How should I manage a 60‑year‑old woman with no prior cardiac disease who presents for cardiovascular evaluation after a murmur, with echocardiogram showing mild left‑ventricular hypertrophy, preserved left‑ventricular ejection fraction (55‑60 %), and mild‑to‑moderate mitral and tricuspid regurgitation?

Management of Mild-Moderate Mitral and Tricuspid Regurgitation with Preserved LV Function

This 60-year-old woman with mild LVH, preserved ejection fraction (55-60%), and mild-to-moderate mitral and tricuspid regurgitation requires clinical correlation with a meticulous history and physical examination to determine if the echocardiographic findings match the clinical severity, followed by periodic surveillance echocardiography and cardiovascular risk factor optimization. 1

Immediate Clinical Assessment

Perform a detailed cardiovascular examination to establish concordance between clinical findings and echocardiographic severity:

• Assess for symptoms including dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, fatigue, palpitations, or lower extremity edema that would suggest hemodynamically significant valve disease 1
• Evaluate the apical impulse for displacement or hyperdynamic quality, which would suggest more severe chronic mitral regurgitation than reported 1
• Auscultate carefully for holosystolic murmur intensity, presence of S3 gallop (indicating volume overload), and abnormal S2 splitting 1, 2
• Examine jugular venous pressure and assess for hepatojugular reflux to evaluate right heart hemodynamics related to tricuspid regurgitation 2, 3

Critical pitfall: Echocardiographic reports can underestimate or overestimate regurgitation severity—eccentric jets may appear mild despite severe regurgitation, while central jets may overestimate severity if chamber sizes remain normal 1. If clinical examination suggests more severe disease than the echo report indicates, additional investigation is warranted 1.

Verify Echocardiographic Findings

Ensure the echocardiogram assessed all parameters of regurgitation severity:

• For mitral regurgitation: Confirm the report includes effective regurgitant orifice area, regurgitant volume, left atrial size, and left ventricular dimensions—not just jet area 1
• For tricuspid regurgitation: Verify assessment of right atrial and right ventricular size, estimated pulmonary artery systolic pressure, and inferior vena cava size/collapsibility 2, 4
• Check for concordance: If left atrial and left ventricular sizes are normal in an asymptomatic patient, severe chronic mitral regurgitation cannot be present 1

If discrepancies exist between clinical findings and echocardiographic severity, or if the echo report lacks quantitative parameters, repeat echocardiography or consider transesophageal echocardiography for better characterization 1.

Establish Underlying Etiology

Determine the mechanism of regurgitation to guide management:

• Evaluate for hypertension as the likely cause of mild LVH and potential contributor to functional mitral regurgitation 1
• Screen for atrial fibrillation with ECG, as AF is strongly associated with functional mitral and tricuspid regurgitation even with preserved LVEF, and the combination predicts poor outcomes 4
• Assess for coronary artery disease if there are risk factors or symptoms of angina, as ischemic mitral regurgitation requires different management 1
• Rule out primary valve pathology such as mitral valve prolapse, rheumatic disease, or degenerative changes 1

Surveillance Strategy

For asymptomatic patients with mild-to-moderate regurgitation and preserved LV function:

• Repeat echocardiography in 1 year to assess for progression of valve disease, changes in chamber dimensions, or decline in LV function 1
• Annual clinical follow-up with focused cardiovascular examination to detect new symptoms or physical findings 1
• If symptoms develop or if there is progression to severe regurgitation, left atrial enlargement, or LV dysfunction on follow-up echo, reassess for potential valve intervention 1

Medical Management

Optimize cardiovascular risk factors and treat underlying conditions:

• Control hypertension aggressively to reduce afterload and prevent progression of LVH and functional mitral regurgitation—target blood pressure <130/80 mmHg 1
• Screen for and treat atrial fibrillation if present, as AF with both mitral and tricuspid regurgitation carries a 79% event rate (cardiac death, heart failure admission, or valve surgery) at 24 months 4
• No specific medical therapy (such as vasodilators) is indicated for asymptomatic mild-to-moderate mitral or tricuspid regurgitation with preserved LV function 1
• Avoid volume depletion with aggressive diuresis unless symptomatic, as this may worsen functional capacity without improving valve function 1

Patient Education and Activity

Counsel the patient on symptom recognition and activity:

• Educate on warning symptoms including new or worsening dyspnea, orthopnea, edema, palpitations, or decreased exercise tolerance that should prompt urgent re-evaluation 1
• No activity restrictions are necessary for mild-to-moderate regurgitation with preserved LV function and no symptoms 1
• Endocarditis prophylaxis is NOT recommended for native valve regurgitation unless there is a history of prior endocarditis, prosthetic valve, or certain congenital heart diseases 1

When to Escalate Care

Refer to cardiology or consider intervention if:

• Symptoms develop despite optimal medical management 1
• Progression to severe regurgitation on surveillance echocardiography 1
• Left ventricular dysfunction develops (LVEF <60% or LV end-systolic dimension >40 mm) 1
• Significant left atrial enlargement or new atrial fibrillation develops 4
• Pulmonary hypertension emerges (PA systolic pressure >50 mmHg at rest) 1