What medications are recommended for an adult patient with mitral valve prolapse (MVP) experiencing chest pain?

Management of Chest Pain in Mitral Valve Prolapse

Beta-blockers are the first-line pharmacologic treatment for chest pain in patients with MVP, though reassurance and lifestyle modification (eliminating caffeine, alcohol, and cigarettes) should be attempted first. 1, 2

Initial Approach: Reassurance and Non-Pharmacologic Management

Reassurance is the cornerstone of management for MVP-related chest pain. The chest pain in MVP is atypical, rarely resembles classic angina, and occurs in patients with normal left ventricular hemodynamics and no structural explanation for symptoms. 1, 2

• Strongly reassure patients that their chest pain does not indicate coronary disease or structural heart damage and that MVP has a benign prognosis. 2, 3
• Encourage normal lifestyle and regular exercise rather than activity restriction. 1, 2

Lifestyle Modifications Before Medications

Eliminate stimulants first—this alone may be sufficient to control symptoms: 1

• Stop all caffeine intake (coffee, energy drinks, caffeine-containing medications). 1, 4
• Discontinue alcohol consumption. 1
• Cease cigarette smoking. 1

Heavy coffee drinking is a significant predictor of palpitations and chest pain in MVP patients, particularly in men. 1 In many cases, cessation of these stimulants alone controls symptoms without need for medication. 1

Pharmacologic Treatment: Beta-Blockers

If lifestyle modifications fail, beta-blockers are the recommended medication for chest pain in MVP. 1, 2

• Beta-blockers are indicated for patients with MVP who have chest pain, palpitations associated with mild tachyarrhythmias, increased adrenergic symptoms, anxiety, or fatigue. 1
• Propranolol and metoprolol are the most studied agents. 5, 6

Evidence Quality and Caveats

The evidence supporting beta-blocker efficacy is limited and mixed. 2, 7 A 1977 study found that only 37% of MVP patients noted overall symptomatic improvement with propranolol, primarily due to reduction in palpitations, while chest pain improved in only 2 of 8 patients (25%). 6 A 2007 study showed no significant correlation between beta-blocker use and symptom frequency/intensity. 7 However, metoprolol does improve heart rate variability parameters in symptomatic MVP patients, suggesting a physiologic benefit. 5

Despite limited evidence, beta-blockers remain the guideline-recommended pharmacologic option because no other medication class has demonstrated superior efficacy. 1, 2

Important Pitfall

Three patients (19%) in one study experienced symptomatic deterioration with propranolol, particularly increased fatigue. 6 Therefore, continue beta-blockers only in patients who demonstrate clinical response; discontinue if symptoms worsen or fail to improve after an adequate trial. 6

When to Suspect Alternative Causes

Chest pain in MVP does not indicate ischemia in the vast majority of cases. 1, 2 However, if chest pain is typical for angina or if the patient has cardiac risk factors, evaluate for coronary artery disease independently of the MVP diagnosis. 8

• ECG findings in MVP (ST-T wave changes, T-wave inversions, prominent Q waves, QT prolongation) do not necessarily indicate ischemia. 1
• Exercise testing often fails to show impairment in exercise tolerance despite patient complaints of dyspnea and fatigue. 1

Role of Anxiety and Psychiatric Comorbidity

Many MVP patients have significant psychiatric comorbidity that contributes to chest pain: 1

• 45% of patients with panic disorder have MVP. 1
• Significant predictors for symptoms include depression, poor self-rated health, and anxiety. 1
• Addressing underlying anxiety disorders is essential for symptom management. 4

When Medications Fail: Surgical Consideration

Mitral valve surgery for chest pain alone is extremely rare and should only be considered in exceptional circumstances. 8 One case report described successful resolution of disabling chest pain after mitral valve replacement in a patient who failed 30 months of medical therapy with beta-blockers, calcium channel blockers, and nitrates. 8 However, this is not a standard indication for surgery and should not be pursued unless chest pain is truly refractory and severely disabling. 8

Medications NOT Recommended for Chest Pain in MVP

Calcium channel blockers and anxiolytics are widely used despite lack of evidence supporting their efficacy. 7 A 2007 study found only very weak correlations between calcium channel blocker use and symptom improvement. 7 These agents are not guideline-recommended for MVP-related chest pain. 1, 2