Dr. Anna McManamey joins the podcast to discuss heart murmurs in cats. Alabaster is a 4 year old MN domestic shorthair who is in for his first dental cleaning. On physical examination, Alabaster has a grade 2-3/6 systolic murmur. Dr. Mac breaks down what her concerns are, the risk factors and next steps to take. Let’s get into it!
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LINKS
Retain Your Team: Speak the Languages of Appreciation in Your Workplace – May 21, 2022: https://unchartedvet.com/product/appreciation-languages-101/
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Dr. Andy Roark Swag: drandyroark.com/shop
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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 got a great medical episode today with the one and only doctor Mac, Dr. Anna McManamey is on the podcast and she’s been on before. I met her, just, we just sat down next to each other at the VMX conference. And I started talking to her and she was delightful and awesome.
Dr. Andy Roark:
And I learned so much just sitting next to her. I was like, “You have to be on a podcast.” And this is her second appearance on the podcast. She is really great. You guys are going to get some great pearls in a short amount of time. We are talking about a four year old male neuter, domestic short hair who has a systolic murmur. Who’s in for a dental. What do you do with that? Do you do that case? Is that going to be okay? What precautions do we need to take? How concerned should we be. Guys you’ve seen this case. You don’t want to miss this. 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. Welcome back to the podcast, Dr. Mac. Thanks for being here.
Dr. Anna McManamey:
Thank you for having me.
Dr. Andy Roark:
Oh man. I enjoy having you on the podcast. I’m so glad you’re back. I have a, well, let me pause and introduce you to those who don’t know you are a professor of cardiology at Purdue’s College of Veterinary Medicine and a lecturer and a genuinely wonderful smart person and a great darn teacher. And so that’s why I hope that you would be able to help me out with this case.
Dr. Anna McManamey:
Happy to be here. It sounds so fancy when you say it that way.
Dr. Andy Roark:
I know. Yeah, I get introduced and people are, this is Andy and he has this big title and I’m like, that sounds really fancy
Dr. Anna McManamey:
I don’t know if I’m qualified. Yeah. Obvious.
Dr. Andy Roark:
I know. I’m like, boy, I hope they don’t ask me hard questions.
Dr. Anna McManamey:
Yeah. Yeah.
Dr. Andy Roark:
Because I can’t justify this.
Dr. Anna McManamey:
Yeah, I’m a newbie cardiologist, but I’m enthusiastic so.
Dr. Andy Roark:
No, you’re I think you’re amazing. I love having you on the podcast. I have a kitty cat that I need help with. I, and again, maybe this is just my personal bias maybe it’s just the ratio of dogs to cats that we tend to see in practice. Maybe it’s just sort of the secret of nature of cats. Maybe it’s that cats are a little bit harder to physically examine than dogs sometimes. I don’t feel like I find a lot of heart murmurs in cats relative to heart murmurs in dogs. But I got one, I have a four year old male neuter, domestic short hair named Alabaster who came in for a dental cleaning and he’s got a heart murmur. He’s got a grade two, maybe a grade three. I’m not the best at nailing. Exactly. He’s in the grade two, three range.
Dr. Andy Roark:
Yeah, just a systolic heart murmur. No complaints from the owners. He doesn’t seem to be coughing or anything. They said, I asked them, “Is he coughing?” And they’re like, “Not more than usual.” And so that usual, okay. Yeah. So it’s that?.Yeah. So I’m looking at this cat one is anesthesia patient, but then also number two is just a general maintenance of a fairly young cat that I had not heard a heart murmur in before. Dr Mac, how do you treat that? Where do you go with this case?
Dr. Anna McManamey:
Yeah, I think that’s a great question. This is a very common scenario of why a lot of cats come to see me honestly. I think you hit a lot of good points right off the bat. Cats are sneaky. Cats they hide their disease. They don’t usually act sick even when they are sick. And then there’s a very frustrating, I guess, ratio of the number of cats that have heart murmurs that actually have heart disease and vice versa. So when you hear a murmur in a cat, I’d say it’s a 50, 50 chance that they have structural heart disease. So still-
Dr. Andy Roark:
Okay.
Dr. Anna McManamey:
… a reasonable chance that they do have that structural heart disease that you need to further investigate before putting them under an anesthesia where they’re going to get fluids as part of their anesthetic protocol. So in cats, a murmur usually is from some type of outflow tract obstruction. So whether that’s like an HOCM, so hypertrophic obstructive cardiomyopathy. Or some type of less pathologic form, a dynamic right ventricular tract obstruction. But usually that’s where we see these murmurs in these younger cats, mitral valve disease really isn’t common in cats.
Dr. Anna McManamey:
It happens in really older cats like geriatric kind of cats. But in this young of an animal, I think it’s very appropriate. It’s a male cat, it’s a middle aged cat, domestic short hair. Those are animals that are predisposed to HCM and structural heart disease. So what are you going to do with it? Well, I think if this were a dog, the answer would be easy. Take a set of baseline chest X-rays, know what you’re dealing with. Unfortunately in cats because their heart disease, they get most commonly is a hypertrophic cardiomyopathy. It’s a concentric thickening of the ventricle. So the ventricle thickens inward. And so taking X-rays on a cat, their heart can look miraculously normal, even if they have significant disease. So I say that an X-ray is helpful for ruling out severe, severe heart disease, maybe. But honestly, if you see a big heart, they probably have heart disease. If you see a normal looking heart, they still could have heart disease.
Dr. Andy Roark:
So 50, 50 chance they could have like
Dr. Anna McManamey:
Yeah. It’s frustrating, right? Because you got this cat-
Dr. Andy Roark:
Yeah, that’s not-
Dr. Anna McManamey:
… you want to do the dental. It’s asymptomatic.
Dr. Andy Roark:
It’s much less helpful than I thought.
Dr. Anna McManamey:
Yeah. I know. So I still think X-rays are okay. I think that again, if you see a big heart on X-rays, then I’d say, well, you probably do have heart disease. If I see a normal heart on x-rays, it just doesn’t rule out heart disease. So X-rays not wrong to do the other thing that’s growing in popularity that I actually really like is something called the BNP. So it’s just a B-type natriuretic peptide. So this is a biomarker. It is very, very specific for the heart. And what it tells us is if the heart is stretched. So it doesn’t tell us what the heart disease is. It doesn’t matter if it’s even primary heart disease, it could be like in an older cat could be hyperthyroid heart disease, could be systemic hypertensive heart disease. But what it tells us is the ventricles are under some type of duress.
Dr. Anna McManamey:
They’re either having a pressure overload or a volume overload something’s going on. And this is a blood test. It’s usually always going to be sent out like IDEX is the one that owns this test currently. So it’s going to be a turnaround. So it’s not going to be same day results, but it’s a simple blood test. You can do it with their pre anesthetic blood work for example. It goes out the range for cats is pretty tight. It’s about zero to a hundred kind of picomole per decaliter is the range. And usually if it’s in that range, I don’t worry at all about any type of structural heart disease.
Dr. Anna McManamey:
If it’s outside that range, it’s a pretty sensitive test. So you might get cats that have false positives, meaning it’s a little bit outside the range, but their hearts look very normal echocardiographically, but that’s a good screening test. In my opinion, it’s better than maybe even X-rays just because again, you can have pretty severe heart disease, but a normal heart on X-rays. So the BNP, in my opinion is the cheat man’s echo. And if you can’t get to cardiologist right away, or you don’t have the money to get to a cardiologist, then a BNP is a very appropriate screening tool. And I’m looking for that number to be higher than a hundred.
Dr. Andy Roark:
Do you add that in as a routine screening test for patients you’re planning to put under anesthesia? Is it that level of screening tool utility or are you still thinking mostly patients have… I have questions or concerns about I add this on to. I’m just curious.
Dr. Anna McManamey:
Yeah. Yeah.
Dr. Andy Roark:
Are you just sending these out all day or is this a targeted?
Dr. Anna McManamey:
I know. This is a slippery slope. I’m definitely in the case.
Dr. Andy Roark:
You’re a cardiologist too. You’re like, “You’re asking the wrong guy, uh.”
Dr. Anna McManamey:
But I do. I think I realize that not everyone can come see me. Right. I mean, we see-
Dr. Andy Roark:
Sure, totally.
Dr. Anna McManamey:
It’s going to sound really bad when I tell you how many cases I see a day, it’s not enough, but I don’t have enough time to see all these cats. And so what are we going to do in the meantime? But I do think that the BNP in the cat, not so much the dog but in the cat, I think it’s appropriate to start screening cats, just like you do for hyperthyroidism.
Dr. Anna McManamey:
There’s enough cats that don’t have heart murmurs that have heart disease. And so wouldn’t it be nice if we could catch them earlier to just let the client know what’s going on with their pet, what they need to watch out for with their pet. Is there any medication their pet should be on before congestive heart failure or something happens? So I might make some people mad when I say that, but I do. I think it’s-
Dr. Andy Roark:
No, no.
Dr. Anna McManamey:
I think it’s a good enough test that it might be worth doing more often.
Dr. Andy Roark:
I mean, at what age do you start to think about screening for things like this? Right? Because it is a measurement of sort of the state of the heart.
Dr. Anna McManamey:
Yeah.
Dr. Andy Roark:
So it seems like screening kittens is probably not going to be super productive or really insightful for the future. But I mean, are you talking about five year old cats? Are you talking about eight year olds? Is this a senior wellness type of screen in your mind?
Dr. Anna McManamey:
Yeah.
Dr. Andy Roark:
I’m just curious kind of, when you look in your crystal ball, kind of where do you see that going or how do you use that tool in your toolbox?
Dr. Anna McManamey:
Yeah, first of all, highly recommend a crystal ball to every veterinarian because they do come in a very, very handy.
Dr. Andy Roark:
Well mine has been craptastic for the last three, four years. It’s just boy.
Dr. Anna McManamey:
God, I wish I had one of those. But, yeah, I think that’s a great question. So I would say if you look at HCM, hypertrophic cardiomyopathy as a model of heart disease, because it’s the most common heart disease we see in cats, it’s usually around five to eight years of age where that kind of takes its peak effect in cats. However, we see some cats as young as three. So I think five seems like a magic number for me.
Dr. Andy Roark:
Okay.
Dr. Anna McManamey:
I think maybe three is a little early, but you could catch some that are starting to show signs earlier, but I’d say it’s early as five, but I think kind of that eight years of age, when you’re starting to screen for hyperthyroidism, it’s probably appropriate to be doing the same for the heart.
Dr. Andy Roark:
All right guys, I want to jump in here with a couple quick updates. First of all, the uncharted veterinary conference was last week in a Greenville, South Carolina it was amazing. We will have a virtual conference in the back half of this year. It’ll be in October. It is our GSD for Get Stuff Done Shorthanded that’s right. Get Stuff Done Shorthanded is going to be a virtual conference, which means you can join it anywhere. It will be in October more details coming soon. Registration is not yet open, but go ahead and get fired up. This is a great way to see what Uncharted is all about. See is it really different from everything else like people say it is. Yeah, you can come and see just how that works online. And then if you love it, we’ll see you in person April next year in Greenville, South Carolina, or if you’re a practice owner, we’ll see you in person in December for our practice owner summit.
Dr. Andy Roark:
Gang, if you can’t wait that long and you know you can’t wait that long, we have a couple of workshops coming up. We have retained your team, speak the languages of appreciation in your workplace. That is with Dr. Tracy Sands. It is on May 21st. It is all about showing your team appreciation. You know they’re tired, you know they’re overwhelmed, you know that they want to feel appreciated for their work. Are you doing it right? Are you showing them appreciation? There are simple things that you can do that really make a difference. Guys, this is, as I said, May 21st, 2:00 PM Eastern, 11:00 AM Pacific time. It is $99 to the public. It is free for Uncharted members. Jump on a, get registered, come and be there. This one is actually already filling up. It’s a month away and the spots are largely taken. So jump in there and grab a spot while you can.
Dr. Andy Roark:
On June 8th, my friend, Bill Schroeder, founder and CEO of InTouch Veterinary Communications is doing his workshop, creating content that clients crave. This is all about making information in a way that clients will want to consume it. If you’re tired of trying to educate in the exam room, if you want some backup, if you want some help, if you’re like, I don’t have enough time to communicate everything, I need to communicate. Jump in on this webinar or it’s a workshop you’re actually going to work on the thing. That’s the difference in a workshop and a webinar. We do the thing and uncharted. June the 8th, 7:00 PM Eastern, 4:00 PM Pacific time. This is $99 to the public, free for Uncharted members. You can hit the link in the show notes and get registered for that as well. Guys, that’s enough for me. Let’s get back into this episode.
Dr. Andy Roark:
Talk to me a little bit about blood pressure in these cats. Is that going to be an insightful tool when I’ve got this sort of heart murmur? Yeah. I mean, is that something? It didn’t come immediately to hand, I guess when we talked about chest X-rays, when we talked about the BNP.
Dr. Anna McManamey:
Yeah.
Dr. Andy Roark:
Is there real value in trying to get this cat calmed down in a nice secluded place and try to get a good blood pressure and what can I gain from that?
Dr. Anna McManamey:
Yeah, that’s a great question. So I usually will reserve the blood pressure. I think it’s a very important test, but I usually will keep it for a little bit later in the lifespan of a cat. So it’s unlikely that the cat at this age at five years of age is going to have systemic hypertension. However-
Dr. Andy Roark:
Okay.
Dr. Anna McManamey:
… that’s a very cheap, very accessible test to do, because again, if your BNP is high, you’re kind of obligated to check a systemic blood pressure and to check a thyroid level. Again, even though it’s unlikely in a cat that young, if those two diseases are present, whether that’s systemic hypertension or hyperthyroidism, both of those conditions cause a thick left ventricle, would cause an elevated BNP. So definitely has its place again in that age range, I’d be less suspicious of it, but totally appropriate to do.
Dr. Andy Roark:
Okay. Let’s talk about management of heart disease in cats. And I think that’s something that probably compliance and adherence are often a bit of a challenge. It’s hard, especially if we have ongoing medications for these cats. How do you introduce the idea of long term medication to pet owners? What sort of pearls of advice do you have for setting pet owners for success?
Dr. Anna McManamey:
Yeah, it’s a great question. And I think with cats, it’s just a whole nother level of difficulty than compared to dogs.
Dr. Andy Roark:
Yeah.
Dr. Anna McManamey:
You’ll get the occasional cat that just eats everything you put in front of them, but that’s not always going to be the case. So the good news is that cats with heart disease, again, HCM being the most common, really the only medication that we routinely recommend in these guys before congestive heart failure happens is a blood thinner and Plavix clopidogrel, we do think is probably better than just Aspirin for preventing that thromboembolic event. That’s that big scary thing that we really want to be able to just let clients know their cat has a risk for it. I would say a lot of ATEs aortic thromboembolism that I see, unfortunately it’s the first time the owner ever knew their cat had disease.
Dr. Anna McManamey:
So that’s the one that we’re trying to protect them with. And so really the left atrium has to be big for them to be at that risk. In most cases, I’ll say less than less than 5% of cats that have ATEs have a normal left atrium size. So most of the time their left atrium’s big. If they have a high BNP if I would say probably at least over 200 BNP range, if we echo them and they have a big left atrium, blood thinner is what we’re prioritizing in terms of treatment.
Dr. Andy Roark:
Okay.
Dr. Anna McManamey:
It’s a once a day therapy, it’s a small pill. So those things are in our favor.
Dr. Andy Roark:
Yep.
Dr. Anna McManamey:
Once heart failure happens, congestive failure happens, then it’s really Furosemide and they’re Plavix plus or minus an ACE inhibitor. We don’t have that same evidence that it has to have that ACE inhibitor to have a better prognosis once congestive heart failure happens like we do in dogs. Does it make sense that they would do better? Yeah, it makes sense, but we don’t have that exact evidence. So if congestive heart failure happens and I have a cat that the client can’t medicate, well, I’m just going to prioritize what I need to give them. And that’s their Lasix, which is a small pill and that’s their Plavix or some type of blood thinner to try to reduce that risk of an ATE.
Dr. Anna McManamey:
I have cats that are on injectable drugs. They’re on injectable Lasix because the owner can’t medicate them. So it’s kind of like a diabetic cat in that stance. So we’re just giving injections of Lasix twice a day, instead of giving oral medications. And you can coat the meds in some butter, you can coat them in cottage cheese, those kinds of tricks. But unfortunately, at least not yet are transdermal medications. I think that would be a godsend if we could get some bioavailable, transdermal Plavix or transdermal Lasix, something like that for these kind of cats. Yeah.
Dr. Andy Roark:
Okay. I was going to say no success in that regard so far.
Dr. Anna McManamey:
Not yet. Not yet
Dr. Andy Roark:
So I’ve heard people mention Pimobendan and cats.
Dr. Anna McManamey:
Yeah.
Dr. Andy Roark:
Is that-
Dr. Anna McManamey:
That’s yeah.
Dr. Andy Roark:
That’s kind of one of those back alley hey.
Dr. Anna McManamey:
Yeah. I was listening to-
Dr. Andy Roark:
Animal vet, come here.
Dr. Anna McManamey:
… one of your podcasts with Dr. Journey and she was… It’s the religion debate. Right. So-
Dr. Andy Roark:
Yeah.
Dr. Anna McManamey:
Yeah. So I would say that for the asymptomatic cat. So the cat that’s not in congestive heart failure. There’s probably no cardiologist that’s going to recommend Pimobendan in those cats.
Dr. Andy Roark:
Okay.
Dr. Anna McManamey:
So different than dogs. If there is a cat with congestive heart failure, some cardiologists might start Pimobendan in those cats. The rule for me is if there is a murmur, don’t give the Pimobendan because Pimobendan worsens dynamic obstruction. So if you already have a heart murmur, odds are it’s dynamic obstruction, giving Pimobendan will worsen that obstruction. So that’s kind of my general rule. If there’s a murmur and heart failure in a cat, just don’t give Pimo just stick with your Lasix, your Plavix plus, or minus your ACE inhibitor.
Dr. Andy Roark:
That’s super useful. Thank you for walking through this with me. Are there any final pearls or words of wisdom or pitfalls I should look out for just in general dealing with heart disease in a cat?
Dr. Anna McManamey:
Yeah. I think something that you actually mentioned in part of the history was coughing in cats. Coughing in the cat, rarely is from heart disease. Rarely is from congestive heart failure. I’d say the only times they see cats coughing with congestive heart failure is if they have a significant amount of plural effusion or a significant amount of pericardial fusion, which are both presentations of left sided congestive heart failure in the cat. So the coughing cat with a murmur to me, I actually move heart failure way down on my list and prioritize other things.
Dr. Anna McManamey:
The other little tidbit I’ll leave you with is if you’re in the ER setting and you tap a cat’s chest, do a thoracentesis and you just want to know, is this heart failure or not? You can run that sample on a BNP test. So you don’t even have to use the blood.
Dr. Andy Roark:
Really?
Dr. Anna McManamey:
And there’s these BNP tests, the B-type natriuretic peptide tests that are snap tests that are available for the ER setting. It just tells you, is it normal? Is it abnormal? That’s of same day test. It’s snap it’s eight minutes, but you can run that on blood serum or the plural effusion and you actually get a pretty good result with that.
Dr. Andy Roark:
That is super useful. Awesome. Thank you. Thank you. Thanks for sharing. I’ll tell you real quick. I remember being a first year veterinarian and I had a cat that had a chest full of fluid and I was going to tap it and the owner was there and I was getting ready to do it. And he said, “How many of these have you done before?” I was like, “I wish you hadn’t asked me that.” And then I was like, “I’m going to be honest,” and I’m like, “none but I’ve read about them.” And he was like, “I!s there someone else who could do this? And I had to go get… And I did, I went. The most humbling experience but-
Dr. Anna McManamey:
Oh my gosh. That’s-
Dr. Andy Roark:
I guess-
Dr. Anna McManamey:
That still happens to me. They’re like, “How many have you done?” And the devil on my shoulder wants to say, “Whether it’s one or a hundred, I’m all you got so you might as well.”
Dr. Andy Roark:
Yeah. Yeah, exactly. Right. Yeah. And just for me, I worked in a big practice. There were literally a dozen other vets. And they were like, “Why don’t you get somebody else junior?”
Dr. Anna McManamey:
It’s humbling.
Dr. Andy Roark:
Whenever I start to tap a cats chest I think how many of these have I done? It’s like, oh, a dozen. Okay. But, oh man, that’s funny. But yeah. Well the other thing too, you, how many of you done, you did a rotating internship, you did an emergency critical care internship, and then you did a residency. There’s probably not a whole lot that you haven’t done once-
Dr. Anna McManamey:
At least once so yeah.
Dr. Andy Roark:
… already so. At least.
Dr. Anna McManamey:
But it is. It’s always a little humbling and you’re kind of, eh, how do I answer that?
Dr. Andy Roark:
I’ve been doing vet medicine for 13 years and I am humbled every day and then I go in there and go, ah, oh, well, I love it. Yeah, I think if it wasn’t that way, I think it might get boring.
Dr. Anna McManamey:
Yeah I agree.
Dr. Andy Roark:
And that medicine’s a lot of things.
Dr. Anna McManamey:
Never boring.
Dr. Andy Roark:
Borings not one of them. Thank you, my friend. Thanks for being here.
Dr. Anna McManamey:
My pleasure. Thank you.
Dr. Andy Roark:
And that’s our episode, guys. I hope you enjoyed it. I hope you got turned out of it. If you did, please feel free to go leave us an honest review, wherever you get your podcast. It really makes a difference to me. It’s how people find us. It’s the nicest thing that you can do and it only takes a moment. Gang, that’s all I got. Take care of yourselves. Be well. I’ll talk to you soon. Bye.
