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Henry Chatfield: Discussion

A 72 year-old man who was last examined 8 years ago schedules a preventive examination. He is found to have a displaced PMI suggesting cardiomegaly, a soft S1 indicating systolic separation of the mitral valve leaflets, and a loud murmur consistent with advanced mitral regurgitation (MR).

The EKG is normal. Dr. Grey subsequently recommended that Henry have an echocardiogram and consult with a cardiologist. He also gave Henry a prescription for amoxicillin 500 mg, 4 capsules 1 hour before dental visits, for prevention of bacterial endocarditis.(1)

MR in older adults most often results from myxomatous degeneration and associated mitral valve leaflet prolapse. Mild to moderate MR is usually asymptomatic. Even severe MR, as appears to be the case with Henry, may cause few if any symptoms. Henry's "loud" respirations climbing the ladder might indicate left ventricular dysfunction at a high workload.

By improving ventricular performance by afterload reduction, ACE inhibitors can improve exercise tolerance.

The most important question in MR is deciding when to recommend repair or replacement of the mitral valve. The goal of surgery is to prevent deterioration of ventricular function and the onset of atrial fibrillation. Surgery is generally recommended if symptoms develop or when the ejection fraction as measured on the echocardiogram falls from its usually supernormal value to below 60% (2).

The decision to undergo surgery is often challenging for patients because they usually have minimal or no symptoms and must rely solely upon the physician's judgment and recommendations. One might expect that Henry, who avoids doctors, would have a difficult time accepting a recommendation for surgery or even consultation with a cardiologist. Such recommendations would need to be given with care.

Other issues arising at this visit have to do with prevention. At age 72 Henry should have pneumococcal and seasonal influenza vaccinations, a fasting blood sugar, lipid profile, PSA, and 3 hemoccult slides. He is also due for a sigmoidoscopy or colonoscopy.

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