Seeking Advices on "When do you start taking Medicine for MVD"

[summerwalk]

Hi,

I have a cavalier who is 7 and 1/2 years old. He has MVD. This is a rather long write-up, but I feel compelled that I should share more to get more proper and prudent advices.

I am seeking advices on when to start medicine to relieve his coughing from MVD.

A quick background:
My cav has been dry-coughing (hacking kind) seriously for about 5 months now. Coughing became more serious and apparent ever since he had his teeth cleaned (at the time of cleaning, we had no idea that anesthesia could speed things up on MVD). The frequency of coughing used to be about 10 times during the day whenever he gets up from his lying down positions - either on his stomach or on his sides. Lately, the frequency has increased to 15 to 20 times during the day. At night, coughing becomes more frequent because he changes his sleeping position more frequent.

He has been diagnosed with heart murmur at GRADE between 2 and 2.5 for almost two years by his vet. Otherwise, he has been very healthy. He eats well and demands lot of treats. He is still very healthy. He walks with me about 4 miles time to time on weekends. Otherwise he plays around in the backyard a couple of hours a day after dinner. He weighs about 25 pounds - relatively big, but not overweight. He is a big boy. He is all around a great cavalier. He is the center of our attention in our family.

Because of his difficult and laboring coughs, we decided to see a cardiologist two months ago. Ultrasound was performed. The cardiologist diagnosed him at GRADE III/IV systolic murmur with the following additional information:

• Moderate LV volume overload. This stage can still be subclinical and asymptomatic of heart disease but LA size could easily contribute to bronchi compression inducing a secondary cough.

To rule out any non-cardiac etiologies, the cardiologist recommended to have thoracic radiographs being done. There were no pathogens found attributing to any type of coughing. But the X-ray clearly showed his enlarged heart as a result of MVD.
The cardiologist said my cav might be at the border line of taking medicine to help him. The list of potential drugs to start with (by the cardiologist) were:

• Start enalapril 2.5 mg QD x 1 week, then increase to 5.0 mg QD
• Start furosemide 12.5 mg QD to determine if any cardiac role in genesis of current symptoms.
• If no change after 2-3 weeks then stop furosemide, but continue enalapril 5 mg QD until more advanced heart disease is present.
• Continue if beneficial, but decrease furosemide to 6.25mg QD. Keep in mind a few dogs may have an apparent non-cardiac response to diuretics, suggesting early CHF, but in reality it’s could be a respiratory response to diuretics.

Below is what I am struggling with:

• He is relatively young - 7 and 1/2 years old. What are the trade-offs between taking medicine now to get the benefits (assuming that this would relieve his coughing) today but taking the risks of his critical body-part (liver, kidney, etc) failures in his later life.
  Does taking medicine now make sense for my cav?
• Do some of the drugs listed above truly get rid of his nagging coughs? I am assuming diuretics will drain any fluid in his lung and possibly shrink his enlarged heart?
• I am looking for advice on when to start the medicine. It is so painful for us to watch he labors whenever he coughs.
• As per the cardiologist, do you have a direct relationship with him or her, meaning no "in-between" vets? Or do you go through your primary-care vet to get to the cardiologist? My recent experience has been rather confusing and perplexing. My expectation was I would directly work with the cardiologist to deal with this difficult and trying times, but I've learned quickly that the cardiologist was not responsive.

Any advice will be appreciated.
Thank you.

[Karlin]

So sorry you are dealing with this -- many of us have been there.

The difference in murmur grade between what your vet guessed, and the cardio could hear (which is very typical as vets are not heart specialists and most are not great at assigning a grade to murmurs), really underlines why it is so much better for owners of cavaliers to see a cardiologist for diagnosis and care of hearts. Vets often underestimate or overestimate a murmur. A cardio can also tell you much detail about a murmur with 5 minutes of examining a dog.

On your questions:

I would think a dog that is coughing that much should really be on medications -- it's interesting to hear your cardio thinks this is just borderline but they do take many factors into consideration. My girl that recently passed away from MVD never had a cough of that frequency. His age makes no difference for when to start, really(sadly more than half of cavaliers will have murmurs by the age of your fellow -- though he is having fairly fast onset if the murmur is that grade at his age). The protocol suggested by your cardiologist is the general approach. The medications are all pretty well studied -- I've heard of very few having any problems. The meds can greatly relieve the onset of this condition and keep a dog comfortable for, in many cases, years.

I'd guess you are probably only talking about a difference of a few weeks or months anyway in when to start medicating him if he is showing such signs. You would also want to ask a cardio if a 4 mile walk is a good idea any longer -- regular exercise is good but that's a very long distance and may well be too hard on his heart and on him.

I think you will likely find the cough goes very quickly once he is on something to start to manage the disease. Added factors for coughs can be if he is at all overweight -- I know you said he isn't, but sometimes owners don't realise their dog is overweight and it can be easy to misjudge especially with their heavy coat, so it might be worth discussing with your vet. A healthy weight cavalier should have a distinct 'waist' when viewed from above.

On teeth cleaning -- good dental health is actually really critical for cavaliers and heart health. Any kind of gum disease can aggravate heart problems. There's some question over whether doing a dental can flush some bad bacteria into the system and worsen the condition. Someone like Pat or Rod here can probably go into this in more detail but the problem with not doing a needed dental is that just leaving the teeth can also cause heart health to worsen. The best approach is really to take care of teeth daily by brushing and providing good chews etc.

On when to start medications -- now, if your cardiologist suggests it.

I'd seek another cardio though if you are not happy and comfortable with the one you have. You shouldn't need to go through your vet and you should have a good direct relationship and be able to ask all the questions you have asked here, directly of your cardio.

You can get tons of MVD info here:

http://cavalierhealth.org/mitral_valve_disease.htm

And this document -- a consensus statement from cardiologists on how to treat MVD in cavaliers -- is a must read too:

http://cavalierhealth.org/images/acv...ccvhd_2009.pdf

[Karlin]

I forgot to add: be sure to inform the dog's breeder of when a murmur was first diagnosed and the current situation. Any good breeder will value this information for making decisions about their breeding program.

[RodRussell]

... He weighs about 25 pounds - relatively big, but not overweight. He is a big boy. He is all around a great cavalier.

Does he have a visible waistline? 25 lbs. is a whole lot for the breed in general. Read about body condition scoring here: http://www.cavalierhealth.org/diets....dition_Scoring

... What are the trade-offs between taking medicine now to get the benefits (assuming that this would relieve his coughing) today but taking the risks of his critical body-part (liver, kidney, etc) failures in his later life.
Does taking medicine now make sense for my cav?

Yes, since his heart is enlarged and may be impinging upon is airways. His liver and kidneys need to be monitored regularly, but that is one of the things cardiologists do.

... Do some of the drugs listed above truly get rid of his nagging coughs? I am assuming diuretics will drain any fluid in his lung and possibly shrink his enlarged heart?

Some drugs have been known, in some cases, to reduce the size of enlarged hearts. There is a discussion of the drugs regularly prescribed for cavaliers with MVD at http://www.cavalierhealth.org/mitral...tm#--_moderate

Does he have fluid in his lungs? I did not see that you mentioned that in your list of what the cardiologist found. If he does have fluid in the lungs, there are drugs for that, but this condition usually does not arise until the dog reaches the end stage of congestive heart failure. This is from http://www.cavalierhealth.org/mitral...se.htm#--_end:

"Dogs with severe flooding of the lungs should not be exerted in any way. Some cardiologists may prescribe a bronchial dialator, such as aminophylline, oxtriphylline, or theophylline (Corvental), which are human grade prescription medications which relax and open air passages in the lungs, making breathing easier. The onset of acute pulmonary edema requires immediate recognition and therapy, including oxygen treatment, in order to save the dog's life. (See the Darcy's Daily Blog entry dated 8/25/06 for details of symptoms requiring oxygen treatment.) Retained fluids (ascites), which fill the peritoneal cavity of the abdomen due to tricuspid valve deterioration, may be removed periodically by aspiration with a hypodermic needle (abdominocentesis)."

... I am looking for advice on when to start the medicine. It is so painful for us to watch he labors whenever he coughs.

I would follow the advice of the cardiologist. Also, as Karlin suggested, read http://www.cavalierhealth.org/images...ccvhd_2009.pdf Start on page 1145 under the section that is titled "Stage B2, and limit your reading to "small breed dogs".

... As per the cardiologist, do you have a direct relationship with him or her, meaning no "in-between" vets? Or do you go through your primary-care vet to get to the cardiologist? My recent experience has been rather confusing and perplexing. My expectation was I would directly work with the cardiologist to deal with this difficult and trying times, but I've learned quickly that the cardiologist was not responsive.

I must have missed something. In what instances has the cardiologist been non-responsive? Once our cavaliers reach the stage of MVD where yours is, we deal directly with the cardiologist. We schedule either annual or semi-annual visits with the cardiologist. The cardiologist does the prescribing. Your dog is at the stage where he needs a hands-on relationship with the cardiologist.

[summerwalk]

Karlin,

Thank you for your thoughtful and timely advice. I read through the PDF file you suggested this morning. A great technical paper on CCVHD. I learned a lot.
For your reference on the 4 mile walking, I will follow through with my cardiologist to see if that would be OK. As a matter of fact, I was doing the longer exercise for my cav to make him fit. As per your mention of the breeder, it makes sense for us to follow through on that as well.

I truly treasure this website. I feel better equipped now how to proceed with this.

Thank you.

[summerwalk]

Rod,

Thank you for your point-by-point advice and questions. Please see below for my responses to your questions:

Does he have a visible waistline? 25 lbs. is a whole lot for the breed in general. Read about body condition scoring here: http://www.cavalierhealth.org/diets....dition_Scoring

Thank you for the link. Since I am not good at measuring the waistline visually, I tried to go over his entire body with my hands. I feel he is at the "Moderate" stage because I can feel his ribs very easily without "excess fat cover" as well as "Abdomen tucked up when viewed from side." Right now, his chest has bulged a bit to accommodate his enlarged heart.


Some drugs have been known, in some cases, to reduce the size of enlarged hearts. There is a discussion of the drugs regularly prescribed for cavaliers with MVD at http://www.cavalierhealth.org/mitral...tm#--_moderate

Does he have fluid in his lungs? I did not see that you mentioned that in your list of what the cardiologist found. If he does have fluid in the lungs, there are drugs for that, but this condition usually does not arise until the dog reaches the end stage of congestive heart failure. This is from http://www.cavalierhealth.org/mitral...se.htm#--_end:

Yes, you are right on here. I misspoke on this. As I go over the report by the cardiologist again, I only find the "... mechanical compression of bronchi from LA enlargement" regarding the cough. Somehow in my head, fluid and coughing had been tightly interwoven. I need to untangle it. Thank you.

"Dogs with severe flooding of the lungs should not be exerted in any way. Some cardiologists may prescribe a bronchial dialator, such as aminophylline, oxtriphylline, or theophylline (Corvental), which are human grade prescription medications which relax and open air passages in the lungs, making breathing easier. The onset of acute pulmonary edema requires immediate recognition and therapy, including oxygen treatment, in order to save the dog's life. (See the Darcy's Daily Blog entry dated 8/25/06 for details of symptoms requiring oxygen treatment.) Retained fluids (ascites), which fill the peritoneal cavity of the abdomen due to tricuspid valve deterioration, may be removed periodically by aspiration with a hypodermic needle (abdominocentesis)."

Thank you for the info. Karlin also noted on this point. I need to moderate his walking and be thoughtful.


I would follow the advice of the cardiologist. Also, as Karlin suggested, read http://www.cavalierhealth.org/images...ccvhd_2009.pdf Start on page 1145 under the section that is titled "Stage B2, and limit your reading to "small breed dogs".

As as a matter of fact, when I was reading through the paper this morning, I felt he was at the stage of B2 and I read that section carefully.

I must have missed something. In what instances has the cardiologist been non-responsive? Once our cavaliers reach the stage of MVD where yours is, we deal directly with the cardiologist. We schedule either annual or semi-annual visits with the cardiologist. The cardiologist does the prescribing. Your dog is at the stage where he needs a hands-on relationship with the cardiologist.

In a nutshell, my initial visit with the cardiologist was positive. As I noted in my post, ultrasound was performed to diagnose and we discussed the possible medications, etc during the intial visit. To be honest, I wasn't all that equipped at that time to understand the pros and cons of the meds and the right questions to ask to help make up my mind later on on medications. After the initial visit, a page of Cardiovascular Examination Report was sent to me via email. After two weeks, we followed through the chest x-rays as suggested. Once the thoracic radiographs were performed and being sent to him, I was quite anxious to hear from him on his additional diagnosis and possible "next step" to follow through on his suggested medication plan (if that makes sense at all). Unfortunately, I couldn't reach the cardiologist directly (no phone call, no voicemail and no email). I only got his feedback indirectly through the consulting doctor at the veterinary where the radiographs were performed. I was perplexed. I am quite familiar with the general practice and and the interactions with cardiologists for human heart disease because my dad has gone through quite a bit. But Not knowing the general practice in veterinary, I didn't want to be judgmental and ahead of myself.

[RodRussell]

I found this today. It is a just-released study (citation and abstract excerpts are at http://www.cavalierhealth.org/mitral...Bronchomalacia) about whether coughing is due to an enlarged heart.

"Coughing in the small breed dog may be related to cardiac causes associated with myxomatous mitral valve degeneration (MMVD) including pulmonary edema and compression of the mainstem bronchus by a severely enlarged left atrium, or due to respiratory causes such as tracheal and/or bronchial collapse or chronic bronchitis. The purpose of this study was to evaluate the association between left atrial enlargement and large airway collapse in dogs with MMVD and chronic cough. We hypothesized that airway collapse was independent of degree of left atrial enlargement. ... Preliminary results failed to identify an association between left atrial enlargement and airway collapse in dogs with MMVD but did suggest that airway inflammation is common in affected dogs. Further studies are needed to identify factors contributing to airway collapse in dogs with and without MMVD."

So, thus far, the results are inconclusive. It reads almost as if the cardiac cough may be due to an inflammation. It would make more sense that the enlarged heart was impinging upon the airway, but if the heart, enlarged as it may be, still is not touching the airway, what could be the cause of the cough?

We know that, at least in humans, ACE-inhibitors can cause a cough similar to a cardiac cough, but in summerwalk's dog's case, he has not even started taking an ACE-inhibitor. So, as the researchers conclude: "Further studies are needed...".

[RodRussell]

... Unfortunately, I couldn't reach the cardiologist directly (no phone call, no voicemail and no email). I only got his feedback indirectly through the consulting doctor at the veterinary where the radiographs were performed. I was perplexed. I am quite familiar with the general practice and and the interactions with cardiologists for human heart disease because my dad has gone through quite a bit. But Not knowing the general practice in veterinary, I didn't want to be judgmental and ahead of myself.

Some cardiologists are a little quirkly about dealing directly with dog owners. One of the cardiologists we use -- office in Gainesville, Florida -- actually charges more for an ultrasound exam if the owners are in the room with him and ask questions. Since he travels to Orlando, we use him and pay the extra fee for that opportunity. The other cardiologist, who is in Tampa, has no problem meeting with us, talking directly about all aspects of the exam, diagnosis, and treatment, etc. We prefer to use the more open one, of course.

So, if you have the option to choose among two or more cardiologists, you might consider picking another one.