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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Mitral regurgitation

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Escalate

Sudden pulmonary oedema or shock with a new systolic murmur after myocardial infarction, chordal rupture or endocarditis suggests acute severe MR. Call 999, obtain urgent echocardiography and involve cardiology, critical care and cardiac surgery immediately.

Synopsis

Separate primary from secondary and acute from chronic mitral regurgitation, quantify severity, and direct patients to repair, replacement or transcatheter treatment at the right time.

  • Primary MR is a disease of leaflets/chordae, commonly prolapse or flail; secondary MR results from LV or atrial remodelling with initially normal leaflets.
  • A pansystolic apical murmur radiating to the axilla is typical, but acute severe MR can have a short or quiet murmur because LA pressure rises rapidly.
  • Severe primary MR is supported by an integrated echo assessment, often including EROA at least 0.40 cm2 or regurgitant volume at least 60 mL/beat.
  • In chronic primary MR, LVEF 60% or less or LVESD 40 mm or more already signals LV dysfunction and is a surgical trigger even without symptoms.
  • Durable surgical repair is preferred to replacement for suitable degenerative primary MR and should be performed in an experienced valve centre.
  • For secondary MR, first optimise guideline-directed heart-failure treatment, revascularisation when indicated and CRT when eligible; reassess MR after optimisation.
  • Transcatheter edge-to-edge repair can be offered to selected symptomatic patients with severe MR and suitable anatomy when surgery is unsuitable or in selected secondary MR after optimal therapy.
  • Acute severe MR is a mechanical emergency: medical stabilisation is a bridge to urgent surgery, not definitive care.

Key red flags

Acute severe MR

Abrupt breathlessness, pulmonary oedema, hypotension or shock after MI, endocarditis or chordal rupture may occur with a unimpressive murmur.

Investigation priorities

01
Transthoracic echocardiographyFirst step

Define mechanism, severity, LV/LA size, LVEF, pulmonary pressure and other valve disease.

Management branches

acuteAcute severe mitral regurgitation

Abrupt severe MR causes pulmonary oedema, hypotension or shock.

  1. Use ABCDE care, continuous monitoring and oxygen/ventilatory support for hypoxaemia; call cardiology, critical care and cardiac surgery immediately.
  2. Obtain urgent TTE and usually TOE, while investigating MI, papillary-muscle/chordal rupture and endocarditis; take cultures promptly when infection is possible.
  3. Use IV diuresis and specialist afterload/perfusion support as a bridge, tailored to BP; revascularise an acute coronary culprit when indicated.
  4. Proceed to emergency or urgent mitral surgery when the mechanical lesion is confirmed; do not rely on apparent improvement with medical therapy.

Key medicines

FurosemideFor chronic oedema, 40 mg orally in the morning is a usual initial adult dose; maintenance is often 20 mg daily or 40 mg on alternate days. For acute oedema, the injection SmPC gives 20–50 mg IV initially, at no faster than 4 mg/min.Monitor BP, renal function, sodium, potassium, urine output and weight. Diuresis does not repair MR and must not delay urgent surgery in acute severe disease.
RamiprilFor stable symptomatic heart failure, start 1.25 mg orally once daily and double at 1–2-week intervals as tolerated to a maximum 10 mg/day, preferably in two divided doses; for hypertension, a usual start is 2.5 mg once daily.Check BP, creatinine and potassium before and after titration; avoid in pregnancy, previous ACE-inhibitor angioedema and use caution with renal-artery stenosis.
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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG208: Heart valve disease presenting in adultsUK surgical and transcatheter intervention routes and surveillance.
  • ESC/EACTS 2025 valvular heart disease guidelineContemporary primary and secondary MR strategy.
  • ESC: Primary mitral regurgitation questionsLV triggers, repair and follow-up.
  • ESC: Echocardiography in mitral valve diseaseMechanism and integrated echo assessment.
  • eMC: Ramipril SmPCLicensed heart-failure and hypertension dose boundaries.
  • eMC: Furosemide tablets SmPCAdult oedema dosing and monitoring.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom