Management of Mitral Valve Prolapse with Chest Pain
Reassurance is the cornerstone of management for patients with MVP and chest pain, as the vast majority have a benign prognosis with normal left ventricular hemodynamics and no structural explanation for their symptoms. 1
Initial Assessment and Risk Stratification
The first step is to confirm the diagnosis of MVP with two-dimensional and Doppler echocardiography, looking specifically for:
- Valve prolapse ≥2 mm above the mitral annulus in the long-axis parasternal view 1
- Leaflet thickness (≥5 mm indicates high-risk features) 1
- Presence and severity of mitral regurgitation (MR) 1
- Left ventricular dimensions and function 2
ECG findings are often normal, though nonspecific ST-T wave changes, T-wave inversions, prominent Q waves, or QT prolongation may occur. 1 These findings do not necessarily indicate ischemia in MVP patients.
Management Algorithm for Chest Pain
For Patients WITHOUT Significant MR or High-Risk Features:
Provide strong reassurance about the benign prognosis and explain that chest pain in MVP does not indicate coronary disease or structural heart damage. 1 Studies demonstrate that symptomatic MVP patients without significant MR have normal left ventricular hemodynamics, and symptoms cannot be explained by hemodynamic abnormalities alone. 3
Beta-blockers (such as propranolol) are the first-line pharmacologic therapy for symptomatic patients with chest pain, though evidence for efficacy is limited. 4, 5 If chest pain persists despite beta-blockade, consider panic disorder as a co-existing condition, as it frequently co-occurs with MVP and shares similar symptomatology including atypical chest pain. 5
Encourage a normal lifestyle and regular exercise rather than activity restriction. 1
For Patients WITH Significant MR:
The management shifts from symptom control to addressing the structural valve disease:
- Symptomatic patients with severe MR require cardiac catheterization and evaluation for mitral valve surgery, regardless of left ventricular function. 1
- Asymptomatic patients with severe MR should undergo surgery if left ventricular ejection fraction <60%, left ventricular end-systolic dimension ≥40 mm, new onset atrial fibrillation, or pulmonary hypertension develops. 1, 2
- Mitral valve repair is strongly preferred over replacement when technically feasible, with operative mortality under 2% at experienced centers. 1
Surveillance Strategy
Asymptomatic patients with mild or no MR should be evaluated clinically every 3-5 years. 1, 2 Serial echocardiography is not necessary unless high-risk characteristics are present (leaflet thickness ≥5 mm, redundancy, left atrial enlargement, or LV dilatation). 1
Patients with moderate MR require clinical follow-up every 6-12 months with echocardiography every 1-2 years. 2
Patients with severe MR need clinical evaluation every 6 months with annual echocardiography if asymptomatic. 2
Additional Considerations
Antibiotic prophylaxis for endocarditis was recommended in the 2006/2008 guidelines for MVP patients with MR or high-risk features (leaflet thickening, elongated chordae, left atrial enlargement, or LV dilatation). 1 However, note that these are older guidelines and current endocarditis prophylaxis recommendations have changed significantly.
Continuous ambulatory ECG monitoring or event monitors may be useful for documenting arrhythmias in patients with palpitations, but are not indicated routinely in asymptomatic patients. 1 Most detected arrhythmias are not life-threatening. 1
Critical Pitfalls to Avoid
Do not attribute chest pain to coronary ischemia without proper evaluation, as coronary arteries are typically normal in MVP patients with chest pain. 6, 3 However, if the patient has risk factors for coronary disease or typical anginal symptoms, appropriate coronary evaluation is warranted.
Do not delay surgical referral in symptomatic patients with severe MR waiting for left ventricular dysfunction to develop, as earlier intervention leads to improved survival and functional outcomes. 2
Do not overlook panic disorder in patients with persistent atypical chest pain despite beta-blockade, as this frequently co-occurs with MVP and may be the primary driver of symptoms. 5
Vasodilators including ACE inhibitors have no proven benefit in chronic MR without heart failure and should not be used for symptom management in MVP with chest pain. 2