Heart murmur in 4 year old Border Terrier

RE: Heart murmur in 4 year old Border Terrier

Martin Atkinson — Fri, 01 Sep 2017 10:31:33 GMT

[quote user="robloxley"]

You really should invest in an ultrasound machine if you're not retiring imminently.

[/quote]Therein lies the rub: I'm not sure when I will retire and when I do it is likely that I won't sell the practice but will turn it into flats with just a tiny surgery to treat mine and friend's pets as it will be more profitable, therefore equipment is not something that would have much value.

Besides I have invested in digital X-ray, bought a capnograph and become a nurse training centre recently putting two trainees through college all of which amounts to quite a lot of expenditure for a sole charge practice.

I confess I'd rather spend the rest of my money on expensive bikes and ski holidays and refer the odd case where ultrasound is critical.

RE: Heart murmur in 4 year old Border Terrier

Rob Loxley — Fri, 01 Sep 2017 00:07:59 GMT

[quote user="Martin Atkinson"]Its heart was enlarged on X-ray and ECG confirmed that, however it also had significant liver disease, probably a tumour[/quote]

You really should invest in an ultrasound machine if you're not retiring imminently. The learning curve is really not that steep to answer the day-to-day clinical questions (is it heart failure, is there a liver tumor etc) and the payback is really fairly quick, especially with the current crop of decent, far eastern machines.

RE: Heart murmur in 4 year old Border Terrier

Robin Grimmer — Thu, 31 Aug 2017 19:16:29 GMT

[quote user="Martin Atkinson"]

[quote user="Robin Grimmer"]Couldn't you have concluded that anyway? A grade 2 heart murmur is unlikely to cause ascites and peripheral oedema.[/quote]I don't think a murmur particularly tells you anything there are plenty of animals that go into cardiac failure with no murmur at all it just starts to send you in a certain direction. The rapid, weak pulse and slow CRT may have been more significant so I started out thinking it was most likely cardiogenic until we got the liver profile results and could see an enlarged irregular liver on X-ray. But in the absence of ultrasound I could still not exclude cardiac disease as at least a partial component of the epidemiology.

[/quote]

Agree re dcm, but you said little dog so murmur likely to be mvd so grade 2 unlikely clinically significant. Doesn't a case like this make you want to invest in an ultrasound? Could have got from A to B a lot quicker without all the other tests.

RE: Heart murmur in 4 year old Border Terrier

Anthony Todd — Thu, 31 Aug 2017 17:42:34 GMT

[quote user="Martin Atkinson"]Lack of cells on cytology does not discount a non-shedding tumour if that was where you're going.[/quote]

Even I realise that.....

RE: Heart murmur in 4 year old Border Terrier

Martin Atkinson — Thu, 31 Aug 2017 17:36:11 GMT

[quote user="Anthony Todd"]I would have just sent some of the fluid off for cytology, having done a SG, [/quote]It was a pure transudate, no cells, little protein so more suggestive of cardiac origin than hepatic. Lack of cells on cytology does not discount a non-shedding tumour if that was where you're going.

RE: Heart murmur in 4 year old Border Terrier

Anthony Todd — Thu, 31 Aug 2017 17:24:46 GMT

[quote user="Martin Atkinson"]however it also had significant liver disease, probably a tumour. Drainage and diuretics solved the presenting symptoms but the patient was not improving in herself.[/quote]

I would have just sent some of the fluid off for cytology, having done a SG, and gone from there.

RE: Heart murmur in 4 year old Border Terrier

Martin Atkinson — Thu, 31 Aug 2017 17:18:27 GMT

RE: Heart murmur in 4 year old Border Terrier

Anthony Todd — Thu, 31 Aug 2017 17:00:52 GMT

[quote user="Sammy82"]I would not have reached for a test in this case[/quote]

Sorry the one star was me which i didn't mean to do!!! But I can't remove it!

RE: Heart murmur in 4 year old Border Terrier

Robin Grimmer — Thu, 31 Aug 2017 16:40:27 GMT

Couldn't you have concluded that anyway? A grade 2 heart murmur is unlikely to cause ascites and peripheral oedema. Ultrasound would have been more useful in this case to look at the liver and heart especially with all that nice fluid there :)

RE: Heart murmur in 4 year old Border Terrier

Martin Atkinson — Thu, 31 Aug 2017 15:09:56 GMT

Just a bit of an anecdote on the value of NT-proBNP. We had a little dog in last week with marked ascites/peripheral oedema and grade 2 cardiac mumur. Its heart was enlarged on X-ray and ECG confirmed that, however it also had significant liver disease, probably a tumour. Drainage and diuretics solved the presenting symptoms but the patient was not improving in herself. The owner could not afford, nor was willing, to go for ultrasound so we performed an NT-proBNP. This came back as <250 which excluded clinically significant cardiac disease and enabled us to conclude that the symptoms were probably caused by the liver disease alone. As she was failing to respond to treatment for that, the owner elected for PTS.

RE: Heart murmur in 4 year old Border Terrier

Lucy Fleming — Tue, 29 Aug 2017 17:06:58 GMT

[quote user="Sammy82"] I would have mentioned it, suggested to monitor and look out for clinical symptoms and recorded it in the clinical notes.[/quote]

A few years ago I would have said the same, but with the evidence now to hand that treating pre-clinical disease once atrial enlargement present enhances survival times, I tend to suggest an echo

RE: Heart murmur in 4 year old Border Terrier

Anthony Todd — Mon, 28 Aug 2017 16:57:10 GMT

[quote user="Bill Nolan"]Or your hearing just got worse.. [/quote]

Touche; nice one..... serves me right

RE: Heart murmur in 4 year old Border Terrier

Derek Lyon — Mon, 28 Aug 2017 12:05:36 GMT

May I sincerely thank all of you who replied and commented on my original question. It is very much appreciated.

Kind regards

Derek

RE: Heart murmur in 4 year old Border Terrier

Sammy82 — Mon, 28 Aug 2017 09:13:19 GMT

[quote user="Anthony Todd"]

The modvet trend now is to mention every possible cause of anything, and you should see this again in this thread where, immediately, a poster reached for a test.....

[/quote]

I would not have reached for a test in this case, I was just trying to answer Derek's question what heart related bloodtest might have been suggested by the vet who saw the dog. I would have mentioned it, suggested to monitor and look out for clinical symptoms and recorded it in the clinical notes.

RE: Heart murmur in 4 year old Border Terrier

Bill Nolan — Sun, 27 Aug 2017 16:20:00 GMT

[quote user="Anthony Todd"]I never had a problem with that approach and most of the murmurs, I think all, must have disappeared[/quote]

Or your hearing just got worse..

RE: Heart murmur in 4 year old Border Terrier

Nicola Cole — Sun, 27 Aug 2017 13:46:41 GMT

[quote user="Anthony Todd"]

What is monitoring going to do apart from reinforcing the concern in the owner's mind about what may well be an insignificant condition?

[/quote]

1) Allows us to monitor to see whether grade is increasing, monitor rhythm, pulse quality etc so whether needs further investigation or not.

2) If grade not increasing then RE-ASSURES owner that NOT progressing and may well be insignificant!

RE: Heart murmur in 4 year old Border Terrier

Anthony Todd — Sun, 27 Aug 2017 12:18:01 GMT

[quote user="robloxley"]In your world, if you don't tell the owner you've detected a murmur, how are you going to get the owner to come back to check the murmur has indeed disappeared?[/quote]

Don't yours come back for boosters?

What is monitoring going to do apart from reinforcing the concern in the owner's mind about what may well be an insignificant condition?

RE: Heart murmur in 4 year old Border Terrier

Nicola Cole — Sun, 27 Aug 2017 11:53:03 GMT

[quote user="Anthony Todd"]

[quote user="Nicola M"]Telling them doesn't have to worry them-I usually follow it up with 'i've got a murmur-it's not pathological', then a brief discussion about what I recommend (eg. monitoring if I think appropriate, echo etc if I'm worried could be significant).[/quote]

[sigh] Exactly why I don't tell them. Telling them always worries them, that's why I stopped.

[/quote]

(In my opinion) telling them certainly doesn't usually worry them. In fact most people (these days? maybe it's a generational thing) that I've discussed it with have not been worried at all-because I've explained to them (succinctly so as not to overrun the appointment time!) why I'm not concerned or how we're going to approach it.

Many people these days seem more aware of someone/another animal who has a murmur without it being problematic.

I don't have an exact figure of 'worried' owners but I can't honestly remember any that, unnecessarily, worry about it.

(I've included unnecessarily because obviously there are circumstances where it is going to be pathological and result in heart failure etc so if I flag up one I'm concerned about then obviously they're going to worry!)

RE: Heart murmur in 4 year old Border Terrier

Rob Loxley — Sun, 27 Aug 2017 11:22:38 GMT

[quote user="Anthony Todd"]Someone should have some EBVM of the number of "innocent" or temporary murmurs in dogs to support my case.[/quote]

Google (scholar) is your friend!
I would suggest a newly diagnosed murmur in an otherwise well 4yo dog is unlikely to be a flow/physiological murmur that will disappear and more likely some kind of structural heart disease; I'd suspect mitral valve disease would be much more likely if you're just going on the stats? The stats would also suggest a majority of these (especially in a non-CKCS) will not go on to develop clinical symptoms nor need treatment, just monitoring.
In your world, if you don't tell the owner you've detected a murmur, how are you going to get the owner to come back to check the murmur has indeed disappeared?

RE: Heart murmur in 4 year old Border Terrier

Anthony Todd — Sun, 27 Aug 2017 10:44:43 GMT

[quote user="David Mills"]

[quote user="Anthony Todd"]

Four things:

1. is the dog showing any signs of cardiac insufficiency or exercise intolerance?

2. If it isn't, what can you do about it at this stage, ie as it is asymptomatic?

3. Even if you can diagnose it "accurately" at this stage, how will that help the dog?

4. Sometimes these murmurs go away

I always found that mentioning anything to do with the heart worried the owner into heart failure him or herself; and the dog was then treated as if it was an invalid from then on, so I just wrote it in the notes.

This obviously apples to asymptomatic animals.

One anonymous star for certain coming up.

[/quote]

Would you treat aortic stenosis? Or mmvd?

[/quote]

See 1. above and I should have added "cough" etc

RE: Heart murmur in 4 year old Border Terrier

Anthony Todd — Sun, 27 Aug 2017 10:38:44 GMT

[quote user="robloxley"]The art of veterinary medicine is surely in explaining the cause of the murmur[/quote]

My point is missed, which is my fault in not making myself clear.

There are some areas of small animal health which have an exaggerated importance in an owner's mind and the heart is the worst [IMHO] based on no little observation.

This is all I was trying to get across.

Someone should have some EBVM of the number of "innocent" or temporary murmurs in dogs to support my case.

Would you treat aortic stenosis? Or mmvd?

Exactly an example of why I didn't mention [mild] murmurs in an asymptomatic animal!

The modvet trend now is to mention every possible cause of anything, and you should see this again in this thread where, immediately, a poster reached for a test.....

Most modvets now seem to launch into ALL the possible causes of a murmur , or indeed any clinical or non-clinical departure, on discovery, significant or not.

Covering it with long-involved [and I'm sure it would be] dissertation which, as I have claimed, worries the owner unecessarily, particularly and specifically with the heart.

The longer the dissertation and the more achronyms the more the oowner's worry.

The "art" of practice is less is more sometimes.

RE: Heart murmur in 4 year old Border Terrier

Rob Loxley — Sun, 27 Aug 2017 09:46:01 GMT

[quote user="Anthony Todd"]

I wonder what percentage of murmurs progress to disease, and how many remain asymptomatic?

[with petrified owners]

[/quote]

The art of veterinary medicine is surely in explaining the cause of the murmur, whether it is likely to progress, what might be done to treat it (closure for PDA, ballooning of PS, preclinical intervention in DCM or in advanced MMVD as per the EPIC study etc), and to reassure the clients in the cases where it is unlikely to cause a problem and need no treatment? Surely one can explain a murmur without petrifying the owners?

Here's a good article on dealing with those murmurs incidentally detected at general clinical examination: http://www.sciencedirect.com/science/article/pii/S1760273415000636

RE: Heart murmur in 4 year old Border Terrier

David Mills — Sun, 27 Aug 2017 04:24:32 GMT

[quote user="Anthony Todd"]

Four things:

1. is the dog showing any signs of cardiac insufficiency or exercise intolerance?

2. If it isn't, what can you do about it at this stage, ie as it is asymptomatic?

3. Even if you can diagnose it "accurately" at this stage, how will that help the dog?

4. Sometimes these murmurs go away

This obviously apples to asymptomatic animals.

One anonymous star for certain coming up.

[/quote]

Would you treat aortic stenosis? Or mmvd?

RE: Heart murmur in 4 year old Border Terrier

Anthony Todd — Sun, 27 Aug 2017 00:11:33 GMT

[quote user="Clare Tapsfield-Wright"]but then we have gained so much too[/quote]

Gosh, I don't know what, but that's probably a thread on it's own and judging by the threads on here..... I don't think the list would be very long....

I suppose, today, I might not mention a murmur, and get round it, if it was,er, "just a flow murmur" and achieve my original objective.

I wonder what percentage of murmurs progress to disease, and how many remain asymptomatic?

[with petrified owners]

[quote user="Clare Tapsfield-Wright"]unquestioning faith in doctors [/quote]

Yeah, friends of my age never seem to question their doctor and plough on with severe signs and little relief; another generation thing?

PS one exception... I'd always mention anything in a KC Spaniel!!

RE: Heart murmur in 4 year old Border Terrier

Clare Tapsfield-Wright — Sat, 26 Aug 2017 23:43:48 GMT

Yes times have changed and we have lost some good things such as the unquestioning respect of most clients, but then we have gained so much too.There is more good progress than bad and many clients who can still be very reasonable if trust and a sincere two way relationship is maintained. I think my blind unquestioning faith in doctors and the NHS was rather misguided in the past , I do double check and query things now , in a noncombative way and though I want sincere advice I certainly want all the facts.