If I have a heart murmur, does that mean that I will also develop heart disease?
Not necessarily. A heart murmur is generated by blood flowing through the heart. In most people, blood flows quietly through the heart. In other people, this blood flow can be heard with a stethoscope as a "heart murmur" during a physical examination. Heart murmurs can be a normal finding, a sign of cardiac disease, or a result of noncardiac conditions. It is also important to note that heart murmurs may come and go or vary in intensity from time to time.
Heart murmurs are oftentimes caused by abnormalities in the heart's structure. The two most common causes of murmurs are narrowing of valves (called stenosis) or leaking of valves (called regurgitation). Based upon the features of a heart murmur in conjunction with other physical exam findings, I can generally differentiate narrowed valves from leaky valves, determine which of the four heart valves is abnormal and gain a rough idea of the severity of the problem. Congenital heart diseases (problems present at the time of birth) are another very important cause of heart murmurs. An echocardiogram is often helpful in determining whether these conditions are present and the severity of the problem.
Occasionally, high rates of blood flow across normal heart valves can cause a murmur, which is sometimes labeled a flow murmur or innocent murmur because it does not reflect an underlying abnormality in the structure of the heart. These murmurs can become more pronounced when circulating blood flow is increased, as is the case during pregnancy or in disease states such as hyperthyroidism or anemia. While not every heart murmur requires additional diagnostic testing, an echocardiogram may often be helpful in further evaluating murmurs. If you have a murmur and underlying heart disease has been excluded, you are generally not at increased risk of developing cardiac disease in the future.
Do I have to take prophylactic antibiotics before any kind of surgery, including dental, if I have a heart murmur?
You need to discuss this with your healthcare provider. It depends upon both the cause of the heart murmur and the type of surgical procedure planned. Not all murmurs reflect disease of the heart's valves. However, when the heart valves are significantly diseased, you should use antibiotics at the time of dental work and other nonsterile procedures such as urinary catheterization, prostate surgery, tonsillectomy/adnoidectomy, or certain gastrointestinal procedures.
The purpose of prophylactic (preventative) antibiotics are to reduce the risk of endocarditis, a serious bacterial infection of the heart valves. Dental work, for example, produces a brief rise in bacterial counts in the blood due to the small amounts of bleeding that occurs in the mouth. This bleeding provides a passageway for the bacteria that normally live in our mouths to get into our bloodstream. Normally, this poses no significant threat to us. However, when heart valves are abnormal, there is a chance that bacteria could "seed" the abnormal valve, leading to a serious infection of that valve. Antibiotics, usually taken by mouth 60 minutes before the dental procedure, represent an effective way to prevent such infections.
Mitral valve prolapse is one common problem in which prophylactic antibiotics are used. This is a problem of one of the four heart valves (the mitral valve) in which a part of the valve extends to far backward each time the valve closes. Some cases of mitral valve prolapse (when there is no accompanying leaking of the mitral valve) may not require antibiotics. You should review the particulars of your case with your healthcare provider. An echocardiogram can often be helpful in clarifying the nature of your murmur and the condition of your heart valves when uncertainty exists.
What is the difference between heart valve replacements made from metal and tissue?
There are several important differences between mechanical and biological (tissue) heart valves. In simple terms, one must balance the risk of using long-term blood thinners (mechanical valves) against the risk of the valve wearing out and requiring another valve replacement operation in the future (biological valves).
The major advantage of mechanical valves is their durability. In young patients this is particularly important because they may need the valve for many years. Mechanical valves have been reported to last for several decades, a record much better than for biological valves. The major disadvantage is the tendency for blood clots to form on mechanical valves. Not only could blood clots cause the valve to malfunction, but also they could lead to strokes or other serious problems. For this reason, anticoagulation medications are required. Anticoagulants are commonly referred to as blood thinners and warfarin (brand-name Coumadin) is the most frequently prescribed formulation. Unfortunately, these medications carry a risk of bleeding.
On average, a person on anticoagulants has a one to two percent chance of having a significant bleeding episode for each year of use. In addition, blood thinners require regular blood tests to monitor their level, careful compliance and attention to diet in order to keep the blood thinned to the proper level. I am reluctant to prescribe anticoagulants in some situations (and therefore reluctant to place a mechanical valve). These reasons include the desire of a woman to become pregnant, risk of falling, previously diagnosed bleeding disorders, a history of poor medical compliance and a history of alcoholism. On the other hand, if you already require long-term blood thinners for another reason, mechanical valves are generally preferable.
Biological valves, in contrast, have less durability over time, which means that there is a greater potential need for re-operation. For older patients, this may not be a great disadvantage as the projected life-span is typically shorter in this group of patients. As mentioned previously, biological valves are preferred in situations where use of anticoagulants is particularly undesirable.
What exactly is hypertension (high blood pressure)?
High blood pressure is a chronic disease that, in and of itself, usually produces no symptoms. It is also known as hypertension and refers to a condition in which the pressure of the blood within the arteries is at a higher level than normal. Blood pressure is measured using a sphygmomanometer, which is a fancy name for a blood pressure cuff. It should be measured after at least five minutes of relaxation while at rest in a sitting position. The blood pressure is reported as two numbers: the systolic blood pressure (top number) and the diastolic blood pressure (bottom number). The unit of measurement for blood pressure is millimeters of mercury. We need two numbers to describe a person's blood pressure because the blood pressure is constantly changing during the course of each heartbeat. Systolic blood pressure is the highest pressure reached during each heartbeat, whereas diastolic blood pressure is the lowest.
How high is too high has been a matter of debate amongst doctors and has undergone redefinition over time. Currently, we consider blood pressure normal when the systolic pressure is less than 130 and the diastolic pressure is less than 85. High blood pressure is considered to be present when the systolic blood pressure is greater than 140 and/or the diastolic number is greater than 90. Using this criteria, it is estimated that nearly one in every four adults in the USA (or 50 million people) has hypertension. Each year, two million people are newly diagnosed with high blood pressure. It is important to recognize that blood pressure constantly fluctuates and, therefore, several recordings are required before hypertension can be diagnosed. Blood pressures between 130 and 140 systolic or 85 and 90 diastolic are considered "high-normal" and should be monitored more closely. There are some individuals whose blood pressure seems to be higher when they visit their healthcare provider, a condition commonly referred to as white-coat hypertension. For these patients, home blood pressure cuffs are often helpful to evaluate and monitor blood pressure.
Studies have shown that treatment of hypertension can have a major beneficial impact on reducing the risk of complications. With regards to the treatment of hypertension, I would like to make several comments. First, it is important to consider underlying medical causes for hypertension that can be treated. This includes certain kidney and endocrine (hormone-related) diseases. While this accounts for less than five to ten percent of all patients with hypertension, it is important to try to detect such conditions.
Second, non-pharmacological approaches to control hypertension should be instituted first. This includes efforts at losing weight, decreasing alcohol consumption to less than two drinks/day (or even stopping), decreasing dietary salt intake, and increasing aerobic exercise. Such modifications can reduce or even normalize your blood pressure.
Third, if medications are started, it is important for your doctor to gradually increase them until the blood pressure has been normalized. Many patients with hypertension are under-treated and their blood pressure remains above the normal range due to insufficient doses or too few medications. Often several medications must be used together to normalize blood pressure.
Fourth, if you experience side effects from the medications, you must discuss this with your healthcare provider. There are many medications available for treating high blood pressure and there are usually alternative choices that may be better tolerated.
Finally, since the main goal of treating hypertension is to prevent the development of cardiovascular disease, it is important to address all other cardiovascular risk factors. This includes treatment of high cholesterol, smoking cessation, weight loss, and control of diabetes.
What are the dangers of hypertension?
Hypertension is often referred to as the "silent killer." This is because most people with hypertension feel fine. Despite feeling fine with high blood pressure, it causes a wide variety of serious conditions such as cardiac disease, stroke, kidney disease, and peripheral vascular disease.
Hypertension produces damaging effects on the inner surface of the body's arteries, contributing to the formation of blockages in these blood vessels, a condition known as atherosclerosis. This can occur in all parts of the body, including the heart, kidneys, brain and arteries of the legs. In the heart, hypertension is considered to be one of the major risk factors for heart attack and coronary artery disease. In the kidneys, hypertension may lead to a gradual, progressive decline in kidney function. Hypertension is one of the major causes of renal (kidney) failure and the need for kidney transplantation or renal dialysis. With regards to stroke, hypertension is the number-one risk factor promoting stroke.
As we have discussed, hypertension is a chronic disease process that usually produces symptoms only when it begins to cause damage to the body. However, there is one important condition to be aware of: malignant hypertension. This is a condition in which you may feel a headache or notice visual disturbances. In cases of malignant hypertension, the blood pressure is usually extremely high, with systolic blood pressures often well in excess of 200! This condition is a potentially fatal medical emergency, requiring prompt treatment and careful monitoring in an intensive care facility until the blood pressure and other symptoms are stabilized.
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