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Diagnosed with a heart murmur. Found roth spot on eye. Blood test normal. Is this serious?

DOCTOR OF THE MONTH - Nov 2013
Nov 2013
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Hello, I have recently been diagnosed with a heart murmur which my doctor believes is aortic stenosis but am awaiting e chocardiogram. My question is this, sixteen months ago my optician found a roth spot on a routine eye examination. My GP did fbc, esr, crp and several other basic blood tests but said all was fine. He did not check my heart. I want to know if I could be harbouring sub acute endocarditis which has obviously not been treated. I do not have a fever. I am really worried about this as I understand it is fatal if not treated. As a background, I did have rheumatic fever as a child but did not have a heart murmur four years ago when my heart was last listened to and at that time a chest x-ray said heart size was normal size.
Posted Mon, 18 Mar 2013 in Hypertension and Heart Disease
 
 
Answered by Dr. Sudhir Kumar 13 minutes later
Hi,
Thank you for posting your query.
First of all, I would like to reassure you that your clinical findings do not suggest any serious heart diease and there is no risk of severe morbidity or any fatality.
Murmurs suggestive of aortic stenosis (ejection systolic murmur) are relatively common at your age and are often due to sclerotic or calcific aortic stenosis. In this condition, there is thickening and stiffness of muscles & other tissues of the aortic valves, leading to aortic stenosis (narrowing of the aortic valve).
You have very little chance of suffering from rheumatic heart disease at this age, and with lack of any symptoms.
Regarding subacute bacterial endocarditis, you have none of the features, such as fever. Also, your ESR was normal.
So, I am pretty sure your Echocardiogram would not show any features of rheumatic heart disease or subacute endocarditis.
I hope ie helps. Please get back if you have any more queries.
Best wishes,
Dr Sudhir Kumar MD DM
Above answer was peer-reviewed by
 
Follow-up: Diagnosed with a heart murmur. Found roth spot on eye. Blood test normal. Is this serious? 5 minutes later
So please can I be reassured that if I had developed sub acute endocarditis the symptoms if left untreated would have got worse over the past 16 months and not better.
Why did my eye test show up the roth spot (which has now disappeared).

I note that you are not a cardiologist so can I be sure that your reply is accurate. This question is not meant to be rude as I am sure you are a very good doctor.
 
 
Answered by Dr. Sudhir Kumar 13 minutes later
Thank you for getting back with more questions. I appreciate your concern and am pleased to answer your queries.
I agree with you that if subacute bacterial endocarditis (SBE) is left untreated, it would have progressed and worsened over time. In my experience, I have not seen a single patient with SBE presenting without fever or cardiac symptoms (most common are breathlessness and fatigue). Some people also come with long duration fever without any identifiable cause (fever of unknown origin).
Roth spot is a non-specific finding and can be seen in a wide variety of causes, including diabetes and hypertension. Roth spots are small hemorrhages (bleeding) on retina and these hemorrhages are common in diabetes and high BP patients. They do fade or disappear over time.
I had worked at CMC Vellore during 1994-1998 in the departments of Medicine and Cardiology and used to see about five cases of rheumatic heart disease (RHD) per day. (India is among the countries with most number of rheumatic heart disease patients). In fact I remember a visiting cardiologist from US, who mentioned that he saw more cases of RHD in one week at CMC Vellore, compared to what he had seen in 20 years of his practice at USA!
So, I feel you need not worry about endocarditis or RHD at present.
Best wishes,
Dr Sudhir Kumar MD DM
Above answer was peer-reviewed by
 
Follow-up: Diagnosed with a heart murmur. Found roth spot on eye. Blood test normal. Is this serious? 14 minutes later
So as I am allowed one final question would you agree that if untreated sub acute endocarditis had been in my system for 16 months, I would be experiencing acute breathlessness and fatigue rather than just getting out of breath when I go up several flights of stairs. I presume when you say fatigue you mean being too tired to do anything, for instance, not walking around a shopping centre for an hour.
I apolgise for the questions but I was extremely worried that I had developed sub acute endocarditis and that as life expectancy for this disease is approximately one year that the fact that I had now been diagnosed with a heart murmur was a sure sign that I had endocarditis and that it had signficantly progressed.
 
 
Answered by Dr. Sudhir Kumar 10 minutes later
Thank you for getting back.
I agree with you that the symptoms would have been more serious and severe, if someone had SBE for so long and was left untreated. Like, breathlessness on walking a few steps on level ground and severe fatigue so as to not allow even daily hoousehold and basic chores.
I hope it clarifies and reassures you!
Best wishes,
Dr Sudhir Kumar MD DM
Above answer was peer-reviewed by
 
Follow-up: Diagnosed with a heart murmur. Found roth spot on eye. Blood test normal. Is this serious? 12 hours later
Dear Dr XXXXXXX I would like to ask you more about the heart murmur and list some details.
My doctor said the murmur is loud - does this have a bearing on the severity. I also know he said that it transmitted to the carotid arteries - louder on the left than right. Can he tell how severe the situation is by just listening through a stethoscope.
He also said the mitral valve sounded okay-can you say this with listening through a stethoscope.
My blood pressure was 140/90 with pulse 72R. I am on atenolol and perindopril for hypertension.
The only symptoms I have is that I do get out of breath when going up inclines - although I have never been good at this - I can walk for ages on level ground.
Occasionally have experienced a fleeting tightness in my chest lasting maybe less than a minute.
I do not get breathless when lying down. In fact I sleep with only one pillow.
I do not have a cough that wakes me at night although I do have a cough that I have had for many years on and off which my doctor put down to GERD. I did have an chest x-ray between four and five years ago when my heart size was normal and my lungs were clear. Before this the last time I had my heart listened to was four years ago and no one mentioned a murmur then.
I can occasionally feel my heart pumping but this seems to be more since I have known about the situation.
I hope this is enough information for you to give me your assessment of the situation.
 
 
Answered by Dr. Sudhir Kumar 35 minutes later
Thank you for getting back. I am amazed with your details, which are so relevant to your case, and also the fact you remember the relevant details as mentioned by your doctor.

The loudness of the murmur generally correlates with the severity of the stenosis. However, it is not a rule, and exceptions do occur. Regarding radiation to carotids, it is common for murmurs of aortic stenosis to do that, so, it sort of confirms that it is a murmur due to significant aortic stenosis.

Clinical examination with stethoscope is helpful, but the gold standard for assessing the severity is echocardiogram.

Yes, we can make out problems of mitral valve by listening to the heart sounds through stethoscope.

Your other symptoms suggest that you do not have symptoms of mitral valve disease (cough that wakes you up) or that you do not have heart failure (ability to sleep with one pillow).

I hope it clarifies. I would be glad to answer any further queries.

Dr Sudhir Kumar MD DM
Above answer was peer-reviewed by
 
Follow-up: Diagnosed with a heart murmur. Found roth spot on eye. Blood test normal. Is this serious? 7 minutes later
o are you saying that you think the aortic stenosis is now significant and serious rather than your original estimation.

In other words, you know longer believe it to be mild or moderate.
 
 
Answered by Dr. Sudhir Kumar 6 minutes later
Sorry if I made you misunderstand me!

What I meant is that your findings mean that there is aortc stenosis, in that sense, the findings are significant.

This is to differentiate from conditions, where we can hear a murmur similar to what is heard in aortic stenosis (ejection systolic murmur), but the patient would not have aortic stenosis. These conditions are anaemia, young adults, atheletes, pregnancy, etc. In these conditions, the murmur would not be loud, and it would not radiate to carotids.

So, I did not make any comment on the severity of aortic stenosis, but rather the fact that there are good chances of you having aortic stenosis on echocardiogram.

Hope it clarifes.
Dr Sudhir Kumar MD DM
Above answer was peer-reviewed by
 
Follow-up: Diagnosed with a heart murmur. Found roth spot on eye. Blood test normal. Is this serious? 6 minutes later
From the symptoms I have given you are you able to assess how severe you think the aortic stenosis is. In other words would it be controlled by drugs or would I need a valve replacement.
I would add that a few months ago all basic blood tests were normal and I do not have any ankle or feet swelling.
 
 
Answered by Dr. Sudhir Kumar 22 minutes later
It is not possible to judge the severity on the basis of symptoms alone, but I feel it is not severe.

Most likely, you would not require valve replacement.

Best wishes,
Dr Sudhir Kumar MD DM
Above answer was peer-reviewed by
 
Follow-up: Diagnosed with a heart murmur. Found roth spot on eye. Blood test normal. Is this serious? 30 hours later
If my blood pressure is 140/90, the pulse pressure is 50.

Would this indicate aortic regurgitation and is this difference within a reasonable range. Also would the pulse pressure be greater the more severity of the aortic regurgitation.
I have read that a pulse pressure of greater than 60 is what one should be worrying about.

I would appreciate your comments.
 
 
Answered by Dr. Sudhir Kumar 19 minutes later
Thank you for getting back.

I think this is a theoretical question, as all along we had been discussing about the aortic stenosis in your case, and now, you have brought in aortic regurgitation.

Now, coming to your point, a person with aortic regurgitation (AR) can not have a BP of 140/90 mmHg. Typically, in AR, the diastolic blood pressure is reduced, whereas systolic BP remains normal. So, a patient with AR would have BP such as 140/50 mmHg and so on. It is the fall in diastolic BP, that leads to an increase in pulse pressure.

Now, coming to your case, your BP of 140/90 is normal and you do not have aortic regurgitation.

I hope it clarifies.

Best wishes,

Dr Sudhir Kumar MD DM
Above answer was peer-reviewed by
 
Follow-up: Diagnosed with a heart murmur. Found roth spot on eye. Blood test normal. Is this serious? 19 minutes later
Sorry if you think I changed the subject but I have read that aortic stenosis and aortic regurgitation go hand in hand.

Reading on the internet they did not say that it was a low distolic pressure which was important. Just that the pulse pressure would be raised. I could not read anywhere where it said about a low distolic pressure.

In fact on the Mayoclinic site it actually says that a pulse pressure of 50 is abnormal and probably indicates a leaking valve.
 
 
Answered by Dr. Sudhir Kumar 23 minutes later
Thank you for getting back.

I agree with you that aortic regurgitation (AR) and aortic stenosis (AS) can co-exist in the same patient, especially if it is due to rheumatic fever.

However, in your case, the murmur is loud (whereas in aortic regurgitation, the murmur is faint), and the murmur is radiating along the carotids (which never happens in aortic regurgitation). So, the characteristics of murmur in your case are unlike AR.

I think the information on websites may be incomplete or there may be difficulty in understanding. Just to re-emphasise, the diastolic BP is lower in AR, and that is the cause of high pulse pressure.

And also your BP of 140/90 mmHg is normal, and a person with AR can not have a BP of 140/90 mmHg.

Best wishes,
Dr Sudhir Kumar MD DM
Above answer was peer-reviewed by
 
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