What to do, what to do.

Re: What to do, what to do.

Anthony Todd — Thu, 16 Feb 2012 23:25:04 GMT

[quote user="Lorna McHardy"]Am I right in thinking that treating asymptomatic heart murmurs will make no difference to either the patient or the murmur,[/quote]

Wasn't there some analysis done in the dinosaurial period which suggested, in racing greyhounds in Glasgow, that the better performers had the loudest murmurs ie that a murmur did not necessarily mean a reduced cardiac output and could be asymptomatic??

I was always reluctant to discuss or mention murmurs in puppies with the owner for fear of turning a "normal" pup into a life-long invalid.

The risk was that some whizz kid would tell the owner later and I had, therefore, not heard it.....

Re: What to do, what to do.

james herriot lied — Thu, 16 Feb 2012 23:07:11 GMT

Nice. Definitely one for final year students.

Re: What to do, what to do.

An On MRCVS — Thu, 16 Feb 2012 21:01:06 GMT

Postscript.

Biopsy not cancer. Through events beyond our control, only saw the cat back yesterday. Much better set of rads, which were fairly diagnostic on plain survey, culminating with a bit of contrast in:

Fixed today.

Re: What to do, what to do.

Arlo Guthrie — Mon, 06 Feb 2012 18:38:32 GMT

[quote user="Martin Atkinson"]

[quote user="Neil Wheadon"]I agree entirely, I love these cases as they make you stop, think and they are great CPD. Mike Martin, Francis Barr etc,[/quote]

That's a point: can we claim it as part of our recommended 105 over 3 years? For some of us this could add up to several hours a week! [/quote]

Yup: http://www.vetsurgeon.org/blogs/veterinary_news/archive/2009/12/17/10473.aspx

Re: What to do, what to do.

Martin Atkinson — Mon, 06 Feb 2012 18:16:49 GMT

[quote user="Neil Wheadon"]

I agree entirely, I love these cases as they make you stop, think and they are great CPD. Mike Martin, Francis Barr etc,

[/quote]

That's a point: can we claim it as part of our recommended 105 over 3 years? For some of us this could add up to several hours a week!

Re: What to do, what to do.

Mark Holmes — Mon, 06 Feb 2012 13:01:08 GMT

[quote user="Rob Davis"]

[quote user="Mark Holmes"]In cats I have been promtoing pro bnp tests and have found some very suprising positives which has encouraged me to suggest them routinely if a murmur is noted.[/quote]

Do you find the pro-bnp is reliable? Do you perform this before, after or instead of ultrasound? Do you recommend it in all cats with murmurs?

Sorry for all the questions - it's not something I've used, and having tried the pro-ANP touted around several years ago I am sceptical...

[/quote]

If a cat presents symptomless at a booster with an aquired murmur I suggest it and have picked up quite a number with significant heart disease which were "asymptomatic" In hindsight they were possibly a little more lethergic but this is generally difficult to assess. If the pro bnp levels are high >300 I xray and scan. If they are moderate I usually retest in 3 months. If normal I recheck q 6-12 months. I used to have difficulty knowing what to do with these cases. If owners were worried I found it difficult to say we'll just keep an eye on it and equally difficult to book every cat in for a cardiac work up when in 12 months it would be similarly difficult to say if there were any signicant changes. The results do seem to corrolate pretty well with what I am finding on radiographs/echo, that said I am not taking pictures or scanning those with normal blood results.

My review of the test would be that it seems to be pretty accurate, it is very convenient and well accepted by clients who would be less inclined to sedate and xray an apparantly "normal" cat.

The other thing is that a normal result is taken better. If you note a murmur and then persuade somebody to investigate only to have normal xrays etc at the end of the process owners are inclined to ask "What have we achieved?" Particularly when those normal results are of finite significance.

Essentially "I thought the cat was normal and you've spent £X telling me he was normal but you can only be happy he is normal for 12 months(+/-) before we will be non the wiser"

Bloods allow you to say " Good news, the bloods don't show anything that gives me cause for concern right now lets review in 6-12 months" (Note I don't say he's fine)

As dogs are much better at demonstrating cardiac disease and don't (in general) get the sudden catastrophic deterioration that cats do I use it rarely relying on clinical signs and exam.

Re: What to do, what to do.

Frances Barr — Mon, 06 Feb 2012 12:48:54 GMT

I'm with Mike and Niall on this one. I'm pretty sure this is a peritoneo-pericardial diaphragmatic hernia. When you look at the apex of the 'heart' there's a strange triangular shape, which is often seen when there's a bit of liver in the pericaridal sac along with a bit of fat to highlight. Good news about PPDH is that it can be completely incidental clinically, although I agree owners still should be told.

If you don't have ultrasound, a lateral abdominal X ray sometimes helps in these cases. There is often a definite lack of liver in the cranial abdomen. Hope that helps.

Frances

Re: What to do, what to do.

tess — Mon, 06 Feb 2012 12:10:36 GMT

a) and b) then advise O what symptoms to look for in the future. Most seem happy with this- there is the option to do a work up at any time.

Re: What to do, what to do.

Rob Davis — Wed, 01 Feb 2012 18:17:48 GMT

[quote user="Mark Holmes"]In cats I have been promtoing pro bnp tests and have found some very suprising positives which has encouraged me to suggest them routinely if a murmur is noted.[/quote]

Do you find the pro-bnp is reliable? Do you perform this before, after or instead of ultrasound? Do you recommend it in all cats with murmurs?

Sorry for all the questions - it's not something I've used, and having tried the pro-ANP touted around several years ago I am sceptical...

Re: What to do, what to do.

Mark Holmes — Wed, 01 Feb 2012 17:34:12 GMT

Personally in dogs they get noteda nd a work up advised if clinical signs become evident. However in DCM prone breeds I pay close attention to soft murmurs and take careful note of heart rate and pulse volumes and question very carefully onexercise tollerance as early DCM can be very subtle. (It tends not to stay subtle for long).

In cats I have been promtoing pro bnp tests and have found some very suprising positives which has encouraged me to suggest them routinely if a murmur is noted. I also repeat them 3, 6, or 12 monthly depending on the results and suggest a full heart workup if they are +ve

Re: What to do, what to do.

james herriot lied — Wed, 01 Feb 2012 16:14:39 GMT

Interesting. I've lost count of the number of heart murmurs I've found over the years 'for the first time', at booster consults. I ALWAYS talk about them, whilst explaining that I ALWAYS talk about them, even though many of them are not significant in the long run. As it is indeed not useful to dive in on treatment before signs become apparent - although signs become apparent to some owners long before others (!) - and I live in a one of the poorest areas of the country, immediate investigation is often not something that people want. I did go through a phase of doing a lot of pro-BNPs, but they unfailingly came back as negative or 'borderline' and so I stopped. If I were in permanent practice, I'd think about doing a clinical audit, but as a locum it's difficult. It would be interesting to see how many actually did become a problem in the end.

Obviously, that's dogs. Cats is different. Finding VPCs and Tachs in cats is a definite work up; murmurs I'd be a little more persuasive with than with dogs - but perhaps that's just my perception of cat hearts.

Generally, I find that people are quite happy that you've been diligent enough to find the murmurs, and grateful that you're on board and on the case, even if nothing 'needs' to be done right now.

Re: What to do, what to do.

Rob Davis — Wed, 01 Feb 2012 15:22:56 GMT

[quote user="Lorna McHardy"]a), b), and c)discuss the option of further investigation, but not necessarily push it at that stage.[/quote]

Ditto. If the owners do not wish to investigate then I would advise a reexamination in 2-4 months.

We have an obligation to inform owners of our findings, even if we are not certain of their significance. There are very few situations in which witholding information would be justifiable, and there is a fair chance it would come back and bite you on the bum!

Re: What to do, what to do.

Hannah Wynne Richards — Wed, 01 Feb 2012 13:56:25 GMT

Slight variation a) b) and treat for lungworm,then reassess-but that could just be because I'm in the lungworm capital of GB

Wynne

Re: What to do, what to do.

Lorna McHardy — Wed, 01 Feb 2012 13:53:29 GMT

[quote user="james herriot lied"]

How do people feel about heart murmurs in, say, young healthy labs, picked up for the first time at 2-3yo in a booster consult, with absolutely no symptoms. Most of us would agree that a large proportion are likely to be innocent/physiological, but how many would a) mention it to the owner, b) write it down in the clinical notes, c) recommend further investigation without any clinical signs, or d) all of the above?

[/quote]

a), b), and c)discuss the option of further investigation, but not necessarily push it at that stage. What I would stress, is the need to monitor it - i.e., make sure owner knows what symptoms to look out for, and make sure it's checked whenever the dog comes in.

Am I right in thinking that treating asymptomatic heart murmurs will make no difference to either the patient or the murmur, and is therefore not advisable unless and until symptoms do develop?

Re: What to do, what to do.

Dagmar Steele — Wed, 01 Feb 2012 13:44:16 GMT

It's d) for me. I have to tell them once I hear it, I have to write it down. And I do recommend further investigation to make sure nothing preventable gets overlooked. I do mention that many of these murmurs are not of any clinical relevance and that I myself have a benign very prominent heart murmur myself since teenage days without any symptoms to date (45 now). If o. opt for investigation, fine, last one was a two yo ELO with septal defect, if not it is the o. decision. I am adamant: if a vet detects anything abnormal on a pet the I. Has the right to know about it and to decide what to do about it. Everything else would be terribly wrong, our customers are grown ups, not toddlers who cannot decide for themselves.

Re: What to do, what to do.

james herriot lied — Wed, 01 Feb 2012 13:27:31 GMT

[quote user="Neil Wheadon"]

My comment is there aren't enough of these cases posted - don't be shy

[/quote]

Agreed. For me, what's significant is that even though at times it seems like members are ready to throttle each other over the difference between, say, unfractionated and 'posh' heparin, when it comes down to brass tacks of whether we have any actual power in the relationship with the client (and thus, the potential to abuse that relationship, e.g. by withholding information that we don't feel the owner needs/wants to know), the consensus is actually that we don't. End of. Nice to see a universal front. I do say, though, that if the biopsy is really bad news, a certain caution might be advisable wrt to chasing a heart condition (asymptomatic?) if it's going to be very time consuming and/or invasive / stressful, in the face of a fairly short outlook. Of course, they're always the ones that then buck the trend and fail to die of malignant tumours for five years.......

Re: What to do, what to do.

Neil Wheadon — Wed, 01 Feb 2012 12:44:13 GMT

[quote user="Bob Russell"]

Why the red star? This is a genuine request for advice. OK a DV would have been wise but so what?

Interesting case, moral dilemma - precisely what makes VetSurgeon so welcome!

[/quote]

I agree entirely, I love these cases as they make you stop, think and they are great CPD. Mike Martin, Francis Barr etc, THANKS. My comment is there aren't enough of these cases posted - don't be shy

Re: What to do, what to do.

An On MRCVS — Wed, 01 Feb 2012 12:42:15 GMT

Interesting replies.

Rest assured, all isn't quite as it was put: what didn't happen is that a VD/DV didn't get taken - a salutary lesson, really. BUT, owner's been informed that the heart shape is not right, but we're waiting till biopsy back before going down any investigation route.

Pleased to hear re the possible herniation: shows me I'm not such an idiot after all, as I was looking up peritoneal contrast yesterday (no U/S here). We're waiting on the lab, but should be seeing cat back shortly after for bloods and xray/ECG/BP.

I wanted really to fish for that ethical question of what should we tell the owners: simple answer, everything. It's not our right to withhold, although it is our prerogative to advise sensibly. If the biopsy does come back nasty, we'll still be doing the heart work-up as the owner wants it. But it wouldn't have been that remiss to give sensible advice about the likelihood of which would kill the cat first, tumour or heart.

Thanks to all.

Re: What to do, what to do.

Niall Taylor — Wed, 01 Feb 2012 12:37:25 GMT

[quote user="Mike Martin"][quote user="Niall Taylor"]congenital pleuro-peritoneal-mediastinal diaphragmatic hernia[/quote]

Yep......congenital pericardio-diaphragmatic hernia.[/quote]

Ahem, obviously that's what I meant...

Thanks Mike.

Niall

Re: What to do, what to do.

Bob Russell — Wed, 01 Feb 2012 10:55:21 GMT

The dilemma was whether to tell the owner or not. The universal answer from others (including me!) is tell the owners - dilemma hopefully sorted!

Re: What to do, what to do.

Hannah Wynne Richards — Wed, 01 Feb 2012 10:00:33 GMT

You've got to tell the owner

Wynne

Re: What to do, what to do.

Kate Richardson — Wed, 01 Feb 2012 09:59:25 GMT

Absolutely agree with all the above, you should tell them, after all you have to treat the whole cat. Assuming there is cardiac disease, imagine if the cat was to suddenly go into congestive heart failure or develop an aortic thromboembolism and the owners had no idea the cat might have an underlying heart problem and they could have had the option of preventative treatment for such scenarios (not that they always work of course), how would they feel? And it affects the management of the presenting problem as well in terms of possible GA risk, and also long term prognosis if the cat has advance cardiac changes. Yes, you must tell them.

Re: What to do, what to do.

Martin Atkinson — Wed, 01 Feb 2012 09:48:56 GMT

I can't see there is a dilemma - you've spotted an abnormality on the X-ray the owner should be informed asap, period. Cats do very well at hiding cardiac disease so I agree about the NTproBNP (my pet subject) to start with. From where I'm sitting it doesn't look like a pericardio-diaphragmatic hernia, I can see a complete diaphragm but its an odd shape for a heart with HCM, how about a mass overlying the heart? Ultimately if you're going to investigate it then echo is going to be advisable anyway.

Re: What to do, what to do.

Bob Russell — Wed, 01 Feb 2012 09:22:42 GMT

Why the red star? This is a genuine request for advice. OK a DV would have been wise but so what?

Interesting case, moral dilemma - precisely what makes VetSurgeon so welcome!

Re: What to do, what to do.

Mike Martin — Wed, 01 Feb 2012 09:05:53 GMT

[quote user="Niall Taylor"]congenital pleuro-peritoneal-mediastinal diaphragmatic hernia[/quote]

Yep......congenital pericardio-diaphragmatic hernia. Am I allowed to say : I get really frustrated by people not taking DVs in situations when it is needed, what excuse can there be?... Does the cat/dog and owner not deserve the best from a Professional? [Head and parapet comes to mind on this forum]

Ultrasound is the best way to confirm. 95% of the time corrective surgery is a simple laparotomy, pull everything back, repair the hole. 5% of time, the liver is adhesed to the heart - not good!