Veterinary cardiologist Dr. Mac is back on the podcast! We are talking about an 8 year-old Maine Coon Cat named Jerry who came in for limping… and who happens to have a very large heart on radiographs. How concerned should we be? How much deeper should we investigate? What do we tell the owners? This and more coming up in this episode of the Cone of Shame!
LINKS
Purdue University College of Veterinary Medicine: https://vet.purdue.edu/
Believing We Can – Leading a Solution Oriented Team: https://unchartedvet.com/product/solution-oriented-team-workshop/
Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/store/
What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/
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:
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Dr. Andy Roark:
Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am back with my friend, cardiologist Dr. Mac from Purdue University’s College of Veterinary Medicine. She is amazing. Guys, we are talking about big cats and big hearts. We’re talking about a Maine Coon cat who’s in for limping, and when we take a radiograph of the shoulder, we see his heart’s really big. What do we do with big hearts in cats? Heart disease, cardiomegaly, in cats is a interesting subject area. It’s a point of a lot of debate for cardiologists. I want to make sure I’m getting it right, or at least starting my clients off down the right path so that we can figure out what to do together. Gang, super great episode. Really good information, so many pearls. Dr. Mac is amazing, I hope you agree. 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 back to the podcast, Dr. Anna McManamey. How are you?
Dr. Anna McManamey:
I’m good. How are you?
Dr. Andy Roark:
I am so good. I am so thrilled to have you back. How have you been?
Dr. Anna McManamey:
I’ve been good. How are you doing?
Dr. Andy Roark:
I am okay. My mom is coming to visit this weekend and she’s supposed to be here anytime, and so-
Dr. Anna McManamey:
Don’t mind me.
Dr. Andy Roark:
… I sent her a message and I was like, “Don’t come in my room, Mom. I’m hanging out with my friends. I’m hanging with my friend.” It’s a language that she would understand and would come back to her from the past. So, we’ve got to get this done, because my mom’s coming over.
Dr. Anna McManamey:
Sounds good.
Dr. Andy Roark:
All right. Here we go. I’ve got a case for you. It’s probably nothing, it’s probably dumb, it’s probably nothing. I’ve this big, handsome, Maine Coon cat who thinks he’s a dog. You know those cats?
Dr. Anna McManamey:
My favorite cats.
Dr. Andy Roark:
My favorite cats, too. The cat people are like, “Oh, I thought you liked cats?” And I’m like, “I like cats who act like dogs,” and they’re like, “Shut up.” No, I’m kidding. I love cats. But there is something about the big cats that think that they’re dogs, it just makes me smile. And that is our friend. Jerry. Jerry is, I said eight years old, so middle-aged, getting on towards later senior years there. But anyway, Jerry’s in for limping, limping on one of the front legs, and we snapped shoulder rads and we got some chest in there. Jerry has a big heart, and I counted rib spaces, but just looking at Jerry he’s just got a big heart and it does not look normal. I look at a lot of cat chest in my time and I see a big heart and I know what a big heart looks like, and I think he’s got a big heart.
Dr. Andy Roark:
I don’t hear a murmur or anything when I listen to this, he’s not asymptomatic, he’s literally here for orthopedics in the front leg. What do you think when I tell you that I see that in Jerry, how do you treat this?
Dr. Anna McManamey:
Yeah, that’s a great question. So, the cardiomegaly in a cat, especially on radiographs, I think, always should alert to the possibility that there could be cardiac disease, especially because the most common kind of cardiac disease in a cat can be really difficult to pick up on radiographs alone. So, anytime I think there’s a big heart, for a cat, I think it’s worth further investigation. The fact that he came in for limping, I think we have to keep in mind, “Is this the weird presentation for an aortic thromboembolism?” So, tying the whole picture together. Again, I think it warrants for the workup of his heart a little bit. So, we have to figure out, “Well, what are we going to be to offer this cat in that setting versus future steps?” So, I would say the easiest things to do when you have a cat at your practice and you don’t have a cardiologist next door, would be to…
Dr. Anna McManamey:
You’ve already done the thoracic radiographs, you’ve seen the big heart. I’d say, “Ooh, cardiac disease is very possible. This is a breed of cat, this is an age of cat, this is a gender of cat that get heart disease,” so working that up a little bit further. It’s an old enough cat where we could see secondary changes from hyperthyroidism, we could see secondary changes from high blood pressure. So, a very basic screening for cats that are over the age of seven, honestly, for me, I do recommend a T4 and I do recommend a systemic blood pressure. Those are accessible, easy to do, just ruling out raging systemic disease that could be causing the heart changes. And then for this guy, the other things I would do, again, just because he’s breed, [inaudible 00:06:09], and gender at risk, he’s got limping and he’s got a big heart on radiographs, is this is a good time to do one of those NT-proBNP, so that biomarker that we talked a little bit about last time.
Dr. Anna McManamey:
So, the BNP, just as a reminder, is that B-type natriuretic peptides, something that’s released by the heart, by the ventricles, when they feel stretched. So, it can be a pressure overload, a volume overload, or a systemic disease process like hyperthyroidism or systemic hypertension. Anything that makes the heart unhappy, it can release this hormone. And so, the NT-proBNP is a send-out test, so it does take a little bit of time, but there are SNAP tests available. So, these are from IDEX, they’re just like a SNAP heartworm or SNAP parvo test. You take a few drops of their blood, put it in the well, wait three minutes, and you get your answer. That one is nice, I think, for these more time-sensitive cases. It basically gives you a qualitative answer, so it tells you, “Yes, there’s likely significant heart disease,” or, “No, there’s likely not significant heart disease,” whereas the send-out test is a quantitative, so it gives you an actual number. But those would be the things I would start with in that cat today, and we can talk a bit more about what I want to see, if you have any questions so far.
Dr. Andy Roark:
No, that totally makes complete sense to me. I have a couple of questions, but I want to go farther down the path before I come back around to them. So, I’m good with this. This all makes sense. This all seems very doable. I am 100% on board. Where do we go from here? What are you expecting to come back? What are you concerned about finding?
Dr. Anna McManamey:
Yeah. So, if I think this catch really has significant heart enlargement, I’ve ruled out hyperthyroidism, I’ve ruled out systemic hypertension. If my BMP result comes back as abnormal or greater than the reference range, at least greater than, honestly, 200 is my number, but the reference range goes to 100, but I just want it to be more [inaudible 00:08:10]-
Dr. Andy Roark:
Oh, gotcha. Okay.
Dr. Anna McManamey:
… if that makes sense. So, the SNAP test, the cutoff is 270, that’s the cutoff, picomoles per milliliter. So, if I get an abnormal BMP result in this cat, I’m going to say, “Your cat likely has structural heart disease.” The lameness, truly, it could be a musculoskeletal issue or a muscular issue, but it could have been a weird transient thrombotic event. So, you can decide, can I get this cat to a cardiologist quickly to make that final diagnosis, or am I going to hedge my bets and maybe even put this cat on a prophylactic blood thinner? Just because if it really is an ATE and we really get a high BNP result, the chances of that being from heart disease are much more likely. Otherwise, I would say we just need to get them seen by a cardiologist to determine what the severity of that heart disease is.
Dr. Anna McManamey:
If you take the lameness part out of this cat’s case altogether and you just took these radiographs as a screening for something else, same thing. If you get a high result, I’d say, “It’s time to go to the cardiologist,” if you get a normal result or a low result, I’d say, “The cardiac enlargement on radiographs is probably not significant for that animal.” There is still a chance, and I still think if that client is interested in a workup, always appropriate to refer, because we know that an echocardiogram is still the gold standard for diagnosing [inaudible 00:09:35] heart disease in a cat. But in that exact moment, having that tool to fall back on, I think is helpful.
Dr. Andy Roark:
Hey, guys, I just want to jump in with a couple of quick announcements. I have got to thank Banfield, the pet hospital, for making transcripts of this podcast possible. Guys, in an effort to increase inclusivity and accessibility in our profession, to get people the information and to make sure everyone is included, Banfield has stepped up and made transcripts possible. You can find them at drandyroark.com. Thank you to them, this is something I wouldn’t be able to do without their help. God, it makes me so good to be able to offer this. Hey, gang, let me ask you a question. If you could make clients easier to handle for your veterinary team, would you do it? Would you make the client experience better for yourself and the people that you work with? Well, if your answer is yes, I just want you to know that I have worked really hard to help make this happen. I have two online, on-demand courses in the Dr. Andy Roark store. One of them is all about charming angry clients, and the other one is all about building trust and relationships with vet owners.
Dr. Andy Roark:
Guys, I worked really hard on these. This is the culmination of over a decade of lecture that I have done around the world and working on these topics. It is my best stuff broken up into 5 to 10 minute modules that you can just drop into staff meetings. You can put them wherever you want, it doesn’t have to be a big deal. You can use them in morning huddles, but it is a way that you can keep giving your people tools just to make their lives easier, because that’s what they’re all about. If you’re interested, head over to drandyroark.com and just click on the store button and you can see what’s there. I’ve also got What’s On My Scrubs? Card game, which is just something fun, a little team-building, educational activity that might make your people laugh. Anyway, I want you guys to know that that’s there, I hope that you will check it out. On Wednesday, August the 10th, my good friend, Senani Ratnayake, RVT is doing an Uncharted workshop. She is doing Believing We Can: Leading a Solution-Oriented Team. What do decision making processes actually look like in your practice?
Dr. Andy Roark:
Get your team to solve problems and find solutions with tips and tricks from this workshop. Guys, Senani is amazing at walking people through how to connect with their team, how to communicate positivity, how to get people in a positive and productive head space to move forward, and to solve their own problems. If you want that for your team, head over to unchartedvet.com, I’ll put a link down in the show notes, but get registered. It is on Wednesday, August the 10th, 8:30 PM Eastern time, 5:30 PM Pacific. It is $99 to the public. It is, as usual, almost always, free to Uncharted members. If you’re like, “Man, they do so many good workshops,” don’t forget to check out the Uncharted membership. I would love to have you in our community. I would talk to you if you were there, because we have a nice, vibrant, active community where we help each other. And if that sounds usual, check it out. All right, guys. And now, let’s get back into this episode.
Dr. Andy Roark:
Let’s just say that we run these tests, we run the proBNP, we do all the things. We get normal results back and we say, “Okay. Still big heart, but we’re not seeing these abnormal structural change markers,” things like that. Do you recheck that cat? Are you going to get this cat back in a year or six months and recheck, what does that look like?
Dr. Anna McManamey:
I think it’s a great question. I think the follow-up’s really important and we can’t forget it. So, I would say 6 to 12 months, I would recheck the same things.
Dr. Andy Roark:
Repeat the rads and compare them, obviously, to the previous year. All right. That totally makes sense to me. When we look at this, we said we’ll probably need to do an echo to get any insight into this. So, I practice in South Carolina and we talk a lot about heartworm disease and we talk about heartworm disease in cats. Is there anything else you would do to differentiate cause, other than the echo, which it seems like that’s cutting to the chase and just saying, “Hey, look, we know we have a large heart. We know we’ve got some abnormalities in here”? I guess I’m dancing around the obvious next step, which is we’re going to get an echo, but anything else that you would add or consider in that phase?
Dr. Anna McManamey:
Yeah. So, heartworm disease in cats is relatively different from the dogs, enough so that it’d be unusual, but not impossible, to see just a big heart from it. So, typically with cats, we look for changes in the lungs a little bit more so, but you could heartworm antigen and antibody test that cat. It’s important to remember to do the antibody test, as well, for cats. But you totally could do that, to just further rule out some things. A lot of practices are getting point-of-care ultrasounds. It doesn’t have to be the full echo machine, I have to be careful of what I say, but if you have a point-of-care ultrasound and you’re just trying to rule other things out, like paracardial fusion. Does this cat have a fusion around its heart and that’s why the cardiac silhouette looks big? If you’re skilled and have the equipment to do that, you could always do that. But again, like you said, the frustrating things, usually, they have to come get an echocardiogram for the definitive diagnosis.
Dr. Andy Roark:
I want to explore the connection that you mentioned early on, just because it’s always worth looking into potentially simple answers. I’ve got a cat that’s limping and a cat with a big heart, are those things related? So, we talked about the aortic thromboembolism as a possibility. When I go back and talk to the pet owners and I say, “Hey, we’ve got a large heart. We’ve done our proBNP’s SNAP test and I want you to go see the cardiologist,” and they say, “Well, okay. But what about the fact that his leg still hurts?” What do you talk about that? Are there things that you would do for pain management in the meantime? Are there ways that you would investigate that intersectionality and say, “Yes, I think that this limping and this heart disease are together,” or, “I’m strongly suspicious of it, I’m mildly suspicious of it, or I’m not suspicious of it”? How do you tease that apart to give them some guidance why the cat is still not fully weight-bearing?
Dr. Anna McManamey:
That’s a great question. So, with the lameness alone, I guess it goes back to what a classic ATE looks like, a classic aortic thromboembolism. It can be in any leg, so it can be just a front leg, so we just can’t forget, it doesn’t have to be the back legs. But the classic things are they’re painful-
Dr. Andy Roark:
I was going to say, screaming pain. I would expect to really hear about this.
Dr. Anna McManamey:
Yeah. They’re painful, but they’re painful for the short term. They are really painful at the beginning and then they lose that sensation over a day or two. They usually have some change to their blood flow, so sometimes you can pick it up because their limb is cold or they don’t have a palpable pulse, where you can’t get a Doppler blood pressure to work on that leg. I try to use my physical exam more so than doing the diagnostics of lactates and blood glucose. I can totally use those things, but then it involves you poking a cat and risk [inaudible 00:16:43] to try and do that. But I think the biggest things that help differentiate a vascular event from a neurologic or an orthopedic event is that temperature of the leg is probably the most important, and then, unfortunately, that lactate and blood glucose differential, those can be helpful. But we see cats that have this partial emboli, they go very transient and they’re just lame.
Dr. Anna McManamey:
And so, I think you have to keep it on your list for that client, but in that moment, you need to take care of that patient, so some type of pain management. Typically, if I know it’s an ATE, I’m going to use some type of an opioid, but tons of people will use Onsior, for example, so some type of an NSAID. That’ll work really well for your musculoskeletal pain. You can do gabapentin, that could work for neuromuscular or just in general pain, but you’ve got to do something for the comfort of the animal. In terms of, if I really think this cat could have had an ATE, the most important thing for me to do, aside from the current management, is trying to prevent another one from happening. And so, the somewhat good news is that a typical dose of Plavix or clopidogrel in a cat, at least short-term, is probably not the end of the world. So, I think it’s just risk benefit again, of that client, of that patient, talking to them about the importance of trying, it versus the side effects of doing so.
Dr. Andy Roark:
So, treat the patient in front of you was basically what I heard. I’ll be honest, when you said ATE, I kind panicked and I was like, “Oh my God,” and everything I know about thromboembolism went out the window. I just forgot everything, I was like, “Ah, what do I do?” I’m back into control now. I feel like if this was a severe thromboembolism, I would know it, I would see it. I would recognize what it was. I would feel the cat’s foot. I would do all the things. I’m back to being comfortable again. I’m like, “Okay.” It’s like when you have limping cat and the specialist says, “Well, have you thought about this horrific thing?” And you’re like, “No,” it was that. The panic moment has passed, I’m back in control. I feel good. Okay. I have a plan. I think I know where to go with this. I still don’t feel like I have a lot of clear advice for the owner, other than we’re going to work this up and if it’s abnormal, we’re going to go down this pathway. It sounds like we have to see what this is.
Dr. Andy Roark:
But we’re going to go along for the ride and investigate. Are there any final words of advice that you have, or things that I should say to the pet owner to set expectations for what’s coming? Just because they’re going to start on this path and we’re going to start a cardiology workup, is there things that they should know before they get into this?
Dr. Anna McManamey:
Cat heart disease is always going to be challenging, and so I think you don’t want to scare a client, without the need to, but it’s important not to overlook some of those even subtle things, like the cardiomegaly and the lameness, could those be correlated or not? And so, I think just being honest, just being open and saying, “Look, we screened, we haven’t found any significant evidence that supports severe cardiac disease, but this is something we’re going to follow-up with in the future, and we’re going to do it by a recheck blood pressure, a recheck diet and recheck BMP level.” Say, “In the future, monitor for recurrent lameness, monitor for any collapsing episodes, shortness of breath.” Anything like that, you know where you’re going to go first. And you already have your baseline diagnostics, which, honestly, is going to be really helpful moving forward with this cat.
Dr. Andy Roark:
Yeah. I completely agree. I’m not a big fan of scaring people, I don’t like that. And at the same time, I really do feel like a lot of pet owners blow off health risks of their cat. I think it’s because cats are stoic and hide pain and illness and things like that. But I think leaning a little bit more heavily into, “Hey, you need to understand this is going on and we’re going to follow up on it,” that makes a lot of sense to me, as opposed to just overcomforting like, “Oh, don’t worry about it,” because I’m worried I’m not going to get that cat back if I don’t impress that on them. Okay. Awesome. This is so helpful, I really, really appreciate it. Thank you so much for being here.
Dr. Anna McManamey:
Thank you for having me.
Dr. Andy Roark:
And that’s it, guys. That’s what I’ve got for you. Thanks again to Dr. Mac for being with me. I’m such a fan of hers. Gang, take care of yourselves. Be well, enjoy practice, keep learning and growing as doctors and technicians, because, gang, that’s all there is. It’s continued growth, it’s lifelong learning. All right. See ya, everybody. Bye.
