Degenerative Heart Disease – when start meds? Chip

Last July my vet's face grew concerned when she listened to Chip's heart during his annual exam. Grade 2 to 3 heart murmur. Referral to cardiologist. Echocardiogram showed chronic degenerative mitral valve disease. The valve is thickened and thus doesn't close fully anymore. I was devastated. Cardiologist said prognosis is difficult, with some dogs it doesn't progress much, others deteriorate rapidly.

So second echocardiogram a year later, now. The disease has progressed. He now has a 'moderate left atrial enlargement.' Last year the left atrium was not enlarged. He still compensates and does everything he wants, he runs, chases squirrels, and goes outside when it's hot (he likes that).

This cardiologist recommended starting him on an ACE inhibitor drug like Enapril while he is still asymptomatic. She said benefits are controversial but she recommends it. It would entail checking renal function before starting the medication, rechecking renal function one week after, and then biannually while receiving this medication.

Does anyone have experience with this? Dogs or human? From what I read, it's more of a small dog issue, one of the few things not common among GSDs. Chip is about eight years old now, plus/minus.

He will have his annual exam with my regular vet this month, and I'll hear what she says. She tends to be conservative with treatments, one reason why I like her. I might get a second cardiologist's opinion, too.

The condition leads to congestive heart failure. An article that Lisa posted in the health stickies: https://docs.google.com/file/d/0B2fU7S3y...en_US&pli=1
The cardiologist said once they are symptomatic, she can keep them going for another year to year and a half on medication.

He is such a loving, happy dog with an incredible spirit.

Commmmon I was just admiring Chip race around in his new harness

My husband takes lisinopril, another ACE inhibitor, for slight high blood pressure, if that makes sense. He really likes the drug-it almost restores vitality, but it is for a different condition. Our previous neighbor dog, a Havanese, had congestive heart failure as an older dog and was on medication for at least two years.

I wish you and Chip the best.

MJ

I don't have any advise or knowledge here but I just want to say I wish the best to you and am so sorry your having to make such a hard decision.

Your both in my thoughts and prayers.

No advice either as I do not know anything about this but just want to send hugs to you and the Chipster.

Probably not much help but my daughter's doctor wanted her to start an ace inhibitor and the nephrologist nixed it. Like many medications there are side effects which I'm sure you're aware of.
Thinking of Chip and you.

Sarah I also have nothing to offer but so many to you and Chip He is such a darling.

Chipster Sarah

I am so very sorry to read this

This is what Indy had. The folks that tend to know the most about this are the CKS people, because of the high incidence of this in their breed: http://www.cavalierhealth.org/mitral_valve_disease.htm
The formal name of the disease is myxomatous mitral valve disease, which might be helpful if you want to google and find more technical info at any point.

First in the category of unusual, I would make sure that tick diseases are ruled out, as things like lyme, and others, can trigger or cause these heaart problems. Indy was on clavamox for about 6 months for a bone infection (thought to be caused by her previous lyme issues), and her murmur went from a 2 to one that the vet could barely find. It got worse again off abx, but I think the abx slowed the progression. Dental disease I am guessing could do the same thing. I would have initial full bloodwork and look for any signs of infection, and rule out lyme for sure.

Indy had two cardiologists. The first one, that I liked the most, put her on enalapril when her murmur got suddenly worse, and thwre were abnormalities in her labwork. It turned out that a tendon in the heart broke and was flapping around in there Important for indy was that her kidneys were also being affected from the lack of blood flow. Her urinary specific gravity was real low, would have to look at her blood kidney levels, I don't recall those. After the enalapril was started, urinary SG resolved, and I believe I recall some other positive signs, but I honestly don't remember. She did get a little stumbly, probably from BP that was too low, and we reduced the dose, and that worked.

I guess that the main problem with enalapril is that in some dogs it negatively affects the kidneys. But when it does this, it does it quickly, so they test the blood in a week. The second cardio told me that once they are okay on it, then they stay okay.

As a side note, in heart disease, the heart and the kidneys are always battling - the kidneys want fluid, and the heart has a hard time managing them. Important to keep in mind if fluid are ever needed in illness.

The cardio had some personal issues and went MIA for awhile, so I had to go to UC Davis. They were great, all very impressed at how great indy had been managed and how well he was doing (I mean they were *really* impresed with the great shap he was in conidering her condition), but their protocol is to NOT start any drugs at all until the dog is in CHF, which is esentially fluid in the lungs on xray. The 1st cardio previously told me that there were studies that showed the benefit of starting an ACE inhibitor earlier in the disease proces, and I am just thankful that I went to her first. Indy did have some enlargement, but I'm not sure how much, and she never entered the CHF stage.

The first cardio did say that the other common drug, that is supposed to strengthen heart contractions (can't remember the name - just found it, vetmedin/pimobendan), should not be started unless there is CHF, since it can speed progression if started too soon (lots of vets/non-cardios will start this too early). This is one reason I would be concerned about giving the herb Hawthorn to a dog with this type of heart murmur. My thought, which I had late in indy's disease, is that, like this drug, strenghthening the heart contractions can place more burden on weakened heart structure. I sometimes wonder if this is what broke the tendon in indy's heart, I had her on hawthorn initially, which is a common protocol.

I did have her on hyaluronic acid to keep the tendons, etc., in the heart supple. For some reaon, I chose HA over extra glucosamine/condroitin - I remember reading the reearch papers, and not being sure, but I came up with that - not sure about that part. There are other supplements useful, but I don't remember them all. I added CoQ10. I added some taurine to her diet. (It is thought that dogs do not need taurine added, and very few kibbles add this, so the addition of it may help a lot. Like cats, it has been found that at least some dogs need it.) She did not tolerate fish oil though, which is important to add to keep the inflammation down. However, she was on permanent low dose doxy for paw knuckling (related to lifetime infection issues), which I later found may have delayed progression of her heart disease process: www.ncbi.nlm.nih.gov/pmc/articles/PMC3367668/

The hard part for us was figuring out thyroid dosage - we didn't want to make it too high, though we may have had it too low.

That's all I can remember right now (oops, just realized thi is Long!). I hope you find a protocol for Chip to keep him healthy and running for a LONG time.

I'm sending good vibes for Chip to be well and feel well. May whatever treatment you and your vet decide upon give you a good, optimistic feeling. I do like the second cardio opinion idea, just for more ideas and potential solutions. Lisa mentioned HA, and Swanson Vitamins has some for humans in a very tiny capsule form. May chip and you have many, many healthy years together!

Thank you so much for your advice and hugs, both felt very good. Lisa, that Cavalier page is a mine of information, thank you! It will take me a while to get through it, so much helpful info. At the Border Terrier health clinic, a woman wheeled in a cart with maybe twenty CKC spaniels for echocardiograms. Now I know why. They all yapped at Chippy who took it in stride and with a smile

He gets tested annually for TBD and HW, has always tested (-). Due to the nature and color of his wire coat, it is very easy to spot ticks, even the tiny nymphs, and I check him carefully. He also wears his BuzzOff bandana during tick season. He doesn't have dental disease. A couple of years ago he needed a dental cleaning. At Patti's advice, I started giving him RMB (chicken necks), and they do a great job cleaning the teeth and gums, as Patti had said. He started eating them only after Elly joined us. I also have finger tooth brushes in case more cleaning is needed.

As of now, he is fine. He has slowed down but he has also aged. We used to play fast games of squeaky toy fetch for maybe half an hour in the evening, now it's five minutes before he comes in for snuggling. But he isn't gasping for air or anything. He chases squirrels and birds less often. He is happy for everything we do together, walks, playing, tracking, snuggling, his whole face happy.

A colleague of mine in Germany got a damaged heart valve replaced by a pig's heart valve. In humans it seems to be a fairly routine surgery. The article mentions surgery on dogs is done in CO at prohibitive cost. I also found a couple of articles on the surgery being done at a Japanese research vet hospital.

My default reaction is to not intervene if the intervention is controversial. But there is a lot more for me to learn about heart disease.

Lisa, as I understand you, the early ACE meds helped dear Indy? Did I get that right indeed?

Our Buddy (adopted Maltese-poodle) developed this and it was detected before he was symptomatic too - 3 months prior no heart murmur to grade 3-4 on a checkup after our dogs had their first fight! The vet advised us that as there was little difference in outcome or longevity if treatment was started before symptoms began and because the tablets were expensive and had side effects relating to urinary incontinence we should wait until there were symptoms.

There was a sudden change in activity for Buddy (as in he collapsed doing his normal walk) and while treatment was initially successful he quickly lost appetite and was difficult to medicate - in hindsight I wish we had started treatment earlier although I think the vet was probably right in that it would not have made any difference. When we got him his teeth were shocking but improved amazingly on a raw diet but the damage was probably done as bad teeth are known to often cause valve damage in dogs (and people) - smaller dogs being the usual candidates.

Best wishes for Chip - many dogs live with this disease for many years. My friend had a Jack Russell who was diagnosed at 2yo and he lived a great life and until well over his 15th birthday, she just let him set his own pace regarding exercise and carried him occasionally on walks as he aged.

Sarah, I went back and looked...

Indy's big worry was the broken tendon. If a major one were to break next, that would have been instant heart failure. Her murmur went from a 2 to a 4 when it broke. The actual degeneration of the valve was labeled low to moderate, and her enlargement was moderate at her last two cardio visits in 2009. Never any fluid in the lungs.

The enalapril did help her, though I think it gave her mushier stools. Before the drug, she had slightly high BUN, her creatinine had shot to the high normal range, and her urinary specific gravity was at 1.021 (just a bit low). After the enalapril, the creatinine decreased from 1.5 to 1.1, her SG resolved, but her BUN always stayed high. As a side note, she ran high end RBC's and funny red blood cell numbers, which may have been from her heart or a chronic infection, don't know.

This paper, under Treatment, discusses the different studies using an ACE inhibitor: http://www.vet.chula.ac.th/tjvm/full_text/v40/v402/402_PDF/03%20TJVM_40_2_Review1April27.pdf

I looked on the old forum (Thread: Advancing Heart Disease, searched for "mitral" in the google box and it popped right up), and this is what I said 4 days after she started enalapril:


(Unfortunately, going back and reading, I can see signs of brain lesions that would eventually take her life the following year, but we do the best we can in the moment.)

Sarah please give your sweet boy a gentle smooch from me

Lisa, just

I had Zamboni (beagle/cocker) on enalapril for years. She did develop renal failure.

As Lisa says, it's a big difficult balancing game.

If we don't control the heart, it affects the lungs. That's pretty significant. Kidneys are a little easier to manage. (Also part of the whole loop, enalapril might affect pancreas in some individuals. Zamboni did get acute idiopathic pancreatitis. Was that caused by the enalapril? My internist couldn't say. She said it could have been caused by toxins from the renal system. Or the pancreatitis could have exacerbated the renal failure.

My head used to spin after my pow-wows with my internist. When the cardiologist joined us, I'd want to crawl under a desk because it was all so overwhelming. )

Chip is pretty young still. If his murmur is getting worse, I'd want to address it. .

If the heart doesn't work right, we're going to have a miserable dog. So I figure, start with the heart. I'd run full renal tests (urine, CBC, Chem screen) to get a baseline. If he has health kindneys, monitor every 3-4 months. If things remain stable for a while, less frequently thereafter.

If his kidney values aren't great, consult with an internist now and establish a plan for future exams, diagnostics, etc.

Also discuss with her dropping fat level in food (and treats) some to protect the pancreas.

As Chip becomes older, it really does become a balancing act. The disease we call "failure" in an older dog means he's lived a good life and his body is showing the miles. It's hard to realize, I know. But parts start wearing out.

The thing is, if we start early, provide good maintenance and upkeep to our older kids, they tend to be like Hondas. They just keep going.

My girl was in congestive heart failure and took enalapril for years. She was in renal failure for years.

I always figured one of those would be the reason that I lost her, but nope, she kept cruising along. When she finally moved on, she was almost 17 and died of something else unrelated.

Sorry you and Chip are experiencing this! Hope he can be symptom free for much longer.

Thank you so much, all, for advice, information, and good wishes. A lot of information to absorb and process. I'll keep you posted.

Luckily he is not terrified of the vets. He used to be during and for a while after his very, very painful leg repair. He used to shake like a leaf already in the any vet hospital hallway. upon seeing a white coat. upon seeing his surgeon in civies at home. Chip has good nerves though, he overcame it, and just endures the echos and blood draws. I only go where I can be with him during the procedures. Of course, I don't want to turn him into a 'patient' with lots of monitoring earlier than necessary. But then, realistically, he already is a patient who needs monitoring.

He is such a happy dog, always hoping for a game of squeaky toy fetch or a walk, beaming at me! And always ready for a snuggle. He and Captain Jack are the sunshine in my life!

I was cleaning out some old papers, and came across this. Looks like ACE inhibitos can make insect stings worse. Might be a problem for dogs (like Jazz), that have bad reactions. http://www.ncbi.nlm.nih.gov/m/pubmed/16569814/

Update:

To get a second opinion, my vet spoke with the cardio vet who comes to her clinic to do echocardiograms. This cardiologist said he would not start medicating before symptoms begin. And that's how we'll go. Love my vet.
Chip will have an echo every six months now, though. Sigh.

I ordered Vetri-Science Cardio-Strength for Chip, replacing the Vetri-Science Coqsol he was on so far. The Cardio-Strength has taurine (thank you for the suggestion, Lisa) and other goodies in addition to co-enzyme Q:
http://www.vetriscience.com/index.php?l=product_detail&p=900602060

I chose the chews b/c I can break them in two. It's one chew/30 lbs. He is such a little guy, 17 lbs. But he can chase a whole flock of geese triple his size! Attitude is everything

Sounds like a good plan. I hadn't seen that product before - looks like it has all the good stuff in it - I like vetriscience products.

I hope that with support, you stop this disease process dead in its tracts

Chippy, please give him a smooch from me!