A 52-year-old man with a history of rheumatic fever presents with dyspnea and orthopnea. Echocardiography reveals mitral stenosis with an area of 1.2 cm². He is in normal sinus rhythm. What is the drug of choice for symptomatic management?

Question

Accepted Answer

C. Atenolol. ## Mitral Stenosis: Pharmacological Management

**Key Point:** In mitral stenosis with normal sinus rhythm, beta-blockers are the first-line agents to control symptoms by reducing heart rate and prolonging diastolic filling time, thereby increasing cardiac output.

### Mechanism of Symptomatic Relief

Beta-blockers (e.g., atenolol, metoprolol) work by:
1. **Reducing heart rate** — allows longer diastolic filling across the stenotic mitral valve
2. **Decreasing cardiac contractility** — reduces demand and pulmonary congestion
3. **Improving exercise tolerance** — prevents reflex tachycardia during activity

### Role of Other Agents

| Agent | Role in MS | Indication |
|-------|-----------|------------|
| **Beta-blockers** | First-line, normal SR | Symptom control, rate control |
| **Calcium channel blockers** | Alternative if BB contraindicated | Diltiazem/verapamil for rate control |
| **Digoxin** | NOT first-line | Only if AF develops (rate + contractility) |
| **ACE inhibitors** | No role | Not indicated in isolated MS |
| **Diuretics** | Adjunctive | For pulmonary congestion only |

**Clinical Pearl:** Diuretics alone without rate control worsen symptoms by increasing heart rate reflexively. Always pair with a rate-limiting agent.

**High-Yield:** In mitral stenosis, **avoid vasodilators** (nitrates, ACE-I, hydralazine) — they cause reflex tachycardia and worsen the stenotic lesion by reducing diastolic filling time.

### Definitive Management

Once symptomatic MS develops (area < 1.5 cm²), **percutaneous mitral balloon commissurotomy (PMBC)** or **surgical commissurotomy** is the definitive treatment. Medical therapy is a bridge to intervention.

**Mnemonic: RATE in MS** — Reduce heart rate, Avoid tachycardia, Treat with beta-blockers, Extend diastolic time.

Answer

A. Lisinopril

Answer

B. Digoxin

Answer

D. Nifedipine

A 52-year-old man with a history of rheumatic fever presents with dyspnea and orthopnea. Echocardiography reveals mitral stenosis with an area of 1.2 cm². He is in normal sinus rhythm. What is the drug of choice for symptomatic management?

Explanation

Mitral Stenosis: Pharmacological Management

Mechanism of Symptomatic Relief

Role of Other Agents

Definitive Management

Practice similar questions

Join our NEET PG community

Agent	Role in MS	Indication
Beta-blockers	First-line, normal SR	Symptom control, rate control
Calcium channel blockers	Alternative if BB contraindicated	Diltiazem/verapamil for rate control
Digoxin	NOT first-line	Only if AF develops (rate + contractility)
ACE inhibitors	No role	Not indicated in isolated MS
Diuretics	Adjunctive	For pulmonary congestion only