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Sprinkles- New MVD and CHF diagnosis. Questions and advice needed!

LexieAndSprinkles

LexieAndSprinkles

Well-known member
I apologize in advance for this being a long post. I’ve had a lot of new info come my way the past few weeks and I think you all might be the ones to help me out!

Backstory-
My name is Jordan and I have a 5-year-old (7/17/10) Blenheim named Sprinkles. I’ve had her since birth (long story) and she has always been a spunky, rambunctious pup.

We had had the same vet since before her birth and because it was an accidental litter with little history on her father side, she monitored her very closely. Luckily Sprinkles was always extremely healthy! I had beat myself up for years over this unplanned puppy and the possible health issues but it seemed that we were in the clear. At our yearly check up when she was 4, her father was still murmur free at age 6 and so was her mother. Our regular vet was in the process of moving so we did one last big check up before she left. At the visit she mentioned she thought she heard something, so she finished the exam, listened again for a long time and concluded she heard nothing but to recheck in 6 months just to be safe.

We were on the search for a new trusted vet so her 6 month check was a cut and dry visit to a vet I ended up not loving. He said everything was fine and they did not hear any kind if murmur. He mentioned that a lot of vets hear “phantom murmurs” in Cavaliers because they are trying so hard to hear one because of the breed history. I didn’t love his “whatever” approach to my dogs so I continued my search for a new trusted vet.

A few months later however, I started noticing small changes in Sprinkles behavior. It was a gradual process, which I think is why I unfortunately let it go on longer than I should have. First she seemed to get very lazy. She had always been a crazy dog… quite the troublemaker to be truthful, but she seemed to mellow over the course of a few months. I was even making comments that she was the best behaved dog in the house now! Next she decided that she didn’t like to go outside anymore, and she slept much more than she once had. I decided that she was just getting older and had finally outgrown her delinquent ways. Both her parents are the ultimate lap dogs so maybe the genetics had kicked in and she was going to be one too! Next she developed a persistent cough that became very prevalent when I took her outside to play. She would come in “out of breath” and “wheezy”. I joked that she was just out of shape. She had put on a few pounds over the few months since her activity level had dropped. At this point it was also the spring so I attributed the cough to allergies. We had just moved to a very large farm and we were all struggling with terrible allergies (humans and dogs alike). But after a few weeks I decided that if this really was allergies, she needed something to treat them STAT. She seemed to be panting more and more, even while she was asleep.

*Note: I know realize that over the course of those 6 months she displayed so many symptoms for MVD and CHD that it should have been obvious. However, all I knew at this point about MVD was that both her parents were murmur free and so was Sprinkles. I had no education on the symptoms. I kick myself looking back on it.

After a particularly rough day of heavy panting, I made an appointment took her to our new vet. The first thing he said after listening was that she had a grade 3-4 murmur. I was floored. I handed him all her previous vet records and explained she’d been carefully listened to by two different vets over the past year. How could it have developed that fast? The rest was a blur. He did x-rays, told me her heart was enlarged (I think he measured a 12), and that she was in CHF based off of the fluid in her lungs and around her heart. I think I cried through the majority of the appointment and actually had to get my mom to call back later that afternoon since I practically went into shock. He put her on 5mg of Benzepril 2x a day and 12.5 of Lasix 2x day and referred us to a cardiologist. The appointment was 2 weeks out so she took her meds and waited. During that time she became a little more like her old self and I realized how sick she had been.

2 weeks later I took her to the cardiologist. She did the exam and informed me that her murmur was only a 2, that the fluid that had previously been in her lungs was cleared and probably caused by pneumonia… and that the meds we were on were pointless because she didn’t need them yet. Um, what? I was extremely relieved but also very confused. How could a vet tell me (and show me) just 2 weeks before that my 5-year-old Cavalier was in CHF… and now this cardiologist basically treated me like an over-reactive dog Mom?

I asked her about the enlarged heart and she told me she only measured a little over a 9. She said that the way the other vet did the x-rays could have distorted it and made it look bigger.

I asked her about the fast respiration when she slept. She told me that dogs do that when they are dreaming…

She said the coughing was caused by the pneumonia.

She explained that it all was just a coincidence that it showed up the same time that we first heard the murmur and that my vet had over reacted. She then sent us on our merry way instructing me to come back in a year for a follow up. I was confused but… she was a cardiologist. She had to know what she was talking about, right?

So I took my Sprinkles pup home, weaned her from her Lasix as instructed and stopped the benzepril. I decided I’d keep a very close eye on her but she was acting much better. Summer ended, we came into fall and she slowly fell back into the symptoms from before minus the coughing. My mom played them off as “fall allergies”, maybe she was getting pneumonia again? Maybe she had asthma? She didn’t act sick or uncomfortable. Just lazy… with a lot of panting.
A few weeks ago, we took Sprinkles’ father in for his yearly check up. Our new, new vet whom we had grown to love listened and said she thought he had a transient murmur. She decided to do a full heart work up and sure enough, he had a grade 2 murmur and had Stage B MVD. We told her about Sprinkles and she had us bring her in immediately (within the hour). She admitted her on the spot just looking at her tongue color. X-rays showed her lungs and heart again full of fluid. Seeing her lung x-ray with only a VERY SMALL spot that wasn’t fluid was terrifying. I have no idea how she was even breathing. She kept her for a week and started her on:

Vetmedin: 5mg 2x a day
Benzepril: 5mg 2x a day
Spironolactone: 25mg 2x a day

She stayed on these for 2 weeks and we went back for a follow up today. She is still full of fluid so she added Lasix 12.5mg 2x a day. We go back in 10 days for more bloodwork and chest xrays. Other than the heavy breathing and a lot of sleeping, she doesn’t seem to be uncomfortable. She isn’t coughing which I guess is a good sign.

Here’s where you guys come in:

Needless to say, I am beyond upset, scared, and frustrated at the whole situation. I just don’t understand how on earth things progressed so quickly and there was so much confusion. Was I just going to a bunch of quack vets and specialists or is this a common thing to have this much trouble diagnosing? I personally feel like the cardiologist we saw royally screwed up and costs us 6 months treatment. I absolutely blame myself for not doing more… but when the specialist tells you that everything is stable and ok for now… what do you do?

Now I am completely out of me element. I don’t even know what questions to ask my vet when I go back in 2 weeks. Here are the questions I have for you guys:

Is there anything specific I need to ask when we go back?

What do I expect from here? How long do Cav’s usually have when they are at the stage Sprinkles is at?

What can I do to help? Other than her meds, is there a specific food she should be on? She needs to loose about 2 pounds but obviously cannot exercise right now.

Any advice or answers that you all have would be much appreciated. I am so worried about my girl. I’ve been on Dr. Google constantly but I don’t even know how to come up with good questions or decipher what I am reading.
 
Hi: I am so sorry you are going through this. It is devastating to get an unexpected diagnosis and especially hard if the professionals are not sure what they are seeing. Sadly, this sort of sudden onset is not unusual with cavaliers. And to be honest: I don't think any of these vets or the cardiologist said or offered anything other than a truthful exam and opinion, within the range of their expertise. These things are not always a clear-cut diagnosis.

According to one UK study, vets miss 50% of early onset murmurs of low grades (1 or 2). So it may well be that your first vet simply missed the murmur and this was actually a slow progression of an early onset murmur (that said, 50% of cavaliers have a murmur by age 5 :( so having a murmur isn't unusual at this stage). Also, cavalier hearts often appear slightly enlarged on xrays when they are not enlarged due to MVD and only some vets know this. As the breed is still not that common in the US, I would not expect most vets would know this.

The second vet is also correct: many vets do hear phantom murmurs in this breed because they expect to hear them. It was a reasonable observation given that Sprinkles had sounded clear to both he and your original vet and your first vet only had a suspicion of a murmur. A vet would be more likely to think they might be hearing something with this breed, than hearing nothing. But early grade murmurs can be really hard to hear and there are generally no other obvious signs.

Cardiologists are really the gold standard for diagnosing and hearing murmurs. This would be the same with human doctors -- GPs are not specialist-trained to hear heart or lung problems. My father was a lung specialist (for humans) of international reputation and known for ability to do very difficult differential diagnosis simply by listening to the heart/lungs and after he passed away, a colleague told me that he could just hear things others could not; a lucky skill. Even amongst specialists some will be better at a diagnosis than others.

Also some have better people skills than others. I'd look for a different cardiologist; one should never make you feel over-reactive. But at the same time: the cardio heard nothing, the fluid was gone (fluid is easy to hear), and his interpretation might well make sense. However: I am surprised he didn't do more tests. Also: it is always a good idea to go right back once you start to see the same suspicious signs. No practitioner can diagnose what might not be there at the time, but often symptoms return and warrant immediate examination. It's a good idea even just to call the reception and ask if they think a dog should come back in. I often do this with my own vet as the nurses can generally give a good recommendation. I'd have sought a different cardio if you didn't like the first man (and I can see why you might not have).

The new vet is taking the right route BUT in your shoes I'd want a cardio to be doing a workup, not a vet. Especially as the fluid had not cleared after two weeks on a diuretic, requiring a second to be added. Grade of murmur is not always associated with severity of CHF, but this is another reason I'd want a referral to a cardiologist once those bloods and chest xrays are done. Generally people don't see CHF signs such as exercise intolerance and fluid buildup til the murmur is a higher grade.

So, some of what has been going on doesn't seem to fit the usual pattern for MVD and CHF, and onset seems fast. Maybe it is a fast onset left side (MVD) murmur, or maybe this is a right side murmur and not MVD, or perhaps the heart murmur is a side issue to something else going on. Two weeks seems a long time to wait to do a blood panel and chest xray but also, I'd be wondering why you have not been referred for an ultrasound (echocardiogram) at this stage to see what is actually going on with the valves -- especially as there's already an xray that could be examined as a starting point and there's uncertainty on the murmur.

If you can see a different cardiologist asap that is what I would want to do, and I'd also want the blood panel immediately to rule out other possibilities causing the fluid etc. eg what about lungworm? Heartworm? Return of pneumonia? Many things might be causing all the other problems as a side to a low grade murmur that isn't actually causing any of these issues -- in which case the heart meds may or may not be of any help. That said: my cardio and vets have pointed out many times that all dogs vary greatly in how MVD/CHF affects them and it is hard to give a definite prognosis. I've had a dog with a grade 6 murmur and severe symptoms last three *years* after diagnosis at that level (astonishing). I've had cavaliers that had fast onset and a sudden collapse. And a mix of the two.

I think we always have to accept we need to be the greatest advocates for our dogs. A vet or specialist only sees the dog in a small window of time and can only make a diagnosis at that time. We know our dogs best, and if we see any possible concerns, any return of strange signs, even just something niggling in the back of our minds, the best option is to get the dog checked right away. It is owner knowledge of their dog that helps the professionals get the right diagnosis eventually.

I hope that helps -- you did take the right route, and all the people you spoke to were right in their own context I think, but a diagnosis is not always straightforward. As you are encountering some odd developments, I'd want a specialist to try to figure out what is happening and I'd definitely want a baseline echo and those bloods done right away.
 
Hi Sprinkles Mum

You and Sprinkles have really been having a bumpy ride! In my experience (having had three Cavaliers dying of heart failure), MVD is a very individual thing. Some Cavaliers can be diagnosed with a 4-5 murmur and suddenly go into heart failure and die a few months later. Others can go into heart failure but with medication live more or less normal lives for several years. Some, like Sprinkles' father, develop a murmur fairly late and it may never get beyond a grade 4 with no symptoms at all (one of my Cavaliers developed a murmur at age 8 and died at 13 still no more than a 4 and not a single symptom). So it is difficult to predict Sprinkles' development.

Vets may not be quacks, but considering how widespread MVD is in Cavaliers, many of them are still woefully ignorant about the disease. They don't know how to interpret what they hear through their stethoscope and have a tendency to think 'Heart murmur - of any grade - must start medication.' Starting medication too early can actually cause harm to the heart. You will find a lot of balanced and sane information about MVD on www.cavalierhealth.org The owner of the site, Rob Russell, is a member of this forum (he's a vet with Cavaliers) and may well pick up on your post and be able to help with his customary sound advice. If he misses it, message him.

The cardiologist may not have been wrong about the pneumonia, as Sprinkles was better over the summer but then got worse in the autumn - you may be dealing with two things here, which adds to the confusion! My Aled, who was a puppy mill rescue, died of MVD last February, and his post mortem showed that in spite of being on a diuretic to control the build up of fluid in his abdomen, he had started pneumonia; any untreated fluid build-up is going to be a nice breeding ground for pneumonia. I hope one of your vets has shown you how to count Sprinkles' breaths, as this is a very good indication of whether his heart is coping or needs urgent attention.

It is important to keep weight down; if Sprinkles eats kibble/dry food, try putting him onto a food specially to control weight - my present Cavalier, Ruby, is permanently on a variety called Burns Weight Control, which works very effectively but I don't know whether it is available in the US. But I'm sure you would be able to find something similar, or someone here will tell you what works.

The ups and downs of MVD make it a very stressful disease for owners as well as dogs, so take care of yourself as well as Sprinkles. I'm sure other people will be able to give you better advice - sadly, a lot of forum members have recently lost their Cavaliers to heart failure - it really is a scourge for the breed,

:hug:

Kate and Ruby (so far heart clear at 6)
 
Thank you both so much! Your replies have given me what I think is a huge step in the right direction. I probably sound like a vet hopping crazy dog Mom, but I'm sure you all understand LOL. After we lost our primary trusted vet that we had for 10+ years, we had all of this craziness start and it has been terrible. It's so hard to know who to trust, especially when GP vets aren't as educated in the cavalier heart issues like you all said. To go from a vet who had known Sprinkles since birth (literally delivered her)... to others who would spend 5 minutes in a room with her and then leave. A few things I should have been more clear on are that:

1: Sprinkles new GP vet has done 2 ultrasounds of her heart. One the day I brought her in on her full cardio work up and another yesterday. When she did the first one, she did explain to me exactly what ventricle was affected and went over her whole condition while showing me on the x-rays and ultrasounds. She even showed me tons of other xrays and ultrasounds from previous cases she had to compare them with. I think it's my fault not not asking more questions when I was not understanding. I think it was just so much information at once that I was just lost. All I heard was "Heart Failure." Between ultrasound pictures, x-rays, and bloodwork results I was seriously clueless as to what it all meant.

2: I am definitely going to find another cardiologist. I called the previous one to update her on the situation after the fact and she seemed very annoyed, again telling me that my dog was "fine" and that vets were over-reacting. Believe me, I really WANT to believe that. It's so hard to know who to trust. I absolutely feel like the cardio should know more about it than the GP vet, however she really isn't listening to my concerns, and seeing the symptoms. The vet she is with now works with our local Cavalier rescue very closely and has done so for 20+ years. However, she is not a certified cardiologist and is treating only from those 20+ years of experience. Another hesitation about the last cardiologist is that I've had three GP vets diagnosis her with the same exact condition twice in 6 months...(I had a second opinion from another vet in our current office after her cardio work up) and this cardiologist still insists she does not need to see her back until the spring. She literally won't do anything right now... meanwhile our GP vet seems so on top of things. With Sprinkles Dad, our vet explained that she thought she heard a murmur, couldn't hear it again but compared it with his sinus rhythm followed by listening for a long time to all 4 ventricles of his heart. She finally heard it a again, did the cardio work up and sure enough his heart was very enlarged. Definitely not something you would expect a GP vet to do... I guess it was her 20+ year history with Cavaliers that her gut told her to keep looking. So I think I will plan on asking her for a cardio referral since I have built up a lot of trust with her. That way I can get the opinions of different cardiologist.

3. Sprinkles respiration's are terrible and her tongue stays a dusky purple color. The main reason I took her in the first time was because her RHR was over 70 one night. Even on all the meds she is on, it's currently between 45-50.

Anyway I hope that clears a few things up! I'm not sure it changes much in terms of what I need to do but I just wanted to make sure I gave you guys all the information. I'm sure I have still forgotten stuff since it's been a whirlwind the past few weeks. Again, thank you guys SO much for your advice and information! I am going to take it all into account and hopefully get my girl in the best vet/cardio situation possible!
 
Wow, that's a very high resting heart rate. Yes,they do sometimes pant while sleeping but it shouldn't be all the time. Your vet doing the workup sounds really good. What did the ultrasound show? Usually they are most worried when tongue and gums are pale and white-ish as it indicates poor oxygen, not sure what purple would mean as I haven;t encountered that.

The cardio just sounds plain rude -- worth talking to someone else.

Kate's right that MVD is so individual. I have had lots of cavaliers with MVD and SM and found managing those with extended periods of CHF the most emotionally difficult (but mine with SM didn't struggle as some dogs do with severe pain, which would indeed be far worse I think). Most of mine that died from MVD would almost certainly have lived years longer without it, as it was the only health issue they struggled with. :( Owning a cavalier almost inevitably means managing MVD eventually. The breed deserves much better.
 
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