Last reviewed: June 2019
Last updated: March  2018



History and exam

Key diagnostic factors

  • presence of risk factors
  • dyspnoea on exertion
  • decreased exercise tolerance
  • lower extremity oedema
  • holosystolic murmur

Other diagnostic factors

  • fatigue
  • displaced point of maximal impulse
  • orthopnoea
  • paroxysmal nocturnal dyspnoea
  • palpitations
  • diaphoresis
  • pulmonary closure is louder than aortic closure
  • S3 heart sound
  • diminished S1 heart sound

Risk factors

  • mitral valve prolapse
  • hx of rheumatic heart disease
  • infective endocarditis
  • hx of cardiac trauma
  • hx of MI
  • hx of congenital heart disease
  • hx of ischaemic heart disease
  • left ventricular systolic dysfunction
  • hypertrophic cardiomyopathy
  • anorectic/dopaminergic drugs

Diagnostic investigations

1st investigations to order

  • transthoracic echo
  • ECG
Full details

Investigations to consider

  • flow convergence method or proximal isovelocity surface area
  • colour Doppler flow
  • transoesophageal echocardiogram
  • left heart catheterisation
  • cardiac MRI
Full details

Treatment algorithm


Authors VIEW ALL

Consultant Cardiothoracic Surgeon

National Heart and Lung Institute

Imperial College Faculty of Medicine

Imperial College Healthcare NHS Trust - Hammersmith Hospital




PPP is an author of references cited in this monograph. PPP declares that he has no competing interests.

Dr Prakash P. Punjabi would like to gratefully acknowledge Dr Samir Kapadia and Dr Mehdi H. Shishehbor, previous contributors to this monograph. SK and MHS declare that they have no competing interests.

Peer reviewers VIEW ALL


Cardiovascular Imaging Center

Department of Cardiology

Cleveland Clinic Foundation




LR declares that he has no competing interests.

Associate Professor of Medicine

Department of Medicine

Baylor College of Medicine




RF declares that she has no competing interests.

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