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)

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.” 

Once Again Unto the Breach-Myrna Develops Congestion, High Breathing Rate, Goes to the ER

(Short version of the "Breach" speech from Shakespeare's Henry V:)
KING HENRY V:
Once more unto the breach, dear friends, once more...
But when the blast of war blows in our ears,
Then imitate the action of the tiger;
Stiffen the sinews, summon up the blood,
Disguise fair nature with hard-favour'd rage...
Hold hard the breath and bend up every spirit
To his full height...
 show us here
The mettle of your pasture; let us swear
That you are worth your breeding; which I doubt not;
For there is none of you so mean and base,
That hath not noble lustre in your eyes...
The game's afoot:
Follow your spirit...

I mean for this to encourage you as the pet owner of an HCM cat to gather your courage and to carry on the fight as we are doing.

Myrna had to go to the ER Wednesday night.  I do believe I waited too long.  But how do you tell when you should go when all could possibly be normal but different?  You add up the "normal but different" and see to what extreme your cat's behavior is different.  

She was breathing 10-12 breaths per 15 seconds, which, for her, should have been 8-10. (Normal is around 6 for healthy cats.)   She wasn't urinating as frequently although she had a huge bladder when she did go.  But she went at 6 a.m. and again at noon but never after that.  She was eating well enough but not finishing her food.  She had been hiding away in the bedroom under the bed but did come down for lunch.    We did treat time and I tried to get her to use the box and I could feel a large bladder but still, she wouldn't go. Later,  I found her in the hall laying still with eyes opened just staring but responsive but she wouldn't eat a treat.  I picked her up and took her to the box but still she didn't go.   She then disappeared under the bed.  I really should have taken her to the ER then.  At 6:30 my husband gave her the evening meds and she returned to hide under the bed.  By 8:30, we had trouble getting her to come out from under the bed for more meds and dinner.  She still had not used the litter box since noon.  With the not going, and not eating treats, and hiding, and the breathing, I finally decided  to take her to the ER.  At 8:30, I sent a text to the vet telling her I was concerned and she agreed Myrna should see the ER. 

At the ER, they took xrays that should mild congestion in the lungs, and did blood work.  The blood work showed high BUN (35, up from 30) and creatinine (2.7 up from 1.7) indicating possible loss of kidney function and onset of kidney disease.  But still, we needed to control her congestion.  They gave her a large lasix injection which still has not brought down her breathing rate (still at 10-12  breaths per 15 seconds at home; was higher at ER but not at home.) They did drain a large volume of urine out of her because she still refused to go.   She did use the litter box at home at 3 a.m. and finally again at 10 a.m.   

She will see the cardiologist on Friday since her breathing is still high.  The cardiologist will do an echo to determine if CHF is onset or if a heart attack or other issue occurred yesterday (which can have mild symptoms.)   The ER vet said xrays lag behind CHF unless a cat is in CHF. Sort of like knowing a dam has broken and water will soon flood the valley but hasn't yet-xrays can't show what's not there. But an echo can show increasing blood veins and heart function pointing to CHF.  

They changed her lasix to 12.5 mg tablets and she will take them four times a day. (A month ago we were at 30mg a day, then 35, then this week 40 so you can see the need for increasing amounts goes along with the increasing heart size/congestion/breathing concern.)

Must say we had excellent care at the ER. I dislike our local ER since they were sold last year to a new service. Since Myrna's cardio is connected to the Novi AEC, it's best to take her there in case she needs hospitalization overnight and needs to see the cardio the next day. Plus, they know her, have her info on file, even access to the cardio files, can call the cardio, all of which they did.  I've had the cardio's cell phone number since June and this was the first time I used it.   I had called the ER to tell them we were coming in and the cardio called them as well to advise them what to do. Even though it was late, 10:30 by the time we arrived, the cardio didn't mind taking calls from the ER vet to consult about Myrna once tests were run.   And luckily, it was a slow night at the ER.   

That she's producing urine and concentrating it enough, is the opposite of kidney failure. But she's not going. And Myrna's always the opposite in so many ways from other cats' reactions to meds and HCM so producing urine and NOT going could be a sign for her of kidney disease.   But they did say if she's not feeling well due to congestion, she could just not care to go.  But Myrna's always gone, even when initially sick albeit she always had a much smaller heart size back then.   There's no real way to mitigate the situation other than to get more water in her to help her kidneys and see if she'll eat a low protein diet (when kidneys are not well, too much protein for kidneys to process taxes the kidneys even more.) And we need to somehow lower her sodium which keeps going up and therefore increases water retention-which yes, is what she needs for kidneys but not for HCM. This has always been a balancing act but things are never really well balanced.   But we are working on it. 

So, as of Thursday a.m., she is still breathing 12 per 15 seconds but she's not hiding and is more social.  She's calm, she's eating more, but still there's that breathing issue.   She is unfortunately, on the decline.  We were here in June but not this badly.  Eventually, in July, she bounced back when we injected lasix. But that led to the skin lesions.  So, now we are trying to fight congestion with pills.  We may need to return to injecting as long as the lesions don't return.  To keep them from returning, we  could inject lasix just once or twice a week (she's allergic to plastic so maybe allergic to the plastic syringes touching her body daily or the lasix or the entire process.)   Unfortunately, to combat the lesions and to heal the skin, we used antibiotics, two of which caused watery stool and upset the gastro system (although by creating watery stool, that meant that fluid was going to her colon and not to her lungs, the only good byproduct of the antibiotic.)  So, if lesions come again, is there another antibiotic to heal lesions and not upset the gastro? 

Possible reason Myrna Loy can't breathe-buried under Katharine Hepburn

Stay tuned.