Baby Heart Health Scare Becomes Just Asthma

We had a health scare this past week. Last weekend-June 8-I noticed Baby breathing hard. I kept noticing it, then noticed that it wasn't just when she was grooming or active or upset. It happened at rest. The breathing rate was 40s-50s. So, I took her to the vet on Tuesday. Xrays showed a possible enlarged heart-one rib larger than last time. Now, the actual mathematical equation used to calculate size of heart to ribcage is more involved than just counting ribs. But to my experienced but untrained eye, it looked larger from both views. The lungs were clear. They emailed the results and xrays to her cardiologist. The dear woman was away at a conference but her office was concerned and called her to take a look. She texted me for feedback and after discussion-she saw no congestion-but since there were no appointments until the following week to see the cardio, she put Baby on lasix 5mg BID (twice a day.) Baby responded well Thursday and Friday morning but the breathing rate was up again so I put her on 5mg TID (three times a day.) She responded well to that. Her breathing rate fell to about 24-32, and she was perkier, and playful.

At some point, I said "No, not again. And poor Baby. But she is 13 so this could happen at any time as she ages."

Finally, we saw the cardio yesterday. And...nothing.

No enlarged heart-it's just slightly larger because it can happen as a cat ages but that is not due to internal workings and does not affect her health. Plus, she wasn't centered well on the xrays. But the echo was clean, no heart size changes, no SAM, no murmurs, no other obstructions or physical changes, no congestion, no fluid in or around the heart or lungs, and no signs of fluid in the body.

So what gives? We had a good laugh because she said my kitties are always coming up with some odd medical thing she's never seen. It's possible it's allergies or asthma kicking up when it was hot and humid. It's possible she needs her albuterol (for asthma) twice a day now instead of once. It's possible that she responded to the lasix because it can have a bronchial effect that is lost with long term use but was there in the short term. So, she's off lasix. She will receive albuterol BID and I may need to put her on the steroid Flovent. But we'll see.

HUGE sigh of relief and a prayer. And a good laugh. Because really-you must laugh.

Why Cats May Need More Lasix, More Often to Combat Congestion

Why cats need lasix, and may need more of it and more often:

"Signs of heart failure decompensation and congestion such as a persistent increase in resting respiratory rate or recurrence of cough may respond to an (often temporary) increase in furosemide dose. In most cases (check with your veterinarian first), if your pet has been doing well on heart failure medication but subsequently develops signs of congestion again, you can increase the dose or add an extra dose."

Myrna's Heart Develops New Complication-AFib

Myrna had her regular check-up with the cardiologist today. She has developed an arrhythmia due to atrial fibrillation.  This is a new complication that will make management of the disease and congestion difficult. And there's very little we can do.  Yet, while this is a new complication, it comes after almost five years of the disease.  Many cats develop it sooner or die of HCM too soon to develop a fib.  And she continues to battle congestion or Congestive Heart Failure.  The cardio reiterated that Myrna is the only patient she and her practice partner Dr. Brown has ever seen with the heart size of Myrna (2.2) that continues to live as long as she does and do as well as she does with the ongoing CHF.  (Good vitamins and supplements, plenty of meds and correct dosing and adherence to the strict schedule, and vigilance on our part as to changes in her physical condition and reactions, and the best damn cardio team all play their part.)

Myrna Loy

She has been suffering with congestion all summer long.  It comes and goes and we deal with it by determining when she needs extra lasix: usually it is when her breathing is above her "normal" breathing rate of  32 a minute (a cat is usually around 24) or when she is breathing hard, making a hard push through the chest cavity.  When she is breathing steadily at 32 and it is not difficult but has a third "bump" in the chest cavity (in, out, BUMP; in, out, BUMP) then we know she needs the inhaler.  That BUMP shows up near the back, near the end of the ribs as she physically makes an effort to exhale.  There have been times when she is breathing above 8 or hard AND has that third BUMP in the breathing process through the chest cavity.  That's when we not only give extra lasix but give a dose of the inhaler as well. And that is the most effective protocol for us to follow.

There are concerns with the inhaler as it can be contraindicated with atenolol, the beta blocker that slows down the heart rate.  The inhaler is inhaled and absorbed into the bloodstream.  If it builds up, it can increase blood pressure and have a negative interaction with atenolol (a process that involves antagonists, beta 1 or 2 receptors, bronchodilators and constrictors,etc.-a process I do not understand well enough to explain.)  We are to give it in the a.m. and p.m. and only in between as needed, which we have been doing.  But the cardio hopes that with cooler weather, the need for it twice a day may decrease.

The arrhythmia was heard via stethoscope and was confirmed via ECG.  The echo showed atrial fibrillation, a process by which too many electrical impulses disturb the heart rate making it erratic.  The heart cannot pump or contract (systole, diastole) correctly.  This allows blood to flow between chambers but without the heart muscle reacting.  This means the unused heart muscle will over time become potentially weak like any muscle that is unused.  This will create a myriad of complications: will make it difficult to fight congestion; will cause a lack of efficient and sufficient circulation of blood and oxygen; will lead to weakness in her body, etc.   From Pet Place website:

"Atrial fibrillation (AF) is a common electrical disturbance or arrhythmia of the heart, marked by rapid randomized contractions of the atrial heart muscle causing a totally irregular, often rapid , ventricular rate. In this arrhythmia the normally coordinated electrical activity in the upper heart chambers, the right atrium and left atrium, is lost. The muscle of these chambers begins to wiggle like a "bag full of worms." Atrial flutter is similar to AF, but the atrial contractions are rapid but regular. Both rhythms are very abnormal and reduce heart function." 

This weakness is already showing up.  She has lately been lacking an ability to jump up and down and to land well enough depending on the angle of the jump.  I was afraid her rear leg pulses were getting weak but they are now strong at 130.  But that is also due to her heart racing at 150-190 (as it was today in the office.)  No, I don't know how a heart cannot contract sufficiently and yet produce a high heart rate.

Because the heart rate is up, and we need to prevent a racing heart, the cardio prescribed additional daily atenolol and she will begin to take it twice a day or BID-1/4 of a tab BID.  Her lasix medication levels will change as well from 15, 13,15,18 mg to 18, 13,15,18mg a day.  (She receives lasix four times a day.)

She also presented with a touch of pleural effusion-fluid around the heart and lungs-in the pericardial-but not enough to aspirate.  But they gave a lasix injection and additional lasix at home may be warranted. But again, this is a troubling sign and due to the new complication.

"Pericardial effusion, sometimes referred to as "fluid around the heart," is the abnormal build-up of excess fluid that develops between the pericardium, the lining of the heart, and the heart itself."

The blood work comes back tomorrow and I'll know more then how her kidney values are doing and if the supplements I've been giving are helping.

She still has a clot in the heart but nothing has broken off that can be seen.  So far, so good.

Here are the cardio's notes: 

The new complication that myrna is presenting us with is an arrhythmia (irregular heartbeat) called atrial fibrillation.  A fib is a persistently irregular heartbeat that results from severe output (amount of blood circulated to the body.) This can result in a relapse of congestive heart failure, generalized weakness, and/or blood clot development.  I am happy to say that it does not appear as though Myrna has experienced a blood clot [Editor's note: In the rear legs. There is one in the heart.].  There were none of the hallmark abnormalities during her examination today and she had normal blood pressure in both of her hind limbs. (130mmHg on the right and 126mmHg on the left.)  [Editor's note: I had been concerned that her rear legs were weak due to low pulses.]  Rather, it appears that her weakness is a result of the new arrhythmia. Unfortunately, the arrhythmia will persists throughout her life-we cannot eliminate it entirely. However, we can improve control of her heart rate by increasing her dose of atenolol.  She is a good candidate for this adjustment because her heart rate is higher today (190/min on the ECG) and her blood pressure is normal.  There is a small amount of fluid accumulation around her heart and lungs today (pericardial and pleural effusion), indicating that we're not keeping up with her congestive heart failure treatment as well as we would like.  We will need to increase her dose of lasix to better manage her heart failure." 

Feline HCM and Kidney Values-Myrna Sees the Cardio for Issues

From Facebook post July 10:

Myrna only had slight congestion. Xrays clearer than when she had asthma. Leg pulses normal, blood pressure normal at 120, heart rate normal at 160. Potassium 4.8-higher than the usual 3.9 (for her-4.8 is more normal), and most other blood levels normal. BUN down a tad at 36 (from 38) and creatinine still at 22. (Those are high due to med effects on kidney function-a.k.a. kidney disease officially.) But other levels-calcium, sodium, magnesium, and some odd ones like CA2+ (ionized calcium) were high.No one knows why except that maybe it's due to a decrease in kidney function. Some of these are elevated in Cooper, also. No one knows why she had weak legs, why little congestion bothered her and made it difficult to breathe, why she was pushing air through her nose. She seems better now and perkier now that she's home. They gave her oxygen and lasix.

Feline Congestion CHF and Meds-What to Know, What to Use, Why Fluid in the Lungs Are NOT Normal

From the June 28 Facebook post about HCM meds:

HCM cats need a lot of meds. The Notes and blog tab Meds discusses what Myrna is on and what the med does. Your cat will need lasix to combat congestion and to keep it at bay. Congestion is extra fluid that backs up into the lungs. Too much fluid in the body and a thick heart valve cannot adequately pump it out or take it in. Then fluid backs up into the lungs, filling the lungs, causing congestion. This isn't about any fluid being "normal". There is NOTHING normal about fluid being in the lungs. Pets are not like us-a bit of fluid and a cough, some decongestant and we're ok. Fluid in pets indicates an illness and usually heart disease and that means a life long struggle for you and the cat to keep fluid out of the lungs by decreasing the amount in the body. And that is what lasix is for-to get rid of extra fluid. Fluid in the lungs leads to a lack of oxygen picked up by circulating blood; leads to overall body weakness; a reduction of needed oxygen to support organs; leads to organ failure; and lungs filling with fluid leads to drowning. It's a very complex bio/chemical process. Giving extra lasix on top of a regular dose-when needed-will help you get ahead of a congestion episode. And these episodes will occur on occasion. Any stress and congestion can seem to quickly escalate. Part of what happens also is that when under stress, the body can't handle the extra fluid that may have been there, not really getting in the way-yet-of breathing. Again, a very complex bio process. Don't be afraid to give more lasix as needed if the cat is congested. The problem with this advice is you personally must experience what we have in order to know what to do the next time there is a problem. And it is always trial and error. And there is always waiting involved. And then there is always trying to figure out if the cat needs the cardiologist or the ER or both and how soon. Develop a protocol: the regular maintenance dose schedule-precise doses and on time. Then know how to count the breathing rate. This is important because how well the cat is able to breathe indicates if the cat is congested and if it needs more lasix. One up and down chest movement is one count. # of those in 15 seconds=a minute rate. Every cat's rate fluctuates at rest, sleeping, playing, etc. They will go from 24 to 40 in a nano second but then come back down to 34 and 24 in the next few seconds. Cats dream. Cats are anxious. The breathing will increase. They sniff things and the rate increases. To truly count, you must see the cat resting. Then count it again a few minutes later. If the rate is 8 in 15 secs (8/15) or higher, that's too high and now's the time to give extra lasix to get ahead of-and not behind-congestion. Don't be afraid to give a little extra now. Don't wait to see if the breathing gets worse. Take care of it now. Right now. Give 1/4 of a tab-of 12.5 tab or 20mg tab (so 3mg or 5mg). Whatever you have on hand. Wait an hour and see if the breathing improves. Then give another 1/4 if the rate doesn't improve. Then wait an hour. If there is no improvement, OR if the rate increases at any time, OR if it's getting late in the day and the vet's office will close soon, call the vet. Or feel free to call the vet at anytime WHILE you also give extra lasix. If the cat collapses-go to the ER NOW. If the cat's rate increases and you can't get to the cardio or vet, go to the ER because the cat will need oxygen and IV lasix. If you have supplies on hand and have learned how to do injections, you could also give .15ml injection to .3ml injection. All this as long as the cat isn't in pain or distress from congestion. If you think the cat's in pain and distress, go to the ER now. It's easy to wait to see if things improve. For some reason, we act as if we expect things to not be as bad as they actually are. We want to will away the problem. We can't believe what we are seeing. But remember a recent blog post-we need to think of our cats like babies-those small little bodies. How long would you let a baby be unable to breathe, or collapse, or be in pain? Not more than a few seconds perhaps. We need to do the same with our cats. Little bodies, with little lungs, and large hearts-makes for a difficult disease to manage. But we can. We just need to act quickly.

Torsemide and Feline Heart Disease Cooper Recovering Today

Cooper's doing better. Breathing rate 10-11. Used the litterbox three times. No gurgles. Handling all that diuretic well. Even ate. His next dose will be 1/4 Torsemide at 8 p.m. and we'll give another 1/4 about 11:30 p.m. We'll see how he does tomorrow but for now we will give 1/2 dose in the morning and take it from there. Thanks for your prayers! What a pain is congestion to get under control. Of all the issues we've ever had with Myrna, she eventually stabilized, and we've had some scary moments with her. But his problem beats all of it. We can't get him to be stable for very long.

Torsemide for Cats May Not Be Working for Cooper Today

Torsemide may not work for Cooper. He was fine yesterday at 8/15 but this a.m. he was at 12/15. Gave 1/4 Torsemide as directed at 8 a.m. but breathing increased. Was at 15/15 by 1. We have another dose before 2 p.m. but then I heard gurgles so we injected him with .3ml lasix. Cardio's on vacation but is able to text. She said the Tor dose and injection together should be fine and to wait to see how quickly it acts. It's been an hour and although he's used the litter box, I'm not sure it's easing the breathing. He may need the ER. Will let you know.

Cooper Back to Cardiologist for More Oxygen and IV Lasik

Cooper has been struggling all week with congestion and we've struggled to figure out the correct dose of lasix needed, timing of doses, and when he needed an injection to overcome the congestion.  We communicated daily and sometimes often during the day with the cardiologist to get input.  We had a protocol, a method, a process to follow. We knew what to do when, how quickly to respond to an increase in breathing, and how quickly to text the cardiologist to alert her of a new issue.  And still, we all struggled to meet his needs.

Katharine Hepburn had an appointment for Thursday due to a gallop murmur (and an earlier post noted the cardiologist heard a mild murmur and saw no signs of heart disease) and Cooper already had the same appointment made in March because this was to be a checkup.  But he had just been to the ER a couple weeks prior and everyone expected that he would recover and not need to be seen at this time.  But we kept the appointment just in case.  Despite recovering from the ER, despite trying a new drug (spironolactone/hydrochlorothiazide) and having it upset his system (nausea, diarrhea) and dropping the drug and bouncing back quickly from it, and despite an even breathing process, and despite controlling for heat, cold, and not allowing him to be in the sun for prolonged periods or in any open window at any time, he still developed congestion.  And we couldn't get rid of it.

So, Thursday, Katharine, Cooper, and I went to the cardiologist.  They took xrays which showed congestion in the right lung and only slight congestion in the left. They were going to give him a lasix injection but then he suddenly couldn't breathe well and was making gurgling, panic noises.

They put him in the oxygen cage and gave him lasix IV injections.  They kept him from 1:30 until 6:30. He quickly responded to the use of oxygen and lasix which was an excellent sign.  They weaned him off oxygen and his breathing rate dropped to 8/15, and we finally went home at 7 p.m.  As of today, his breathing is still at 8.

The cardiologist has taken him off of lasix and given him a new loop diuretic to try.  We will begin using it today. He will get the med twice a day and three times if needed.  We will know after a day or two if the med is working to decrease congestion and we will know in 3-5 days if the med does or does not upset his stomach.  In between doses, we can give injections as needed, which we would more likely consult with the cardio about the dose before giving an injection.  The new drug is called Torsemide. It stays in the body and works in the body longer than furosemide (lasix.)  In human patients it is shown to have a greater decrease in recurrence in congestion.  But it can also deplete the body of electrolytes via extraction of fluid,  leading to many adverse side effects.  It can also deplete the kidneys of potassium and can cause stress on the kidneys. We will give 1/4 of a 10mg pill.  He will go from 80 to 100 mg of lasix to 5mg of Torsemide a day.

Cooper at the cardiologist

She also suggested we use a potassium supplement called Tumil-K (we will use Sundown potassium, and Gerber baby sweet potatoes also as a potassium source.)

The cardio and I had separately come to the conclusion that trips to the vet were becoming stressful for Cooper and counterproductive-although he needed oxygen and IV lasix this time-and that going forward, Cooper will see the cardio or vet only when necessary and not for checkups.

By the way, they know when he's feeling better when he hisses and growls at them!

Here are her notes:
"Despite continued increases in his cardiac medication doses, Cooper has again relapsed into congestive heart failure. He is receiving extraordinary doses of lasix to try to maintain his comfort in breathing and we are having continued relapses in symptoms.  Unfortunately, he did not tolerate hydrochlorothiazide well and that mediation had to be discontinued.  I would now like to switch his lasix to a much more potent diuretic called torsemide.  Torsemide functions very similarly to lasix.  The risks of this medication include kidney failure and electrolyte depletion. The major benefit would be more steady control of Cooper's symptoms.  Today's laboratory results indicate that Cooper is an acceptable candidate for this medication.  To help prevent excessive potassium depletion, I would like you to begin supplementation with Tumil-K (potassium supplement.)

Myrna Gets Congestion Again This Week; We See the Vet Friday

February 1, Myrna had congestion that developed in the morning out of the blue. We fought it with extra lasix and an injection of lasix.  Monday, February 17, Myrna developed congestion again and in the late afternoon into the evening and we gave her more lasix and did another injection.  And then once again, for no reason, except that perhaps Thursday's rolling thunderstorm that happened in the morning and afternoon (while it snowed no less) acted as a trigger, Myrna developed congestion Thursday February 22.  It came on suddenly in the afternoon.  Her breathing rate crept up from 8 to 10 and by the evening was at 12 (in 15 seconds.)  By 8 p.m. it was around 12-14 and eventually seemed to remain at 14 (normal is 6.)  Despite extra 5mg of lasix a couple of times, we had to give an injection around 10 p.m. of .15ml lasix and then 10mg of lasix at 1 a.m.  The breathing rate only came down to about 12 by then.  Between 6:30 p.m. and 1 a.m. she had received a total of 41mg of lasix when she would normally have had back in January 46mg total in a day and as of early February (after the first bout of congestion) she would have received 52mg in a day.  Her total for Thursday was 73mg.

And still, despite all of the lasix, she only urinated every 3-5 hours, her normal time frame, and her normal amount.  This is important to note because how much she urinates determines how quickly the lasix works to get rid of the extra fluid and the congestion.  How well she produces urine and how quickly also indicates how well the kidneys are functioning.   It wasn't until after the injection, that she finally began using the litter box more often.  From 11 p.m. until 6 a.m., she used the litter box about four times.  By the morning, Friday, she was better but still breathing around 10 at rest.

We already had an appointment for Friday to see the cardiologist after Monday's congestion.  Xrays showed she still had congestion-pulmonary edema.  The pleural effusion she had in January (along with pulmonary edema) was not present.  For whatever reason, her blood pressure has dropped again to 93 which made getting a blood sample from her difficult.  Her heart rate is only up slightly, from 140 to 160.  The heart is in stable condition, unchanged from January.  While her cardio function is stable, the cardiovascular system is having trouble.  The rollercoaster congestion, brought on by unknown triggers, requires more and more lasix to beat.  The congestion wears her down, becomes uncomfortable, and impairs normal body function of breathing and getting oxygen to her body.  The drop in blood pressure means the lack of oxygenated blood to the organs.  This makes her easily tired and somewhat weak.   This would explain why she was quiet all this week, even though she was always up and about.  She was never truly lethargic, just tired.

We are to keep her quiet.  She will receive 15mg lasix qid (four times a day.)  I am to tell the vet how well she is doing Saturday and Sunday and Monday. The emphasis will be on pushing lasix to bring down the congestion and get her to a more stable condition.

We discussed how difficult it is to decide when to give more lasix.  It's one thing to count breathing rate and to determine that it's up and she needs more lasix.  But I don't always know how long to wait. When the rate is up but she doesn't appear to be in pain or discomfort, I have no problem waiting before giving more lasix a few hours later.  Lasix pills can take up to four hours to work.  An injection takes about an hour.  When she begins to breathe even faster or if she looks really uncomfortable, my reaction is to give more lasix.  But if given too much, the amount can lead to kidney damage or a reduction in function. But getting rid of congestion is key.  But retaining kidney function is important.

The vet said:  "If she's struggling and she's due for lasix, give her an injection of .15ml.  If she's struggling and not due for a dose, give an injection of .15ml.   If she's wishy-washy-breathing rate up but not very high and she's comfortable, give her 15mg lasix."

Her blood work unfortunately shows a decline in kidney function.  We will push 15mg qid today and cut back as needed once the congestion seems to be going away and see how she does going forward.  The BUN is 35 and high is 36. The creatinine is 2.7 and the norm is 2.4.  Phos is fine, though. Potassium is 3.9-low but fine.   She is not in kidney failure since she's producing so much urine each time. But that she needs higher doses of lasix before she finally urinates indicates that the kidneys are tolerating the lasix in general but that kidney function is showing some decline. That's troubling.

Unless she gets sick again, she will see the vet in late March which was a regularly scheduled appointment.  

Myrna's Breathing Rate Suddenly Increased Monday Night

Ever noticed that your HCM cat is fine one moment but not the next?  Sudden changes can occur in cats with heart disease.  This is why we MUST be aware of what is "normal" for our cats in order to understand what is NOT normal and when and how quickly to react.  We must ALSO understand what needs to be done, what we can do at home, and when the cat needs to see the vet immediately, even the ER vet.

Myrna's breathing suddenly increased rapidly last night.   She was fine all weekend, playing, and breathing well.  But Monday she slept all day although breathing fine.  Granted, she does have her days when it seems, after a weekend or a couple of days of running around, she needs a break and will spend the day resting.  But by the evening, her breathing rate had crept up to 10 beats per 15 seconds and by bedtime to 12 (or 48 a minute when normal at rest for a cat is about 24 and for Myrna it is 8 or 32.)  She didn't hide at any time (which could have possibly indicated another pending heart attack or serious onset of CHF or other serious issue) she took all of her meds all day long, and ate well all day.  But she slept in between and she did not use the litter box as often as she usually does-every 2-4 hours. Instead, she only went about every five hours.  Sleeping contributed to not drinking, and not drinking contributed to less intake and output but should not have contributed to onset of congestion. So, what happened?

We gave her 3mg of extra lasix at 10 p.m. (Her normal doses are 13mg in the a.m., 10mg 2:30 p.m., 13mg 6:30 p.m., 10mg 11:30 p.m.)  The breathing rate did not decrease and she only used the litter box once after 11 p.m.  She was sleeping on our bed for an hour but the breathing rate never settled and remained at 12.  So I gave her a .1 ml injection of lasix at 12:40 and within 20 minutes she used the litter box.   She went again overnight and again at 5:30 a.m.   I did not give more than .1ml  because she had already had so much lasix.  I would have given .15 as I have before if we had not just given her 26mg of lasix over six hours or if the breathing was far more serious than 12 (at which point I think I would have taken her to ER vet.)  

By 5:30 a.m. today she seemed to breathe normally but was walking around and I couldn't get her to settle to count. But her sides weren't heaving when she was sitting.  By 10 a.m., she had breakfast and still seemed to breathe more normally which for her is still high at 8 breaths per fifteen seconds.  

There was nothing that we know of that contributed to sudden onset of congestion. No noise, fumes, or visitors occurred yesterday.  I emailed the vet and told her what happened.  I explained that yesterday she did not urinate enough and I asked how that may have contributed to congestion or if it is a symptom of congestion.   When Myrna urinated, it was the same large amount but she only went every 5 hrs instead of about 2-3. I asked the vet if we should be concerned about kidney function.  That she's producing urine in large amounts shows that the kidneys are functioning.   But not getting rid of fluid leads to congestion.  Here's what the vet said: 

"It sounds like you did a great job getting her back on track last night.  Today, give her 13mg Lasix for her first 3 doses of the day, then you can decide if her final dose will be 10mg or 13mg based on her breathing/urinations/activity throughout the day.  It sounds to me that her kidneys are developing some tolerance to chronic diuretic therapy.  This is a known consequence of diuretic therapy and it necessitates increased doses of Lasix.  While it's encouraging that she's still urinating regularly, we do still have to be concerned about the effects the higher Lasix doses may be having on her kidneys.  Once we're happy that she's stabilized, she should get in for a blood panel.  It may be best to just come to our office to do that so we can reassess her heart at the same time..."

Perhaps I waited too long last night to give Myrna more lasix.  That Myrna slept all day and did not use the litter box often enough is not itself a symptom of the onset of congestion.   We cannot be proactive and give more lasix when it is not warranted, when signs of breathing difficulties do not present.  But we can learn from this incident and understand that not going often or enough can mean a tolerance to lasix has been reached and that breathing must be monitored more closely and more lasix given sooner once we realize that the breathing rate has increased.   We will increase the lasix today and continue to monitor and I will make an appointment to see the cardiologist for later this week. 

Bette (left), Myrna (middle), Elizabeth (right)

Sunday Update on Myrna Loy's Breathing-Better Possibly If She Ever Decides to Stop Moving So That I Can Count

Myrna seems to be doing better this a.m. Gave her 10mg and 1/4 of a 12.5 mg (so about 13+mg overall) of lasix at 8:30 a.m. with the rest of her morning meds. Because she's difficult to get in the a.m., we have no way of getting her, monitoring her breathing, and then deciding what lasix dose she may need. The vet had given me guidelines of dosing lasix based on her breathing rate. So, that's why I gave her the lower dose of 13mg. We will monitor her breathing to see if she needs more. She seemed better today, even better than last night. Her breathing rate all night long was at 12. It's not that noticeable this morning so maybe it is finally lower. But we won't know until she rests but she's spent all morning up and about.

Myrna Had a Cardiology Check-up Thursday; Much Has Improved

Myrna saw the cardiologist Thursday and there was plenty of good news and only one slight problem.  First, we stopped at the regular vet for a blood draw for a full CBC/chem panel blood test that they send out to IDEXX.  While I don’t have the full report yet, her regular vet did call today to say that things look perfect and that her potassium level was up to 4.9 from 3.7 in September!  (Daily I give her a dime size chunk of banana-potassium source- mashed into her food in the morning; two potassium tablets divided into four pieces-one chunk per meal and one at bedtime; and a vitamin paste that has potassium.) They will fax results to the cardiologist.  I also had them do a urinalysis. 

When a cat is ill, and when a pet is receiving meds for an illness or for any reason, a blood test must be done from time to time to check the blood chemistry values.  As I’ve discussed before, kidney and liver function are affected by medications and diseases, especially heart disease.  You need to make sure the kidney and liver are functioning properly and you need to make sure the overall health of the cat is good.  Issues will show up in the blood test.   You can see if a patient has enough electrolytes: sodium, glucose, chloride, potassium, phosphorous, bicarb; you can tell if they are dehydrated: electrolytes will be low, blood count might be high, kidney values will be off; you can tell kidney function: BUN, creatinine, bicarb, potassium, phos, protein; or liver function: ALT, AST, phos, albumin, bilirubin, protein; and you can tell if a cat is hyper- or hypo-of an element such as hypercalcemia-too much calcium; hypokalemia-too low potassium.

A urinalysis is necessary to test kidney function in a cat that is taking meds because meds are processed in the kidneys and can adversely affect kidney function.  A disease may also affect kidney function.  So, an HCM cat on meds must have a urinalysis from time to time.  The test will show if there is glucose, protein, or red blood cells in the urine.   It will show pH levels which are important to know (6-6.5 is best) and will show if there is an infection, UTI, or any inflammation as well as disease of the kidney.   A vet can compare those results with the blood work to note any issues in function.   For example, too much protein in the urine can mean that protein is leaking out of the blood through the kidneys and not being properly processed in the body.   That can indicate kidney damage.  But some protein in the urine could also be something that occurs without kidney damage.  A look at the protein levels in the blood work will tell more.  If the protein is in normal range in the blood work, then protein in the urine shouldn’t be too much of a concern as of yet.  Glucose in the urine is a concern because that could be an indicator of diabetes.  But compared to the blood work, if the blood value is normal, then glucose in the kidneys could be a sign of stress.  Red blood cells found in urine could be a sign of an issue or could be from the needle used when the bladder was aspirated-urine withdrawn.  White blood count in the urine could indicate infection but if low and all other blood work is fine and body temp is normal, then that could just be an anomaly. 

The slight problem was that her breathing rate was high at 60 (should be about 24 at rest and only about 30 if at play or stressed.)   This could be caused by a week of noise from snow blowers and street plows due to the heavy snow fall as well as the stress from the vet visits and being out of the house since 1 p.m. (the cardio visit was at 3 p.m.)  She had some minor pockets of pleural effusion-congestion around the outside of the lungs-but not enough in one spot to be aspirated (withdrawn.)  She did have enough of the type of congestion she usually gets when congested, which is pulmonary edema.  They gave her a 5mg shot of lasix and instructed me to continue with her regular lasix dosages Thursday night; to give her 3 mg more of a lasix pill if needed; and to text the vet before bedtime to let her know if Myrna’s breathing rate had improved and to also let her know the next day.   By the evening, Myrna’s rate was 40 and by this morning it was 32 which for her is normal due to her heart condition. 

The really good news is that Myrna’s blood pressure and heart rate are normal again. The blood pressure had been very low at 90 after the heart attack in September and was 97 by October and was now normal at 118 (normal should be 118 to 124.)  Her heart rate, which had jumped to over 200 with the heart attack in September, and was 176 in October, is now also in the normal range and is at 144 (normal can be as low as 130 but at rest shouldn’t be more than 160. For an HCM cat, 140 is optimal but may be lower if on atenolol-which is what happened originally to Myrna. Her heart rate was once as low as 120 but she was never weak nor at that time, had a low blood pressure.  If the cat tolerates it well-which Myrna did-then there’s no concern for weakness or the heart rate leading to low blood pressure.)

I asked and she still cannot yet have her annual shots. The only one she really needs is the distemper.  There is no cure for distemper if she was to get it and it is a fatal disease.   There’s no way to prevent her exposure.  We could track it into the house on our shoes; it’s airborne; the other cats could pick it up when we take them out.   She cannot have her shot because she’s congested but also because of the immune response that would kick in and cause stress on the body.  Stress-while a natural reaction-could lead to congestion for her.   We will discuss it again at the next visit in March.  If Myrna does not have congestion, then maybe she can have the shot.

So, overall, a very good visit and a very good prognosis.   Here are the doctor’s notes:

Myrna napping in her favorite box

“Myrna’s heart rate has slowed again (144 min) indicating that she is getting more benefit out of her beta blocker (atenolol.)  The echocardiogram did not reveal any significant changes with regard to the left atrial enlargement or left ventricular thickening.  The mild thinning of the left ventricular wall that occurred following her heart attack has not progressed.  A small amount of pleural effusion was visible today and there was mild congestion (pulmonary edema) on her radiographs.  Based on your reports of her stats at home, I do not believe that she has chronic congestion in her lungs.  Rather, I think she is more stressed than usual today, and this is having some negative cardiovascular consequences.  We gave her 5mg Lasix IM (injection) today to help manage the mild congestion that was visible today.” 

Myrna's Thursday Visit to the Cardiologist and a List of Things to Watch in a Cat

On Thursday, Myrna visited her cardiologist for a chest xray recheck.  Two weeks ago she had congestion in her lungs at the last check-up.  It was enough to have increased her breathing.  I noticed the increase breathing rate a few days before the appointment.  I should have called the vet but instead, kept an eye on the count and how often it occurred.  And since we would be seeing the vet soon, I didn’t think it warranted moving up the appointment.  I should have because the sign of increased breathing rate did mean that she had congestion.   Next time, I’ll know better.  She had also, for some time, decreased her level of activity. 

After the last visit, we increased the lasix from ¼ tab (of a 25 mg. pill) in the a.m., 1/8 at lunch, and another ¼ tab in the evening with dinner to ¼ of a tab TID (three times a day.)  After two weeks, well after even three days, her breathing rate had decreased from 32-40 to 28-32.  And there has been a marked increase of energy and an increase in playtime.   

The vet said Myrna is doing well and is stable even as the disease progresses. That might be hard to explain: how can she do so well and yet be so sick?  It means that she responds well to med therapy which props up her heart and keeps it working.  Myrna has always been an unusual case in that she is very sick but (and I’ve mentioned this before) has responded well to her meds.  What should go wrong-some cats have issues with some meds-does not.  What shouldn’t happen-needing Valium for inappropriate litter box use for example-happens.  I’ve also been observant and I’ve been able to catch some odd actions by Myrna that either warranted a trip to the vet or ER-fainting, being anxious with heavy breathing and not settling down after a couple of minutes-or a call to the vet or a mention at the next visit-blanking out or pausing for a few seconds as if in a trance, weakened leg muscles soon after starting Valium, etc.   

One thing that has helped me be vigilant is using a notebook to track questions and issues.  I take notes in the notebook about all seven of our cats.  I use a simple college rule, wire bound, spiral notebook for $1 from the store.  Use anything that helps you track your cat.  I place it in the kitchen cupboard. The pen fits in the spiral binder.  Neat and tidy and easy to reach.

But what are some things you should look out for when tracking your cat’s progress?

Here are some things to watch for:

1)      Take a look at your cat’s legs. Watch your cat for signs that something is different and might be wrong.  Look closely at your cat’s legs as it walks.  Does it slip from time to time? Is it on pain meds or something like Valium that could affect muscle tone?  Or is there a problem with the leg and the ability to walk? A call to the vet should be placed.  If the cat seems in pain or cannot walk, then a visit to the vet or ER is warranted.

2)     Check the paw, paw pads, and color of nail beds now to know how they normally look.   If you feel your cat’s paws and think they feel cold, check the color of the paw pads and the nail beds.  If the nail beds (which should be pink) are getting blue/black or dark grey (as long as dark grey isn’t part of the cat’s normal toe bed color) then a trip to the vet or ER is needed immediately. This could indicate a blood clot in the legs that is causing loss of circulation, blood loss, lack of feeling, and eventually pain and an inability to walk.   

3)     Does your cat clean or pick at its paws or nails?  Cats clean all the time but if the paw bothers the cat because there’s a blood clot, they will pick at it. They will also pick at a paw if there is an infection on the paw pads.  Watch the legs closely and take a look at the nail beds and the paw pads to see if there is anything wrong when you see them constantly cleaning. If there are any concerns or infections or issues, the cat needs to see the vet.

4)     Has your cat ever blanked out? When your cat is walking around or playing or interacting with you, have you ever noticed it suddenly seem to not know what it is doing? Have you ever seen it go blank or stare suddenly after being busy with something else?  Has this trance or pause lasted only a few seconds to 30 seconds or so?  Has your cat ever lifted its paw as if it is trying to decide what to do with it?  These could be due to arrhythmia, an unusual heartbeat and should warrant a call to the vet and a visit to the vet. If it passes in a few seconds, then call the vet cardiologist and discuss it with the vet.  If it is prolonged, then a rush to the ER or vet cardiologist immediately is necessary.  If it’s short but happens again and continues to occur, a call and a visit to the vet cardiologist is in order.  This means that there is a problem with the heart beating, circulating blood, etc. and it needs to be taken care of as soon as possible. 

5)     Have you noticed your cat being sleepy, quiet, or a lack of play or a lack of energy?  This is important to note because it could be due to congestion in the lungs or an increase in heart size.  A visit to the vet cardiologist is needed.

6)     Has the breathing rate of the cat increased even at rest or while sleeping?  Does the cat that is normally breathing 26-30 now breathing 30-40?  This is very important to note and could mean congestion in the lungs.  A call and a visit to the vet cardiologist are needed immediately.  Additional lasix might be warranted. Xrays will be needed to see if the heart has increased or if the lungs have congestion.

7)     Is your cat not eating well? Is your cat not urinating enough? Is your cat not drinking enough? Or is the cat eating too much, drinking too much, and urinating too much?   These are not normal, even for a cat sick with a heart disease.  This requires a trip to the vet to pinpoint any problems.

8)    Is your cat hiding?  Cats that are well do not hide.  Cats that are sick will hide.  A trip to the vet or ER is necessary.  Sure, your cat likes to climb shelves, sleep under the bed, crawl under a blanket, be quiet and disappear for a few hours.  But is it now disappearing for hours on end and not interacting, not playing, not coming out to greet you when you get home, and not wanting to eat?  Those are signs that a cat is very ill.

Being vigilant to changes and the behavior of the cat; being organized; keeping the meds on a set schedule; giving the cat all the meds and vitamins and supplements it needs; keeping it warm/cool as needed; keeping it free from stress; and of course, loving it, will contribute greatly to slowing the progression of the HCM disease.  Good luck!