Heart Murmur in the Morning?

[cbjulian]

Hello. I am a 20 year old male. I have a Littmann Cardio. Stethoscope and I have noticed when I listen to my heart I can never hear my murmur unless it's in the morning. I am 100% positive about this. The murmur disappears during the day and returns most mornings. It is most audible at the mitral and apex area and I have been diagnosed with a bicuspid aortic valve.

Any ideas why it only shows in the morning?

[Jack54]

I agree with my friends here about not becoming obsessed with your murmur. However a bicuspid aortic valve is a very serious matter for someone even at your age, and I understand the nature and seriousness of your question.

How was your bicuspid valve diagnosed? I am sure that you know you need to live a very healthy lifestyle with no bad habits, and stay in touch with your cardiologist. It is good that you can recognize or hear the murmur. From what I have read, they are associated with a bicuspid valve.
Welcome to the board and good luck to you. I have posted some explanations and precautions that I am almost positive that you are aware of, but I wanted to be extra sure :)

Jack
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Bicuspid Aortic Valve

Medical Care:

No specific medical care is required for individuals with bicuspid aortic valve, unless they have progressive deterioration or infection. Serial follow-up evaluations are important for early recognition of potential complications (valve insufficiency, valve stenosis, progressive aortic root dilation) and the prevention of possible bacterial endocarditis.

Patients with bicuspid aortic valve are at increased risk for infective endocarditis. Prophylactic antibiotics are required for dental or surgical procedures as recommended by the American Heart Association. A single dose of antibiotic is generally administered approximately 1 hour before an invasive procedure (ie, one that has the potential to produce bacteremia). Follow-up doses are not usually required. For more information, see Antibiotic Prophylactic Regimens for Endocarditis.

Aortic root dissection:

Findings on histologic studies of the aortic root in individuals with bicuspid aortic valve are controversial. Enlargement of the root is often attributed to poststenotic dilatation. However, the root may dilate without significant valve stenosis, and abnormal histology consistent with cystic medial necrosis has been identified in a number of studies.

The risk of aortic root dissection is much higher for individuals with Marfan syndrome (approximately 40%) than for those with bicuspid aortic valve (approximately 5%). However, because bicuspid aortic valve is more prevalent in the general population, this disorder is more commonly associated with aortic root dissection.

Prognosis:
Overall prognosis for the individual with bicuspid aortic valve is good. Reviews and reports in the past have emphasized the fairly benign course for patients with bicuspid valves. However, more recent reports on the natural history of these valves suggest a number of more serious problems and an acceleration of normal valvular wear and tear. These problems may not develop until adulthood. Routine and regular follow-up for the child or adolescent with bicuspid aortic valve is recommended.

Stenosis of a bicuspid aortic valve is more likely to develop in persons older than 20 years and is caused by progressive sclerosis and calcification. High levels of serum cholesterol have been associated with more rapidly progressive sclerosis of the congenitally bicuspid aortic valve.
Children who develop early progressive, pathologic changes in the bicuspid aortic valve are more likely to develop valve regurgitation than stenosis. Bicuspid aortic valve was identified in 167 (0.8%) of 20,946 young Italian military conscripts. Of these, 110 were found to have either mild or moderate aortic insufficiency.

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I have tried to explain a possible theory on why the murmur occurs only during the morning, by using some excerpts from various web sites. Basically the viscosity of our blood is lower (thicker) in the early morning, and our autonomic system wakes up with an erratic surge maybe. The later would probably be involved more with acute events such as strokes, etc.
Early morning blood viscosity and ischemic events:

Abstract:
Early-morning blood pressure is generally viewed as an important therapeutic target, for two reasons. First, for antihypertensive agents taken once daily in the morning, the timing of the trough plasma drug level, and thereby the lowest pharmacodynamic effect, often coincides with the early morning rise in blood pressure and heart rate. Evidence has been accumulated to suggest that blood pressure control throughout the 24 h period may be necessary to gain complete benefit from antihypertensive medication. In fact, in a longitudinal study, the regression of cardiac hypertrophy in patients with hypertension was more accurately predicted by treatment-induced changes in average 24 h ambulatory blood pressure than by clinic or home-monitored blood pressure readings.
The other reason for the importance of morning blood pressure is that cardiovascular risk is heightened at this time of day.

A morning surge in sympathetic activity alters haemodynamic forces and predisposes vulnerable coronary atherosclerotic plaques to rupture. At the same time as this risk of plaque rupture is greatest, circadian variations in haemostatic and fibrinolytic factors result in morning hypercoagulability and hypofibrinolysis, promoting the formation of intraluminal thrombi. We recently showed that, in older hypertensives, a greater morning blood pressure surge, mediated at least in part by an exaggerated [alpha]-sympathetic activity, is associated with more advanced silent cerebrovascular disease as well as a higher future incidence of stroke. The early morning surge in blood pressure could become a new therapeutic target for preventing target-organ damage and subsequent cardiovascular events in hypertension. Of greatest interest is the potential benefit of a chronotherapeutic approach, involving, for example, long-acting chronoformulations, which has not yet been extensively studied.

http://www.bpmonitoring.com/pt/re/bpm/abstract.00126097-200112000-00015.htm;jsessionid=HHxXLzgLG0GW59C6ZsqHr8zLcssrgXlTnlflHyKt2XLTGq7mgRBP!1105064230!181195628!8091!-1
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The relevance of other triggering factors remains unproven. Increase in platelet aggregatability and activation, 23,24 increase in hematocrit and blood viscosity,25 increase in catecholamines and sympathetic tone,24,26 decrease in fibrinolytic activity,27 decrease in endogenous tissue plasminogen activator activity corresponding to levels of plasminogen activator inhibitor,27,28 and circadian fluctuations in central dopamine activity,29,30 may result in an increased susceptibility of the brain to ischemia during the morning hours.
The rapid physiologic increase in blood pressure, particularly after awakening in early morning, may lead to over response of autoregulation.
http://www.kfshrc.edu.sa/annals/143/93068.html
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A morning increase in platelet aggregability, blood viscosity and haematocrit has also been suggested as factors triggering cerebral and myocardial infarction.[28-31] Physical and mental stress at the time of wakening could be triggers to rupture of a vulnerable plaque.[28] Morning reduction of cerebral vasomotor reactivity may be related to early morning stroke risk[32] Peak levels of lipoprotein-a and fibrinogen have been found to coincide with repeated morning peak frequencies of myocardial infarction and stroke[33]
http://www.medscape.com/viewarticle/515642_4

[ireneo]

Or maybe he's a med student or has a strong family history of heart problems. How many people can even hear a murmur unless it's severe.

[maggiemag]

Why on earth is a 20 year old guy sitting around listening to his heart beat with a steth?  Throw it away and go out and party!  Go meet some friends, go to a movie, but do not focus on your health and become a cyberchondriac.  Please.

[ireneo]

Do you listen while still in bed, in a prone position? Do you have any trouble with fluid retention? Or perhaps you're a bit dehydrated in the morning and that changes the way the valve opens and closes. I'm just guessing here.