What is the medical management for mitral stenosis?

Medical Management for Mitral Stenosis

The medical management of mitral stenosis primarily involves diuretics for symptom relief when edema or congestion is present, heart rate control with beta-blockers or calcium channel blockers in atrial fibrillation, and anticoagulation with vitamin K antagonists for patients with atrial fibrillation or at high risk of thromboembolism. 1

Symptom Management

• Diuretics are recommended for symptom relief when edema or congestion is present 1
• Heart rate control is effective for symptom relief in two scenarios:
  • In atrial fibrillation: beta-blockers or calcium channel blockers 1
  • In sinus rhythm: ivabradine may be considered 1, 2
• Digoxin may be used for heart rate control specifically in patients with atrial fibrillation (recommended in ESC guidelines) 1

Anticoagulation Therapy

• For patients with atrial fibrillation and mitral stenosis, anticoagulation with oral warfarin is strongly recommended 3
• Target INR should be maintained between 2.0-3.0 for patients with mitral stenosis 3
• Anticoagulation is also indicated in patients who remain in sinus rhythm but have:
  • History of systemic embolism 1
  • Dense spontaneous contrast in the left atrium on echocardiography 1
  • Enlarged left atrium (M-mode diameter >60 mL/m²) 1
• Direct oral anticoagulants (DOACs) are not recommended for patients with mitral stenosis and should not replace vitamin K antagonists 3

Monitoring and Follow-up

• The frequency of follow-up for asymptomatic severe mitral stenosis (MVA ≤1.0 cm²) varies among guidelines:
  • ACC/AHA and Japanese guidelines recommend follow-up every 3-5 years 1
  • ESC guidelines suggest follow-up every 2-3 years 1
  • Australian guidelines recommend annual follow-up 1
• Regular echocardiographic assessment is essential to monitor disease progression 1

Special Considerations

• For patients with mitral stenosis in sinus rhythm experiencing exertional symptoms, ivabradine may provide better symptom control and exercise capacity compared to metoprolol 2
• In patients with reactive airway disease where beta-blockers are contraindicated, ivabradine should be strongly considered 2
• For patients with degenerative mitral stenosis (as opposed to rheumatic), medical management with heart rate control and diuretic therapy remains the mainstay of treatment 4

When to Consider Intervention

• Percutaneous mitral balloon commissurotomy (PMBC) is the first-line intervention for symptomatic severe rheumatic mitral stenosis with favorable valve morphology 1
• Indications for intervention in asymptomatic patients include:
  • Elevated pulmonary artery systolic pressure >50 mmHg 1
  • New-onset atrial fibrillation 1
  • High risk of thromboembolism (history of embolism, dense spontaneous contrast) 1
  • Need for major non-cardiac surgery or desire for pregnancy 1

Common Pitfalls and Caveats

• Medical therapy alone is palliative and does not prevent disease progression; regular monitoring for development of indications for intervention is essential 1
• Anticoagulation management requires careful INR monitoring as both under and over-anticoagulation carry significant risks 3
• Beta-blockers may improve symptoms but could potentially worsen hemodynamics in some patients with severe mitral stenosis by prolonging diastolic filling time 2
• Patients with mitral stenosis and atrial fibrillation should be kept on vitamin K antagonists and not receive NOACs 1