Cardiology Series: Case 6


A. A 72-year old gentleman is visibly short of breath at rest. He says he is unable to sleep well at night as he coughs and wakes up short of breath.

B. On physical examination, you note a displaced apex beat and heaves over his precordium. When auscultating, you can make out a soft first heart sound (S1), followed by a high-pitched and mid-frequency murmur, hear at the apex and radiating to the axilla.

1. What is the symptom mentioned in A called ?

2. What is the murmur described in B called ?

3. What is the most likely diagnosis in this patient ?

4. List the common causes of this condition.

5. How would you investigate this patient ?

6. How would you manage this patient ?



1. Paroxysmal Nocturnal Dyspnoea (PND)

2. Pansystolic Murmur or Holosystolic murmur

3. Mitral regurgitation or Mitral Insufficiency



5. Investigations

  • Routine blood investigations: FBC, Renal function, Lipid profile ecc.
  • ECG showing evidence of left atrial enlargement (P mitrale) and left ventricular hypertrophy as well as signs of Atrial Fibrillation in long standing mitral regurgitation
    P-mirale is seen as broad and notched P waves seen in several leads.
  • Chest X-ray showing left atrial enlargement and cardiomegaly
  • Echocardiogram (TTE– to assess blood flow from left ventricle to left atrium during ventricular systole and TEE-to determine the severity of mitral regurgitation in some patients)

6. Management

The treatment of mitral insufficiency depends on the acuteness of the disease and whether there are associated signs of hemodynamic compromise.


Notes on Treatment

-Mitral valve replacement is preferred over mitral valve repair (1st choice if rupture of papillary muscle or chordae tendineae)
– Vasodilators e.g. nitroprusside (if Acute Mitral Regurgitation and normotensive)
-Diuretics e.g. ACE inhibitors in chronic mitral regurgitation









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