Veterinary cardiologist Dr. Anna McManamey joins the podcast to talk about how she approaches the coughing cat. Is this a cardiology problem, or is it something else? If it is a cardiac problem, how do we even get diagnostics without putting the patient in danger? All that and more on this episode!
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LINKS
ACVIM Consensus Statements: https://www.acvim.org/news-publications/consensus-statements
Practice Managers’ Summit – March 22, 2023: https://unchartedvet.com/upcoming-events/
Uncharted Veterinary Conference – April 20-22, 2023: https://unchartedvet.com/uvc-april-2023/
Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/on-demand-staff-training/
Dr. Andy Roark Swag: drandyroark.com/shop
All Links: linktr.ee/DrAndyRoark
ABOUT OUR GUEST
Dr. McManamey (aka Dr. Mac) is a veterinary cardiologist. She received her degree of veterinary medicine from the University of Missouri. She then completed a rotating internship at the Ohio State University followed by an emergency and critical care internship at North Carolina State University. She finished her cardiology residency at North Carolina State University and became an ACVIM diplomate in 2021.
Dr. Mac is currently an assistant clinical professor at Purdue University in Indiana. Cardiology is her favorite subject because it can be made as simple or as complex as needed. Furthermore, every animal has a heart and that means Dr. Mac gets to work with all kinds of species. Her areas of interest within cardiology are echocardiogram, congenital heart disease and interventional procedures, as well as emergency management of cardiac disease. She has a very supportive and patient husband along with three canine fur-children, one of which had a patent ductus arteriosus (of course).
EPISODE TRANSCRIPT
This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.
Dr. Andy Roark:
Welcome, everybody, to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here with the one and only Dr. Mack, cardiologist at Purdue, is back and we are talking about the coughing cat. This is a great episode for working with these cases. It’s interesting what percentage of these are cardiac cases and what percentage is not, and how do you separate them, and how do you know. And so we go through that. This is quick and to the point. It’s a great episode. I took a ton of notes on this. Oh man, I just love having Dr. Mack here. Guys, you’re in for a treat. Let’s get into this episode.
Kelsey Beth Carpenter:
(Singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to The Cone of Shame with Dr. Andy Roark.
Dr. Andy Roark:
Welcome to the podcast, Dr. Anna McManamey. Thanks for being here, Dr. Mack.
Dr. Anna McManamey:
Hi. It’s nice to be here.
Dr. Andy Roark:
Oh man, I love having you on the podcast. You’re so great.
Dr. Anna McManamey:
[inaudible 00:01:04].
Dr. Andy Roark:
I was just thinking back. I was just thinking about recently, when you and I met, and I just happened to sit next to you at a table at the VMX conference a year ago, and we started talking, and I was like, “This person is super fun. And so you’ve been on the podcast I think at least four times now.
Dr. Anna McManamey:
I think so, yeah.
Dr. Andy Roark:
And so anyway, maybe six. I don’t know. You’re up there. Gosh, I enjoy my time with you.
I got something super fun for you today. I want to talk to you about coughing cats. And when I was in vet school, I distinctly remember being taught coughing cats are an emergency and they’re a cardiac emergency, and so I just wanted to stop and run through that. I have had some stressful situations in my career where the coughing cat or the heavily breathing, gasping cat comes in, and I’ve had those patients die, and it is awful, and it’s scary and stressful. I just want to talk through that with you. Talk to me about the coughing cat, if you don’t mind, and how do you look at these cases, and what should general practitioners know?
Dr. Anna McManamey:
Yeah, I think it’s a great question, and I think there are kind of like two schools. I’ve had people that say, “Well, I was taught cats cough with CHF in school,” and then I have the others who are like, “Pretty sure they said they don’t cough with CHF.” So it’s still I think cats in general are so challenging even for cardiologists.
So I would say that anecdotally, so I’m still a young cardiologist, and I’ve been a doctor since 2016, but only a cardiologist for a year and a half, but anecdotally, it’s very uncommon for cats with pulmonary edema from heart disease present with cough. It’s unlike dogs. And I don’t think we still know. We all give this just it sounds good answer of, “Oh, their cough receptors are different.” But it is interesting to me that cats with pulmonary edema secondary to cardiac disease, they don’t tend to cough. I mean, they might have a cough, but it’s not like a dog with mitral valve disease or with DCM. So it’s interesting. I would say the ones that I have seen cough because of congestive heart failure have had severe pleural effusion or severe pericardial effusion. So I don’t think it’s fair to say that they never cough with CHF, but I do think it’s uncommon to be cardiogenic pulmonary edema as the cause. So if I have a referral for a coughing cat, we don’t roll our eyes, but we’re like, “Oh, it might not be even heart disease.” The animal may have concurrent heart disease, but we may have more work than just saying, “Oh yes, this is congestive heart failure.”
So typically when I have a coughing cat, ideally the most important test is going to be thoracic radiographs. That’s the most important thing. And I think you bring up a really good point that some of these animals are very fragile by the time they get to you. And we have that saying, “No animal should die in radiology,” and I think that’s very true. So things that you can try to do… My thing, I’m in favor of doing a dorsal-ventral view. Might not be great. Don’t get a hand in there. But just do something that gives you a quick snapshot. Does this animal have severe pleural effusion? Does this animal have severe edema? Or is there no edema, and this is an asthmatic cat with [inaudible 00:04:21] and bronchial coughing. So I think at least that view gives you something to work with.
I think treatment-wise, oxygen is never a bad idea unless the animal’s on fire.
Dr. Andy Roark:
Yeah, exactly.
Dr. Anna McManamey:
[Inaudible 00:04:37] oxygen. I think sedative-wise, butorphanol is my favorite, because it is probably one of the safest cardiovascular drugs we have, and it is a cough suppressant, so kind of two birds, one stone with that. I’ll use doses anywhere from 0.2 MGs per K all the way up to 0.5 MGs per K, IV or IM, for butorphanol in kittycats. But I think that ultimately that thoracic radiographs are going to give you the most important information in that nitty-gritty timeframe. Then I think if you have it, point-of-care ultrasound, so those little Sonosites that you can use to do cystocentesis on, I think that’s a great way to just look. Is there severe pleural effusion? I can tap that and stabilize this animal. Yes or no? That can be very helpful. Once you get skilled enough, you can actually start to look at chamber sizes of the heart, the left atrium in particular. But I think that that’s a little bit more specialized of a skillset and so not going to [inaudible 00:05:34]
Dr. Andy Roark:
I’ll be honest, that’s beyond me. I can see the heart. I can see it beating. I have not crossed that threshold of being able to [inaudible 00:05:40]. I’m like, “Yep, there it is.”
Dr. Anna McManamey:
Fluid, no fluid is really all you got to know. [inaudible 00:05:46]
Dr. Andy Roark:
All right, good. Now, see, that’s what I need, validation. I feel good.
Dr. Anna McManamey:
But when it comes to trying to decide, “Does this animal have heart disease? Does this animal have a thing I need to do further investigation for or start treatment for congestive heart failure?” I would say the nice thing about congestive heart failure is that it’s very treatable and it should respond very quickly to medications. So unlike… I always pick on pneumonia, but unlike pneumonia, where there can be a radiographic lag between when the pulmonary pattern shows up and when it resolves, congestive heart failure, it’s like it’s there or it’s not there. And then once you start giving a diuretic, it really should start working within an hour of giving that. So it’s something that’s easy to rule out if they fail therapeutic trial for that disease process. That’s the nice thing about it.
I think cats in general with heart disease, it’s everybody’s nemesis. They can be so tricky. They don’t have to have a heart murmur. I think having the presence of a murmur, the presence of a gallop sound, so it’s like that third heart sound that kind of sounds like a horse literally galloping, or the presence of an arrhythmia, those things would increase my index of suspicion that there is truly heart disease. But there are so many other reasons for cats to get those, so it’s not the most sensitive, but at least lets you go down that pathway.
So if I have any of those findings on my physical exam, then what I do is I do things like… I know it sounds kind of off the wall, but a T4, so including in my blood work check their thyroid level, because if I think this cat has heart disease, I need to rule out hyperthyroidism and I need to rule out systemic hypertension. So T4, blood pressure, those are going to be on my list if I’m going down the cardiac pathway.
The other test I think could be helpful is the BNP test. So this is the biomarker. I think I talked a little bit about it in one of the podcasts previously, I should say. But this is a biomarker that basically assesses for heart stretch. So it’s like the heart’s own diuretic, if you will. It’s a natriuretic peptide, so it’s released by the ventricles when they feel stretched, and it goes to the kidney and tells the kidney to urinate sodium, and then therefore water follows. So this tells you if the heart feels any type of duress. Doesn’t tell you why it does. It just tells you that it’s got some sort of disease going on. So there’s a send-out test and there’s a SNAP test, and you can use the greater severity of that number to help you say, “Is it likely CHF? I should treat this,” or, “Unlikely CHF. I need to go down a different pathway.”
And so I think it’s still the most prudent to rule out congestive heart failure, because, again, it’s the easiest thing to treat, fastest thing to treat, probably most life-threatening. And then once you’ve done that, then you can feel a bit more comfortable about doing things like treating for airway disease, chronic inflammatory airway disease, asthma, bronchitis, those kinds of things, which will need beta agonists like albuterol or steroids, which is always a little bit scary to do with cats [inaudible 00:08:58]
Dr. Andy Roark:
Yeah, always.
Hey guys, I just want to jump in here with a quick update. Have you seen the Dr. Andy Roark team training courses yet? Guys, over at drandyroark.com, I have got resources for people who want to work with our team. I have my angry client course, and I have my exam room toolbox course. These are great little modules that are made to be broken up and popped into staff meetings so that you can cover a quick topic about either dealing with angry clients, complaining clients, or to talk about different tools and working with clients in the exam room. Guys, this is fantastic. I’ve got discussion questions to ask your team, so they can talk about what they do, and just is a great way for everybody to see the same thing together, to talk about what works in the practice and what they think is important, and just to get on the same page. Anyway, I hope you guys will check it out. It’s over at drandyroark.com. I’ll put a link in the show notes. Let’s get back into this episode.
Talk to me a little bit more about the interaction with hyperthyroidism and cardiac disease. Are you okay to break that down a little bit?
Dr. Anna McManamey:
Sure, absolutely. So I kind of teach it as there are three hypers whenever you see a thick left ventricle. So you could have primary hypertrophic cardiomyopathy, so HCM, which technically is idiopathic, so there’s just this innate thickening of the muscle and rearrangement of the fibers. There’s no underlying other disease. But you could also have something we call an [inaudible 00:10:22] phenotype, so it’s thickening of the left ventricle, but it’s because of systemic hypertension or hyperthyroidism, which is pretty common in our older cat populations.
So I could talk probably an hour about how the thyroid hormone affects the heart, but the nitty-gritty is that ultimately it puts the body in an upregulated metabolic demand. So we have hypertrophy of the heart muscle. Even if there’s no systemic hypertension, this still will happen. And they get fibrosis of those cells. The thyroid hormone acts inside the nucleus, so it affects the DNA of those heart cells, so it’s long-lasting change. And so these animals can get these thick ventricles, these dilated hearts, big left atrium, and still have congestive heart failure just because of hyperthyroidism. And so the nice thing with it is it’s reversible in a lot of cases.
So one of my favorite stories is a cat named Sylvester, who was 18 years old. He had never been to a vet ever. And he showed up in my residency dying. He went on the ventilator, and his thyroid was 13.4, his T4. And we were like, “This isn’t good. You’ve never been to a vet. Are you okay to manage heart failure ventilation and [inaudible 00:11:34] therapy?” And she did it. And that cat lived for three more years. It came off all of its heart meds. Ended up dying of like a gastric carcinoma. But I think-
Dr. Andy Roark:
[inaudible 00:11:44].
Dr. Anna McManamey:
I mean, something’s got to get them. But I think that it just reemphasizes the importance of looking for those underlying comorbidities that could be reversible and lead to a really more positive prognosis.
Dr. Andy Roark:
Yeah, that’s amazing. Cool, cool. All right, wonderful. That totally makes sense. It checks all the boxes for me. Is there anything else, any other pearls that you can think of to be looking for in these patients? Anything that tends to get missed when things get referred to you?
Dr. Anna McManamey:
Yeah, I think that for coughing animals that get referred, I think one of the biggest probably pitfalls is that there’s just not the time for that clinician to really get a good history on these patients. I think we’re also busy, and unlike academia where I’ve got hours to talk to clients in my day, you guys have to do these cases in like 15 minutes.
And so I think what I started doing was to have a history form that my clients filled out, so they filled it out at the time of the appointment or in the waiting room, whatever it is. And that just really helped me, because I think help having the knowledge of, how often is this animal coughing? When is it coughing? Is it self-limiting? Is there something that always incites this coughing? What’s the character of the cough? Do they have a video recording of the cough? Whatever that is, it really helps narrow down your differential list. And so if you don’t have the ability to run all of the tests, you can focus your energy on the things that are more likely. So I think the thing that gets overlooked the most is just really getting a good history and asking questions, sometimes repeating them, ’cause I feel like as a student, we always ask, “Is your dog vomiting?” They’re like, “No.” And then the doctor would go in, and they’d be like, “Oh yeah, five times a day. Vomiting [inaudible 00:13:29].”
Dr. Andy Roark:
Exactly.
Dr. Anna McManamey:
So I think it helps to just really hone in on that history question. And I think that’s something that gets missed quite a bit, just because of time.
Dr. Andy Roark:
Yeah, that totally makes sense. Are there any resources that you really like? Any tools in the toolbox that you’re like, “Oh man, I wish more people knew about this.”
Dr. Anna McManamey:
I think for cats in particular, it’s a little nerdy, but the ACVIM consensus statements. So this is the American College of Veterinary Internal Medicine. They publish these big old articles usually once every five years on a certain topic. You can Google it, ACVIM consensus statement. You don’t need special memberships to read these. And it’s basically a bunch of specialists’ just opinions/what is proven/what they would do with all of these situations. And so they have one for feline cardiomyopathy. They have one for mitral valve disease, systemic hypertension, pulmonary hypertension, hyperthyroid. They have them for everything almost. So I think those are really helpful, and they also are filled with references at the bottom, so if you want to learn more you can always go there next.
Dr. Andy Roark:
That’s fantastic. That’s great advice. Thank you so much. Thanks for being here. I always appreciate having you. Where can people find you if they want to reach out?
Dr. Anna McManamey:
Yeah, I think the easiest is probably on the Purdue Veterinary Medicine website, so I’m one of three cardiologists there. You can Google Anna McManamey in Purdue, and you should find me there. My email’s listed there, as well as some information about our clinic and what we do.
Dr. Andy Roark:
That’s outstanding. Thanks for being here. Hey, take care everybody. I hope you enjoyed it.
Dr. Anna McManamey:
Thanks, everyone.
Dr. Andy Roark:
And that is our episode, guys. I hope you enjoyed it. I hope you got something out of it. As always, if you did, share the episode with your friends. Honestly, I just want to share the learning, and that’s how we do it. Also, it always helps me if you write an honest review wherever you get your podcast. It’s how people find the show. Anyway, gang, take care of yourselves. Be well. I’ll talk to you later on.
