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Functional mitral regurgitation (MR) is frequently present in patients with acute coronary syndrome and can be observed by contrast ventriculography or Doppler echocardiography.1–5 It is, however, poorly detected by auscultation.1,6 Ischaemic MR results from either tethering force that restricts the ability of the mitral leaflets to close, reduced left ventricular (LV)-generated closing force, or both.7 Tethering is produced by global LV remodelling—increased LV sphericity and annular dilation—or more frequently by mitral valve distortion, characterized by systolic valvular tenting due to apical and outward displacement of the posterior papillary muscle or of both papillary muscles. Reduced closing force can be determined by reduced LV contractility or LV regional dyssynchrony. In the acute phase of myocardial infarction (MI), MR may pre-exist or result from the acute event through regional LV dilation and loss of contraction. Most studies have shown that functional MR in early MI is associated with a worse prognosis and is an important, independent predictor of cardiovascular mortality. The incidence of functional MR in the prospective studies is highly dependent on the method used to document it. The lowest frequency (9%) is observed when the detection of the MR relies only on cardiac auscultation.8 The frequency varies from 13 to 19% when MR is diagnosed by contrast ventriculography.1–3 The highest incidence is found, not surprisingly, in the trials using Doppler echocardiography.4,5

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