Dear Dr. Roach: When I was discharged from the Army in 1966, I was diagnosed with a heart murmur. It seemed to be insignificant; however, in April 2011 during a routine exam, I was diagnosed with atrial fibrillation, admitted to the hospital the same day and had a cardioversion. Since then, I have had numerous problems with my heart, including a blood clot. Could the atrial fibrillation have been caused by the heart murmur? J.E.T.
A heart murmur is a noise made by the heart that is heard during examination. Many heart murmurs are 鈥渇unctional鈥� or 鈥渋nnocent鈥�: The examiner can hear the blood flowing through a normal valve. These are more common in thinner people or people with a high metabolic rate. Murmurs also can indicate diseased heart valves or abnormal connections (鈥渉oles鈥�) in the heart. Depending on how the murmur sounds, the doctor may choose to obtain an echocardiogram to see whether there is anything wrong. This wasn鈥檛 available in 1966, but it鈥檚 pretty routine now to get an echo for a worrisome heart murmur.
All four valves in the heart can cause murmurs, either from a too-tight valve opening (stenosis) or a valve that leaks when closed (regurgitation or insufficiency). Disease of the mitral valve, which connects the left atrium and the left ventricle, can cause gradual enlargement of the left atrium. As the atrium enlarges, it becomes susceptible to atrial fibrillation, with its attendant risk of clots.
A history of rheumatic fever is the most important risk factor for development of mitral stenosis (a narrowing of the mitral valve); however, many people are unaware of having had it. There are other causes, including congenital mitral stenosis.
So, yes, it鈥檚 possible that the same underlying cause was responsible for your heart murmur more than 50 years ago and your atrial fibrillation now. I would have expected some doctor or nurse listening to your heart between now and then to have heard the murmur again and gotten an echo, so it also is possible that you just happened to have a heart murmur back then and developed atrial fibrillation for some other reason (there are many, many causes besides valve disease) years later.
Dear Dr. Roach: My great-niece is nine years old. She saw her doctor for a bad complexion, and was told that she is stage three for puberty. What does this mean, and how many stages are there? F.N.
Puberty is a process, not an event. It goes on normally for several years.
There are five stages of puberty, usually called Tanner stages. There are specific criteria for development that correspond to each stage. Nine years old is on the younger side for Tanner stage three, but puberty starts at different times for different people, with significant differences that run in families and by ethnic background.
Your great-niece鈥檚 complexion issue probably relates to high levels of adrenal hormones, which start increasing even before puberty. Very high levels early in puberty should raise concern for a condition called congenital adrenal hyperplasia, although most cases of acne in early puberty are quite normal. If the gynecologist is worried, some simple blood and urine tests can tell you more.
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