Holosystolic murmur at apex → axilla, soft S1
Most accurate: Echocardiogram
Chronic primary MR (normotensive, preserved LV): Vasodilators NOT indicated (2020 ACC/AHA COR 3 No Benefit) — treat hypertension if present; vasodilators/HF GDMT are for secondary (functional) MR
Severe / symptomatic / ↓EF → Valve repair or replacement; transcatheter edge-to-edge repair (MitraClip) if prohibitive surgical risk (2a), or secondary MR despite GDMT (COAPT)
Acute (papillary muscle rupture post-MI) → emergency surgery + afterload reduction/IABP
Order set
- Echo (severity, EF)
- ECG
- CXR
Criteria
AdmitAcute severe MR / pulmonary oedema
ICUAcute papillary rupture — pre-op support
VasopressorsBridge with afterload reduction/IABP
DischargeStable, surveillance or surgical plan
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Acute severe (papillary rupture) with edema/shock
Differentials
- Aortic stenosis (radiation)
- VSD
- Tricuspid regurgitation
Common mistakes
- Missing acute MR post-MI
- Delaying surgery in severe symptomatic MR
Disposition & follow-up
Chronic primary MR → surveillance + treat hypertension; severe/symptomatic → surgery (TEER if prohibitive risk).
Discharge package
MedicationsNo routine vasodilators in primary MR (treat hypertension); HF GDMT for secondary MR
Follow-upCardiology + serial echo
Warning symptomsBreathlessness, palpitations, oedema
💊 Treatment detail — doses & preparation
EnalaprilACE inhibitor
DoseStart 2.5–5 mg BD, titrate to 10–20 mg BD
Preparation2.5/5/10/20 mg tablets
MonitorCreatinine + K⁺ at 1–2 wk; cough/angioedema
Furosemide POloop diuretic
Dose20–80 mg OD/BD, titrate to dry weight
Preparation20/40/500 mg tablets; take morning/midday
MonitorDaily weight, K⁺, renal function
Valve surgerydefinitive
DoseRepair preferred over replacement for severe symptomatic MR
PreparationPre-op echo + coronary angiography
MonitorPost-op warfarin (mechanical) or antiplatelet (tissue/repair)
📖 ESC/EACTS Valvular Heart DiseaseReviewed July 2026