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View Full Version : Question about grade 3 murmur and Vetmedin



george108
19th August 2009, 12:48 PM
We've just returned from the vet for George to have a check up and the vet said that George has a grade 3 (possibly 4) heart murmur (this is the second vet to say this). Our vet said we could put him on Vetmedin before his murmur progresses but didn't push it and said it was totally our choice. George is doing really well in general. He still loves his walks, has no problems with his food and has recently lost 1.5kgs which is really good. We're just not sure whether to start him on meds now or to wait. We don't want to wait until it's too late for George. Can anyone give us any advice? Thanks in advance.

Love my Cavaliers
19th August 2009, 02:03 PM
I would recommend going to a cardiologist so that they can determine exactly the grade and what else might be going on. Cardiologists are trained to pick up on subtleties and would know the most appropriate course of treatment for George. They would probably do some further testing - particularly if it is a grade 4. Good luck

Cathy T
19th August 2009, 03:50 PM
Yep, I'd see a cardiologist before looking at medication. Shelby has a grade 4 and isn't on any meds. We had an echo done and saw that her heart is in relatively good shape, no need for meds yet.

george108
19th August 2009, 04:08 PM
Thanks guys. Can anyone tell me what exactly a cardiologist will do? Does it involve George being sedated? Is there many tests etc? Thanks.

Love my Cavaliers
19th August 2009, 04:50 PM
My little guy, Oz, was diagnosed with a murmur when he was 5 months old. He had an echocardiogram so that they could visualize the heart and he also had an ECG. Because he showed some intermittent second degree AV block, he also wore a digital Holter monitor for 24 hours. He was so little they had to use the one they usually use for cats. I'm pretty sure he was not anesthetized for the echo. He is 2 yers old now and sees the cardiologist once a year. His murmur has not changed at all and he is no meds at present.

Cathy T
19th August 2009, 07:23 PM
A cardiologist is better trained to listen to your dog's heart and make a more accurate assessment of the grade of murmur than a regular vet. Shelby was not sedated for the echo.

Jay
19th August 2009, 08:02 PM
Sapphire is going to the cardiologist tomorrow for an annual echo. This will be her second. Monty has had 4 echos. They are never sedated. The last time the cardiologist tested them, he asked if he could shave a small portion of hair from their side to get better pictures. My check book will suffer more from the procedure than the dogs. I also agree about seeing a cardiologist first. At this point in time, none of my dogs are on heart meds.

J.

Louise1823
19th August 2009, 08:44 PM
Sorry to hear about Goerge - unfortunately it seems to be the case in Ireland that the chances of getting an appointment with a cardiologist is very slim.
I asked my vet about this last week as we got some bad news about Rex's heart, and he said that it is virtually impossible to get referred in this country. Its very frustrating and you would wonder just how ill your dog would need to be before you could get to see one.
We have started Rex on Vetmedin and so far (touch wood) he is tolerating it fine with no side effects.

george108
20th August 2009, 11:25 AM
Sorry to hear about Goerge - unfortunately it seems to be the case in Ireland that the chances of getting an appointment with a cardiologist is very slim.
I asked my vet about this last week as we got some bad news about Rex's heart, and he said that it is virtually impossible to get referred in this country. Its very frustrating and you would wonder just how ill your dog would need to be before you could get to see one.
We have started Rex on Vetmedin and so far (touch wood) he is tolerating it fine with no side effects.


Thanks guys for all your input.

Louise I didn't realise it was that difficult to get a referral. Absolutely crazy! So you started Rex on the meds on the advice of your vet? Glad that he's doing well on them.

Pat
20th August 2009, 07:24 PM
Pimobendan (Vetmedin) should not be started until a dog is in congestive heart failure, and even then it should not be started until contractility is affected. The grade of heart murmur does not tell you if the dog is in heart failure - symptoms like coughing, exercise intolerance, difficulty breathing, etc. tell you if a dog is in CHF. The drug makes the heart contract (pump) more strongly, and if the contractility is normal, pimobendan can cause the heart to pump too strongly which can actually be detrimental and cause the left atrium to enlarge more quickly because of the more forceful pumping action (the forward flowing blood is pushed along more strongly as well as the regurgitant jet - blood flowing the wrong way - being ejected more forcefully). Read Rod's website for a lot more explanation of this.

http://cavalierhealth.org/mitral_valve_disease.htm#A_Few_Words Read "A Few Words about Pimobendan" here.

Generally, the drug is used earlier in the course of CHF in the UK than in the US. In the US, it seems to be reserved by cardiologists until the first line drugs for heart failure (furosemide and an ACE Inhibitor like enalapril or benazepril) stop working well to control symptoms. In the UK, GP vets tend to start the drug when CHF ensues. I would not start the drug without having an echocardiogram done to determine contractility.

FYI, it is different for DCM (dilated cardiomyopathy) where contractility is usually compromised very early in heart failure. In MVD (endocardiosis), contractility is usually good until end stage heart failure. We have discussed this in detail in the yahoo Canine CHF group.

I can't imagine having my GP vet do diagnosis and treatment planning for heart failure - I really rely on access to a cardiologist. I'm sorry that everyone doesn't have that option!

Pat

Pat
20th August 2009, 07:44 PM
Forgot to answer part two of your question:

A cardiologist will:

Get a history and perform a physical exam including auscultation (listening with a stethoscope). He is listening for a murmur, any irregular heart rate, and any lung sounds.

If needed, do a two view chest x-ray to determine heart size, condition of lungs (whether or not there is fluid in or around lungs), look for the presence of other lung disease such as COPD, look to see if enlarged heart is pressing against the main airway, look at the great vessels, etc.

If needed, do an echocardiogram with color doppler - which is an ultrasound of the heart that shows exact chamber sizes, condition and functioning of the valves, whether there are ruptured chords (chordae tendineae), measures regurgitant blood flow velocity and amount, measures contractility (pumping strength of the heart), looks for pulmonary hypertension (high blood pressure in the vasculature of the lungs only versus systemic blood pressure) and more.

If needed (because he hears an irregular heartbeat) do an ECG - electrocardiogram - which measures heart rhythm and looks for arrhythmias (irregular heart rate - too slow, too fast, or other irregularity).

If needed, check blood pressure.

None of these tests require sedation and none are invasive.

On the basis of the test results, the cardiologist will "stage" the disease, give a prognosis, and determine if and what meds are indicated.

BTW, Rod I noticed a typo on your "a few words about pimobendan" - the word is "contractility" not "contractibility." (pointing out in a friendly and not a critical way!!)

Pat

Karlin
20th August 2009, 08:10 PM
If Irish vets in the Dublin area are being reluctant about referring to a cardiologist then I recommend switching to one of the Anicare branches (www.anicare.ie). I was on the phone today to talk to a vet and discussing the mobile cardiac unit that goes around once a week and will do an echocardiogram. I assume this is a cardiologist doing the echo or someone well able to refer on. At any rate ANY vet can refer a client on to a cardiologist -- if a vet was telling me it was hard to get a referral to one, I'd ask them why they couldn't do it? Isn't this their option to do so?

I've also spoken to Anicare vets about getting in touch with the cardiologist to see if we could set up a group auscultation day for Cavaliertalk members at some point -- though I am not sure what the cost would be. I know it is about €200+ for an echo from the mobile unit, as I asked today.

I'd recommend ringing the Blanchardstown branch and talking to them, or to Plmerstown if that is closer. The vet there, Susan, is away for two weeks but the locum is named Fionnuala and she went through the heart options with me.

There's little tradition to refer on to a cardio though in Ireland -- most do very few tests on hearts either; there's just a standard order for prescribing hearts meds.

sins
20th August 2009, 08:10 PM
I'm not sure if they have a veterinary cardiologist still visiting the vet college in UCD.
I also found this link which lists a vet in Nutgrove veterinary hospital.

http://www.bsava.org.uk/vcs/testing/auscul.htm

Sins

Louise1823
20th August 2009, 08:23 PM
Sorry if I got this wrong, but I got the very distinct impression from our vets that getting an appointment with a cardiologist was hugely unlikey - regardless of your situation or how much money you were prepared to pay.

It would be absolutely FABULOUS if this isn't the case! I would feel so much better if I could get Rex to see a heart specialist.


I've also spoken to Anicare vets about getting in touch with the cardiologist to see if we could set up a group auscultation day for Cavaliertalk members at some point -- though I am not sure what the cost would be. I know it is about 200+ for an echo from the mobile unit, as I asked today.

Wouldn't this be brilliant? - if it is possible, you could definitely put us down to attend, no matter what the cost.

I will have to mention it again though to our vet, as it seems what Ive been told isnt really the case.

shippers
20th August 2009, 09:48 PM
Sally had a cardiologist review only a few months back after our regular vet detected a heart murmur. We went to the cardiologist at Liverpool University and they were fantastic. Sally had an ECHO, ECG, bloods, CXR and blood pressure. The ECHO was abnormal (I did type out the report in the MVD section at the time). The cardiologist advised that as Sally isn't showing any signs of heart failure they wont start any medication as yet. They have done some research which showed that starting medication before the onset of heart failure doesn't really delay the dog going into heart failure. We only need to take her for a re scan again in 2 years. In the meantime we just keep her trim and well exercised. Good luck in getting your cardiologist referral.

Pat
20th August 2009, 10:19 PM
They have done some research which showed that starting medication before the onset of heart failure doesn't really delay the dog going into heart failure.
--------------------
Actually, the research is somewhat ambiguous, and there are some definite flaws. This too has been discussed quite a bit in the Canine CHF yahoo group. I can elaborate more but it will be very long and technical!

I have generally started an ACE Inhibitor before my dogs have gone into CHF - based on the results of echocardiograms and under the supervision of my cardiologist. We begin the drug when CHF is "imminent" - when the heart is moderately to markedly enlarged and the regurgitant jet is significant. Several of my Cavaliers were on enalapril for quite a few years and died of other causes before ever going into CHF. (Darby is a good example - heart murmur heard at age 18 months, enalapril started at age 7 1/2 based on echo results - died at age 15 without ever having gone into CHF or having any other heart meds added. Same with Nominee, started on enalapril at age 6, died at 14 without having gone into CHF.) Of course I have no way to determine if they would have had the same results had they not been on the drug. But I would definitely do it again and have with other Cavaliers. Again, this is always under the supervision of a cardiologist.

Pat

Karlin
20th August 2009, 11:12 PM
I would at least have an echo done on George by the mobile unit -- call and have a chat with Fintan at Blanchardstown. He can explain who runs the unit and what the set-up is. I'd never understood it was difficult to see a cardiologist. If so I'd just go up to Northern Ireland -- am sure there must be someone up there.

Pat thanks for the info -- very interesting as always!

Karlin
20th August 2009, 11:15 PM
Looks like this guy isn't a cardio but has postgrad work in the area:

http://www.equineclinic.co.uk/Veterinary-Cardiology.html

I think the Nutgrove guy in Dublin is the sole cardiologist and is associated with UCD but may be wrong. It was a while back that I talked to the Anicare locum from UCD about doing a clinic. Looked on the UK list of cardios and can't find anyone for N. Ireland.

Pat
21st August 2009, 12:14 AM
One caveat - an echo is ONLY as good as the person doing the scan and the interpretation. There is definitely skill and experience and training involved. I would not waste my money on a GP vet or even a radiologist doing the scan......I would only use a cardiologist or a board certified internist. (I don't know how this translates across the pond.....do you have board certified internists there as well as board certified cardiologists?)

Pat

Karlin
21st August 2009, 12:18 AM
Don't know about internists. Not much choice on cardiologists -- we only have one in Ireland! The Echo unit is from the vet school however.

Pat
21st August 2009, 02:18 AM
I can't tell if the "mobile unit" is the same unit described in the link. If so, that's not good as you need the color doppler flow capability to see the regurgitant jet/s from the malfunctioning valves. As they said, a measurement of cardiac wall thickness and contractility is more useful for the cardiomyopathies - this is different from the valvular diseases. They say they can refer for the "full color doppler" but where are they referring to? If the mobile unit doesn't have the color doppler capability, I wouldn't spend my money on the mobile unit but wait until I could get a more appropriate echo.

Pat

Louise1823
21st August 2009, 10:05 AM
I just spoke with the receptionist at the Nutgrove clinic and she said Mr Mullaly would be happy to see us, but only on referral from our vets. Once he has Rex's history and medical notes, he can perform adn ECG and ultrasound for us.
So... just been onto our vets to get the referral done! Just waiting on a call back.
I cant believe it was that easy (touch wood we will get an appointment!).. Thanks Sins for posting that link..

sins
21st August 2009, 10:32 AM
Good to hear you have an appointment:p,hopefully it won't cost too much but it really seems like having an expert opinion is the way to go.Let us know how you get on.
Sins

george108
22nd August 2009, 01:01 PM
Thanks a million to everyone for your very helpful replies. Very kind of you all to take the time out to give us some very good advice.

At present George is doing really well. He appears to be showing no signs at all. Loves his walks, dinnertime, hugs etc. He's always been a very laid back dog that doesn't play much bit we have noticed that since Chrissie has joined our family, he's slightly more active and excitable. In fact we think there's some definite flirting going on!! :-) He's also lost 1.5kg which is just fantastic. We followed Karlins link on here to Roy Croft and so far it's a great success. He's losing it slowly too which we're very happy with.

We've to see our vet next week to check up on Chrissie's eye ulcer so we'll discuss the referral then. Hopefully we can get it done soon enough. Once again, thanks for some great advice!

george108
26th August 2009, 09:53 AM
Just to update you about George. We spoke to our vet and in his opinion he thinks that there is no need for George to go on any meds and as long as he's doing well he doesn't think he would need to see a cardiologist but he can refer him at any stage.

pepedogdoza
29th August 2009, 06:36 PM
I am glad George is doing fine.My pepe had a grade 3 heart murmur early last year my vet said there was no need for medication.It has now developed into a grade 5 he also has chf.He coughs and collapses especially when he gets excited.Only since he have been having these symtoms is vet have put him on vetmedin and frusemide.He did try him on lanoxin first but he was being sick.
Pepe is doing fine otherwise and have only collapsed once since he have been taking the meds.
I wish george all the best :)

Lisa x