prolapse is five times that of the general  population (13). In patients with precordial systolic murmurs, the risk is even  higher (14). Occurrence of systolic murmur in patients with mitral valve  prolapse is about 32% (5). Patients with thickened mitral leaflets and  redundancy are at higher risk than those without thickened leaflets (15). Among  all patients with mitral valve prolapse, the occurrence of infective  endocarditis is 32 cases per million dental procedures; among patients with a  systolic murmur, the incidence is 78 cases per million dental procedures (16).

Atrial fibrillation, stroke, and sudden cardiac death According to a recent study (5), the incidence of atrial fibrillation and  cerebrovascular accidents in patients with mitral valve prolapse is no higher  than in the general population. However, the issue of sudden cardiac death in  patients with mitral valve prolapse is controversial. In a forensic series (17),  patients with mitral valve prolapse accounted for about 1% of those who died  suddenly of cardiac arrest, which is below the expected prevalence of sudden  cardiac death in the general population. However, patients with mitral valve  prolapse who have electrocardiographic changes such as QT interval prolongation  and ST-T wave changes, unexplained syncope, or arrhythmias or who have been  resuscitated from cardiac arrest should undergo ambulatory electrocardiographic  monitoring and invasive electrophysiologic evaluation if necessary.

Management

The majority of patients with mitral valve prolapse have a benign course,  without serious complications. It is important to reassure patients and educate  them about the disorder. The age-adjusted survival in both men and women with  mitral valve prolapse is similar to that of the normal population, but in  general, complications are higher in men than in women. Most patients are  concerned by the fact that they have a cardiac "abnormality," so the usual  benign course should be emphasized.

Although mitral regurgitation is the most significant complication of mitral  valve prolapse, the majority of patients have mild or no mitral regurgitation.  The American College of Cardiology and American Heart Association do not  recommend routine follow-up echocardiography in patients with mitral valve  prolapse and no mitral regurgitation (18). Asymptomatic individuals with mitral  valve prolapse and no mitral regurgitation need a clinical examination every 2  to 3 years. If there is a change in physical findings, such as the development  of a new murmur, a change in murmur, or symptoms, then echocardiography with  Doppler ultrasonography should be performed for the assessment of hemodynamic  severity of mitral regurgitation, leaflet morphology, and left ventricular  function. In addition, patients who have carried the diagnosis for several years  without proper validation should be reassessed according to current  echocardiographic criteria.

To prevent the development of severe mitral regurgitation in patients with  mitral valve prolapse, the two potentially reversible risk factors--hypertension  and higher body mass index--should be favorably modified. Patients with moderate  to severe mitral regurgitation should undergo echocardiography with Doppler  every year to assess the progression of mitral regurgitation. If symptoms  develop because of severe mitral regurgitation and decreased cardiac reserve,  they should be treated accordingly and referred for surgical repair or  replacement of the mitral valve. Acute mitral regurgitation, which can occur  because of the rupture of chordae tendineae, requires emergent mitral valve  surgery. Patients who have survived sudden cardiac death or who have a dilated  left ventricle, decreased left ventricular systolic function, uncontrolled  tachyarrhythmias, a long QT interval, unexplained syncope, or aortic root  enlargement--when present individually or in combination--should be restricted  from participating in competitive sports.

Chest pain and dyspnea on exertion have never been conclusively linked to  uncomplicated mitral valve prolapse. Chest pain should be clinically evaluated  and stress echocardiography or cardiac nuclear imaging conducted to exclude the  possibility of associated coronary artery disease. Patients with palpitations  should be reassured that uncomplicated mitral valve prolapse has a benign course  and should be advised to stop use of stimulants such as caffeine, alcohol,  nicotine, and certain drugs. If symptoms still persist, beta-blockers may be of  benefit.

Infective endocarditis prophylaxis for procedures that can cause bacteremia  should be given to patients with systolic click and murmur or systolic click and  echocardiographic evidence of mitral valve prolapse with mitral regurgitation.  Patients with systolic click and no or equivocal evidence of prolapse or  regurgitation by echocardiography do not require endocarditis prophylaxis (19).

Antiplatelet therapy with aspirin is recommended for patients with symptoms  of transient ischemic attacks. Oral anticoagulants are necessary for poststroke  patients, who should also refrain from smoking and avoid use of oral  contraceptives. Patients with mitral valve prolapse without any evidence of  transient ischemic attacks or strokes do not need routine antiplatelet therapy  or anticoagulation (19).

Summary

Although mitral valve prolapse is common in developed countries, its  prevalence and its complications are much lower among the general population  than was previously thought. No association has been conclusively documented for  a myriad of neuropsychiatric symptoms previously speculated to be associated  with mitral valve prolapse. Moreover, the prevalence of mitral valve prolapse  does not appear to be affected by male or female sex. The most important  management issues are mitral regurgitation and antibiotic prophylaxis for  procedures that can cause bacteremia. For patients who are asymptomatic,  reassurance becomes a critical component of treatment. If symptoms develop  because of severe mitral regurgitation and decreased cardiac reserve, surgery  may be required.

Symposium Index

VALVULAR HEART DISEASE: Introduction to a four-article symposium by    Mandeep R. Mehra, MD TIMELY    INTERVENTION IN ASYMPTOMATIC AORTIC STENOSIS: Emerging clinical    parameters may help predict outcomes by Myung H. Park, MD MYSTERIES OF MITRAL VALVE PROLAPSE: Proper treatment requires    consideration of all clues by Mahesh S. Mulumudi, MD, Krishnamoorthy    Vivekananthan, MD NATIVE    MITRAL VALVE REGURGITATION: Proactive management can improve outlook    by Robert L. Scott, MD, PhD    VALVULAR HEART DISEASE AND PREGNANCY: A high index of suspicion is    important to reduce risks by Ananth K. Prasad, MD, Hector O. Ventura, MD

AHA Scientific Statement:

Improving Survival From Sudden Cardiac    Arrest: The "Chain of Survival" Concept Guidelines for Cardiopulmonary Resuscitation    (CPR) and Emergency Cardiac Care (ECC) Low-Energy Biphasic Waveform Defibrillation:    Evidence-Based Review Applied to Emergency Cardiovascular Care Guidelines ILCOR Advisory Statements:

Utstein-style Guidelines for Uniform Reporting of    Laboratory CPR Research Recommended Guidelines for Uniform Reporting of    Pediatric Advanced Life Support: The Pediatric Utstein Style Recommended Guidelines for Reviewing, Reporting,    and Conducting Research on In-Hospital Resuscitation: The In-Hospital 'Utstein    Style' In-Hospital Resuscitation A Reappraisal of Mouth-to-Mouth Ventilation    During Bystander-Initiated Cardiopulmonary Resuscitation

Advisory Statements of the International      Liaison Committee on Resuscitation Single-Rescuer Adult Basic Life Support The Universal Advanced Life Support Algorithm Early Defibrillation Pediatric Resuscitation Special Resuscitation Situations

Angina Pectoris Blood Tests for Rapid Detection of Heart Attack    Cardiopulmonary Resuscitation (CPR)    Cough CPR (c-CPR) Emergencies Heart Attack Heart Attack and Angina Statistics Heart Attack Treatments Heart Damage Detection Stroke Symptoms/Warning Signs Ambulatory Electrocardiography    Angina Pectoris Treatments Heart Attack Heart Attack and Angina Statistics Heart Attack Symptoms / Warning Signs Heart Attack Treatments Heart Damage Detection Tests To Diagnose Heart Disease

Arrhythmias Cardiopulmonary Resuscitation (CPR)      Cough CPR (c-CPR) Defibrillation Heart Attack Heart Attack Symptoms / Warning Signs      Operation Heartbeat      Operation Stroke Stroke Stroke Symptoms / Warning Signs