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
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
Before we go any further, let's talk about how we rate any murmur:
andbull; Trivial: Insignificant, don't even bother me with it.
andbull; 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
andbull; 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).
andbull; 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
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
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
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 knowandhellip;
Email suggestions for future House Calls columns to Beth Liles at Sutter Coast Hospital, firstname.lastname@example.org