MetroHealth Heart & Vascular Center
What is a heart murmur?
During a physical exam, your doctor listens to your heart with a stethoscope. The doctor listens to your heart at different places on your chest to hear the sounds your heart valves make as blood travels through your heart.
Normally, the heart beat has two sounds – lub-dub.
• The first sound is heard as the mitral and tricuspid valves close.
• The second heart sound is the aortic and pulmonic valves snapping shut.
A heart murmur is a swishing sound heard when there is turbulent or abnormal blood flow across the heart valve.
What causes a heart murmur?
Heart valve disease is the most common cause of a heart murmur.
• Valve stenosis – a narrow, tight, stiff valve, limiting forward flow of blood.
• Valve regurgitation – a valve that does not close completely, allowing backward flow (a "leaky" valve)
• The abnormal changes to the valve cause the abnormal heart sound (murmur).
Other causes of heart murmurs include:
• Hypertrophic cardiomyopathy
• Septal defect
Murmurs can be caused by increased blood flow across the valve related to other medical conditions without heart disease, such as:
• Innocent murmurs
Murmurs can be present without any medical or heart conditions. Two common examples include:
• Childhood murmurs
Important information about heart murmurs
• It is important to have regular physical exams to detect any abnormal heart sounds. If a murmur is heard, further evaluation will be required to determine why the murmur is present, which valve is involved, and the severity of the problem.
If the murmur is due to a heart valve problem:
• Follow-up with a cardiologist will be required to evaluate the progression of the valve disease.
Most people who have a heart murmur require measures to prevent valve infection. These include:
• Tell all your doctors and dentist you have valve disease
• Call your doctor if you have symptoms of an infection
• Take good care of your teeth and gums
• Take antibiotics before you undergo any procedure that may cause bleeding
• A wallet card may be obtained from the American Heart Association with specific antibiotic guidelines. Call your local American Heart Association office or nationally, 1-800-AHA-USA1 or go to http://www.americanheart.org/
Types of Heart Valve Disease
There are four valves within your heart.
• Mitral valve
• Tricuspid valve
• Aortic valve
• Pulmonic valves
The valves make sure blood flows in only one direction through the heart.
What is heart valve disease?
Valve disease occurs when your heart's valves do not work correctly. This can be caused by
• valvular stenosis or
• valvular insufficiency.
In valvular stenosis
• the tissues forming the valve leaflets become stiffer, narrowing the valve opening and reducing the amount of blood that can flow through it.
• If the narrowing is mild, the overall functioning of the heart may not be reduced.
• However, the valve can become so narrow (stenotic) that heart function is reduced, and the rest of the body may not receive adequate blood flow.
In valvular insufficiency (or regurgitation, incompetence, "leaky valve")
• occurs when the leaflets do not close completely, letting blood leak backward across the valve.
• This backward flow is referred to as “regurgitant flow.”
A narrowed or “stenotic” valve requires the heart to pump harder, which can strain the heart and reduce blood flow to the body.
A regurgitant (incompetent, insufficient, or leaky) valve does not close completely, letting blood move backward through the valve.
Some patients may have both valvular stenosis and valvular insufficiency in one or more valves. Valve disease causes the heart muscle to work harder to circulate the right amount of blood through the body.
Normal Aortic Valve
Bicuspid Aortic Valve
What causes heart valve disease?
There are many types of valve disease. Valve disease can be congenital (present at birth) or may be acquired later in life. Sometimes the cause of valve disease may be unknown.
• Congenital valve disease is an abnormality that develops before birth. It may be related to improper valve size, malformed leaflets, or an irregularity in the way the leaflets are attached. This most often affects the aortic or pulmonic valve.
o Bicuspid aortic valve disease is a congenital valve disease that affects the aortic valve. Instead of the normal three leaflets or cusps, the bicuspid aortic valve has only two. Without the third leaflet, the valve may be:
• Normal aortic valve Bicuspid aortic valve
• stenotic - stiff valve leaflets that can not open or close properly
• leaky - not able close tightly
• This occurs more frequently in some family members. About 1/4 of patients may have some enlargement of the aorta above the valve.
• Bicuspid aortic valve disease affects about 2 percent of the population.
• Acquired valve disease includes problems that develop with valves that were once normal. These may involve changes in the structure of your valve or infection.
o Infective endocarditis and rheumatic fever are the two common infections that cause valve disease.
- Rheumatic fever causes a common type of valve disease, rheumatic heart disease.
- the heart valve leaflets to become inflamed
- may cause the leaflets to stick together and become scarred, rigid, thickened and shortened
- may cause one or more of the valves (most commonly the mitral valve) to become stenotic (narrowed) or leaky
- Rheumatic fever is usually caused by an untreated streptococcal infection, such as strep throat. The use of penicillin to treat strep throat can prevent this disease.
- Rheumatic fever occurs most often in children aged five to fifteen, but symptoms of valve disease may not be seen for years.
- The valve itself is not infected in rheumatic fever.
- Antibodies developed by the body to fight the infection react with the heart valves, causing inflammation and eventual scarring.
o Endocarditis is a major infection and can be life-threatening. It occurs when germs (especially bacteria) enter your blood stream and attach to the surface of your heart valves. With endocarditis:
- germs attack the heart valve, causing growths on the valve, holes in the valve or scarring of the valve tissue
- may cause the valve to leak or become stenotic (narrowed)
- The germs can enter your blood stream during:
- dental procedures
- intravenous (IV) drug use
- severe infections
- If you have valve disease (unless you have mild forms of mitral valve prolapse) or have had valve surgery, you are at increased risk for getting this life-threatening infection. Click here to learn more.
- Other causes of valve disease include: coronary artery disease, heart attacks, cardiomyopathy (heart muscle disease) , syphilis, hypertension, aortic aneurysms , connective tissue diseases, and less commonly, tumors, some types of drugs and radiation.
- Changes in your valve structure can occur due to both acquired and congenital causes. These include:
- Stretching or tearing of chordae tendineae or papillary muscles most commonly occurs to the mitral valve. This can be a result of:
o heart attack
o heart valve infection
o If the chordae become torn or papillary muscles become stretched, the leaflets may flop backward when the ventricles contract (flail leaflet), causing a leaky valve.
Mitral valve prolapse (MVP)
| Normal mitral valve
| Mitral valve prolapse
• Is a type of myxomatous valve disease.
• MVP causes the leaflets of the mitral valve to flop back into the left atrium during the heart's contraction.
• MVP also causes the tissues of the valve to become abnormal and stretchy, causing the valve to leak.
Is mitral valve prolapse serious?
• MVP occurs in about 1 to 2 percent of the population and equally in men and women.
• Most often it is not a cause for concern.
• Only 1 in 10 patients with MVP eventually require surgery.
• If the prolapse becomes severe or is associated with torn chordae or flail (floppy, lacking support) leaflets, the leak may be greater, and surgery may be needed.
All patients with MVP should ask their doctor if they require measures to prevent endocarditis. Click here to learn more about MVP.
• most commonly affects the aortic valve.
• It most often occurs in adults over the age of 65.
• This condition can be compared to atheroma in coronary artery disease.
• The valve leaflets become fibrotic (thickened) and calcified (hardened), producing a narrowed valve opening.
• Risk factors for this type of valve disease include:
o increased age
o low body weight
o high blood pressure
Dilatation of the valve annulus
• is a widening or stretching of the annulus.
• This causes the leaflets to lack support and not close tightly.
Dilatation may occur when the heart muscle is damaged due to:
• a heart attack (heart muscle injury)
• cardiomyopathy (weakened heart muscle)
• heart failure
• advanced stages of high blood pressure
• inherited disorders (such as Marfan syndrome )
Symptoms of valve disease
Symptoms can occur quickly if the onset of your valve disease is severe and sudden. If your disease develops slowly and your heart has time to adjust, you may barely notice your symptoms.
The following are symptoms of valve disease:
shortness of breath or difficulty catching your breath
You may notice this most when your are active (doing your normal daily activities) or when you lie down flat in bed. You may need to sleep propped up on a few pillows to breathe easier
palpitations: This may feel like a rapid heart rhythm, irregular heart beats, skipped beats or a flip-flop feeling in your chest.
swelling of your ankles, feet or abdomen. This is called edema. Swelling may occur in your belly, which may cause you to feel bloated.
weakness or dizziness. You may feel too weak to carry out your normal daily activities. Dizziness can also occur, and in some cases, passing out may be a symptom.
quick weight gain. A weight gain of two or three pounds in one day is possible.
discomfort in your chest. This may feel like a pressure or weight in the chest with activity or going out in cold air.
Call your doctor if you begin to have new symptoms or if they become more frequent or severe.
Symptoms do not always relate to how serious your valve disease is. You may have no symptoms at all and have severe valve disease, requiring prompt treatment. Or, as with mitral valve prolapse, you may have severe symptoms, yet diagnostic tests may show your valve leak is not significant. These symptoms may cause you to worry, but they are not dangerous or life-threatening, and may not require treatment at all.
How is Valve Disease Diagnosed?
Your cardiologist (heart doctor) will diagnose valve disease after:
• Talking to you about your symptoms and medical history
• Performing a physical exam. A physical examination may reveal fluid in the lungs, an enlarged heart, or a heart murmur, which is the sound made by blood moving through a stenotic or a leaky valve.
• Performing diagnostic tests. These tests help your cardiologist evaluate the extent of your valve disease, its effect on the function of your heart, and the best form of treatment for you. Tests may include:
o Echocardiogram (echo) - An "echo" is a graphic outline of the heart's movement. A sound-wave transducer wand is placed on the surface of the chest. High frequency sound-waves are used to provide pictures of the heart's valves and chambers and to look at the pumping action of the heart. Echo is often combined with Doppler ultrasound and color Doppler to detect changes in the blood flow across the heart valves and pressures within the chambers. An echocardiogram can be performed at rest or during exercise.
o Transesophageal echocardiogram (transesophageal echo or TEE) - TEE is similar to a Doppler echo. During a TEE, a sound-wave transducer is placed on the end of a special tube (called an endoscope) and passed into the mouth and down the esophagus (food pipe). This allows doctors to get a closer look at the valves, the heart chambers and the back of the heart.
o Cardiac catheterization (cardiac cath or angiogram) - A catheter (inserted into your arm or leg) is guided to your heart, contrast dye is injected and x-ray movies of you coronary arteries, heart chambers, and heart valves are taken.
o Electrocardiogram (EKG or ECG) - The electrical activity of the heart is recorded on graph paper, using small electrode patches attached to the skin that transmit information to a computer.
o Additional tests, such as the exercise stress echocardiogram , radionuclide scans, and magnetic resonance imaging (MRI) may also be used.
By repeating these tests over time, your doctor can see the progress of your valve disease and help you make decisions about your treatment
Treatment of Valve Disease
When you have valve disease, it is important to protect yourself from future heart problems, even if your valve has been repaired or replaced with surgery.
• Know the type and extent of your valve disease.
• Protect your valve from further damage.
Ask your doctor if you are at risk for infective endocarditis. This infection can greatly damage or destroy your heart valves and can be fatal. You require the following steps to prevent endocarditis if you:
• Have had valve surgery (valve repair or replacement)
• Have had a previous episode of endocarditis
• Have acquired heart disease (such as rheumatic heart disease)
• Have other types of valve disease (except mitral valve prolapse without thickening or regurgitation/leaking)
To prevent infective endocarditis:
• Tell all your doctors and dentist you have valve disease. You may want to carry a card with this information.
• Call your doctor if you have symptoms of an infection. Do not wait a few days until you have a major infection to seek treatment. Colds and flus do not cause endocarditis. But infections, which may have the same symptoms (sore throat, general body aches, and fever) do. To be safe, call your doctor.
• Take good care of your teeth and gums. See your dentist for regular visits.
• Always carry your American Heart Association bacterial endocarditis card.
• Take antibiotics before:
• dental procedures
• procedures on the bowel or bladder
• Check with your doctor about the type and amount of antibiotics you should take. Plan ahead to find out what steps you must take before the day of your appointment.
Medical Treatment of Vlave Disease
Your medications are used to control your symptoms and help your heart pump blood more efficiently. Some medications may be stopped if you have valve surgery to correct your problem. Others may need to be taken lifelong.
Follow your doctor's instructions when you take your medications. It is important to know:
• the names of your medications
• what they are for
• how often and at what times to take your medication.
• Keep a list of your medications and bring them to each doctor visit.
• If you have questions about your medications, ask your doctor or pharmacist.
Common types of medications
• Diuretics ("water pills") remove extra fluid from the tissues and bloodstream; lessen the symptoms of heart failure
• Antiarrhythmics control the heart's rhythm
• Vasodilators lessen the heart's work. Also encourages blood to flow in a forward direction, rather than backwards through a leaky valve
• ACE inhibitors a type of vasodilators used to treat high blood pressure and heart failure
• Beta blockers treat high blood pressure and lessen the heart's work by helping the heart beat slower and less forcefully. Used to decrease palpitations in some patients
• Anticoagulants ("blood thinners") prolong the clotting time of your blood, if you are at risk for developing blood clots on your heart valve. See coumadin for more information
.See your cardiologist for regular visits.
You will need to schedule regular follow-up appointments with your cardiologist to make sure your heart valves work as they should. Ask your doctor how frequent theses should be spaced. Call your doctor sooner if your symptoms become more severe or frequent.
Schedule regular appointments with your cardiologist (even if you have no symptoms).
Your appointments may be spaced once a year or more often, if your doctor feels you need to be followed more closely.
Your appointments should include a medical exam, and diagnostic studies (such as an echocardiogram) may be repeated at regular intervals.
Call your doctor sooner if your symptoms worsen or become more severe or frequent.
If you ARE having symptoms, or if diagnostic tests show your valve disease is severe, your doctor may suggest you undergo an invasive procedure or heart surgery.
Medications, surgery and other treatments will not fully cure your heart valve disease. You will always need lifelong medical follow-up to make sure your heart valves work as they should.