Our Cavalier has been diagnosed with heart trouble

[cwaters]

Last November, our vet diagnosed "Freckles", our nine-year old female Blenheim, with a 'level 2 to 3' heart murmur. A cardiologist visit followed, in which the murmur was confirmed; everything else seemed to be fine. The cardiologist recommended a six-month follow-up visit.

About a month, ago, Freckles began "the cough" that we were told to be on the watch for. We immediately scheduled another cardiologist visit; that visit will occur next Friday.

At Freckles' annual vet exam earlier this week, the murmur was described as 'level 3 to 4'. The cardiologist asked the vet to have X-rays taken, in preparation for next Friday's appointment. The X-rays showed some enlargement of the heart but not much else. I became understandably worried. Freckles' activity and appetite don't seem to have been affected yet.

I just received a call from the vet, in behalf of the cardiologist. The cardiologist examined Freckles' x-rays, determined that there is some fluid present (not sure what she meant by that), and wants us to start administering medication immediately--presumably to address the fluid. Starting today, I'm administering Freckles, from the vet but at the cardiologist's direction, 12.5mg of "Furosemide; Lasix" (two per day) and 2.5mg of Enalapril (one per day). The Lasix bottle says "May cause increased thirst and urination."

Can anyone comment on this? Is this a typical progression of events, given my description? Also, I see references on this subforum to "frusemide"; is that the same as Furosemide?

I'm understandably worried about our girl.

[meljoy]

Hiya,
Sorry to read your post.
Frusemide is the same drug.....its a diuretic to get rid of excess fluid around Freckles lungs. She will definitely pee more while she's on it.
My Leo was diagnosed about 6 months ago. He started on Vetmedin, Fusemide and Cardalis tablets......since then he's done really well. There are too many of us here with dogs on these meds...you'll get a lot of support.
Its good you have a cardiologist's input as hopefully with the right meds Freckles will feel much better.

Mel

[cwaters]

Thanks for the reply, the information, and the comforting message of support.

This is Day 2 of the medication. Freckles is peeing more but has had no accidents, so far--even overnight. Do dogs typically adjust--or will peeing more be the norm?

Do the beneficial effects of the medication usually take effect immediately? Or does it take a few days/weeks? I can't say I've noticed any difference yet. Freckles had her now-typical cough this morning and coughed a few more times so far today. She enjoyed her morning walk.

I'm surprised/concerned the cardiologist prescribed the medication prior (7 days) to the appointment. I'm hoping it's primarily because she's looking to see how Freckles is responding prior to the visit.

So far, Freckles is OK with the steps in our house. I'm wondering if we should discourage her from using them?

Lastly, does the prescription of the medication mean she has entered CHF stage? Or isn't it that simple?

[jasperpaw]

My oldest cavalier developed a cough when he was about 9 and a half and he is now just over 14 years old, so has done very well on the medication he was put on, he is on Frusemide on various doses over time, Fortekor and more recently has been on Vetmedin as he started to cough more. I never remember Jasper having any accident and never really saw his peeing more, although I think he does now he is on 1 tablet a day which I give first thing in the morning. My boy had a ECG and heart scan prior to the medication, but always had energy, but with him being the age he is it`s difficult to know how much for him now is his age. Good luck when you go to the cardiologist, I hope the medication improves Freckles. I remember the vet saying when he was first put on medication not to wrap him up in cotton wool, as he does not realize he has problems, you just learn over time to adapt to your dogs needs.

[RodRussell]

I'm surprised/concerned the cardiologist prescribed the medication prior (7 days) to the appointment. I'm hoping it's primarily because she's looking to see how Freckles is responding prior to the visit.

So far, Freckles is OK with the steps in our house. I'm wondering if we should discourage her from using them?

Lastly, does the prescription of the medication mean she has entered CHF stage? Or isn't it that simple?

Fluid in the lungs plus symptoms like a "cardiac cough" are indications that you dog is in CHF. At that point, I would not hesitate to give him the prescriptions. MVD is a progressive disease, meaning that it usually gets worse over time. As it gets worse, ultimately the dog enters CHF, and at that point it needs medications, including a diuretic and an ACE-inhibitor. Vetmedin may be prescribed, but personally I would not give it to my dog without first having the dog examined by a cardiologist or internal specialist.

[cwaters]

Thanks, Rod. We're concerned with some of the potential damaging side-effects of Furosemide and Enalapril upon Freckles' kidneys. From what I've read, it appears that the two medications are usually prescribed together. Is that so? Are most Cavaliers able to tolerate these medications?

Freckles has only been on these two medications for five days; we have a cardiologist appointment on Friday, at which point she will have been on them for seven days. Is that sufficient time to know whether they're working? So far, she still has the occasional cough when she stretches out on her front legs; sometimes, too, when she yawns. I figure that, where there's still a cough, there's still fluid; that worries me. Or is the goal of the medications to not necessarily eliminate the cough, but to slow down the worsening of the condition?

Freckles has always been a loud snorer. She also occasionally snorts and sneezes. These things have brought us many chuckles over the years. Maybe I'm being paranoid but now that she has CHF, I'm wondering if any of these--especially the sneezes--are a result of fluid in the lungs. What do you think?

The Furosemide is causing Freckles to drink and urinate more. Is the increased drinking the only cause of the increased urination--or does the medication itself also cause it, perhaps a side-effect upon the kidneys?

We've noticed that Freckles has become a bit restless over the last year or so; we figured it was due to age and/or the minor arthritis in her hips she was diagnosed with a few years ago. Over the same about of time, she has also begun favoring lying on harder surfaces instead of in her bed or on our bed--although she still does use the beds quite a bit. It's difficult sometimes to know what things are typical for her vs age-related vs boredom vs something else. Can restlessness--and favoring harder surfaces--be additional indicators of CHF?

[RodRussell]

Thanks, Rod. We're concerned with some of the potential damaging side-effects of Furosemide and Enalapril upon Freckles' kidneys. From what I've read, it appears that the two medications are usually prescribed together. Is that so? Are most Cavaliers able to tolerate these medications?

I apologize for missing this message until now. The two meds are typically prescribed together. While there have been concerns in the past about the effects of ACE-inhibitors such as enalapril upon the kidneys, the concerns are not great, although periodic monitoring is part of the protocol. Diuretics such as furosemide also can adversely impact the kidneys, but remarkably, recent research has found that when the two drugs are given in combination, the ACE-inhibitor tempers the potential bad side-effects of the diuretic upon the kidneys.

According to the cardiologists I've read or listened to recently, if the cavalier is in CHF, then definitely these two drugs should be given together as soon as the CHF is diagnosed.

Freckles has only been on these two medications for five days; we have a cardiologist appointment on Friday, at which point she will have been on them for seven days. Is that sufficient time to know whether they're working?

The monitoring at a week is really advisable because the drugs were prescribed before the cardiologist had the opportunity to examine him. Typically, cardiologists like to re-check the effects of these drugs in 3 months.

So far, she still has the occasional cough when she stretches out on her front legs; sometimes, too, when she yawns. I figure that, where there's still a cough, there's still fluid; that worries me. Or is the goal of the medications to not necessarily eliminate the cough, but to slow down the worsening of the condition?

The diuretic is intended to remove excess fluid, so if the cough is due to lung congestion or fluid around the heart, it should help to relieve the cough.

Freckles has always been a loud snorer. She also occasionally snorts and sneezes. These things have brought us many chuckles over the years. Maybe I'm being paranoid but now that she has CHF, I'm wondering if any of these--especially the sneezes--are a result of fluid in the lungs. What do you think?

I haven't heard of fluid accumulations due to CHF causing sneezes.

The Furosemide is causing Freckles to drink and urinate more. Is the increased drinking the only cause of the increased urination--or does the medication itself also cause it, perhaps a side-effect upon the kidneys?

The drug's removal of fluids from the body would prompt the dog to want to drink more.

We've noticed that Freckles has become a bit restless over the last year or so; we figured it was due to age and/or the minor arthritis in her hips she was diagnosed with a few years ago. Over the same about of time, she has also begun favoring lying on harder surfaces instead of in her bed or on our bed--although she still does use the beds quite a bit. It's difficult sometimes to know what things are typical for her vs age-related vs boredom vs something else. Can restlessness--and favoring harder surfaces--be additional indicators of CHF?

Our dogs with enlarged hearts due to CHF have found some positions to become uncomfortable, and they have tended to move around a bit more than usual, appearing to be restless at times. Lying on hard surfaces has been helpful to them. So, I would say the moving around while trying to rest may be due to the enlarged heart making them feel uncomfortable. For our cavaliers which have approached the end-stage of CHF, we have offered them a small "egg-crate" mattress to lie on. It is made of a sturdy foam. This type of foam mattress also can be more comfortable for dogs with hip issues.

[cwaters]

Thank you for the comprehensive, very helpful reply, Rod!

Freckles' cardiologist visit went better than I expected. Based on the x-rays (which had been forwarded to her about a week in advance) -- and, perhaps, based on my panic-stricken phone call a week prior to that, when I began noticing the coughing -- the cardiologist prescribed the medication, and was expecting Freckles' condition to be considerably worse than it was at her visit seven months ago.

In addition to detailed echocardiogram and doppler readings, the cardiologist's report includes the following comments:

• Cardiovascular Examination: Grade IV/V coarse holosystolic murmur PMI L apex w/precordial thrill (faint). Grade II-III/V on R. Lungs clear. Pulses s/s. Tongue slightly cyanotic. Stertor seems more pronounced.
• Cardiovascular Diagnosis: Mild mitral insufficiency (5.5 m/s). Same as in previous study. Mild LAE. Mild triscuspid insufficiency 2 m/s. Good LV function. No pulmonary hypertension.
• Comments: There has been mild progression since last visit--mostly due to increase in TR (which is still mild). CVD, MR, TR: Still stage B2. I am questioning now if infiltrates on rads was all edema. Consider work-up for soft palate / upper airway issues. Steroids if severe stertor.

So Freckles has Stage B2 MVD. Hearing that troubles me; but at least it hasn't worsened significantly over the last seven months. It seems that the depiction of the fluid and the enlarged heart from the x-rays a week earlier *may* have been a bit exaggerated. The cardiologist said that Freckles is OK for now and that there are many options to treat her as the condition worsens. The cardiologist wants to see her again in three months.

I asked the cardiologist whether, in hindsight, starting her on medication may have been premature. She replied that she didn't think it was, and that it would help treat the disease. (Now, I'm wondering: If her condition hasn't worsened that much in the preceding seven months, why is she only now being put on medication? Should she have been put on it earlier?)

Based on the findings, the cardiologist recommended *decreasing* the Furosemide/Lasix from two 12.5mg tablets per day to one, and *increasing* the Enalapril from one 2.5mg tablet per day to two (morning/evening). I did that immediately and will be updating the cardiologist in a week. She said to watch for increased restful breathing. So far, Freckles' breathing has remained unchanged at about 20 per minute--which seems to be what it was prior to her even being put on *any* medication. (The cardiologist said she might recommend a further reduction of the Furosemide/Lasix to one-half 12.5mg tablet per day.) On Friday, Freckles' vet will perform blood work to monitor the effect upon the kidneys. The cardiologist doesn't recommend VetMedin yet.

Freckles panted for the entire 45 minute drive to the office, as well as in the waiting and examination rooms, and during the examination. During the examination, my wife noticed that Freckles' tongue had a slight bluish appearance. We've never noticed this before; on the other hand, it's not something we had been looking at. We're unsure if the coloring was due to the panting, the MVD, or something else. She didn't pant going home, and her tongue looked fine. We're now monitoring this.

Concerning Freckles' restlessness (especially at night) and her favoring harder surfaces to lay on, the cardiologist said it could be due to arthritis and/or general aches and pains of age, or even cognitive changes. I wonder if there's any medication that can help with that; on the other hand, I'm reluctant to put her on additional medication.

Concerning Freckles' snorting and snoring (which she has done her whole life), the cardiologist said it could be due to a soft pallet; she suggested having it looked at. Like you, Rod, the cardiologist said that Freckles' occasional sneezing doesn't seem to be a symptom of the MVD; we're not sure *what's* causing it, or if it's anything to be concerned about.

Over the last year or so, my wife and I have been discussing getting another Cavalier. The cardiologist said that, given Freckles' present condition, and as long as she gets along well with other dogs, getting another Cavalier shouldn't be an issue. We're undecided, however, since we certainly don't want to hasten the deterioration of Freckles' condition.

Not surprisingly, Freckles didn't cough at all during the visit. The cardiologist administered a Convenia injection -- in case the morning cough and occasional-stretch cough is due to an infection. So far, I haven't noticed an improvement; however, it's not like she's been coughing often. The cardiologist said that if the cough doesn't go away (or if it improves but then returns) to get more x-rays, two weeks after the injection -- to check again for fluid. The vet told me that when Freckles gets her blood work done on Friday they will check for other causes such as an infection, bronchitis, an allergy, etc. The vet cautioned that if it's an allergy they will need to be careful in administering steroids since that can cause fluid retention. Surprisingly, no one seems to attribute the coughing to the MVD at this point. What does a MVD-related cough sound like? How frequently does it occur? Does it sound different from a cough caused by something else?

[RodRussell]

... I asked the cardiologist whether, in hindsight, starting her on medication may have been premature. She replied that she didn't think it was, and that it would help treat the disease. (Now, I'm wondering: [B]If her condition hasn't worsened that much in the preceding seven months, why is she only now being put on medication? Should she have been put on it earlier?)

The furosemide is a diuretic, and if the cardiologist detected excess fluid build-up related to the MVD, then I guess giving a diuretic would be appropriate as needed. Enalapril is an ACE-inhibitor, and the current general consensus (although not unanimous) among cardiologists is that ACE-inhibitors are of no value to cavaliers prior to congestive heart failure (CHF). This consensus is based upon a research report on a 2002 Scandinavian study (the "Scandinavian Veterinary Enalapril Prevention [SVEP] Trial") of 229 asymptomatic cavaliers with mild MVD murmurs, which has shown that ACE-inhibitors had no significant affect upon the time from the initiation of ACE-I therapy to the point of heart failure. Nevertheless, a 2007 study (the "VETPROOF Trial"), sponsored by a drug manufacturer and involving 124 dogs of several breeds (including only 10 cavaliers), showed that enalapril given to dogs with only mild MVD murmurs and some enlargement of the heart but which otherwise are symptomless, "modestly delayed" the onset of CHF. So, since cardiologists treat many breeds of dogs in addition to cavaliers, some of them tend to prescribe the ACE-inhibitor rather early.

However, in order to offset the possible side-effects of the diuretic on the kidneys, the ACE-inhibitor may have been prescribed along with the furosemide.

... The cardiologist doesn't recommend VetMedin yet.

That's good to know.

... Freckles panted for the entire 45 minute drive to the office, as well as in the waiting and examination rooms, and during the examination. During the examination, my wife noticed that Freckles' tongue had a slight bluish appearance. We've never noticed this before; on the other hand, it's not something we had been looking at. We're unsure if the coloring was due to the panting, the MVD, or something else. She didn't pant going home, and her tongue looked fine. We're now monitoring this.

That probably is due to her knowing where she was going and not wanting to go. I think it's called vet clinic stress.

... Concerning Freckles' restlessness (especially at night) and her favoring harder surfaces to lay on, the cardiologist said it could be due to arthritis and/or general aches and pains of age, or even cognitive changes. I wonder if there's any medication that can help with that; on the other hand, I'm reluctant to put her on additional medication.

Unless she is diagnosed with a structural disorder, I would not give her anything for that, but I think it always is advisable to give a mild bone and joint supplement to older dogs.

... Over the last year or so, my wife and I have been discussing getting another Cavalier. The cardiologist said that, given Freckles' present condition, and as long as she gets along well with other dogs, [B]getting another Cavalier shouldn't be an issue. We're undecided, however, since we certainly don't want to hasten the deterioration of Freckles' condition.

I think it depends upon the personality of the dog you have. She needs to understand that she is not being replaced, but that she is being given a companion. We got our (after I got married) first cavalier a second one because he wanted a companion. Has anybody else bought a cavalier for the one you already have? We added a puppy last summer to our brood, and he has given new life and vigor to our teenaged male.

... What does a MVD-related cough sound like? How frequently does it occur? Does it sound different from a cough caused by something else?

The cardiac cough is a dry, hacking sound coming deep within the body. There have been a couple of veterinary websites with audios of the sound, but I have not been able to find them today. YouTube has a few videos of MVD-dogs coughing, but they are not very well produced videos.

[cwaters]

Thanks again, Rod. Given my dog's MVD condition, is it accurate to say she has CHF?

I wish I knew conclusively what the cause of the cough is. It's still not something we hear often; we listen for it, but notice it only once or twice a day.

Now that she's been on it for almost two weeks, I'm wondering whether the medication is truly needed (the cardiologist says it is), why it's being changed (halving the Furosemide; doubling the Enalapril) (I didn't really understand the cardiologist's explanation--even after she repeated it numerous times), and whether the new amounts are safe (the cardiologist assured me it is). Perhaps most importantly, I'm wondering how to know if the medication is helping Freckles' condition.