Routine Physical Goes Wrong

[Buf- CR]

I am a 28 y/o white male, 175 lbs, 5'9. Chol 198 B/P 117-135/70-85, run 3-4 miles per day, lift weights.

Recent routine physical (1st compl. phys in 12 yrs) disc. previously undiscovered murmur. Echo revealed:

M Mode: LA Size 3.5 AoRoot 4.1 RV 2.4 LVED 5.6 LVES 3.2 EF 72% IVSed .8 IVSes 1.4 LVPWed .9 LVPWes 1.5 No peri. eff.

Dop.: MR- mild TR-trivial PR-mild PS-16 mmHg.

Rep.: fair parasternal, fair apical views, normal left vent. size & contracility, normal right vent. size & contractility, normal left & right atrial sizes - prom. Eust. valve (benign var.), mobile interarial septum thickened as with lipomatous hypertrophy, dilated aortic root - 4.2 cm, no sig. pericardial disease, thickened aortic valves that open well, mitral valve leaflet show redundant chordal structures and mild mitral regurg., tricuspid leaflets are mobile and show triv. regurg., pulmonic valve leaflets in some views show some doming, gradient across of 16 mmGh and mild. pulm regurg, no intracardiac thrombus or mass.  

Impr.: good left vent contractility, mild pulmonic stenosis, mild aortic valve sclerosis with dilated aortic root, mild mitral regurg.

Ques:
1) Could you explain this report? How abnormal are these findings?
2) No hist. of rheumatic fever & no doctor has ever disc. a murmur/valve problems before, what would cause this?
3) What is the likelihood of progression?
4) Lifestyle limitations?
5) Would you recommend an ACE inhibitor to prevent calcif. of valves?
6) Given aortic scl. should I get a stess test or C-reactive prot. test?
7) Any recommendations?

Thanks

[CCF-M.D.-MJM]

Hello,

We don't see a lot of pulmonary stenosis and pulmonary stenosis is rarely cased by rheumatic fever, especially if there is no other significant valvular involvement--and it doesn't look like there is.

It is hard to tell if this was truly a new murmur or just one not heard before.  Sometimes murmurs change in there character and hint in a change to their severity, but the only way to tell is to actually listen to it yourself (or myself, over time).

1) Could you explain this report? How abnormal are these findings?

The notable things on this report are the pulmonary stenosis, which is mild, and the mildly dilated aortic root.  It would be interesting to see this echo to see how prominent these findings are.  It is difficult to tell in a written report.

2) 2) No hist. of rheumatic fever & no doctor has ever disc. a murmur/valve problems before, what would cause this?

You correct that this is not a rheumatic valve.  This is likely a congenital problem, one that you were born with and hasn't been discovered until now.  It is possibly of genetic origin.  I cannot tell without seeing the echo and even then I may not be able to tell.

3) What is the likelihood of progression?
I don't have a lot of experience with pulmonary stenosis.  I would follow it with echo's and certainly if you started to have symptoms of increasing shortness of breath or swelling in your legs, would re-evaluate with echo.  If you problem is simply pulmonary stenosis, excellent results are obtained by dilating the valve with a balloon.  Surgery is not needed.  I would also follow the size of your ascending aortic arch, which is mildly enlarged.  It is hard to tell, but it may eventually need replaced.

4) Lifestyle limitations?  No

5) Would you recommend an ACE inhibitor to prevent calcif. of valves?

If you blood pressue is not elevated, I don't think an ACEI is indicated.  I would not start it to prevent calcium on the valve because I don't think there is good data to suggest that ACEI really do this.

6) Given aortic scl. should I get a stess test or C-reactive prot. test?

No stress test unless you are having symptoms.

CRP would be interesting, but good diet and exercise is all I would do for someone your age.  If the CRP was exceedingly high, I would look for the cause, but I doubt this is the case.

7) Any recommendations?

I would not stress about this and just have it followed with serial exams and echo's when indicated.  If will ask around a bit about your echo and see if some of my collegues have other ideas.

Hope this helps.

[Erik36]

My opinion is that the thickening or mild enlargement that your echo shows is related to your level of fitness. People who run a lot over a period of time usually have a slightly enlarged heart due to exercise. The Mild and trivial leakage of your valves is probably nothing to be concerned about. Most people who have echos have some degree of leakage. The mild pulmonic stenosis is something that should be watched with follow-up echos but probably won't be a problem. I think that most of the findings on the echo fall into the category of normal variances.

I think you are doing a lot of the right things and should continue.


I am not a Doctor and this is just my opinion and shouldn't be mistaken for medical advice which you should only get from your own doctor.

Good luck!

Erik

[lak]

Hey Erik,

I was hoping you would be around today.  I have talked with you before about my arthymia.  PVC,TRI,BI, Left Bundle Branch Block.
I just wanted to ask you about the pain.  My pain has moved to the left side of my heart, upper chest toward arm.  It is very painful and moves into my jaw and cheek area. It is sharp and frequent.  It just started really being annoying the last couple of weeks, probably stress related but I was just curious when you have pain with yours, what type of pain and where it is located?

[Erik36]

When I get pain it is on the left side of my chest and it goes into my shoulder and armpit area. I believe it is stress also. I have anxiety so I think that can cause it. Sharp pains usually don't indicate Cardiac pain. I would check with your doctor make sure everything else has been ruled out. These pains probably don't come from an Arrhythmia. Good luck.

Erik

[lak]

Thanks for the response Erik.  I do think it is stress related. I have had all tests including chest e-ray and that is the only think I would think it could be where it is located.  But, it is where you indicated upper chest next to armpit.  But, I never have had pain in my armpit. Maybe stress muscle spasm.
I do have an old whiplash injury that bothers my neck but this pain and just surfaced here lately.
I do have a stressful life though, I am an administrative assistant, wife, mother and grandmother.  I have a 21 year old son still living at home and has not done well in college so thats probably enough to send anyone over the edge.....

Thanks again,
Lisa

Do you have pain with your pvcs and if you do where? I am not sure in your answer you defined that.

[lak]

Boy! For someone who is an admin I sure made alot of typo's in my post  Ha Hope you can make it out

[Erik36]

Sometimes I will get a twinge of pain in my chest that lasts as long as the PVC does. It is very brief but very scary. I have learned to live with this. If you are stressed then your muscles in your chest wall may get tense in response to your PVC. Treat the anxiety and the pain will get better. Paxil has helped me a great deal. I also take Toprol XL. Good luck!

Erik

[knicks30]

Hold on to the topic starter....and to everyone i have a question.

If he has thickening of his heart...like LVH, can he still keep at the same fitness level?

Or what about if you have LVH from high blood pressure? Can you still lift weights or at least to sit ups and push ups since its isometric exercise?

[Avel]

Hi,
I would like to encourage you to be further checked by a center that is familiar with congenital connective tissue conditions that may affect the heart valves and aorta.  Recommendations about exercise, blood pressure treatment, etc. are important for anyone with an enlarged aorta.

Echocardiography does not always reveal the presence of a bicuspid aortic valve, which is a congenital condition that can also involve other heart valves and enlargement of the aorta.

Here are some links that may be helpful.

http://www.cedars-sinai.edu/aorta
http://www.bicuspidfoundation.com

Best Wishes,
Avel