Rheumatic fever hx (often immigrant): dyspnea, hemoptysis, AF; diastolic rumble + opening snap, loud S1 at apex
Diagnostic: Echocardiogram (valve area, calcification)
Rate control: Metoprolol (↑ diastolic filling time); diuretic for congestion; AF in rheumatic MS → anticoagulate with warfarin (INR 2–3) — DOACs contraindicated (INVICTUS)
Definitive: Balloon valvuloplasty (safe in pregnancy) → surgical repair/replacement if unsuitable
Order set
- Echo
- ECG (AF/LA enlargement)
- CXR
- Anticoagulate if AF — warfarin (INR 2–3); DOACs NOT indicated in rheumatic MS (INVICTUS)
Criteria
AdmitDecompensation, new AF, haemoptysis
DischargeRate-controlled, anticoagulated with warfarin if AF, valvuloplasty referral
Key
- Worsens with tachycardia/pregnancy (less diastolic filling time).
- AF with moderate–severe rheumatic MS → vitamin-K antagonist (warfarin, INR 2–3). DOACs are contraindicated in rheumatic MS (2020 ACC/AHA VHD Class 1; INVICTUS).
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Hemoptysis
- New AF with instability
- Pregnancy decompensation
Differentials
- Left atrial myxoma
- Cor triatriatum
- Pulmonary HTN other cause
Common mistakes
- Tachycardia worsening filling
- Missing rheumatic history
Disposition & follow-up
Balloon valvuloplasty referral; endocarditis awareness.
Discharge package
MedicationsRate control; anticoagulation if AF
Follow-upCardiology; valvuloplasty planning
Warning symptomsBreathlessness, haemoptysis, palpitations
💊 Treatment detail — doses & preparation
Metoprololβ-blocker
DoseIV 2.5–5 mg q5 min ×3; PO 25–100 mg BD (succinate OD for HF)
PreparationIV 1 mg/mL ampoule undiluted, slow push; PO immediate- vs extended-release not interchangeable mg-for-schedule
MonitorHR, BP; avoid in decompensated HF/asthma/high-grade block
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
Digoxincardiac glycoside
DoseLoad 500 mcg PO/IV ×2, 6 h apart, then 62.5–250 mcg OD (lower in elderly/CKD)
PreparationPO tablets/elixir; IV 250 mcg/mL dilute in 50 mL NS over ≥10 min
MonitorLevel 6 h post-dose (target 0.5–0.9), K⁺, Mg²⁺, renal function, toxicity signs
WarfarinVKA anticoagulant
DoseLoad 5 mg OD ×2 d then INR-guided; target INR 2–3 (valves may differ)
Preparation0.5/1/3/5 mg tablets — colour-coded
MonitorINR q2–3 d until stable; diet consistency, interactions (amiodarone, antibiotics)
📖 ESC/EACTS Valvular Heart DiseaseReviewed July 2026