A 28-year-old woman presents to the cardiology clinic with a 6-month history of exertional dyspnea and palpitations. On examination, a high-pitched, blowing, holosystolic murmur is heard best at the apex and radiates to the axilla. The murmur increases with handgrip. Echocardiography confirms mitral regurgitation with a regurgitant volume of 45 mL per beat and left ventricular ejection fraction of 58%. What is the most appropriate next step in management?

Question

Accepted Answer

B. Initiate ACE inhibitor therapy and schedule follow-up echocardiography in 6–12 months. ## Clinical Context
This patient has chronic mitral regurgitation (MR) with preserved left ventricular function (LVEF 58%) and moderate regurgitant volume. The holosystolic murmur that increases with handgrip (increased afterload) is pathognomonic for MR.

## Management Strategy for Chronic MR

**Key Point:** In asymptomatic or mildly symptomatic chronic MR with preserved LV function (LVEF ≥60%), medical management with vasodilators (ACE inhibitors or ARBs) and serial echocardiographic surveillance is the standard approach.

**High-Yield:** Indications for surgical intervention in chronic MR include:
- Symptomatic patients (NYHA II–IV)
- Asymptomatic with LV dysfunction (LVEF <60% or LV end-systolic diameter >45 mm)
- Atrial fibrillation
- Pulmonary hypertension (RVSP >50 mmHg)

This patient is **mildly symptomatic** (exertional dyspnea) with **preserved LV function** — she does not yet meet surgical criteria.

## Rationale for Correct Answer

1. **ACE inhibitor initiation** reduces afterload, decreasing the regurgitant fraction and slowing LV remodeling
2. **Serial echocardiography** (every 6–12 months) monitors for progressive LV dilatation or systolic dysfunction, which would trigger surgical referral
3. This approach delays or prevents the need for surgery while maintaining symptom control

## Why Other Options Are Premature

Surgical intervention is not indicated at this stage because the LV is not yet dysfunctional. Cardiac catheterization is unnecessary without evidence of coronary disease. Aggressive diuretic therapy alone does not address the underlying pathophysiology.

[cite:Harrison 21e Ch 297]

Answer

A. Refer for immediate mitral valve repair

Answer

C. Perform cardiac catheterization to assess coronary anatomy

Answer

D. Start diuretics and arrange urgent surgical consultation

Explanation

Clinical Context

Management Strategy for Chronic MR

Rationale for Correct Answer

Why Other Options Are Premature

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