Myxomatous valvular degeneration, which increases in frequency with aging, is the maior cause of mitral valve prolapse in the elderly. Mitral valve prolapse, severe enough to require surgical intervention, is more common in elderly men than in elderly women. The associated

dissolution of collagen in the elongated chordae tendineae may explain the high incidence of chorda] rupture that often produces life-threaten¬ing heart failure in these patients. Myxomatous degeneration of I he aor¬tic valve often coexists.
Symptoms, Signs, and Laboratory Findings
Presenting symptoms may include disabling chest pain inconsistent with the pain of myocardial ischemia, palpitations or syncope due to arrhythmia, and heart failure secondary to mitral regurgitation. Hearl failure appears to be more common in men. Arrhythmias are common, even in patients with normal ventricular function. The onset of atrial fibrillation may accentuate both mitral and tricuspid valve prolapse and often precipitates hemodynamic deterioration.
The clinical picture includes a midsystolic click or clicks and a late systolic or holosystolic murmur, with characteristic postural variations such as an earlier, louder murmur and earlier and more clicks on assum¬ing the upright position. In contrast to the prominent clicks in younger persons, the mitral regurgitant murmur predominates in elderly pa¬tients. Although patients often have a long history of cardiac murmur, the mitral regurgitation may progressively worsen. Syslemic emboliza¬tion and sudden death may occur.
The ECG often shows abnormalities. The left ventricle may be en¬larged, although the ejection fraction remains normal.
Diagnosis
When chest pain is the predominant finding in mitral valve prolapse, ventricular function is often preserved. Even so, coronary arteriogra¬phy is often needed to differentiate Ihe chest pain of mitral valve pro¬lapse from that of coronary atherosclerosis. Palpitations may be due to both ventricular and supraventricular arrhythmias, and an ambulatory ECG is helpful in documenting Ihe cause. Echocardiography may dif¬ferentiate mitral valve prolapse from other causes of mitral regurgita¬tion and can help assess ventricular chamber size and function.
Treatment
Anticoagulants are given to prevent systemic emboli, which occur predominantly with atrial fibrillation and heart failure. Digitalis is used to control the ventricular response to atrial fibrillation. Hearl failure is managed with digitalis, diuretics, and vasodilators. Mitral valve re¬placement may be indicated for progressive ventricular dilation, which occurs predominantly in men; the surgical risk is acceptable because ventricular function is usually preserved.