What is the best treatment for palpitations due to mitral valve prolapse?

Management of Palpitations in Mitral Valve Prolapse

Beta blockers are the first-line treatment for palpitations due to mitral valve prolapse (MVP), with metoprolol being particularly effective for improving heart rate variability and reducing symptoms. 1, 2

Diagnosis and Assessment

Before initiating treatment, confirm the diagnosis of MVP with:

• Physical examination focusing on the characteristic midsystolic click, often followed by a late systolic murmur 3
• Two-dimensional and Doppler echocardiography showing:
  • Valve prolapse ≥2 mm above mitral annulus in long-axis parasternal view
  • Leaflet thickness ≥5 mm (if present)
  • Mitral regurgitation typically presenting as high-velocity eccentric jet in late systole 1

Treatment Algorithm for MVP-Related Palpitations

First-line Treatment

• Beta blockers (particularly metoprolol 25-100 mg/day) 1, 2
  • Effectively reduces palpitations by decreasing sympathetic tone
  • Significantly improves heart rate variability parameters
  • Metoprolol has been shown to normalize heart rate variability indices in symptomatic MVP patients 2

For Patients with Orthostatic Symptoms

• Volume expansion
• Support stockings
• Consider mineralocorticoid therapy or clonidine 1

For Patients with Atrial Fibrillation

• Warfarin therapy is recommended for patients with MVP and atrial fibrillation who are:
  • Older than 65 years
  • Have hypertension
  • Have mitral regurgitation murmur
  • Have history of heart failure 3

For Patients with Cerebral Ischemic Events

• Aspirin therapy (75-325 mg per day) is recommended for symptomatic patients with MVP who experience cerebral transient ischemic attacks 3, 1

Monitoring and Follow-up

• Asymptomatic patients with no/mild mitral regurgitation: clinical evaluation every 3-5 years 1
• Patients with high-risk features: annual follow-up with serial echocardiography 1
• High-risk features include:
  • Leaflet thickness ≥5 mm
  • Moderate to severe mitral regurgitation
  • Left ventricular dysfunction (EF ≤60%)
  • Left atrial enlargement
  • Flail leaflet 1

Important Considerations

• Propranolol, while effective in some patients, shows variable response rates:

  • 37% of patients experience symptomatic improvement
  • 44% remain unchanged
  • 19% may experience symptomatic deterioration 4
  • Premature ventricular contractions can be reduced by at least 75% in approximately 56% of patients 4

• Reassurance is a major component of management for MVP patients with mild symptoms, as most have a benign prognosis 3, 1

• Regular exercise and normal lifestyle should be encouraged in most patients with MVP 3

• For severe cases with progressive mitral regurgitation, surgical intervention (repair preferred over replacement) may be necessary 1, 5

Potential Pitfalls

• Overdiagnosis of rheumatic heart disease based solely on elevated ASO titers without other supporting evidence 1
• Unnecessary anticoagulation in MVP patients without appropriate indications 1
• Failure to recognize that fatigue may appear or worsen during beta-blocker therapy in some patients 4
• Continuous ambulatory ECG recordings or event monitors may be useful for documenting arrhythmias in patients with palpitations but are not indicated as routine tests for asymptomatic patients 3