PING Phil progressive HCM; is there anything I can do?

Last May our cat (now age 11) was diagnosed with very mild HCM. I
posted the echo results here and the repeat echo in Dec 2007. It
showed no significant changes so the cardiologist said to repeat echo
in one year.

We just had the recheck echo with a different cardiologist. Our cat
has been asymptomatic all this time on atenolol for mild SAM/LVOT.
While the atenolol eliminated the SAM and LVOT, it did not completely
eliminate mitral valve regurgitation. We were shocked to be told at
this recheck today that she has progressed from very mild HCM to
severe in just 11 months. I have not gotten a copy of the report yet
but the cardiologist said that her left atrium was twice the size it
should be (it was previously normal; in fact, in May 2007 LA/Ao was
1:19 and in Dec. 2007 it was 1:15.)

He said the left ventricle had not changed from the previous echo
(normal function, small bulge at base of septal wall). Papillary
muscles are now enlarged.

We are having trouble understanding how her heart could have gotten so
bad so fast. The cardiologist said it was not what he was expecting
but this kind of progression was not unusual. There is also "extremely
mild" pleural effusion--not enough it would bother her, he said. She
is now on enalapril, furosemide, and plavix in addition to the
atenolol. I asked about diltiazem and he said it is not indicated for
LVOT. He also said the results of the study which showed some reversal
of HCM with diltiazem have not been able to to be duplicated.

I assume that as long as there is some mitral valve leakage her heart
is going to keep getting worse, but is there anything we can do? She
is still asymptomatic and I don't see how her heart can be this bad
yet she can still run up a couple of flights of stairs and not even
get out of breath.

Is it possible that the first cardiologist missed some of this, or are
echoes pretty standard from machine to machine? She uses a mobile
ultrasound and goes from clinic to clinic.

Phil, you may remember some of this discussion from last year when I
posted the echo results. Thanks again for any advice. Does this still
sound as though it may be primary mitral valve disease rather than
HCM, not that it seems to matter now.
-yngver

yngver wrote:

He also said the results of the study which showed some reversal
of HCM with diltiazem have not been able to to be duplicated.

My Maine Coon mix was diagnosed with mild HCM and began Diltiazem
4 mg bid, reduced to qd a year later; no other heart meds. There
was marked reversal of the HCM and the murmur became nearly inaudible.
He received annual echo exams to monitor the problem.

He was seven years old at diagnosis, died at age 13 of unrelated
cancer.

Thanks, Bryce, that is good to know. I have heard of several other
cats who had reversal of HCM on diltiazem, but the cardiologist said
with our cat's symptoms (obstructive HCM) atenolol is better for that
than diltiazem. I wish we could try it. I don't know whether it would
help reverse atrial enlargement however or whether anything can. I did
find a small study that did seem to show some reversal of atrial
enlargement with enalapril, so I am hoping that may happen now that
she is taking it.
-yngver

On Nov 12, 7:44 am, Bryce wrote:
yngver wrote:
He also said the results of the study which showed some reversal
of HCM with diltiazem have not been able to to be duplicated.

My Maine Coon mix was diagnosed with mild HCM and began Diltiazem
4 mg bid, reduced to qd a year later; no other heart meds. There
was marked reversal of the HCM and the murmur became nearly inaudible.
He received annual echo exams to monitor the problem.

He was seven years old at diagnosis, died at age 13 of unrelated
cancer.

"yngver" wrote in message
...


I'm sorry for the delayed response, Sue. I've been really busy. This has
been the worst year for kittens and surrenders that I've ever seen.


Last May our cat (now age 11) was diagnosed with very mild HCM. I
posted the echo results here and the repeat echo in Dec 2007. It
showed no significant changes so the cardiologist said to repeat echo
in one year.

We just had the recheck echo with a different cardiologist. Our cat
has been asymptomatic all this time on atenolol for mild SAM/LVOT.
While the atenolol eliminated the SAM and LVOT, it did not completely
eliminate mitral valve regurgitation. We were shocked to be told at
this recheck today that she has progressed from very mild HCM to
severe in just 11 months. I have not gotten a copy of the report yet
but the cardiologist said that her left atrium was twice the size it
should be (it was previously normal; in fact, in May 2007 LA/Ao was
1:19 and in Dec. 2007 it was 1:15.)


Something's not right. I think someone screwed up- probably the travelling
show vet. I have no faith in them whatsoever- regardless of their
credentials. The worst echoes I ever saw were done by travelling show vets.



He said the left ventricle had not changed from the previous echo
(normal function, small bulge at base of septal wall). Papillary
muscles are now enlarged.


I think I asked you if the papillary muscles were hypertrophied. You said
she didn't mention them at all in her report. I remember that because I
thought it was very unusual- especially when the echo was done on a cat with
SAM.


We are having trouble understanding how her heart could have gotten so
bad so fast. The cardiologist said it was not what he was expecting
but this kind of progression was not unusual. There is also "extremely
mild" pleural effusion--not enough it would bother her, he said. She
is now on enalapril, furosemide, and plavix in addition to the
atenolol. I asked about diltiazem and he said it is not indicated for
LVOT. He also said the results of the study which showed some reversal
of HCM with diltiazem have not been able to to be duplicated.

I don't know where he got his information from. I can personally attest to 4
cases- right off the top of my head- in which the LV or IVS hypertrophy and
the dimensions of the LA were reduced after beginning diltiazem therapy.



I assume that as long as there is some mitral valve leakage her heart
is going to keep getting worse, but is there anything we can do? She
is still asymptomatic and I don't see how her heart can be this bad
yet she can still run up a couple of flights of stairs and not even
get out of breath.

Is it possible that the first cardiologist missed some of this, or are
echoes pretty standard from machine to machine? She uses a mobile
ultrasound and goes from clinic to clinic.


My guess is the travelling show cardiologist not only missed a few things-
especially the papillary muscles- she probably got a few measurements wrong,
too. Their primary concern is volume- not patient care.



Phil, you may remember some of this discussion from last year when I
posted the echo results. Thanks again for any advice. Does this still
sound as though it may be primary mitral valve disease rather than
HCM,

The LVFW and IVS are normal, right?


not that it seems to matter now.
-yngver

Send me the report when you get it. I'll be able to tell you more after I
see the numbers. Send me the first report too, ok?

Keep the faith,

Phil

On Nov 15, 12:08 am, "Phil P." wrote:
"yngver" wrote in message

...

I'm sorry for the delayed response, Sue. I've been really busy. This has
been the worst year for kittens and surrenders that I've ever seen.

I am sure the poor economy has something to do with it.

Last May our cat (now age 11) was diagnosed with very mild HCM. I
posted the echo results here and the repeat echo in Dec 2007. It
showed no significant changes so the cardiologist said to repeat echo
in one year.

We just had the recheck echo with a different cardiologist. Our cat
has been asymptomatic all this time on atenolol for mild SAM/LVOT.
While the atenolol eliminated the SAM and LVOT, it did not completely
eliminate mitral valve regurgitation. We were shocked to be told at
this recheck today that she has progressed from very mild HCM to
severe in just 11 months. I have not gotten a copy of the report yet
but the cardiologist said that her left atrium was twice the size it
should be (it was previously normal; in fact, in May 2007 LA/Ao was
1:19 and in Dec. 2007 it was 1:15.)

Something's not right. I think someone screwed up- probably the travelling
show vet. I have no faith in them whatsoever- regardless of their
credentials. The worst echoes I ever saw were done by travelling show vets.

She may have. I don't know. The new cardiologist accepted her
measurements as valid, and he knows her. I had to get a referral from
my regular vet to see this cardiologist (Luethy) and he said the other
option was to have a consult with the mobile cardiologist. He didn't
push me either way, just said they are both good.



He said the left ventricle had not changed from the previous echo
(normal function, small bulge at base of septal wall). Papillary
muscles are now enlarged.

I think I asked you if the papillary muscles were hypertrophied. You said
she didn't mention them at all in her report. I remember that because I
thought it was very unusual- especially when the echo was done on a cat with
SAM.

No, there was nothing in the previous two echo reports on the
papillary muscles. The assumption of the new cardiologist was that
they were normal previously, but perhaps they weren't. I have read
that assessment of papillary muscles is pretty subjective as there
aren't any clear-cut standards.



We are having trouble understanding how her heart could have gotten so
bad so fast. The cardiologist said it was not what he was expecting
but this kind of progression was not unusual. There is also "extremely
mild" pleural effusion--not enough it would bother her, he said. She
is now on enalapril, furosemide, and plavix in addition to the
atenolol. I asked about diltiazem and he said it is not indicated for
LVOT. He also said the results of the study which showed some reversal
of HCM with diltiazem have not been able to to be duplicated.

I don't know where he got his information from. I can personally attest to 4
cases- right off the top of my head- in which the LV or IVS hypertrophy and
the dimensions of the LA were reduced after beginning diltiazem therapy.


He meant that additional studies have not duplicated the results of
the initial small study. He doesn't seem like the kind of cardiologist
who puts much weight on anecdotal evidence. I have known a few cases
as well in which diltiazem has resulted in some reversal of HCM but as
a rule these seem to be cats without outflow obstruction, since
atenolol is normally prescribed when there is obstructive HCM. Both he
and the other cardiologist think atenolol is best for LVOT. I have
questioned this but I can't get them to prescribe diltiazem when they
say atenolol is the better treatment in this case.


I assume that as long as there is some mitral valve leakage her heart
is going to keep getting worse, but is there anything we can do? She
is still asymptomatic and I don't see how her heart can be this bad
yet she can still run up a couple of flights of stairs and not even
get out of breath.

Is it possible that the first cardiologist missed some of this, or are
echoes pretty standard from machine to machine? She uses a mobile
ultrasound and goes from clinic to clinic.

My guess is the travelling show cardiologist not only missed a few things-
especially the papillary muscles- she probably got a few measurements wrong,
too. Their primary concern is volume- not patient care.

Now I wonder what she would have said if we had gone ahead and had the
consult with her.


Phil, you may remember some of this discussion from last year when I
posted the echo results. Thanks again for any advice. Does this still
sound as though it may be primary mitral valve disease rather than
HCM,

The LVFW and IVS are normal, right?

They were, and the cardiologist this time said the condition of the
left ventricle hadn't changed, but I haven't seen the actual report
yet.

not that it seems to matter now.

-yngver

Send me the report when you get it. I'll be able to tell you more after I
see the numbers. Send me the first report too, ok?

Okay, thanks so much. I will get a copy of the report this Sat. when
we take our cat back for a chem panel (to make sure the drugs aren't
affecting her kidney function--her labs were all "perfect", according
to my vet, when they were done in late August) and x-ray to make sure
the tiny amount of pleural effusion is gone.

Keep the faith,

Phil

Thanks, we are trying. It was just such a shock--my regular vet called
me to see how I was doing when he got the report, so even he was
concerned. I really wish if there is a mistake, it is with the new
echo rather than the previous two, but I guess I am just in denial. I
will send you the info on all three reports when I get the last one.

The new cardiologist is located in a veterinary emergency clinic. We
were not present for the actual echo but he came in the room
afterwards and showed us the video. He said the left atrium and the
aorta should be about the same size and so unless it was the wrong
cat, it was pretty obvious from what he showed us that the left atrium
was a lot bigger than the aorta. I don't know whether this will show
on x-ray Sat.

The only good part of this is that our cat seems perfectly fine and
runs around the house without getting out of breath, same as before.
The new drugs haven't had any bad side effects yet that I can see.
-yngver

"yngver" wrote in message
...
On Nov 15, 12:08 am, "Phil P." wrote:
"yngver" wrote in message


...

I'm sorry for the delayed response, Sue. I've been really busy. This
has
been the worst year for kittens and surrenders that I've ever seen.

I am sure the poor economy has something to do with it.


We've been getting several cats back that we adopted out 2 to 4 years ago.



Last May our cat (now age 11) was diagnosed with very mild HCM. I
posted the echo results here and the repeat echo in Dec 2007. It
showed no significant changes so the cardiologist said to repeat echo
in one year.

We just had the recheck echo with a different cardiologist. Our cat
has been asymptomatic all this time on atenolol for mild SAM/LVOT.
While the atenolol eliminated the SAM and LVOT, it did not completely
eliminate mitral valve regurgitation. We were shocked to be told at
this recheck today that she has progressed from very mild HCM to
severe in just 11 months. I have not gotten a copy of the report yet
but the cardiologist said that her left atrium was twice the size it
should be (it was previously normal; in fact, in May 2007 LA/Ao was
1:19 and in Dec. 2007 it was 1:15.)

Something's not right. I think someone screwed up- probably the
travelling
show vet. I have no faith in them whatsoever- regardless of their
credentials. The worst echoes I ever saw were done by travelling show
vets.

She may have. I don't know. The new cardiologist accepted her
measurements as valid, and he knows her. I had to get a referral from
my regular vet to see this cardiologist (Luethy) and he said the other
option was to have a consult with the mobile cardiologist. He didn't
push me either way, just said they are both good.



He said the left ventricle had not changed from the previous echo
(normal function, small bulge at base of septal wall). Papillary
muscles are now enlarged.

I think I asked you if the papillary muscles were hypertrophied. You
said
she didn't mention them at all in her report. I remember that because I
thought it was very unusual- especially when the echo was done on a cat
with
SAM.

No, there was nothing in the previous two echo reports on the
papillary muscles. The assumption of the new cardiologist was that
they were normal previously, but perhaps they weren't. I have read
that assessment of papillary muscles is pretty subjective as there
aren't any clear-cut standards.


Its true there aren't any standard dimensions published for feline papillary
muscles, but after looking at enough normal ones you'll know hypertrophied
papillary muscles when you see them.






We are having trouble understanding how her heart could have gotten so
bad so fast. The cardiologist said it was not what he was expecting
but this kind of progression was not unusual. There is also "extremely
mild" pleural effusion--not enough it would bother her, he said. She
is now on enalapril, furosemide, and plavix in addition to the
atenolol. I asked about diltiazem and he said it is not indicated for
LVOT. He also said the results of the study which showed some reversal
of HCM with diltiazem have not been able to to be duplicated.

I don't know where he got his information from. I can personally attest
to 4
cases- right off the top of my head- in which the LV or IVS hypertrophy
and
the dimensions of the LA were reduced after beginning diltiazem therapy.


He meant that additional studies have not duplicated the results of
the initial small study. He doesn't seem like the kind of cardiologist
who puts much weight on anecdotal evidence. I have known a few cases
as well in which diltiazem has resulted in some reversal of HCM but as
a rule these seem to be cats without outflow obstruction, since
atenolol is normally prescribed when there is obstructive HCM. Both he
and the other cardiologist think atenolol is best for LVOT. I have
questioned this but I can't get them to prescribe diltiazem when they
say atenolol is the better treatment in this case.


If the LVFW and IVS are normal, then atenolol would be the best medication
for SAM and LVOT obstruction. I mentioned diltiazem if the IVS was
hypertrophied because a hypertrophied IVS can affect the mitral valve
leaflets.




I assume that as long as there is some mitral valve leakage her heart
is going to keep getting worse, but is there anything we can do? She
is still asymptomatic and I don't see how her heart can be this bad
yet she can still run up a couple of flights of stairs and not even
get out of breath.

Is it possible that the first cardiologist missed some of this, or are
echoes pretty standard from machine to machine? She uses a mobile
ultrasound and goes from clinic to clinic.

My guess is the travelling show cardiologist not only missed a few
things-
especially the papillary muscles- she probably got a few measurements
wrong,
too. Their primary concern is volume- not patient care.

Now I wonder what she would have said if we had gone ahead and had the
consult with her.


Phil, you may remember some of this discussion from last year when I
posted the echo results. Thanks again for any advice. Does this still
sound as though it may be primary mitral valve disease rather than
HCM,

The LVFW and IVS are normal, right?

They were, and the cardiologist this time said the condition of the
left ventricle hadn't changed, but I haven't seen the actual report
yet.

not that it seems to matter now.

-yngver

Send me the report when you get it. I'll be able to tell you more after
I
see the numbers. Send me the first report too, ok?

Okay, thanks so much. I will get a copy of the report this Sat. when
we take our cat back for a chem panel (to make sure the drugs aren't
affecting her kidney function--her labs were all "perfect", according
to my vet, when they were done in late August) and x-ray to make sure
the tiny amount of pleural effusion is gone.

Keep the faith,

Phil

Thanks, we are trying. It was just such a shock--my regular vet called
me to see how I was doing when he got the report, so even he was
concerned. I really wish if there is a mistake, it is with the new
echo rather than the previous two,

I know what you mean. I wish so too.



but I guess I am just in denial. I
will send you the info on all three reports when I get the last one.

The new cardiologist is located in a veterinary emergency clinic. We
were not present for the actual echo but he came in the room
afterwards and showed us the video. He said the left atrium and the
aorta should be about the same size and so unless it was the wrong
cat, it was pretty obvious from what he showed us that the left atrium
was a lot bigger than the aorta. I don't know whether this will show
on x-ray Sat.

The only good part of this is that our cat seems perfectly fine and
runs around the house without getting out of breath, same as before.
The new drugs haven't had any bad side effects yet that I can see.
-yngver


If you saw the video of the last echo, my guess is the travelling show vet
screwed up the first echo. It possible for HCM to progress as much as it did
in that amount of time but its not probable- at least not without symptoms.

I'm sorry I can't be more helpful- You're doing all you can and you're
making all the right decisions. Not much I can add.


I'm wishing you and Pye the best of luck.

Keep the faith,

Phil

On Nov 21, 12:18*am, "Phil P." wrote:
"yngver" wrote in message

... On Nov 15, 12:08 am, "Phil P." wrote:
"yngver" wrote in message

...



I'm sorry for the delayed response, Sue. I've been really busy. *This
has
been the worst year for kittens and surrenders that I've ever seen.

I am sure the poor economy has something to do with it.

We've been getting several cats back that we adopted out 2 to 4 years ago..









Last May our cat (now age 11) was diagnosed with very mild HCM. I
posted the echo results here and the repeat echo in Dec 2007. It
showed no significant changes so the cardiologist said to repeat echo
in one year.

We just had the recheck echo with a different cardiologist. Our cat
has been asymptomatic all this time on atenolol for mild SAM/LVOT.
While the atenolol eliminated the SAM and LVOT, it did not completely
eliminate mitral valve regurgitation. We were shocked to be told at
this recheck today that she has progressed from very mild HCM to
severe in just 11 months. I have not gotten a copy of the report yet
but the cardiologist said that her left atrium was twice the size it
should be (it was previously normal; in fact, in May 2007 LA/Ao was
1:19 and in Dec. 2007 it was 1:15.)

Something's not right. I think someone screwed up- probably the
travelling
show vet. I have no faith in them whatsoever- regardless of their
credentials. *The worst echoes I ever saw were done by travelling show
vets.

She may have. I don't know. The new cardiologist accepted her
measurements as valid, and he knows her. I had to get a referral from
my regular vet to see this cardiologist (Luethy) and he said the other
option was to have a consult with the mobile cardiologist. He didn't
push me either way, just said they are both good.

He said the left ventricle had not changed from the previous echo
(normal function, small bulge at base of septal wall). Papillary
muscles are now enlarged.

I think I asked you if the papillary muscles were hypertrophied. You
said
she didn't mention them at all in her report. I remember that because I
thought it was very unusual- especially when the echo was done on a cat
with
SAM.

No, there was nothing in the previous two echo reports on the
papillary muscles. The assumption of the new cardiologist was that
they were normal previously, but perhaps they weren't. I have read
that assessment of papillary muscles is pretty subjective as there
aren't any clear-cut standards.

Its true there aren't any standard dimensions published for feline papillary
muscles, but after looking at enough normal ones you'll know hypertrophied
papillary muscles when you see them.









We are having trouble understanding how her heart could have gotten so
bad so fast. The cardiologist said it was not what he was expecting
but this kind of progression was not unusual. There is also "extremely
mild" pleural effusion--not enough it would bother her, he said. She
is now on enalapril, furosemide, and plavix in addition to the
atenolol. I asked about diltiazem and he said it is not indicated for
LVOT. He also said the results of the study which showed some reversal
of HCM with diltiazem have not been able to to be duplicated.

I don't know where he got his information from. I can personally attest
to 4
cases- right off the top of my head- in which the LV or IVS hypertrophy
and
the dimensions of the LA were reduced after beginning diltiazem therapy.

He meant that additional studies have not duplicated the results of
the initial small study. He doesn't seem like the kind of cardiologist
who puts much weight on anecdotal evidence. I have known a few cases
as well in which diltiazem has resulted in some reversal of HCM but as
a rule these seem to be cats without outflow obstruction, since
atenolol is normally prescribed when there is obstructive HCM. Both he
and the other cardiologist think atenolol is best for LVOT. I have
questioned this but I can't get them to prescribe diltiazem when they
say atenolol is the better treatment in this case.

If the LVFW and IVS are normal, then atenolol would be the best medication
for SAM and LVOT obstruction. *I mentioned diltiazem if the IVS was
hypertrophied because a hypertrophied IVS can affect the mitral valve
leaflets.









I assume that as long as there is some mitral valve leakage her heart
is going to keep getting worse, but is there anything we can do? She
is still asymptomatic and I don't see how her heart can be this bad
yet she can still run up a couple of flights of stairs and not even
get out of breath.

Is it possible that the first cardiologist missed some of this, or are
echoes pretty standard from machine to machine? She uses a mobile
ultrasound and goes from clinic to clinic.

My guess is the travelling show cardiologist not only missed a few
things-
especially the papillary muscles- she probably got a few measurements
wrong,
too. *Their primary concern is volume- not patient care.

Now I wonder what she would have said if we had gone ahead and had the
consult with her.

Phil, you may remember some of this discussion from last year when I
posted the echo results. Thanks again for any advice. Does this still
sound as though it may be primary mitral valve disease rather than
HCM,

The LVFW and IVS are normal, right?

They were, and the cardiologist this time said the condition of the
left ventricle hadn't changed, but I haven't seen the actual report
yet.

not that it seems to matter now.

-yngver

Send me the report when you get it. I'll be able to tell you more after
I
see the numbers. Send me the first report too, ok?

Okay, thanks so much. I will get a copy of the report this Sat. when
we take our cat back for a chem panel (to make sure the drugs aren't
affecting her kidney function--her labs were all "perfect", according
to my vet, when they were done in late August) and x-ray to make sure
the tiny amount of pleural effusion is gone.

Keep the faith,

Phil

Thanks, we are trying. It was just such a shock--my regular vet called
me to see how I was doing when he got the report, so even he was
concerned. I really wish if there is a mistake, it is with the new
echo rather than the previous two,

I know what you mean. *I wish so too.

but I guess I am just in denial. I

will send you the info on all three reports when I get the last one.

The new cardiologist is located in a veterinary emergency clinic. We
were not present for the actual echo but he came in the room
afterwards and showed us the video. He said the left atrium and the
aorta should be about the same size and so unless it was the wrong
cat, it was pretty obvious from what he showed us that the left atrium
was a lot bigger than the aorta. I don't know whether this will show
on x-ray Sat.

The only good part of this is that our cat seems perfectly fine and
runs around the house without getting out of breath, same as before.
The new drugs haven't had any bad side effects yet that I can see.
-yngver

If you saw the video of the last echo, my guess is the travelling show vet
screwed up the first echo. It possible for HCM to progress as much as it did
in that amount of time but its not probable- at least not without symptoms.

I'm sorry I can't be more helpful- You're doing all you can and you're
making all the right decisions. Not much I can add.

I'm wishing you and Pye the best of luck.

Keep the faith,

Phil- Hide quoted text -

- Show quoted text -- Hide quoted text -

- Show quoted text -- Hide quoted text -

- Show quoted text -

I'm impressed that your regular vet called you. I feel like I'm more
critical of vets I go to than a doctor I'd bring MYSELF to! Of
course, I had Guinea Pigs which were quite hard to find a "good" vet
for. Some vets seemed to dabble in exotic pets, and their answer to
EVERYTHING is a shot of antibiotics. One vet also told us our male
Guinea Pig was a female. When we took "him" to a good vet they were
like WHAT!?!?!!

T