to the editor: In the article on mitral valve prolapse (MVP),¹ I thought it was great that the authors mentioned the significance of the “subclinical” disorder of “mitral valve prolapse syndrome,” in which 2 percent of the population with MVP are symptomatic during a given year. They stated that “reassurance is the major task of management because most patients with MVP are asymptomatic and not at high risk.” I believe it is critical, however, that patients who are symptomatic also receive the same reassurance, because the symptoms—especially the chest pain and tachycardia—often feel life-threatening to the patient.

Furthermore, I believe the authors too easily brushed off the association of MVP with panic disorder as being a chance occurrence. Many times, a person's panic disorder is started by MVP symptoms that seem to hit “out of the blue,” resulting in a whole series of unfortunate associations that begin a vicious circle of panic and anxiety attacks, ultimately leading to frequent emergency department visits. Treating the anxiety and panic that is often associated with MVP is critical.

In addition, a subpopulation of the 2 percent of symptomatic patients with MVP develop some level of depression (which was at one time called a “neurotic depression”). This may, in part, be precipitated by the patient's long-standing symptoms. These patients are often concerned that they are dying or that something is seriously wrong. These patients go from doctor to doctor and are not diagnosed or treated properly. Both of these subpopulations of the 2 percent of the symptomatic patients respond well to the proper care and concern from their family physician and a couple of visits with a behavioral medicine subspecialist or health psychologist. Often, they require beta-blocker or psychotropic therapy for a short time while they make the necessary lifestyle changes mentioned in the article. I hope that future authors are encouraged by the editors to not miss the relevant aspects of behavioral medicine.

editor's note: This letter was sent to the authors of “Current Management of Mitral Valve Prolapse,” who declined to reply.