What is the medical management for moderate mitral (mitral valve) regurgitation?

From the Guidelines

Medical management for moderate mitral regurgitation should focus on symptom control, preventing disease progression, and monitoring for worsening that may require surgical intervention, with a multidisciplinary approach and consideration of transcatheter interventions for eligible patients. For asymptomatic patients with preserved left ventricular function, regular clinical and echocardiographic follow-up every 6-12 months is recommended without specific medication requirements, as suggested by 1. For symptomatic patients, diuretics like furosemide (20-80 mg daily) or hydrochlorothiazide (12.5-25 mg daily) help manage fluid overload and reduce pulmonary congestion. Afterload reduction with ACE inhibitors such as enalapril (2.5-20 mg twice daily) or lisinopril (10-40 mg daily) can decrease regurgitant volume by reducing the pressure gradient across the mitral valve.

• Key considerations in management include:
  • Symptom control and prevention of disease progression
  • Monitoring for worsening that may require surgical intervention
  • Multidisciplinary approach to care
  • Consideration of transcatheter interventions for eligible patients, as discussed in 1
• Medications used in management may include:
  • Diuretics (e.g. furosemide, hydrochlorothiazide)
  • ACE inhibitors (e.g. enalapril, lisinopril)
  • Beta-blockers (e.g. metoprolol, carvedilol)
  • Aldosterone antagonists (e.g. spironolactone)
  • Blood pressure control is essential, with a target below 130/80 mmHg, and patients should also receive endocarditis prophylaxis for dental procedures if they have risk factors such as previous endocarditis or prosthetic valves, as supported by the most recent and highest quality study 1.

From the Research

Medical Management for Moderate Mitral Regurgitation

• The medical management of moderate mitral regurgitation involves the use of angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) to reduce the severity of mitral regurgitation and improve clinical outcomes 2, 3.
• A study published in 1997 found that treatment with lisinopril, an ACE-I, reduced the severity of chronic moderate mitral regurgitation in asymptomatic patients with normal left ventricular function 2.
• Another study published in 2023 found that the use of ACE-I/ARB in patients with moderate-to-severe mitral regurgitation and preserved to mildly reduced left-ventricular ejection fraction was associated with improved clinical outcomes, including a lower risk of death and heart failure-related readmission 3.
• The management of mitral regurgitation also involves careful assessment of the severity of the condition and identification of the underlying cause, which can dictate the management strategy and influence subsequent outcome 4.

Surgical Management

• The surgical management of moderate ischemic mitral regurgitation is debated, with some studies suggesting that coronary artery bypass grafting (CABG) alone is beneficial, while others recommend the addition of mitral valve repair 5, 6.
• A study published in 2014 found that the addition of mitral-valve repair to CABG did not result in a higher degree of left ventricular reverse remodeling, but was associated with a reduced prevalence of moderate or severe mitral regurgitation and an increased number of untoward events 6.
• Another study published in 2014 suggested that the standard surgical treatment of chronic ischemic mitral regurgitation is CABG associated with undersized annuloplasty using a complete ring, but noted that the recurrence of mitral regurgitation remains high due to continuous left ventricle remodeling 5.