What is the management of Mitral Valve Prolapse (MVP) with audible clicks or opening snaps on auscultation?

Management of Mitral Valve Prolapse with Audible Clicks

When you hear a midsystolic click on auscultation, perform echocardiography to confirm MVP, assess mitral regurgitation severity, evaluate leaflet morphology (particularly thickness ≥5mm), and determine ventricular compensation—this is a Class I indication. 1

Initial Diagnostic Approach

Physical Examination Findings

The midsystolic click is the hallmark auscultatory finding of MVP, representing sudden tensing of the mitral valve apparatus as leaflets prolapse into the left atrium during systole. 1

Perform dynamic auscultation to confirm the diagnosis:

• Standing (decreases LV end-diastolic volume): The click moves earlier in systole, closer to S1 1
• Squatting (increases LV volume): The click moves later in systole, closer to S2 1

The click may be followed by a late systolic murmur (medium-to-high pitched, loudest at apex, occasionally musical or honking quality). 1

Echocardiography Indications

Class I (Must Perform):

• Diagnosis and assessment of hemodynamic severity, leaflet morphology, and ventricular compensation in patients with physical signs of MVP (clicks or murmurs) 1

Class IIa (Reasonable to Perform):

• Risk stratification in patients with physical signs of MVP or known MVP 1

Class III (Do Not Perform):

• Screening asymptomatic patients with ill-defined symptoms and no physical findings or family history 1
• Routine repeat echocardiography in asymptomatic patients with no MR or mild MR without clinical changes 1

Risk Stratification

High-risk echocardiographic features that predict complications:

• Leaflet thickness ≥5mm (predicts endocarditis, need for mitral valve surgery, complex ventricular arrhythmias) 1
• Moderate-to-severe mitral regurgitation (strongest predictor of cardiovascular mortality and need for surgery) 1
• Left ventricular internal diameter ≥60mm (predicts need for mitral valve replacement) 1
• Leaflet redundancy with enlarged mitral annulus and elongated chordae 1

Management Strategy

Reassurance and Lifestyle

Reassure patients with mild or no symptoms and milder forms of prolapse about the benign prognosis. Encourage normal lifestyle and regular exercise. 1

The overall complication rate is approximately 2% per year, with cumulative risk by age 75 of 5-10% for men and 2-5% for women. 2, 3

Antiplatelet/Anticoagulation Therapy

Class I Recommendations:

• Aspirin 75-325mg daily for symptomatic patients with MVP who experience cerebral transient ischemic attacks 1
• Warfarin for MVP with atrial fibrillation if age >65 OR hypertension OR MR murmur OR heart failure history 1
• Aspirin 75-325mg daily for MVP with atrial fibrillation if age <65 AND no MR, hypertension, or heart failure 1

Class IIa Recommendations:

• Warfarin for MVP patients with stroke history who have leaflet thickening ≥5mm and/or redundancy (without MR, atrial fibrillation, or left atrial thrombus) 1
• Aspirin for MVP with stroke history in patients without MR, atrial fibrillation, left atrial thrombus, or high-risk leaflet features 1

Class IIb Recommendation:

• Aspirin 75-325mg daily may be considered for patients in sinus rhythm with echocardiographic evidence of high-risk MVP 1

Arrhythmia Evaluation

ECG is often normal but may show nonspecific ST-T changes, T-wave inversions, prominent Q waves, or QT prolongation. 1

Ambulatory ECG monitoring or event monitors are useful for documenting arrhythmias in patients with palpitations, but are NOT indicated routinely in asymptomatic patients. 1

Most detected arrhythmias are not life-threatening, and patients often report palpitations when monitoring shows no abnormality. 1

Common Pitfalls to Avoid

• Do not rely solely on apical 4-chamber echocardiographic views—there is disagreement about reliability of anterior leaflet billowing in this view alone; use parasternal long-axis views showing ≥2mm prolapse above the mitral annulus 1

• Do not overdiagnose MVP—physical examination remains the optimal screening method; echocardiography without supportive clinical findings leads to false-positive diagnoses 1

• Do not attribute all symptoms to MVP—controlled studies show true MVP syndrome consists of low body weight/blood pressure, minor skeletal abnormalities, orthostatic hypotension, and palpitations, but NOT atypical chest pain, dyspnea, or anxiety/panic attacks in isolation 2, 3

Follow-Up Strategy

Frequency and intensity of follow-up should be governed by:

• Presence and severity of mitral regurgitation 2
• Male gender and age >45 years (independent risk factors for complications) 3
• Presence of high-risk echocardiographic features 1

Patients with neither a murmur nor Doppler evidence of mitral regurgitation may be reassured their condition is benign and require minimal follow-up. 2