House Calls runs every two weeks. Today’s column is written by Randy Landenberger registered diagnostic cardiac sonorophone at Sutter Coast Hospital.
There’s a murmur going’ around this town. Word is, dang near everyone’s got one. A heart murmur, that is.
So what exactly is a murmur and why do so many patients state, “Well I’ve never had one before.”
The first definition is that a murmur is an extra sound your doctor or nurse hears when they place the stethoscope over your heart. Typically we expect to hear the classic “boom-boom, boom-boom.” Any other sound is a murmur. Those “boom-booms” are made by your heart valves closing. You have four valves, two on each side of the heart, and they close two at a time.
Most murmurs we hear are caused by the valves. Some problems you’re born with, and some you develop over time, either due to normal wear and tear of aging, or some type of trauma, such as exposure to disease or drugs.
Heart valves are similar to your sink faucet at home. When the valve is open, blood flows through, and when it’s closed, it’s stopped from flowing backward. So any valve can have two problems; either it gets clogged or it leaks. A clog is called stenosis, or stenotic, and primarily caused by calcium buildup. A leak is called regurgitation or insufficiency.
Before we go any further, let’s talk about how we rate any murmur:
• Trivial: Insignificant, don’t even bother me with it.
• Mild: No big deal. Almost everyone has some kind of trivial to mild murmur, even if your doctor never mentioned it (and there’s good reason for that).
• Moderate: You may or may not feel the effects of this, typically with symptoms of shortness of breath, difficult breathing with moderate exertion and possibly edema (fluid retention such as swollen ankles) or CHF (congestive heart failure).
• Severe: Yes you are feeling this one with shortness of breath, probably need to sleep with two or three pillows, or even sleeping sitting in your recliner. You can’t walk very far without having to stop and catch your breath.
When your murmur is rated severe, it’s time for that conversation with your cardiologist to develop a plan for that valve’s repair or replacement. You may have a few years, but he or she will want to watch it closely. You’ll probably be in for an echocardiogram every six months and schedule your surgery before it gets critical.
Once a valve murmur is critical, and there are other health or frailty problems, then the surgeon may decline to operate. But if you’re in otherwise good health, then all is not lost. In some cases the valve can still be replaced and the patient can go on to have many years of healthy living.
So why don’t many doctors mention that you have a murmur, or if they do, they don’t explain much? If they can hear that it’s trivial or mild, there’s no reason to cause undo alarm. There is nothing you can do to improve it. Neither exercise nor diet will diminish a murmur.
They often want to know more about the murmur before they tell you. The best information they can get without sticking wires and tubes in from your groin and up to your heart usually comes from the echocardiogram, which can see and quantify the murmur on the trivial to critical scale.
Sometimes valve leaking is not due to a problem with the valve itself, but that the heart has become so stretched out and dilated from another disease, that the valve cannot close competently. If the underlying disease can be addressed, then the heart may shrink back to its normal size and the leakage is significantly reduced.
Illicit IV drug use is another big killer of valves. Cocaine and meth are like running bleach through your faucet, they destroy your whole heart — the muscle and the valves. The unsterile technique also introduces bacteria and viruses that love to eat heart valves.
You may have been born with a mildly abnormal valve. No big deal and not cause for concern until you go to the dentist or need some type of surgery. That’s why every dentist’s form that you fill out asks about a murmur. Your mouth is full of staph germs and during dental work, if there’s blood, then it may provide a direct path for that staph to get to your heart. In a normal person, the immune system takes care of it, but with an abnormal valve, it’s like taking a fork to your Teflon pan; Everything (like the staph) will stick to it.
If you do need a valve replaced, you have two options; a mechanical valve (metal and plastic), or a tissue valve taken from a cow (bovine), a pig (porcine), a human (a homograft or allograft). Each type has its advantages and challenges. The good news is that most of them are lasting 15 years or more. Although they may be rated for 10 years, I often see patients who’ve had them going on 20 years.
The other common types of murmurs are from a hole in your heart between the right and left sides. Unless you’ve come into contact with bullets, knives, arrows, spears or daggers from your lover’s eyes, then you were born with it. You don’t acquire them as you age, but you may well heal them as you get older.
The most common type is more like a doorway than an out and out hole. Some doors will open at the slightest breeze, others need a strong shoulder to push open. We are all born with the doorway and it needs to be open while we are in the womb. For most of us, when you take that very first breath or cry when you make your appearance here on earth, that’s when the door slams shut.
The healing process is like painters covering the wall and door without taping it off — they literally paint the door closed. For the others, the painters were on vacation when you were born so the door remains functional.
Most of your life, having a door that opens is no big deal, it probably won’t affect you at all. However it can come into play if you’ve ever had a stroke caused by a blood clot or built up nitrogen bubbles in your blood when scuba diving. And there’s still research as to whether it may contribute to migraine headaches.
If you do have an actual hole, without a door that closes, whether or not to have it fixed depends on how large it is, where it is, and if there’s any accompanying problems.
There are a few other varieties, but another “unexplained” one is exactly that, no visible cause. Your doctor hears an extra sound and the echo shows nothing. We’ll call this a flow murmur.
Picture yourself down by the Smith River on a sunny, warm summer day. Nice. Quiet and peaceful. The river flows by and you don’t hear much at all. A few months later after the rain, the river is roiling and now quite loud. The river is not bad or diseased, it just has more water and more rocks and branches to go around.
Same with your heart, there may just be more tissue inside the heart for the blood to go around, or your heart is squeezing more tightly.
So to answer your statement: “I’ve never had a murmur before.”
Guess that’s because you’ve lived long enough to acquire it. Your brand new faucet probably worked fine for a lot of years too, and if you live in the house long enough, you know…