Normal pulmonary vascular resistance

Symptoms include:

• dyspnoea - there is a progression of symptoms through the spectrum of increasing exertional dyspnoea, paroxysmal nocturnal dyspnoea, orthopnoea and finally pulmonary oedema. The progression of these symptoms reflects a gradual elevation in left atrial pressure. These features are aggravated by the increased blood volume of pregnancy or the tachycardia of atrial fibrillation
  
  
• palpitations
  
  
• haemoptysis - may be due to pulmonary infarction

Signs include:

• pulse - small; may be irregular if atrial fibrillation
  
  
• jugular venous pressure - normal
  
  
• cardiac impulses - palpable mitral first sound - tapping beat of mitral stenosis
  
  
• auscultation:
  • loud first heart sound unless reduced mobility of a calcified and fibrotic mitral valve
  • opening snaps - this is a high-pitched early diastolic sound. It is maximal internal to the apex
  • diastolic murmurs:
    • presystolic murmur - when in sinus rhythm a presystolic murmur following left atrial contraction
    • mid-diastolic murmur - this is a longer, low frequency, rumbling murmur. It is best heard at the apex with the bell. The tighter the stenosis the longer the murmur.