Heart Murmur

[chrisyross]

Hi,

I recently went for my JAA initial class 1 medical at Gatwick and everything was fine until the physical examination.
When the doctor was listening to my Heartbeat I could tell something was up as he was spending such a long time taking my blood pressure then listening to my heart again. Eventually he got another doctor in who confirmed a slight murmur could be heard on my Heartbeat. Both doctors said this was a fairly common occurrence and probably nothing to worry about but I would need to get a cardiologist to carry out an echocardiogram.

They said my ECG was fine?

I need to have a decision on my medical before the 13th July as I plan to go abroad to do some flight training (if possible). I know I should have gone for the medical first before making plans but there’s not much I can do about that now.

I was told I had 3 options,

1) Visit my local GP who would schedule a cardiologist appointment.
2) Visit the cardiologist at Gatwick (unfortunately off the day I was there) or one from a CAA List
3) Visit any other Cardiologist privately

Option 1 is no go due to the time constraints so I am going to have to see a cardiologist privately. I was told an initial consultation may cost around £150 (CAA - costs £165 but that includes treadmill) though could cost a lot more if I require ultrasound tests. No one was really too sure of prices though I suppose that depends where you go and what tests they carry out.

Has anyone been in a similar situation?
What prices were they quoted?

One of the doctors did suggested that because I had a slow pulse/heart rate and am quite large (6ft) the heart needs to pump more blood so this could be the cause of the sound - even suggested the cardiologist may say its ok without a in depth investigation due to my size and ECG?

If I were to pursue a career in aviation isn't this going to be a problem every time I need to renew my medical?

Would I have to visit a cardiologist every medical just to make sure everything was fine?

[gingernut]

Chris, it's likely that your going to need an echocardiogram to reassure the medics that everything is ok. (a scan on the heart, simillar to what is performed on pregnant ladies.)


It may be worth approaching your GP, as he may be able to access the test fairly quicky- the delay is probably going to be in the reporting, and it does sound like your working to a tight time frame.

It may be worth giving a private health provider a ring (some one like "BUPA" )and asking them the price for an echiocardiogram.) I've no idea how much this will be, I guess somewhere in the region of about 500 quid.

I tried to look on their web site, but it doesn't appear to be working.

Good luck.

[slim_slag]

Sounds like you have a grade 1 murmur. That's one that you have a good chance of missing if you have been to a loud rock concert the night before, or you are using a cheapo NHS stethoscope because somebody has pinched your fancy cardiology one. Often first picked up by students who don't have a clue what they are listening to but have good hearing, though these walkmans are taking a toll on that.

So it could be considered bad luck they found it in the first place.

An ECG isn't a particulary useful investigation when digging into a grade 1 heart murmur in a fit and healthy youngster. ECG looks at the electrics, heart murmur is down to the plumbing. An echocardiogram uses sound waves to look at the blood flow in the heart, and the fancy electronics can show turbulence in the flow which causes the noise. Sounds like you are on course to shell out a load of money for the test.

This comes up quite a bit with fit and healthy young people doing class 1 at Gatwick, and it appears the CAA have a policy to get a second opinion. Doesn't happen in other parts of the world, and planes aren't falling out of the sky as a result.

[chrisyross]

Thanks for the response.

I've got the list of acceptable cardiologists from the CAA website so i'll try calling a few of them to get and idea of costs.

I'll report back what i find out.

Is this going to be a factor in every medical I get?

[gingernut]

I'm not sure, I'm taking a guess, but it'll likely be dependent on the grading of the murmur, whereabouts in the cycle it's occurring and, probably most importantly, on the initial opinion of the cardiologist, and the results of the echo, if deemed neccessary.

I guess the CAA will be able to tell you more following your initial cardiological consult.


As slim states, these things are sometimes difficult to elicit and interpret objectively, you probably do need the opinion of someone who is doing so on a daily basis.

Thinking about the cost implications, I wonder if it would be worth asking your GP if he has any direct access to echocardiography- it may be possible to combine this with a private cardiac opinion, it may be worth asking.

[Thomas coupling]

Chrisyross: get your ECG done ASAP. Forget the costs, you have a deadline time wise and thats what counts, no?

When the results come back, make sure the reporting officer annotates your notes accordingly so that future medical renewals don't keep re-inventing the wheel with you sending you down the investigative route every time you have an aviation medical. Once it's in print on your records, it's there for everyone to refer to when/if they 'discover' a glitch o the ECG. Ocassionally the CAA 'may' need a review of your predicamnet after 'x' years to see if the situation has changed.

[Hugh Spencer]

When I volunteered for aircrew in 1942, during the medical the doc's said there was a heart murmur but I passed without the condition affecting my RAF service. When I retired my GP heard the murmur and sent me to see a cardiologist and he discovered I had a leaky mitral valve and subsequently I was checked annually but there was no deterioration. I think I was born with it and it has stayed in the same condition ever since, as far as I know.

[slim_slag]

I'm not sure, I'm taking a guess, but it'll likely be dependent on the grading of the murmur, whereabouts in the cycle it's occurring......Come on ginger, you know enough from the first post to say what is going on :) Let's stick our necks out.

It's a grade 1 midsystolic ('ejection' ) murmur in a youngster. Completely innocent.

An echo is a complete waste of time and money from a clinical point of view, but (s)he needs it otherwise every single time it gets pickup the medical will be on the line. That's a CAA policy, and if it's as surmised as above there no evidence I am aware of which makes it a sensible policy.

What would you do if you picked up such a murmur in a primary care setting?

Here you go, cannot beat google. AHA algorithm

http://depts.washington.edu/physdx/images/chart1a.gif

[gingernut]

What would you do if you picked up such a murmur in a primary care setting?

I'd probably be using one of those crappy nhs stethoscopes you mentioned, so it's likely I wouldn't hear it.:)

Your spot on, it's likely to be innocent, but in terms of risk assessment, I guess these guys have got to cover their arses.

[chrisyross]

Thought I would post an update to this problem.

I decided yesterday that I was going to need to see a cardiologist privately if I wanted any chance of having my medical for going to Spain.

I chose to go to one of the cardiologists from the CAA list as it said on my letter that would mean only the report would have to be sent (and not the tape).

When i arrived everything was a bit rushed so never had a chance to ask many questions.

Even though one of the doctors during the class 1 medical had said the cardiologist may not have to carry out a echocardiogram if he felt there was little need for this, unfortunately it didn't say that in the letter it just said I required a echocardiogram to be carried out, so this is what the consultant did.

I was only in for about 10 minutes where he asked me stuff like - was i very active when i was younger and what exercise i do now?.

He commented that I had a large heart (needs less beats) and that my heart beat was slow (44bpm?) for someone who wasn't super fit.

I asked what happened next and he said he would analyse the results then send his report and the video on to the CAA. I think sending his decision to send the video was due to an error reading the letter on his part as he had already planned to do this even before examining me.

Is there likely to be any problem getting my class 1 medical after this examination?

[veetwo]

I had this happen to me at my initial class 1 at Gatwick. I knew the doc was spending too much time listening to my heart and then the next doctor listened for a similar length of time.

Anyway, in the end they both agreed that it was because I was young and said that it was nothing to worry about, no further tests or examinations required. Since then I have revalidated my class 1 twice without any problems whatsoever.

I wouldn't worry ;)

[Bendo]

Hi Chrissy,

It's a good thing your murmur was investigated and you should pay attention to the report issued by the Cardio.

My sister and I were both diagnosed with mid-systolic murmurs as kids - they are pretty common - but mine didn't resolve like my sister's did.

Examination showed a bi-cuspid aortic valve (a genetic abnormality giving my valve 2 leaves instead of 3), and these do have a tendency to narrow and harden over time.

I have held an Aussie class 1 medical for 15 years now with no real problems BUT I will probably need a valve replacement at some stage in the future. I don't know what this means in the UK but in Australia after the operation I will be limited to multi-crew ops only.

Good luck :ok:

[Inverted81]

Hi,
Just to let you know you are not alone! As an ATCO we get issued Class 1 medicals also, but with slightly different criteria.
As a baby i was diagnosed with a murmur, but as i grew up the doc said it was no longer present. Went through an air force medical, and nothing found there either. When i went for my ATCO medical the doc got quite worried, and booked me in for an echocardiogram at a private hospital the following week. The consultant there listened o my heart first and i later found out she panicked as she thought i had some form of aortic murmur (which could be quite dodgy apparently). had the ECG and the consultant told me there and then everything was ok, and in fact i had "beautiful delicate valves" whatever that means! (maybe i pulled! but too late now :( ) Sending the vid is usually standard procedure so that the CAA can sign you off.

I wouldn't worry about it, best it has got checked.. let us know how u get on!
81 :ok:

[chrisyross]

Here is a copy of the letter that was sent to the CAA.



I carried out an echocardiogram on Mr Ross and enclose a DVD of this. He had a resting bardycardia of about 45 bpm. His left ventricular endiastolic dimension was about 5.9 cms. Left ventricular ejection fraction was normal. There was no evidence of significant left ventricular hypertrophy though the posterior left ventricular wall was slightly thicker than the inter-ventricular septum. I looked closely for any evidence of hyper-trabeculation of the left ventricle but this is not really a significant feature. No valvular disease was noted.

My feeling is that the increase in the left ventricular endiastolic volume reflects his resting bradycardia.

Best wishes
Yours sincerely,Does this mean is the murmur is caused by my slow heart rate and is nothing to worry about?

[db16]

I had not even heard of an echocardiogram before the CAA said that it was a requirement for us oldies. I was 65+, went to a BUPA clinic and it cost £150 'cos a technician did it and not a cardiologist! db16

[gingernut]

Hi chrisy, it sounds like the scan was essentially normal. (The important bits are working well).

I'm wondering if the original doc heard a "third" heart sound- sometimes a result of a problem with the heart filling (although your echo would suggest against this), sometimes found in healthy young adults (sounds like this is the case for you.)

I aint no cardiologist, perhaps someone more knowledgeable would care to contribute, otherwise I guess the picture is positive.

Keep us updated. Ginge:)

[slim_slag]

Good man ginger, stick your neck out. Who knows, but the patient did say it was a 'murmur' in his first post......

Chrisy. Load of gobblydegook eh? I guess you want to know what it means.

Well, coffee just kicking in, so lets try.

Cardiac output (CO, the amount of blood your heart pumps per minute) is calculated by

CO = SV x HR

where

SV = Stroke Volume, how much blood pumped out each time your heart beats
HR = Heart Rate.

Simple stuff eh?

For the mythical normal man
HR = 70 per min
SV = 70ml
That gives a cardiac output of approx 5 litres/min and that is what is needed to keep all your cells alive.

Now, you have a HR of 45. To get a cardiac output of 5 litres per min you need to up your stroke volume to approx 110ml per beat. So you need a larger ventrical volume to fill with blood. That is the 'increase in the left ventricular endiastolic volume' the cardiologist mentions.

Now, a clever chap called Starling discovered that if you increase the size of your resting ventricles (which the echo shows you have), your heart muscles will contract harder when they come around to pumping. So it would not be surprising if they get a little thicker. And it seems there is an area of your heart which is a little thicker, but no big deal.

So we can explain everything and it's all well and good. The trabeculation bit just means he has looked for specific type of thickening and it isn't there. So no problem.

As you appear to be healthy, probably a lot healthier than most of us, the 'out of range' findings can be explained. That's all that really matters and you should get a class 1, but we knew that already :)

Edit: Coffee fully kicked in now, so can see what I missed, how does this all fit with the murmur?

Well, we surmised you are ejecting 110ml of blood instead of 70 ml of blood. The arteries and valves don't stretch so easily, so the cross section area this blood has to pass through stays the same. So more blood per beat going though the same sized hole, hardly surprising you might get a little extra noise generated.

[MelbPilot85]

At 18 I went for my class 1 renewal and was told I had a murmur. Obviously it had been missed a year earlier for my initial with the same doctor. Unlike veetwo, I was sent for an ECG and echocardiogram, possibly because my blood pressure was through the roof. (something like 160/120). I wore a blood pressure monitor for 24 hours and the average ended up being 112/78.
I was cleared after all these tests, and the doctor thought white coat syndrome was the cause of my blood pressure spike. As far as renewals go, I have not had any murmur issues since, and if my blood pressure is high, the Doc makes a nurse sit with me and retest it until it goes down. This was only the case for the following year, and I have had no issues since.
I also had a foreign class 1 issued, and the docs got wind of my history as they required previous reports from Aus. Once I showed them the specialist reports (which I took with me) no further questions were asked and I was not subjected to any further tests.

[gingernut]

Don't know about you Slim, but I still get things mixed up in the cardiac cycle as possibly did the AME.

I reckon I'd bet ya' a nights beer money that he heard a third heart sound.;)


But the important thing Chris, is that your scan results sound normal.:)


PS, never ceases to amaze me the old ticker- pumps out about 5litres a minute, every minute, for 70-80 years, without ever stopping and with minimal maintenance. Couldn't get owt like that at B+Q.

[chrisyross]

I've just phoned the CAA, who have informed me that my Class 1 medical certificate is getting sent out today - quite fortunate timing as I go to Spain on Friday for training.

Thanks to all those that to the time to reply - especially Slim_slag and gingernut for the explanations.

One more question :

Should i speak to the CAA to make sure my notes are annotated correctly regarding this matter or would having a copy of the cardiologists report be a better bet in case this issue comes up at future medicals?