E-case #1 - Jan 1-5, 2001

Christopher H. Smith, M.D.

A 24-year-old woman presents to discuss anxiety attacks.  She notes increasing frequency over the last few weeks of feeling like she is "freaking out".  She has been experiencing discrete episodes of feeling out of control, associated with irrational fearfulness and palpitations.

Because of these feelings, she was seen at Virginia Mason Urgent Care center one week ago and given Xanax.  She has found this helpful, and comes in today to discuss the best future treatment.  She notes no history of mental health problems, but states that lately she has been feeling depressed and does not sleep well despite spending long periods of time in bed.  She feels tired and has had a loss of appetite with a weight loss of 10-15 pounds per her report, though weight has been stable over the last four months per review of the chart.  She notes increasing stress at work and will be quitting her job to return to school in the near future.

PMH: allergic rhinits, pyelonephritis.   Meds: Xanax 0.25 mg. BID prn, and oral contraceptives

All: Cipro caused nausea

Habits: She does smoke cigarettes, but denies use of illicit drugs; no prior IVDU.

SH: She works as an executive assistant for a software company.  Plans to study public relations at a community college.  Never married, no children.

FH: She states that there is no official history of mental health problems in her family, though she suspects that her grandmother may have suffered from depression.

ROS: She adds that the UCC physician who examined her noted an abnormal heart sound, and suggested that she see an MD in follow-up.  She notes no history of dyspnea, chest pressure, LE edema or rheumatic fever.

O: This is a thin polite, conversant young woman.  BP 110/58, P 60. WT 119. Chest clear, cardiac notable for variable rate but regular rhythm.  When I examine her, rate is closer to 100, but it does later come down to 70, as she becomes more relaxed.  S1 and S2 are normal, no murmur noted, but there is a mid to late systolic click.  Extrem without edema.

ECHO obtained one week later revealed thickened mitral valve, with prolapse of the anterior leaflet and mild mitral regurgitation.  TSH was normal.

Questions:

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Discussion of Ecase #1 - Mitral Valve Prolapse

Katerndahl, David. Panic and prolapse: meta-analysis J Nerv Ment Dis 181:539-544, 1993.
This review attempts to identify whether there is a significant relationship between panic disorder and MVP.  Unfortunately the literature is flawed.  MVP criteria were not always clearly defined.  The authors conclude that there does appear to be a significant association between the two disorders, though publication bias may account for this.  That is, a lower p-value may persuade reviewers to publish particular studies and not those that don't show an association; ".what we read may represent a distorted view of the issue".  Since this was a meta-analysis, it was limited to what had been published.

Freed, Lisa. Prevalence and clinical outcome of mitral-valve disease.  NEJM 341:1-13, 1999.
In this prospective cohort study, the data from the fifth exam of the Framingham Heart Study is reviewed.  This included 3736 individuals who underwent echocardiographic exams.  MVP was clearly defined (> 2mm displacement of valve leaflets during systole) and divided into two groups based upon ECHO characteristics of the mitral valve.  Those with "classic" MVP had thickened valves >5mm, "non-classic" < 5mm.

There were two noteworthy findings: prevalence of MVP was lower than previously thought: 1.3% of this population had classic MVP, 1.1% non-classic, total prevalence = 2.4% (84 out of 3491 subjects).  Secondly, complications of MVP were also substantially lower than expected.  There was no greater incidence of CHF, A fib, cerebrovasc disease, syncope, CP or dyspnea in those with MVP versus controls.  Mild MR did occur more frequently in those with classic MVP than in those with non-classic or controls without prolapse.

Dajani, Adnan. Prevention of bacterial endocarditis: recommendations by the American Heart Assoc. JAMA 277:1704-1801, 1997.
This is the frequently cited article that is used as a guide for determining whom to treat, and with what antibiotics.  I would like to quote a few passages relevant to this case:

"There are currently no randomized and carefully controlled human trial in patients with underlying structural heart disease to definitively establish that antibiotic prophylaxis provides protection against development of endocarditis during bacteremia-inducing procedures."

"When normal valves prolapse without leaking as in patients with one or more systolic clicks but no murmurs and no Doppler-demonstrated mitral regurgitation, the risk of endocarditis is not increased above that of the normal population.. Patients with prolapsing and leaking mitral valves.should receive prophylactic antibiotics.  This is supported by formal cost-benefit analysis."

A separate table lists "MVP with valvular regurgitation and/or thickened leaflets" in the moderate risk category.

This article is a useful reference and I like to keep it on hand when answering clinical questions that arise in the care of patients.  A revised update may be forthcoming.