Heart Murmurs, Part 1 "Innocent" Murmurs

Heart murmurs are sounds made by blood moving through the valves that control the flow of blood between the chambers of the heart or to the major blood vessels leaving the heart.  They are usually described as a "whooshing" sound, occurring at a certain point during the "lub-dub" cycle of each heartbeat.  Click here to listen to examples of heart murmurs.

What causes heart murmurs?  Most heart problems, including coronary artery disease, are not typically associated with heart murmurs. When present, however, they may indicate that a heart valve is diseased.  The murmur produced when a valve is diseased comes from turbulence when blood is forced through a constricted heart valve or through a heart valve that does not shut completely.  Sometimes heart murmurs can be heard with perfectly normal hearts.  For example, with pregnancy or in conditions such as anemia or with an overactive thyroid, the heart may be required to beat faster or to have to pump a greater amount of blood than usual.  In these situations a murmur may be heard even though the heart is not diseased.  Even more common than this type of murmur is the so-called "innocent" murmur.  These murmurs are also termed "functional" or "physiologic" murmurs because the sound is produced by normal blood movement through the heart's chambers, valves, and blood vessels. Innocent murmurs are commonly seen in newborns and in children and are quite harmless.  It is estimated that at some time in their lives most children will have an innocent heart murmur.  In most instances children "grow out" of the murmur with the sound disappearing by adulthood.

How are murmurs diagnosed?  Most murmurs are found when listening to the heart through a stethoscope during a regular exam.  The likelihood that the murmur represents a disease process hinges on a number of factors including the patient's age, associated symptoms, and certain characteristics of the murmur, such as its loudness and position during the heart cycle.

How are innocent murmurs distinguished from those requiring medical attention?  Sometimes, when a murmur is first heard, tests may be necessary to help distinguish an innocent murmur from something more serious.  Tests that help with this include chest X-ray, electrocardiogram (EKG or ECG), or echocardiogram (sometimes called an "echo").

What should be done about innocent murmurs?  An innocent heart murmur is not a disease and does not pose a health threat.  Innocent murmurs have nothing to do with congenital heart disease, such as having a "hole in the heart" (septal defect).  No medication or other treatment is required.  Children with innocent heart murmurs can run, jump and play with no limits on their activity.  It is especially important that they not be labeled as being "sickly" or "weak" because of an innocent murmur.  The child can be as active as any other normal, healthy child.

Some innocent murmurs may persist throughout life.  When this is the case, taking special precautions or treatment is generally unnecessary.  The outlook and treatment for abnormal heart murmurs depends on the type and severity of the heart problem causing them and will be discussed further in next week's Health Tip.

Tennis elbow, which treatments work?

Tennis elbow is the common name for an overuse injury that results in pain on the outside (lateral aspect) of the elbow. The name comes from its association with playing tennis, although in most people tennis elbow develops for reasons other than a flawed backhand stroke.  Known in the medical literature as "lateral epicondylitis", tennis elbow occurs where the forearm muscles and tendons attach at the elbow.  Repetitive use of the forearm muscles, as when using a hammer or screwdriver, leads to "micro-trauma" at this attachment with ensuing inflammation.


How do you know if you have tennis elbow?  The signs and symptoms of tennis elbow may include: 1) pain at the bony prominence (lateral epicondyle) on the outside of the elbow, 2) pain that is worse when squeezing objects or shaking hands and, 3) the sensation of weakness when attempting to grip or lift because of discomfort.

How is tennis elbow diagnosed?  Doctors who have seen this condition often can often make the diagnosis from a description of the symptoms alone.  There are no diagnostic blood tests and x-rays are usually shown to be normal.  A few simple physical maneuvers performed by the doctor helps to confirm the diagnosis.  Rarely other tests, such as a nerve conduction study or MRI, may be recommended, but this is done to investigate for other conditions rather than to confirm the diagnosis of tennis elbow.

How is tennis elbow treated?  Conservative treatment involves rest, ice, stretching, strengthening, avoiding activity that hurts, and, as inflammation resolves, strengthening exercises.  Taking anti-inflammatory medications, such as ibuprofen, may help for the discomfort associated with tennis elbow, but there is little evidence that it helps to hasten its resolution. If self-care is ineffective, other treatment measures include:

• Corticosteroids.  For severe or persistent pain, a corticosteroid injection can often provide short-term benefits.  Steroids can also be delivered without injecting via a physical therapy modality called iontophoresis.
  
  
• Counterforce bracing.  The so-called tennis elbow strap is widely available in sporting goods stores.  They are worn around the forearm, just past the bony prominence (lateral epicondyle) of the elbow.  While the results of studies evaluating their usefulness are mixed, many people with tennis elbow find relief during activity while using this device.
  
  
• Physical therapy.  Initial physical therapy measures include application of ice, use of ultrasound, deep-tissue massage, and iontophoresis, with or without corticosteroids.  Once the initial pain and inflammation has calmed down, a gradual stretching and strengthening program can improve functional activities and promote a return to normal function.
  
  
• Extracorporeal shock wave therapy (ESWT) is a newer treatment used occasionally for tennis elbow.  Focused shock waves are delivered to the region of the bone-tendon connection at the lateral elbow.  Studies evaluating ESWT in tennis elbow have not shown consistent benefit in terms of improving pain and function.
  
  
• Surgery.  Ninety to ninety-five percent of people with tennis elbow will improve with conservative treatment.  Surgery should only be considered for persistent symptoms that have not responded to conservative care.  Most surgical procedures for tennis elbow involve removing diseased muscle and reattaching healthy muscle back to bone.

Can tennis elbow be avoided?  When lateral epicondylitis develops in tennis players, it is usually due to poor technique or improper equipment.  Equipment modification (lower string tension, increase grip size, reduce the size of the racket head, etc.) can help as can attention to proper racket swing technique.  Since tennis elbow may occur in the occupational setting also, attention to ergonomics and proper technique, particularly in those who perform repetitive activities is important.

Fish may really be "brain food"!

Some old wives' tales, such as arthritis resulting from cracking knuckles, have not held up to scientific scrutiny.  Others have stood the test of time, such as the idea that drinking cranberry juice can help fight urinary tract infections.  The concept of fish being good for the health of the brain has also gained credibility from recently published reports.

The protective benefits of fish appear to be related to its high content of omega-3 fatty acids.  Fatty fish like salmon, flounder, halibut, sardines and tuna are particularly high in omega-3 fatty acids.  For some time now, consumption of omega-3 fatty acids has been considered beneficial for those at risk for, or who have, heart disease.  The American Heart Association recommends eating fish at least two times (two servings) a week.

Omega-3 fatty acids are highly concentrated in the brain and appear to be important for cognitive (brain memory and performance) function.  Eating fish, particularly those with higher levels of omega-3 fatty acids, appears to maintain healthy levels of fatty acids in the brain and prevent the loss of brain tissue and cognitive function.

One study supporting the role of fish in maintaining brain health was recently presented at the annual meeting of the Radiological Society of North America.  This study involved 260 elderly subjects in whom brain volume was measured by MRI scanning at the beginning and at the end of the study period.  Over a period of time that averaged 10 years, those subjects who ate fish at least once a week showed less loss of brain tissue in the areas of the brain responsible for regulating memory (hippocampus and frontal cortex).  Perhaps more importantly, fish eaters were significantly less likely to develop dementia or Alzheimer's disease.

A second, recently published study by UCLA researchers involved over 1,500 normal subjects who averaged 67 years of age.  Each subject underwent MRI scanning of the brain as well as tests to measure mental functioning and omega-3 fatty acid levels in their body.  Study subjects with the lowest levels of omega-3 fatty acids were found to have loss of brain volume equivalent to approximately two years of brain aging, and performed worse on tests of memory and reasoning.  This supports the notion that a diet lacking in omega-3 fatty acids could cause the brain to age faster and lose some of its memory and thinking capabilities.

Neither of these studies was designed to determine the optimal amount of fish consumption necessary to maintain brain volume and cognitive function.  Nevertheless, the recommendation from the American Heart Association of getting at least 2 servings of fish per week seems reasonable from the standpoint of both heart and brain health.

It is not known if taking fish oil supplements provides the same level of benefits as eating fatty fish.  Most experts, however, say that it's best to get nutrients from food.  For people who dislike eating fish or are strict vegetarians, omega-3 supplements, or products fortified with algae oil DHA may be a reasonable substitute.  One concern regarding fish consumption relates to the high level of mercury that some fish contain.  For this reason, it is best to avoid eating king mackerel, shark, swordfish, or tilefish (golden bass or golden snapper).

Should I be concerned about infections caused by "flesh-eating bacteria"?

Recently, several reports of infections caused by "flesh eating bacteria" have appeared in the news.  Such infections have been responsible for amputations as well as death.  In one instance, the infection appears to have developed after a serious cut was exposed to contaminated water.  Just how common is this disease and do we need to be concerned about becoming infected if we cut ourselves outside?

What are "flesh eating bacteria"?  The term refers to several different types of bacteria that are capable of causing a disease known as necrotizing fasciitis (neck-row-tize-ing fash-e-i-tis).  Most commonly, this is caused by an invasive type of Streptococcus, a bacterium similar to the one that causes strep throat.  The term "flesh eating bacteria" is actually a misnomer since the bacteria are not actually "flesh eating".  The destruction of tissue is due to harmful substances (toxins) that are released by the bacteria.

How does necrotizing fasciitis develop?  It is not uncommon for a skin cut or scrape to become infected.  Most of these infections, however, are caused by relatively benign organisms that the body fends off, or that can be treated with common antibiotics.  Necrotizing fasciitis develops when one of the so-called "flesh eating" bacteria enter the body through a break in the skin.  The bacteria multiply along connective tissue planes (fascia) that separate the skin from underlying muscle, an area that is poorly defended by the body.  Toxins are then released by the bacteria that can destroy skin, fat, and the tissue covering muscles within a very short time.  If not treated, the bacteria may enter the blood stream and spread throughout the body.  Necrotizing fasciitis is fatal in approximately 25% of cases.

How common is necrotizing fasciitis?  Necrotizing fasciitis is considered to be a rare disease.  The Centers for Disease Control (CDC), has reported up to 15,000 infections each year caused by invasive Streptococcus bacteria, but only a small percentage of these result in necrotizing fasciitis.  Necrotizing fasciitis is seen most commonly in those individuals whose immune system is compromised, such as someone with diabetes or cancer.

What are the early signs of necrotizing fasciitis?  The initial signs and symptoms include pain, redness, and swelling at the site of the infection along with fever.  The skin changes can progress rapidly, with the development of ulcerations and fluid draining from the infected area.

How is necrotizing fasciitis treated?  It is critical that treatment of necrotizing fasciitis begin as soon as possible. Treatment may include:

• Antibiotics given through a vein (IV) that are specific for the bacteria causing the infection.
• Surgery to remove infected tissue to stop the spread of the infection. On occasion, removal of limbs (amputation) or organs may be necessary to save the person's life.
• Procedures to treat complications such as shock, breathing problems, and organ failure.
• Hyperbaric oxygen therapy (100% oxygen under pressure) may be used for certain types of bacterial infections.
• In some cases, medicines called immunoglobulins (antibodies) may also be used to help fight the infection.

Can necrotizing fasciitis be prevented?  There does not appear to be a common cause linking the cases recently reported in the press.  These infections were apparently caused by different organisms with no common mode of exposure.  "Flesh eating infections" remain rare and most people have nothing to fear, even with the occurrence of minor cuts or scrapes sustained in the outdoors.  It is important, however, that any cut, scrape or puncture wound to the skin be cleaned thoroughly to avoid infection, including one caused by "flesh-eating bacteria".  If rapidly progressing signs of infection (redness, swelling, pus, etc.) develop in spite of taking these measures, medical attention should be sought.