Handgrip Maneuver Effect on Mitral Regurgitation
Mitral valve prolapse regurgitation (MVP) responds differently to handgrip compared to other forms of mitral regurgitation—the murmur becomes longer and often louder, whereas other types of mitral regurgitation (rheumatic, functional, and ischemic) all increase in intensity similarly with handgrip. 1
Mechanism of Handgrip Effect
Handgrip is an isometric exercise that increases systemic vascular resistance (afterload), which has predictable effects on cardiac murmurs:
- Handgrip increases afterload, which augments the regurgitant fraction across incompetent valves 1, 2
- Most left-sided regurgitant murmurs increase in intensity with handgrip, including mitral regurgitation, aortic regurgitation, and ventricular septal defects 1, 2
- The increased afterload forces more blood backward through the regurgitant valve, making the murmur louder 3
Differential Response by MR Etiology
Rheumatic, Functional, and Ischemic MR (Options A, B, D)
- All three increase similarly with handgrip through the same mechanism of increased afterload 1, 3
- Functional MR shows a 42% average increase in regurgitant area during handgrip 3
- Ischemic MR demonstrates an even greater response with 59% increase in regurgitant area during handgrip 3
- Approximately 54% of patients with secondary MR show increased severity during handgrip exercise 4
- In secondary MR, handgrip can reclassify 28% of patients from non-severe to severe MR 4
Mitral Valve Prolapse (Option C) - THE DIFFERENT ONE
- MVP murmur becomes longer and often louder with handgrip, showing a qualitatively different response 1
- The increased afterload in MVP causes earlier and more pronounced prolapse of the leaflet into the left atrium during systole 1
- This makes the murmur start earlier in systole and extend longer, not just become louder 1
Clinical Utility of Handgrip Testing
Handgrip is particularly valuable for evaluating functional MR in the following contexts:
- During acute heart failure, when formal exercise testing is not feasible 5
- The response varies depending on heart failure status—MR may worsen dramatically during acute decompensation but show minimal change after stabilization 5
- In symptomatic patients with non-severe MR at rest, handgrip can unmask exercise-induced severe MR 6, 4
- Handgrip-induced increases in MR correlate with higher NYHA functional class 4
- Changes in pulmonary artery pressure during handgrip correlate with changes in effective regurgitant orifice area (r = 0.456 for degenerative MR, r = 0.326 for functional MR) 6
Key Clinical Pitfall
Do not confuse the timing and quality changes in MVP (longer, often louder murmur) with the simple intensity increase seen in other forms of MR 1. The MVP response reflects the unique pathophysiology of leaflet prolapse being exacerbated by increased afterload, causing earlier systolic prolapse and a longer duration murmur, whereas rheumatic, functional, and ischemic MR simply increase in intensity through increased regurgitant volume 1, 3.
Answer: C) Mitral valve prolapse regurgitation shows a different response pattern (becomes longer and often louder) compared to the other three options which all simply increase in intensity with handgrip 1.