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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 stenosis

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

RapidFull
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Escalate

Call 999 for acute pulmonary oedema, hypoxaemia, shock, ongoing chest pain or a rapid arrhythmia with haemodynamic compromise. In unstable AF, use synchronised electrical cardioversion; pulmonary congestion and a very fast rate can sharply worsen transmitral obstruction.

Synopsis

Recognise clinically significant mitral stenosis, manage congestion and atrial fibrillation safely, and select transcatheter commissurotomy versus surgery.

  • Rheumatic commissural fusion is the classic cause; degenerative mitral-annular calcification is increasingly important in older adults and is not treated like pliable rheumatic disease.
  • Exertional dyspnoea, orthopnoea, haemoptysis and declining exercise tolerance reflect raised left-atrial and pulmonary pressure.
  • An opening snap followed by a low-pitched mid-diastolic apical rumble is typical; a longer murmur and shorter A2-to-opening-snap interval suggest greater severity.
  • Clinically significant stenosis is generally a mitral valve area 1.5 cm2 or less; mean gradient varies with heart rate and flow and must be reported with them.
  • AF removes atrial contribution, accelerates filling and increases embolic risk; new AF can abruptly unmask severe symptoms.
  • Use a vitamin K antagonist for AF with moderate-to-severe rheumatic mitral stenosis; direct oral anticoagulants are not the recommended substitute.
  • Percutaneous transcatheter commissurotomy is preferred for symptomatic rheumatic stenosis with favourable anatomy, no left-atrial thrombus and no more than mild MR.
  • Surgery is used when anatomy is unsuitable for commissurotomy, significant MR or other surgical disease coexists, or the percutaneous result is inadequate.

Key red flags

Systemic embolism

Focal neurological deficit, limb ischaemia or organ infarction can arise from left-atrial thrombus and requires emergency assessment.

Investigation priorities

01
Transthoracic echocardiographyFirst step

Measure valve area, mean gradient at the recorded heart rate, MR, LA size, RV function and pulmonary pressure.

Management branches

acuteAcute pulmonary oedema or unstable AF

MS presents with respiratory failure, hypotension, ischaemia, syncope or shock.

  1. Use ABCDE care, monitoring, IV access and oxygen for hypoxaemia; call cardiology/critical care urgently.
  2. If tachyarrhythmia is causing life-threatening compromise, perform synchronised electrical cardioversion with sedation/anaesthesia support when feasible.
  3. Treat congestion with an IV loop diuretic while monitoring BP, renal function and electrolytes; identify infection, anaemia or other precipitants.
  4. After stabilisation, evaluate urgently for valve intervention and institute stroke prevention appropriate to rheumatic MS and AF.
surgeryWhen surgery is preferred

Symptomatic clinically significant MS is unsuitable for balloon commissurotomy.

  1. Identify contraindications or poor-result features: LA thrombus, more than mild MR, absent commissural fusion, severe calcification or important associated valve/coronary disease.
  2. Discuss mitral replacement or selected repair/commissurotomy in the multidisciplinary valve team, incorporating frailty and pulmonary vascular disease.
  3. If other cardiac surgery is needed, plan combined treatment rather than an isolated balloon procedure.
  4. Continue symptom and thromboembolism treatment while awaiting surgery and reassess rapidly if pulmonary oedema or right failure develops.

Key medicines

WarfarinDose orally once daily and adjust to INR; typical maintenance is 3–9 mg once daily, but the exact dose is individual. For AF with rheumatic MS, the usual INR target is 2.0–3.0.Check baseline and frequent INR, interactions, adherence and bleeding. Pregnancy requires specialist anticoagulation planning. A fixed tablet dose without INR adjustment is unsafe; DOACs are not the recommended alternative in moderate-to-severe rheumatic MS.
BisoprololA common adult starting dose is 2.5–5 mg orally once daily, titrated to symptoms and ventricular rate; the SmPC hypertension/angina usual dose is 10 mg once daily and maximum 20 mg/day.Avoid or reduce in bradycardia, high-grade AV block, hypotension or acute decompensated heart failure; use caution in asthma and do not stop abruptly.
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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 transcatheter valvotomy, referral and monitoring recommendations.
  • ESC/EACTS 2025 valvular heart disease guidelineCurrent valve intervention and antithrombotic principles.
  • ESC: Expert review of mitral valve diseaseCommissurotomy selection and AF considerations.
  • ESC: Echocardiographic haemodynamics in mitral diseaseValve-area and gradient interpretation.
  • eMC: Warfarin SmPCINR-guided dosing and typical maintenance range.
  • eMC: Bisoprolol SmPCAdult dose range and contraindications.

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