Can increased stress exacerbate or cause mitral regurgitation?

Can Increased Stress Cause Mitral Valve Regurgitation?

Increased stress does not cause new mitral regurgitation, but it can significantly worsen existing mitral regurgitation of any etiology through physiologic mechanisms including increased heart rate, blood pressure, and myocardial contractility. 1

Mechanism of Stress-Induced Worsening of Mitral Regurgitation

Physical stress (exertion) worsens mitral regurgitation through hemodynamic changes:

• Secondary mitral regurgitation from ischemic heart disease is particularly likely to worsen during exertion, though this phenomenon occurs with any mitral regurgitation etiology 1
• Physical stress can induce myocardial ischemia with associated dynamic ischemic mitral regurgitation, especially in patients presenting with unexplained acute pulmonary edema 1
• The dynamic nature of mitral regurgitation means physiological fluctuations occur in response to exercise and ischemia, which can precipitate symptoms and cardiac events 2

Psychological stress also affects mitral regurgitation, particularly in mitral valve prolapse:

• Mental stress prominently augments mitral valve prolapse in approximately 38% (3 of 8) of patients with this condition 3
• Acute psychological stress increases heart rate and blood pressure, which mechanically worsens the degree of prolapse 3
• Anxiety accentuates the click in mitral valve prolapse patients and can trigger arrhythmias in approximately 33% (5 of 15) of patients 4
• Post-traumatic stress disorder occurs in 23% of patients with moderate-to-severe organic mitral regurgitation versus 9% in controls, though PTSD itself does not determine objective mitral regurgitation severity 5

Clinical Implications for Assessment

Stress echocardiography is the gold standard for evaluating dynamic mitral regurgitation:

• Exercise valve stress echocardiography should be performed in symptomatic patients with nonsevere mitral regurgitation to assess for exertion-induced worsening 1
• An increase in mitral regurgitation severity by ≥1 grade during stress, systolic pulmonary artery pressure ≥60 mmHg on exertion, and lack of contractile reserve (<5% increase in ejection fraction) are markers of poor prognosis 1
• Patients with mitral regurgitation that decreases during stress have worse outcomes after percutaneous mitral valve repair, with all such patients remaining in NYHA class III-IV or dying within 6 months 6

Dobutamine stress should not be used to assess dynamic mitral regurgitation behavior because its effects are not physiologic, except when evaluating for inducible ischemia in patients unable to exercise 1

Management Considerations

Surgical decision-making incorporates stress testing findings:

• Mild mitral regurgitation is an indication for exercise valve stress echocardiography before coronary artery bypass grafting, as mitral annuloplasty at the time of CABG in patients with moderate ischemic mitral regurgitation at rest or developed on exertion improves functional capacity and left ventricular remodeling 1
• The European Society of Cardiology guidelines recommend mitral valve surgery at the time of CABG in patients with moderate mitral regurgitation, using valve stress echocardiography to assess symptoms and exertion-induced mitral regurgitation severity 1
• Combined surgery is a Class IIa indication for patients with moderate secondary mitral regurgitation, planned coronary artery bypass grafting, shortness of breath, and exercise pulmonary hypertension with dynamic worsening 1

Common Pitfalls to Avoid

• Do not assume stress "causes" new mitral regurgitation in structurally normal valves—stress only unmasks or worsens pre-existing valve disease 1, 2
• Do not dismiss psychological symptoms as purely psychiatric—post-traumatic stress disorder is prevalent (23%) in moderate-to-severe mitral regurgitation patients and is linked to symptoms like dyspnea that may be attributed solely to cardiac causes 5
• Do not use dobutamine stress echocardiography to evaluate dynamic mitral regurgitation behavior—exercise testing provides physiologic assessment of how mitral regurgitation responds to real-world stress 1
• Do not overlook the prognostic value of stress testing—patients with marked increases in regurgitant volume or systolic pulmonary artery pressure during exercise have lower symptom-free survival 2