Our patient’s diagnosis is severe rheumatic mitral regurgitation. When she was seen for this evaluation, she had symptoms of left ventricular failure and was treated by further salt restriction, maintaining her on beta blockers, and increasing her dose of diuretics. In chronic mitral regurgitation with preserved left ventricular systolic function, afterload reduction is generally not indicated. Some practitioners might choose an ACE inhibitor or angiotensin receptor blocker, ARB, for our patient with transient heart failure and preserved left ventricular function, but there is no data to definitively support this. ACE inhibitor or ARB therapy should certainly be considered for those patients with hypertension, diabetes, and/or left ventricular systolic dysfunction. Because of her intermittent episodes of atrial fibrillation, and the left atrial thrombus observed on her echocardiogram, she was also treated with warfarin as prophylaxis for embolic events.
She lost several pounds, her symptoms of dyspnea on exertion improved, and she had no more episodes of nocturnal dyspnea. However, she was still dyspneic while carrying out routine house work and shopping.