Re: [FH] intro: Terry - Had echo, mystery patient (long)
- It sounds like you have your hands full with Terry. I'm sorry to hear about his health issues.
In answer to your question about the echo results, it depends on the cardiologist. Many only give a written summary. Some will also provide still photos of the salient parts of the echocardiogram. I've not encountered any cardiologists who put the echo on a CD but that doesn't mean there isn't anyone out there who does.
It can be a very difficult decision whether to give steroids in these situations or not but the truth is sometimes in cases of feline asthma, the steroids are necessary to save the cat's life. Some vets don't like using the Depo-Medrol and repository types of steroids because of their long-acting nature. You can't stop giving the medication and see if the symptoms go away as you can with prednisolone. But again, sometimes, they're a calculated risk, especially if the cat is difficult to medicate or becomes excited/stressed when medicated.
The plan you outlined below seems reasonable to me given Terry's situation. I wish you success in his treatment. I'm sorry either one of you has to go through this.
Lorie Huston, DVM
From: cc <chrisc987@...>
To: feline-heart <firstname.lastname@example.org>
Sent: Fri, Jan 28, 2011 5:24 am
Subject: [FH] intro: Terry - Had echo, mystery patient (long)
I scanned the faq here, and had a brief look at some of the files. I wish I had known about your excellent echo info before we had ours done. Anyway, I need to get your eyes on this now, as I continue to read your resources. My 16 year old British Shorthair, Terry, had an echo-cardiogram yesterday. Background: he was always healthy, except for in his senior years he got arthritis managed by cosequin and he had some kidney issues that were managed by once a week sub-Q's (100ml).
(IF YOU WANT TO SKIP THE BACKGROUND, AND IT'S LONG SO I WOULDN'T BLAME YOU, PLEASE GO DOWN TO THE CARDIOLOGIST'S REPORT)
We noticed he had been "snoring" for the past six months. He had gained weight due to my spouse being home and over-feeding him (the past year and a half). He stopped climbing up his cat tree about 6 months ago. In early Dec, we got a Christmas tree (like usual) and Terry had his first attack. He was having problems breathing, was coughing, in distress, and was rushed to the closest vet. X-rays were not conclusive. The vet noticed his heart was enlarged but she said it could just be that he's fat. She had no diagnosis and gave him Covenia and suggested we go to the specialty care clinic if he had another attack.
He did have another attack and specialty care said they thought he had feline asthma. We bought an inhaler and Flovent and they gave us Predisolone and Terb. But this was not managing the breathing problems (he was also having bad side effects from the Covenia which made everything harder) and we went to a vet who gave him a Depo shot. It turned out that the specialty clinic had a policy of not wanting to give injections over oral meds.
In about a day, his breathing returned to normal. We were able to give Flovent regularly with ease. But after a few weeks his breathing became noisy again, although he did not have an attack.The vet had us add back the Predisolone (10 mg a day) and Terb. We had concerns if we didn't get a hold of his inflammation at the start, that we might have a more difficult time later due to possible scarring. So after consulting several vets, we decided that a second Depo shot would be in order. This wasn't a casual decision, he was having great difficulty consistently. His BPM was 50 (fast) and his stomach was struggling to breathe in an unusual way. We realized the risk to his kidneys and the potential for diabetes with the shot, but not the risk to his heart. But in any event, when the cat can't breathe properly, it takes top priority.
He got the second Depo last Monday. On Tuesday he had improved breathing. Then on Wed morning very early, he had an attack. I did not see it, my spouse did, but Terry was struggling to breathe, his paws out front, and in distress. I wasn't clear whether this sounded like coughing or sneezing. We gave him puffs of Albuterol and a dosage of Terb, but it didn't help. We rushed him to an emergency/specialty facility (that is listed in your files actually). I picked this one because I knew they had a cardiologist there, we had an appt for a couple of weeks later (my vet had heard a gallop heartbeat and recommended we see a cardiologist). This place told me on the phone that we could see the cardiologist that day if the initial doctor recommended it. I drove for 1 1/2 hours in rush hour traffic, blasting the a/c into Terry's carrier, hoping he would not worsen.
This first facility put him in oxygen and gave him a shot of Butorphanol (Torbugesic). A doctor came in to ask me questions but she had not been the one to give the shot. I told her that I wanted to see the cardiologist so we could see if his heart was all right, but she sort of dismissed that and went off to get x-rays. I spoke with the scheduler to see if there was any way to get in, but she just said if the doctor recommends it.
After I waited for a couple of hours, the doctor said that the cardiologist would probably not see Terry as she only will fit patients in if they are showing signs of cardiac (something - I was very tired by this point and cannot recall if she said "arrest" or something else). I told her that this was the reason I drove there as I discussed on the phone. She said she was tired of being in the middle between the cardiologist and patients, that many times they get angry because they could not see her (she wasn't talking about me). She mentioned there were two other places where we could get a cardio today.
The front desk gal came in the room a bit later with an estimate for my deposit to keep Terry overnight. They were not going to do anything other than keep him in oxygen and they could not guarantee that he would see the cardiologist that day or the next morning. The estimate was $1390-1990.
The doctor (who is not an internist, my cat was never seen by the internists there) returned to say the cardiologist looked at the new x-rays and decided she wasn't going to see my cat, presumably because they didn't look bad enough. I called another place and was told I could see a cardiologist right away. So I paid the bill and drove even further to the second facility. There, we had an appt with one of the cardiologists and then an echo and this is the main part of her report below. I omitted the history since it was covered above. I typed x-ray as a shorthand and if there are typos, they are mine, not hers.
THE REPORT:Xrays revealed a bronchointerstitial pattern. He also had
bladder stones, as well as stifle and spinal degenerative joint disease.
Xrays from today revealed a bronchointerstitial patter and
pleural fissure lines.
HR: 240, rhythm: gallop, no murmur
Crt <2 seconds, moist, pink mm
Pulses: moderate and synchronous
Respirations: mild increase bronchovesicular sounds,
intermittent referred upper airway sounds, tachypneic
Cardiac ultrasound report:
2/D M-Mode (cm):
LVID(D): 1.49 LVPW(D): 0.75 LVID(S) 0.63
LA/AO: 1.46 2D, 1.3 M-MODE
SF 0/0: 58.1 PERCENT
Comments: standard images are somewhat difficult to obtain
due to sternal deformity and obesity.
There is segmental left ventricular concentric hypertrophy
affecting the LV free wall, with prominent papillary muscles and areas of
subendrocardial fibrosis. The left atrial size is upper limits of normal to
mildly enlarged. The right
ventricle appears mildly diated and the right atrium appears normal. Mitral
inflow E wave velocity is elevated (~1.8 m/s), suggestive of elevated LV
filling pressures. No pericardial effusion is present. Pleural effusion is not
seen on ultrasound, although scant effusion is evident on radiographs.
AO: 113 cm/sec
PA: 214 cm/sec
MV: mild MR
TV: mild TR
Segmental LV concentric hypertrophy r/o hypertrophic
cardiomyopathy vs secondary to systemic hypertension
Scant pleural effusion r/o congestive heart failure vs other
Respiratory distress with reported “noisy breathing” – r/o
upper airway disease vs lower airway disease
Systolic BP 180-190 mmHg
Start Lasix 7 mg PO SID due to concern for possible
steroid-induced congestive heart failure. Although the cardiac enlargement is
not as significant as expected with congestive heart failure, the elevated
mitral E wave velocities suggest elevated left atrial pressures. Since the Depo-medrol is long acting,
the risk of steroid associated CHF will contiue over the next month, therefore,
a low does of Lasix is being given as a precaution. Will recheck renal values,
electrolytes, blood pressure, and thoracic radiographs in 1 week. Okay to start
doxycycline. Recommend internal medicine consultation for further evaluation of
respiratory disease and anemia.
(END OF REPORT SEGMENT)
Because Terry's first attack was brought on by the Christmas tree (the day we brought it home) and continued until we figured out that was the problem (and took it outside), it seems to point to either feline asthma or allergies. His heart problems may be from the steriods or he may have had these problems before them, due to his increased weight. But we're all feeling there might be something else, because the breathing was never fully brought under control for a length of time (like a week or two), and it should have been. We will see an internist to determine what else might be going on -- a polyup? Some infection? That is my understanding on what has happened, but I'm no expert. His breathing is much better today, so does that mean the attack yesterday morning was really a heart thing?
The cardiologist was conflicted about treatment. She was concerned about his kidneys and potential diabetes, and she seemed to feel that he wasn't an obvious heart patient, as I understood her. So she said she was opting for a very low dose of Lasix.
Whenever I get x-rays, I get a cd copy. With an echogram, do you typically get any physical record, like a copy on cd or is that impractical?
Thanks for reading any part of this long intro.
Chris and TerrySoCal
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