Counseling Sheet

Agatha M. Thrash, M.D.
Preventive Medicine‍

CASE HISTORY

‍A 41-year-old white woman arrived at Uchee Pines Institute in a wheelchair. She had had increasingly severe chest pains, palpitations, shortness of breath, fatigue, and anxiety over the previous 18 months. Her pulse was 96 at rest; BP normal; heart normal (no murmur), but she did have a characteristic "systolic click" sound. Electrocardiogram was normal, echocardiogram confirmed MVP. Several days were spent in reassurance and tapering off medications. She was given hawthorn berry tea, Epsom salts, and catnip tea as needed through the day for anxiety; hops and catnip tea allowed her to sleep without medication. She began a graduated walking program with her Lifestyle Counselor at her side for reassurance. Each day, she went further and gained confidence. By the end of the third week, she was walking 6-8 miles a day and was almost totally asymptomatic. She donated her wheelchair to the Institute and returned home with no further significant symptoms.

What is now agreed to be the most common valvular disorder was not even recognized until around the early 1970s. The advent of echocardiography, which for the first time allowed the cardiologist to see what was going on inside the heart in real time, allowed the diagnosis of mitral valve prolapse. It involved between 25 and 30% of all women in the U.S., most being diagnosed in the 25-35 age group. It is a strange disorder, generally quite benign, but fraught with much mystique. Bondelais, writing in the American Heart Journal of October, 1989, proposes that it be divided into two groups: the first he calls the Anatomic group, and the second he would call the Mitral Valve Prolapse Syndrome group.

The anatomic group is older, with an average age of 76 years; 85% were over 50 years of age when symptoms developed. This group had much more severe symptoms, with more severe valvular involvement. Eighty-five percent had had congestive heart failure, and 58% had atrial fibrillation, an erratic "quivering" arrhythmia of the upper heart chambers. Eighty-five percent of these patients required valve surgery. Fortunately, this group is much less common than the other.

The "Mitral Valve Prolapse (MVP) Syndrome" is said to be characterized by a symptom complex of palpitations, chest pains, easy fatigue, exercise intolerance, shortness of breath, easy fainting, anxiety, and predisposition to panic attacks. The average age was 30 years. The symptoms, which can cause extreme anxiety in some, can be disabling, even though the disorder is generally quite benign. There is evidence of increased activity of the sympathetic nervous system with increased levels of stress hormones (catecho1amines) in the blood and urine.

The cause of the symptoms are poorly understood. The chest pain may be due to stretching of the chordi tendoni ("heart strings") which anchor the mitral valve to the interior wall of the heart. It is usually described as a dull aching beneath the breastbone and under the left breast, with much anxiety. It can last for hours and is not aggravated by exercise, in contradistinction to angina, which comes on after exercise and emotional upsets, and usually lasts only a short time after resting.

Treatment of the latter group, which are much more common than the former, involves a great deal of support and reassurance. Patients may become "cardiac cripples" if not handled properly. It is common for cardiologists to give strong medication, such as the so-called "beta blockers," examples being propranolol or atenolol; and antiarrhythmic drugs to these patients. While the beta blockers slow the heart and often give a measure of relief, they should not be used in most cases. In fact, it is well to avoid the pharmacological treatment of the MVP Syndrome. Beside frequent reassurances, graduated exercise out-of-doors is an excellent method of physiological dissipation of the excess catecholamines. The resting pulse is slowed naturally, chest pains melt away, and anxiety and fatigue are relieved. If anything is needed for the palpitations, some simple herbs such as hawthorn berry tea, are very helpful. Since most of these patients have a total body deficiency of magnesium, for unknown reasons, supplementation with Epsom salts (magnesium sulfate, one teaspoonful in a glass of water twice daily); or magnesium chloride or oxide tablets, two tablets three times a day, are also quite helpful. These seldom need to be continued very long if the patient will embark on a serious exercise program. We do not use prophylactic antibiotics before dental manipulation for these patients, as they are prone to develop the Candida Related Complex (chronic yeast syndrome). In fact, one study of Candida patients showed over 60% with MVP.