From the Guidelines
Hypertension significantly exacerbates the symptoms and complications of mitral stenosis by increasing the workload on the heart and elevating pulmonary pressures. When considering the management of patients with mitral stenosis, especially those undergoing non-cardiac surgery, it's crucial to assess the severity of mitral stenosis and the presence of symptoms, as well as the systolic pulmonary artery pressure, as guided by the 2017 ESC/EACTS guidelines for the management of valvular heart disease 1.
Key Considerations
- In patients with non-significant mitral stenosis (valve area >1.5 cm2) and asymptomatic patients with significant mitral stenosis and a systolic pulmonary artery pressure <50 mmHg, non-cardiac surgery can be performed safely, according to the guidelines 1.
- However, for symptomatic patients or those with systolic pulmonary artery pressure >50 mmHg, correction of mitral stenosis, preferably through percutaneous mitral commissurotomy (PMC) if possible, should be considered before high-risk non-cardiac surgery 1.
Management Approach
- Controlling hypertension is vital to reduce the strain on the heart and minimize the risk of pulmonary congestion and edema.
- Medications such as ACE inhibitors, ARBs, or calcium channel blockers can be used to manage hypertension in these patients, aiming for a blood pressure target of less than 130/80 mmHg.
- Diuretics may also be beneficial in reducing pulmonary congestion, but careful consideration must be given to avoid dehydration and potential worsening of renal function.
- The ultimate goal in managing patients with both hypertension and mitral stenosis is to alleviate symptoms, prevent complications, and improve quality of life, which may involve addressing the valvular disease through interventions like balloon valvuloplasty or valve replacement in severe cases.
From the Research
Hypertension and Mitral Stenosis
- Hypertension can affect mitral stenosis by increasing the pressure gradient across the mitral valve, leading to worsening symptoms and disease progression 2.
- Pulmonary hypertension is a common complication of mitral stenosis, and can lead to increased morbidity and mortality 2, 3.
- The transpulmonary gradient (TPG) is an important factor in determining the severity of mitral stenosis and the presence of pulmonary hypertension 2.
Diagnosis and Treatment
- Exercise hemodynamics can be useful in differentiating between mitral stenosis and pulmonary hypertension, and in determining the severity of mitral stenosis 3.
- Percutaneous balloon mitral commissurotomy (PBMC) is a effective treatment for mitral stenosis, and can improve symptoms and reduce the pressure gradient across the mitral valve 4, 2.
- The use of beta-blockers and ACE inhibitors can be beneficial in patients with mitral stenosis and hypertension, as they can help to reduce blood pressure and improve cardiovascular outcomes 5, 6.
Patient Outcomes
- Patients with mitral stenosis and pulmonary hypertension tend to have worse symptoms and higher right-sided pressures than those without pulmonary hypertension 2.
- However, PBMC can still be effective in improving symptoms and reducing the pressure gradient across the mitral valve in these patients 2.
- The combination of beta-blockers and ACE inhibitors can provide effective blood pressure lowering and improved cardiovascular outcomes in patients with hypertension and mitral stenosis 6.