Feline cardiology

RE: Feline cardiology

Charlie G — Wed, 14 Dec 2016 22:57:55 GMT

There was an interesting article recently in BSAVA Companion, some useful stuff on thromboembolic disease and pro-BNP testing. Also the FATCAT study looking into clopidogrel vs aspirin - the survival times they published following an ATE were surprising, much longer than I have generally found in practice!!

RE: Feline cardiology

Martin Atkinson — Tue, 13 Dec 2016 14:09:16 GMT

[quote user="Martin Atkinson"][quote user="robloxley"]If only they all had a murmur prior to developing heart failure (or indeed thromboembolism or sudden death)[/quote]True they are the tricky ones to manage. Some reputable breeders of 'at risk' cats like Maine Coons monitor their charges annually with echo, I'm fairly convinced that annual testing for NT-proBNP would be as reliable and a lot cheaper and more convenient. [quote user="robloxley"]I trust you accept the figures that a lot of the cats with a murmur never progress to heart failure anyway, so their alive and healthiness may be in spite of such medication. [/quote]My experience is that about 1/3 of cats which develop a cardiac murmur in young-middle age will progress to acute cardiac failure or ATE. That these are usually fatal problems is a good reason to monitor them more closely, once again NT-proBP is a good monitoring tool. In my survey every cat with a level of 350 pmol/l or greater was either in or developed heart failure within a short period of time. Even if the level is below that* I give my clients the option of doing nothing and there is a 30% chance your cat will die within a couple of years or give it some possibly unnecessary treatment and it will probably live to old age.

*Idexx quote a level of > 270 pmol/l indicates cardiac failure but don't depend on the SNAP test, it is unreliable. [quote user="robloxley"]The EPIC trial in preclinical dogs with MVD was on patients with echocardiographic changes (stage B2 rather than B1).[/quote]Look and ye shall find.[/quote]

RE: Feline cardiology

Rob Loxley — Tue, 13 Dec 2016 13:47:44 GMT

[quote user="Martin Atkinson"]take a step backwards and review what happened when these cats were first presented a few years ago with an asymptomatic murmur[/quote]

If only they all had a murmur prior to developing heart failure (or indeed thromboembolism or sudden death)

[quote user="Martin Atkinson"]no evidence pre-emptive treatment is effective and its all anecdotal but I have a lot of anecdotally alive and healthy cardiac cats![/quote]

You may not agree with 'the cardiologists' but I trust you accept the figures that a lot of the cats with a murmur never progress to heart failure anyway, so their alive and healthiness may be in spite of such medication.

The EPIC trial in preclinical dogs with MVD was on patients with echocardiographic changes (stage B2 rather than B1).

RE: Feline cardiology

Lucy Fleming — Tue, 13 Dec 2016 12:30:12 GMT

[quote user="Kate Richardson"]c) any concurrent illness- so for example if cat has manky teeth I kind of feel it's not fair to the cat to pursue management of its cardiac disease if we can't address its dental disease[/quote]

This is a bit of a tangent, Kate, but do you (or anyone else) have any tips for getting owners to take this seriously? Had one the other day, hyperthyroid cat, BCS of 2/9 at most, breath that you could smell across the room but of course the owners 'don't think she can be in any pain because she still eats'. I'm normally pretty good at getting this across to owners, but always appreciate hearing a few different approaches.

RE: Feline cardiology

Martin Atkinson — Tue, 13 Dec 2016 09:24:23 GMT

Difficult to add anything to what the other's have said so far but take a step backwards and review what happened when these cats were first presented a few years ago with an asymptomatic murmur.

I would take NT-proBNP as a prognostic indicator and if the value is over 300 would start them on something pre-preemptively even before there are indications from echocardiograpy (previously benazepril/aspirin now pimobendam/clopidogrel) and they don't then present later in cardiac failure.

The cardiologists (cue David) will sneer at that and say there is no evidence pre-emptive treatment is effective and its all anecdotal but I have a lot of anecdotally alive and healthy cardiac cats!

RE: Feline cardiology

Kathryn Burton — Tue, 13 Dec 2016 08:42:16 GMT

Thanks everyone, that's really helpful.

RE: Feline cardiology

Kate Richardson — Mon, 12 Dec 2016 21:03:43 GMT

My answer is 'it depends', but generally give them a poor prognosis. What does it depend on (other than costs)?

a) their ability and willingness to medicate the cat from that point onwards because it will need medicating at least once daily

b) the cat's tolerance to above medicating

c) any concurrent illness- so for example if cat has manky teeth I kind of feel it's not fair to the cat to pursue management of its cardiac disease if we can't address its dental disease

d) how likely do I think hyperthyroidism is the underlying reason for the CHF- above factors taken into consideration, but prognosis much better if you can treat the underlying disease.

so[quote user="K Burton"] I seem to end up putting a lot of these cats to sleep when presented in a crisis, in part because a lot of owners don't feel they can medicate them going forwards, but perhaps I'm also being overly pessimistic! [/quote]

this is actually a very sensible approach IMO

RE: Feline cardiology

David Mills — Mon, 12 Dec 2016 17:21:00 GMT

There is some data out there, but it is limited and mainly referral populations.

RCM and DCM - awful, probably about 30 days max

HCM - depends. There was a study of cats at the RVC that gave a median survival of 194 days for HCM cats with CHF but the range is huge.

http://onlinelibrary.wiley.com/doi/10.1111/j.1748-5827.2010.00989.x/full

There's a bit more discussion here:

http://onlinelibrary.wiley.com/doi/10.1111/jvim.12215/full

UCM - no-one really knows.

Pimobendan is in vogue and actually has the greatest evidence-base (which is not saying much in cats) - it's supposed to work by increased rate of relaxation (lusitropy). In cats, the half life is about 18h so it can be given once a day.

Having owners inject dimazon at home sq can work well for cats.

RE: Feline cardiology

Thomas Johnson — Mon, 12 Dec 2016 15:12:27 GMT

[quote user="K Burton"]For example is a bi-cavitary effusion associated with a worse prognosis?[/quote]

I also find it very difficult to give a prognosis in cats that present in heart failure, but I have found that if it is secondary to hyperthyroidism and you can get good control of the thyroid hormone levels the prognosis is much better. I saw a cat last week that presented with a pleural effusion 8 months ago and was diagnosed at referral with hypertrophic cardiomyopathy on ultrasound. Its thyroid is well controlled on Felimazole and it is on low to moderate doses of Libeo, Vetmedin, Prilactone and Fortekor, it is showing no clinical signs of hyperthyroidism or heart disease.

RE: Feline cardiology

Rob Loxley — Mon, 12 Dec 2016 14:57:26 GMT

There seems to be a great variation in overall outcomes in these cats, but recently we've had good success with pimobendan in cats (off label discussion etc) presenting with heart failure. There's a study at https://www.ncbi.nlm.nih.gov/pubmed/25148095

Generally, I usually say to clients we hope for 6 months and if they do well 12 months upwards, though some just don't do well and end up PTS a few weeks later.

If they present with a thromboembolism (or have a clot in the atrium) the prognosis is much less good. If they have renal disease then I'd also be concerned about how well they might tolerate the medication. We see few these days with underlying thyroid problems, as most are presented for other symptoms before heart failure. We should probably be looking more for primary hypertension also. I read somewhere that bradycardia and/or hypothermia at presentation of CHF are poor prognostic indicators, though I've not found that to be the case in the bradycardic CHF cats we've treated.

Re medication putting clients off, consider frusol syrup as an alternative to tablets, though I find most cats will take the tablet