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Yet another vet visit update

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  • lclarizia@aol.com
    Hi all, Back from the vet ... good news and interesting developments. As Baby Boy was being passed around various laps belonging to the Ipswich Animal Hospital
    Message 1 of 6 , Oct 22 5:46 PM
      Hi all,

      Back from the vet ... good news and interesting developments.

      As Baby Boy was being passed around various laps belonging to the Ipswich
      Animal Hospital staff, the vet and I discussed his condition. First, the pleural
      effusion has resolved. This is good. Second, he sent Baby Boy's films and
      his ultrasound to a cardiologist, who he spoke with today. The written report
      isn't in yet, should come tomorrow and I'll get a copy next week.

      He appears to have very mild hypertrophy. I don't recall the numbers
      offhand, but they were indicative of very mild hypertrophy. However, the
      cardiologist is concerned about the contractility of his heart. The thinking is that he
      should discontinue enalapril for now and start diltiazem (calcium channel
      blocker) combined with lasix. The hope is that this will improve (or help with)
      his relatively poor contractility and therefore help prevent future episode of
      pleural effusion.

      I kind of wanted him to stay on the enalapril, since he's doing so well with
      it and because there have been good results with it in terms of slowing
      remodeling of the ventricle. Plus diltiazem is weaker in terms of slowing the heart
      rate BUT his heart rate is not all that elevated ... around 180 at the vet's.
      And I suppose I'm also not looking forward to the possibility of another
      "I'm adjust to a new med so I won't eat" episode. I asked the vet if he could
      stay on enalapril AND take diltiazem, he said yes but wants to see how he does
      with the diltiazem alone first. I don't know what I think about that,
      especially since he's still on lasix ... but it would be for just a week, we go back
      again next Friday.

      Opinions?

      Lisa


      [Non-text portions of this message have been removed]
    • Susan
      ... First, the pleural ... I don t know what I ... Lisa, I guess what bothers me is I always get a sense that your vet is just learning as he trys different
      Message 2 of 6 , Oct 23 6:49 AM
        --- lclarizia@... wrote:
        First, the pleural
        > effusion has resolved. This is good. Second, he
        > sent Baby Boy's films and
        > his ultrasound to a cardiologist, who he spoke with
        > today. The written report
        > isn't in yet, should come tomorrow and I'll get a
        > copy next week.
        >
        > He appears to have very mild hypertrophy. I don't
        > recall the numbers
        > offhand, but they were indicative of very mild
        > hypertrophy. However, the
        > cardiologist is concerned about the contractility of
        > his heart. The thinking is that he
        > should discontinue enalapril for now and start
        > diltiazem (calcium channel
        > blocker) combined with lasix. The hope is that this
        > will improve (or help with)
        > his relatively poor contractility and therefore help
        > prevent future episode of
        > pleural effusion.
        >
        > I kind of wanted him to stay on the enalapril, since
        > he's doing so well with
        > it and because there have been good results with it
        > in terms of slowing
        > remodeling of the ventricle. Plus diltiazem is
        > weaker in terms of slowing the heart
        > rate BUT his heart rate is not all that elevated ...
        > around 180 at the vet's.
        I don't know what I
        > think about that,
        > especially since he's still on lasix ... but it
        > would be for just a week, we go back
        > again next Friday.

        Lisa,

        I guess what bothers me is I always get a sense that
        your vet is just learning as he trys different things.
        I remember telling you that lasix monotherapy is not
        recommended when Baby Boy was first diagnosed. I knew
        this and I am just a layperson who reads Atkins, Fox
        etc. With your background in science I almost feel
        like you could manage this case as well by using VetGo
        Cardiology Concepts as a reference. Part of what gives
        me such confidence in my own vet is his decades of
        clinical experience and his advanced ACVIM degree. Is
        the cardiologist your vet is consulting with far away?
        Are there any Small Animal Internal Medicine vets near
        you?

        see:
        http://acvim.org for specailists by state

        The contractility thing makes me think of dilated
        cardiomyopathy. Is it possible there was a period of
        insufficient taurine that may have had a lasting
        effect on the heart? Did you try a 6 week course of
        taurine just to see if it might help? See Phil Fox for
        dosage.

        VetGo Cardiology Concepts:
        http://www.vetgo.com/cardio/concepts/concindx.php

        Susan



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      • lclarizia@aol.com
        In a message dated 10/23/2004 9:50:00 AM Eastern Daylight Time, ... I know it must seem that way, but that s probably because of the way I tell you about it.
        Message 3 of 6 , Oct 23 10:50 AM
          In a message dated 10/23/2004 9:50:00 AM Eastern Daylight Time,
          somnamblst@... writes:


          > I guess what bothers me is I always get a sense that
          > your vet is just learning as he trys different things.
          > I remember telling you that lasix monotherapy is not
          > recommended when Baby Boy was first diagnosed. I knew
          > this and I am just a layperson who reads Atkins, Fox
          > etc. With your background in science I almost feel
          > like you could manage this case as well by using VetGo
          > Cardiology Concepts as a reference. Part of what gives
          > me such confidence in my own vet is his decades of
          > clinical experience and his advanced ACVIM degree. Is
          > the cardiologist your vet is consulting with far away?
          > Are there any Small Animal Internal Medicine vets near
          > you?
          >

          I know it must seem that way, but that's probably because of the way I tell
          you about it. The vet and I talked for an hour yesterday, and part of that was
          a debate about what would slow/prevent remodeling best -- his point was that
          by slowing the heart rate, improving fill and ejection, the diltiazem had a
          better probability of doing that by relieving stress, I countered with RAAS
          activation, he said I had a point and there was no reason why he couldn't be on
          both if necessary but wanted to see if diltiazem might not improve the fluid
          issue which then might let us titrate back the lasix though he'd probably always
          need to be on it and yes RAAS was an issue but the contractility was a greater
          concern, and so forth. It's not that he doesn't know what he's talking about
          or that he's just throwing things at it in the hope that something will work.
          The night he was diagnosed, the vet asked me what he was eating, told me he
          would check for hyperthyroidism to rule that out, etc. and explained the
          various forms of cardiomyopathy.

          He did initially start on lasix alone, but the vet intended to start him on a
          heart med as well -- he wasn't sure which one, primarily because of the
          rather confusing fact that the initial ultrasound he did indicated the cat has very
          mild hypertrophy combined with poor contractility and CHF. I was a little
          twicked about giving heart meds, I hoped like heck I wouldn't have to though it
          quickly became obvious that wasn't a choice. He's not adverse to polypharmacy
          in treating this, but felt that in his clinical experience giving the cat the
          wrong med for what ailed him would be worse, especially while in "active" CHF
          -- he said that in his experience, cats can decompensate so quickly. The
          night Baby Boy was diagnosed he told me about the various options for meds --
          beta and calcium channel blockers, diuretics, etc. and explained that he was
          going to be on some combination of meds and soon, but wasn't sure which he was
          going to go with.

          He did a more extensive ultrasound two weeks ago, sent it to a cardiologist,
          which confirmed this. I doubt he's as experience as your vet, but he has had
          lots of clinical experience with heart kitties, and does know his own
          limitations -- he knows he's not a specialist. Pretty much all of this has been done
          in conjunction with a cardiology consult (I don't remember her name offhand --
          one of the cardiologists at Angell Memorial in Boston). The combined
          lasix/enalapril did resolve the pleural effusion for a time, but it appears that he
          just fills with fluid pretty easily, which the cardiologist thinks is the
          result of the contractility issue. The enalapril may have driven the last of the
          fluid off, which made him feel better which made him more active (several
          houseplants have gone to a better world because of the enalapril) which, because of
          his poor contractility, may have caused him to start filling up again.

          I'm calling on Monday to schedule an in-person visit with the cardiologist
          for Baby Boy, since he's doing well clinically we think he can stand the stress
          of a strange vet and an echo -- which he needs for a definitive diagnosis. I
          just hope I can stand the stress of a trip into Jamaica Plain -- I used to
          work at a lab near Angell and have not-so-fond memories of driving in that area!

          >
          > The contractility thing makes me think of dilated
          > cardiomyopathy. Is it possible there was a period of
          > insufficient taurine that may have had a lasting
          > effect on the heart? Did you try a 6 week course of
          > taurine just to see if it might help? See Phil Fox for
          > dosage.
          >

          I don't think so -- both kitties were eating commercial cat food. I had
          started Wysong, but only for week or so before Baby Boy was diagnosed, and even
          then it was supplemented and mixed with commercial. Neither of them liked it,
          and until I'm more knowledgeable about their nutritional needs, and especially
          since one of them is medically fragile, we're sticking with higher-end
          commercial food. Looking back, he was definitely eating less in the two weeks before
          he was diagnosed, but I think that was because he was feeling so poorly --
          but because he's always been a very fussy eater, and because I was switching
          brands, I didn't think anything of it.

          I asked about the possibility of it being DCM b/c of the contractility, and
          he is going to go for an echo so he can be definitively diagnosed, though the
          consensus is that it's HCM. But, on the off chance that it is taurine-related
          I'll check out the dose schedule.

          I hope I don't sound too defensive of him -- because your points are very
          good ones. I obviously really like my vet, he's a great guy who does all kinds
          of pro-bono stuff, loves animals, comes out at night on emergency visits and of
          the last six visits has only charged me cost for x-rays and ultrasounds but
          nothing for the office visit -- yesterday was completely free -- but as nice as
          all that is, it doesn't necessarily mean he's the best choice to treat my
          cat, right? I really appreciate your input on this -- it helps to have someone
          else question these choices I make. It never occurred to me -- or the vet --
          that he *could* have a taurine deficiency b/c he eats commercial food, but now
          that I think about it -- is it possible it could happen anyway? A deficiency
          can have several causes -- not just "not feeding" whatever's deficient. The
          hypertrophy is so mild as to possibly be on the high end of normal, suppose it
          is DCM masquerading as HCM? I don't know -- but I will find out.

          Thank you, Susan! :)

          Lisa


          [Non-text portions of this message have been removed]
        • Susan
          ... But wasn t Baby Boy a stray? I wonder if taurine deficient DCM though reversible with taurine might leave lasting contractility issues. I think I remember
          Message 4 of 6 , Oct 23 2:11 PM
            --- lclarizia@... wrote:

            >
            > > The contractility thing makes me think of dilated
            > > cardiomyopathy. Is it possible there was a period
            > of
            > > insufficient taurine that may have had a lasting
            > > effect on the heart? Did you try a 6 week course
            > of
            > > taurine just to see if it might help? See Phil Fox
            > for
            > > dosage.
            > >
            >
            > I don't think so -- both kitties were eating
            > commercial cat food.

            But wasn't Baby Boy a stray? I wonder if taurine
            deficient DCM though reversible with taurine might
            leave lasting contractility issues.

            I think I remember reading once that it is possible
            for a taurine deficiency to exist with seemingly
            adequate intake in rare instances.
            >
            > I asked about the possibility of it being DCM b/c of
            > the contractility, and
            > he is going to go for an echo so he can be
            > definitively diagnosed, though the
            > consensus is that it's HCM. But, on the off chance
            > that it is taurine-related
            > I'll check out the dose schedule.

            Taurine definittely can't hurt.
            >
            > I hope I don't sound too defensive of him -- because
            > your points are very
            > good ones.

            No not at all, you're right he is weighing options in
            an unusual case. If HR reduction is desired why not
            beta-blockade? Diuretic, ACE-I and beta-blockade is
            the gold standard in human CHF and some vets are
            suggesting it on an experimental basis for felines.

            Also if contractility is an issue wouldn't a positice
            inotropic drug like digoxin be mentioned? I guess I
            only really understand how beta-blockade works and not
            calcium channel blockers.

            It never
            > occurred to me -- or the vet --
            > that he *could* have a taurine deficiency b/c he
            > eats commercial food, but now
            > that I think about it -- is it possible it could
            > happen anyway? A deficiency
            > can have several causes -- not just "not feeding"
            > whatever's deficient. The
            > hypertrophy is so mild as to possibly be on the high
            > end of normal, suppose it
            > is DCM masquerading as HCM?

            VetGo Cardiology Concepts. It's huge and has a Q&A
            format. I seached for contractility and got lots of
            results

            Susan



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          • brinkett
            ... Feline cardiology does involve trial and error. Often vets will try different medications until they find one that the cat responds to, and my vet
            Message 5 of 6 , Oct 23 8:39 PM
              > I guess what bothers me is I always get a sense that
              > your vet is just learning as he trys different things.

              Feline cardiology does involve trial and error. Often vets will try
              different medications until they find one that the cat responds to,
              and my vet explained to me that sometimes there is no explanation
              for why one cat responds well to medication A while another responds
              well to medication B.

              I don't see anything alarming about a vet changing medications based
              on updated clinical information or because he has a gut feeling that
              a cat may respond more favorably to a different regimen.

              Also, I have a degree in science but I never would have tried to
              manage Morag's case on my own. I'm not a vet - being able to read
              and understand scientific jargon and papers isn't enough.

              Sarah.
            • lclarizia@aol.com
              In a message dated 10/23/2004 5:12:09 PM Eastern Daylight Time, ... Yes, but that was three years ago. To the best of my knowledge, he was being fed by about
              Message 6 of 6 , Oct 24 3:43 PM
                In a message dated 10/23/2004 5:12:09 PM Eastern Daylight Time,
                somnamblst@... writes:


                > > I don't think so -- both kitties were eating
                > > commercial cat food.
                >
                > But wasn't Baby Boy a stray? I wonder if taurine
                > deficient DCM though reversible with taurine might
                > leave lasting contractility issues.
                >

                Yes, but that was three years ago. To the best of my knowledge, he was being
                fed by about 10 different house, but I don't know what they were giving him
                or for that matter, how long he was a stray.

                > I think I remember reading once that it is possible
                > for a taurine deficiency to exist with seemingly
                > adequate intake in rare instances.
                >

                That's what I wonder about ... I have a similar issue with vitamin C, myself.


                > > I asked about the possibility of it being DCM b/c of
                > > the contractility, and
                > > he is going to go for an echo so he can be
                > > definitively diagnosed, though the
                > > consensus is that it's HCM. But, on the off chance
                > > that it is taurine-related
                > > I'll check out the dose schedule.
                >
                > Taurine definittely can't hurt.
                > >
                > > I hope I don't sound too defensive of him -- because
                > > your points are very
                > > good ones.
                >
                > No not at all, you're right he is weighing options in
                > an unusual case. If HR reduction is desired why not
                > beta-blockade? Diuretic, ACE-I and beta-blockade is
                > the gold standard in human CHF and some vets are
                > suggesting it on an experimental basis for felines.
                >

                I'll mention it to him tomorrow ... thanks!


                Lisa


                [Non-text portions of this message have been removed]
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