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Ask Dr. Michael Salkin Your Own Question

Dr. Michael Salkin
Dr. Michael Salkin, Veterinarian
Category: Dog Veterinary
Satisfied Customers: 12711
Experience:  University of California at Davis graduate veterinarian with 42 years of experience
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My dog is 14 and was diagnosed with a heart murmur (grade 3)

Customer Question

My dog is 14 and was diagnosed with a heart murmur (grade 3) 5-7 years ago. He began coughing a few days ago and we took him to a new vet (our regular vet passed away last week) and they diagnosed him with upper respiratory infection and graded his murmur a 4. He was placed on a steroid BID and cephalexin. He did well Saturday and barely coughed at all, bu yesterday he began coughing again and his respiratory rate and heart rate have increased. HR is 148 right now and resp rate is 52. I do not hear any crackles in his lungs but he is becoming less active and I am concerned.
Submitted: 1 year ago.
Category: Dog Veterinary
Expert:  Dr. Michael Salkin replied 1 year ago.
Aloha! You're speaking to Dr. Michael Salkin
I would be concerned as well. The standard of care is to X-ray a coughing 14 year old dog who has such a severe murmur. I can't imagine prescribing a steroid with the significant risk of a decompensating heart much less in the presence of infection - if infection is truly present.

Steroids will cause fluid retention and could precipitate congestive heart failure. In addition, steroids will immunosuppress - making it more difficult to fight off an infection. His respiratory rate exceeds 30/minute which is worrisome. His heart rate is likely elevated although a small dog might have a normal rate in that range.

I recommend that Toby be rechecked as soon as possible. Chest films are a must and perhaps having him seen by another vet would be appropriate. I admit that our dogs can have a heart condition and respiratory infection concomitantly but it's imperative that we rule out a decompensating heart first.

Please respond with further questions or concerns if you wish.
Customer: replied 1 year ago.

They did an xray and it did not show fluid, just slight cloudiness throughout the lungs fields bilat. His heart is slightly enlarged as well, displacing the trachea slightly, but they felt it was not heart failure at that time. I guess my question is can he be seen in the morning (it is 4:30 am here). We had our vet for 30 years and it is hard to trust someone else, do you think they misdiagnosed him and are not treating properly? Our vets funeral is tomorrow (he was a good friend) but I am concerned for time. How long can he maintain this HR and respirations?

Expert:  Dr. Michael Salkin replied 1 year ago.
Thank you. I would need to see that X-ray to know better what the slight cloudiness indicates. If not incipient heart failure, then pneumonia should be considered when the respiratory rate is so high at rest. If his heart is enlarged enough to displace his trachea, however, then his left atrium is enlarged enough for us to make the call of heart failure. I admit that it can be difficult at times to distinguish respiratory from cardiac disease but perhaps another set of eyes on Toby and his films is indicated. In addition, a blood test called the cardiac troponin 1 (cTn1) can be helpful in clarifying if cardiac disease is significant at this time and I suggest that it be run.

To answer your question directly, his respiratory rate at rest is significantly elevated; his heart rate isn't dangerously elevated at this time but that can change quite rapidly. It may not sound very technical to you but by the principle of Occam's Razor we should consider a coughing 14 year old with an enlarged heart and grade 4 murmur to be symptomatic due to a decompensating heart rather than a respiratory infection. Believe me, I'd rather be wrong but better safe than sorry. I understand the logistical dilemma vis a vis Toby and the funeral. Perhaps Toby can be dropped off at the vet and picked up later? Having him seen at an ER isn't unreasonable either although you're only a few hours from opening time at a regular vet hospital.

It's quite late here now (midnight) and I have to leave my computer but I'm going to check back with you soon for an update. Feel free to return to our conversation - even after rating - prior to my contacting you if you wish.
Customer: replied 1 year ago.

Thank you, XXXXX XXXXX me make an informed decision. Have a wonderful day on The Big Island.

Expert:  Dr. Michael Salkin replied 1 year ago.
You're quite welcome. I'll speak to you soon.
Dr. Michael Salkin, Veterinarian
Category: Dog Veterinary
Satisfied Customers: 12711
Experience: University of California at Davis graduate veterinarian with 42 years of experience
Dr. Michael Salkin and 6 other Dog Veterinary Specialists are ready to help you
Expert:  Dr. Michael Salkin replied 1 year ago.
Thank you for your kind accept. I appreciate it. Do you have an update for me?
Customer: replied 1 year ago.

I took him to the emergency vet at 5:00 am. By the time I got there his respirations had improved some and his HR was down a little. They felt like I could wait until the next day but he did say Toby had a large mass in his abdomen.


 


After the funeral on Monday I took him back to the same vet hospital (different vet) because I had already spent so much money on labs/x-rays. She said she did not feel a mass and I agreed to another x-ray to be sure. The x-ray came back normal except he had a slightly enlarged liver and spleen. She determined he had a "twisted spleen" which "fixed itself" and would have caused all of the symptoms. She said this could have felt like a mass.


 


They are trying to get me to agree to a cardiac ultrasound, which I think is silly. He is an older dog, we know he has a murmur that is progressing, so I asked if they could start him on heart meds when it is time without an ultrasound. She started him on enalapril and lasix. I have had him on the new meds for a few days and he does not do well during the day after he has had the meds (faster HR and lethargic) but by the next morning when it is time for his next dose he is active and happy. I held the lasix today to see how he did, and when I picked him up he was very active, alert, and exited to see me, basically back to his normal self. I am not sure if it was because I held the lasix or because he is just getting better.


 


I do not agree with the vet clinic I have taken him to so I am taking Toby to a new clinic next Tuesday. If our vet was still alive we would have answers by now, even if it was not what I wanted to hear, but I feel like we do not have any answers, and they only want me to spend endless amounts of money.


 


To answer your question directly, Toby is much better but something was wrong and he still has a cough at times. I want to make sure the meds he has been placed on are appropriate for his condition and necessary at this time. I also would like another vet to review his records and symptoms. I would like to have Toby a few more years, but if that is not possible, I want to make sure I am not adding to the problem.


 


Hope this answer is not too long, I am frustrated. We lost a good friend and a Veterinarian who loved animals and someone we trusted care for our 4 legged family members. It seems like the people we have to go to now only care about money and not the animals they are treating.

Expert:  Dr. Michael Salkin replied 1 year ago.
Thank for the thorough update. I appreciate it. Of course, I'm puzzled as you are. We've gone from a palpable mass in his abdomen to enlarged liver and spleen to a splenic torsion which "fixed itself".

He's now taking a diuretic and a calcium channel blocker both of which can be quite successful in treating a valvular insufficiency that may have caused incipient congestive heart failure (the cloudy films). If his coughing exacerbates, reach for the Lasix. It can't hurt and can be life-saving.

Most important, please have him checked by the new vet. Pick up his previous X-rays and records so the new vet can review them. Is the liver and spleen enlarged secondary to lymphoma and the lymphoma is also in his chest? Is there really a mass in his abdomen not associated with the liver or spleen? If so, did it metastasize to his lungs? Is his coughing unrelated to changes in his abdomen - a primary cardiac disorder?

These are the questions you'd like answered and I'd like to hear from you after Toby's visit on Tuesday.
Customer: replied 1 year ago.

Hi Dr. Salkin,


 


Toby is doing so much better and we had a great visit to the new vet. today. They reviewed his x-rays, meds, and symptoms. They determined his cough was caused by his enlarged heart irritating his esophagus/trachea. They kept him on the enalapril, lasix, and pepcid and started thyroid meds because his thyroid was low (he has a hx of hypothyroidism).


 


Toby is so much better he is like a new animal (I mean human, he does not know he is a dog). I am so glad we have someone we can trust with Toby now. The new Dr. is a lot like our other vet. He explains everything and is very thorough, he does not try to sell unnecessary tests.


 


He thinks the enlarged liver and spleen is secondary to heart failure and he is not concerned at this time.


 


Thank you so much for your help. I appreciate your concern and your knowledge on the subject even though you have ever seen the patient. You helped me through a very tough time with a sick dog, and losing our good friend and the only vet we had ever known/used. Thanks again.

Expert:  Dr. Michael Salkin replied 1 year ago.
Thank you for such a good update! I appreciate it.

Please disregard the info request.
Customer: replied 1 year ago.

Hi, I am back. I think Toby is dying. We took him to a specialist yesterday and she said Toby had a pericardial effusion and she increased his lasix dose from 6.25 mg daily to 25 mg twice a day. He was doing better yesterday before we started the new lasix dose but today he can barely walk and he is not eating. He began fainting about 2 weeks ago and is has gotten more frequent. When this happens his gums turn pale or purple, he moans, and he is incontinent. Today he can barely stand without collapsing. Te Dr.'s have not been good at follow up, I feel like they just throw new meds at him without checking to see how they are working. He has not had labs checked since I talked to you last. If we have done all we can do for him I wish they would tell me that, but they act like this treatment should be working and it is not. He is currently taking enalapril, vetmedin, lasix, pepcid, and thyroid. He seems comfortable, he is not restless or in distress, but he is weak and not eating. His heart rate is still between 150 and 170 at rest. Do you have any recommendations? I do not want to extend his life unnecessarily but would like to know if we are doing everything we can to improve his quality of life. If something is not done I do not think he will live much longer. Do you think he is in pain?


 


Thank you so much for you help.


Natalie

Expert:  Dr. Michael Salkin replied 1 year ago.

I'm sorry to hear of this, Natalie. Without knowing what's causing the pericardial effusion, I can't know if you're already doing everything you can. We have to differentiate effusion due to neoplasia (hemangiosarcoma, heart base tumors), idiopathic (unknown cause), and congestive heart failure. Whatever the cause, Toby's repeated syncopal (fainting) episodes are life-threatening. It's likely that he needs removal of the pericardial effusion by aspiration (pericardiocentesis).

While removal would undoubtedly improve Toby's quality of life, if there's an underlying tumor causing the effusion I can't in good faith subject Toby to the repeated pericardiocentesis necessary. Did the specialist conjecture what the cause of his effusion was; was anything seen on ultrasound other than the fluid surrounding his heart?

Customer: replied 1 year ago.

No, nothing else was seen. They think it is CHF but the x-rays do not show fluid on his lungs. His bronchioles were "dilated" so they think he may have some underlying lung disease as well. Do dogs his age (14) do well with pericardiocentesis? I am not sure he will be here many more days and I cannot get anyone to take me seriously. They just keep saying watch him.


 


Can he get too much lasix? His episodes have worsened today after he is receiving the higher dose of lasix. Is that coincidence? He was just having 1 or less syncopal episodes per day but now he cannot stand, he seems very dizzy. We have to carry him outside and help him stand to go to the bathroom.

Expert:  Dr. Michael Salkin replied 1 year ago.
I suspect that he suffers right-sided congestive heart failure which may not cause pulmonary edema but, instead, fluid buildup in the abdominal and/or thoracic cavities. He undoubtedly suffers from cardiac tamponade - a life-threatening situation in which there is such a large amount of fluid (usually blood) inside the pericardial sac around the heart that it interferes with the performance of the heart. If cardiac tamponade is left untreated, the result is dangerously low blood pressure and death. The excess fluid in the pericardial sac acts to compress and constrict the heart. Cardiac tamponade can be due to excessive pericardial fluid, a wound to the heart, or rupture of the heart.

Just sedating him to have pericardiocentesis performed would be very risky but I feel that you're going to lose him soon if the fluid isn't removed. It's a Hobson's choice at this time.

The higher dose of Lasix is likely to be dehydrating him which lowers his blood pressure even futher. You're going to need to return to his previous dose. The higher dose isn't removing the fluid around his heart but, instead, promoting more hypotension.

I wish I had some magic for Toby.
Customer: replied 1 year ago.

I did forget to say he has mitral and tricuspid regurg. I will try to talk to his vet tomorrow to see if he will consider the procedure. If he makes it through the procedure, what kind of life will he have. Is the treatment for tamponade the pericardiocentesis?


 


If we were to leave him untreated is this a painful way to die?

Expert:  Dr. Michael Salkin replied 1 year ago.
Thank you. I suspected so. The pericardiocentesis is the treatment and could be life-saving. My concern, however, is that repeated procedures might be necessary. In some dogs we have to surgically remove the pericardium so fluid can't return - not a surgery I could recommend at his age.

I suspect that a heart trying to expand against constricting fluid would be painful. His death, however, would likely result while he had fainted.
Dr. Michael Salkin, Veterinarian
Category: Dog Veterinary
Satisfied Customers: 12711
Experience: University of California at Davis graduate veterinarian with 42 years of experience
Dr. Michael Salkin and 6 other Dog Veterinary Specialists are ready to help you
Expert:  Dr. Michael Salkin replied 1 year ago.
Thank you for your kind accept. I appreciate it. I'll speak to you soon.

I'm going to check back with you in a few days for an update. Feel free to return to our conversation - even after rating - prior to my contacting you if you wish.

Please disregard the info request.
Customer: replied 1 year ago.

I took Toby back to his specilaist today and she said she would not do a pericardiocentesis because the effusion is not large enough. She noticed his abdomen has been swelling, as did we, so she did an ultrasound to check for ascites. She found a liver mass measuring 4.5 X 6.2 cm. She thinks some of his symptoms could be caused by pan so she gave him ultram. He has improved some today but he did not receive his arsenal of meds last night. She wants us to continue to give him the high dose of lasix because she thinks we can remove get him out of heart failure and possibley operate on the tumor next week.


 


I do not know what to do. Are his symptoms improved today because he did not have the meds, or because he had the ultram? I do not want to have another day like yesterday where he could not stand up because he was so dizzy and week. She did say she could have caused his pressure to drop so she changed his enalapril to 1/2 tab BID but still wants us to give the lasix 25 mg twice a day. I do not think he will tolerate that.


 


Does he need to be on enalapril and vetmedin since they are similar in action?


 


His sodium and potassium were normal today but his BUN was elevated at 59 with normal creatinine.


 


If, by some miracle, he were to come out of heart failure, should we even consider this type of surgery at his age? What if it has metastasized? I am not ready for Tobee to leave us but I do not want to keep him here for our selfish purposes. He walks around with his tail down all the time now. I feel so helpless.

Expert:  Dr. Michael Salkin replied 1 year ago.
I'm pleased to hear that about the pericardial fluid but not the liver mass. The narcotic Ultram shouldn't address dizziness and difficulty standing. It does sound reasonable that the enalapril caused the hypotension so I'm glad it was reduced.

Enalapril and Vetmedin work in very different manners and should both be continued.

Considering his age and pre-existing heart condition (which isn't compensated at this time) I couldn't in good faith recommend surgery. In addition, half of splenic masses are the highly malignant hemangiosarcomas. Pragmatically speaking, how much would surgery extend such a patient's life span?
Customer: replied 1 year ago.

If we did not treat the mass how long will he live? Should we consider euthanizing him soon?

Expert:  Dr. Michael Salkin replied 1 year ago.
Most dogs will be lost to hemangiosarcomas of the spleen within 3-6 months. However, if we can't get Toby's CHF compensated soon, that splenic mass will be moot. If Toby's quality of life is poor in spite of all his heart meds it's time to consider euthanasia. My patient's quality of life is more important to me than extending an uncomfortable life for my sake.

Let me know if that sounds reasonable to you, please.
Customer: replied 1 year ago.

That is reasonable, my husband and I feel the same way, but we struggle with making the choice to kill him. He is our family and we would never put a family member down.


 


Toby does everything with us, if we go somewhere in the car he goes, too. He has comforted me through three of my husbands deployments, he sits at my daughters door every morning and will not get in the car until I have gotten her, he goes on every vacation with us. We feel like we are saying none of that mattered and we are just going to get rid of you in your time of need.


 


We do not want him to suffer, but how can we take his life?

Expert:  Dr. Michael Salkin replied 1 year ago.
We all struggle with that decision. I think of euthanasia as performing the final kindness. There are times when we "pull the plug" on our family members. We might not call it euthanasia (or killing) but I don't feel that semantics should trump kindness.

Let's see if the new dosing regimen of the enalapril and Lasix is effective. Continue the Vetmedin. I'm going to check back with you in a few days for an update. Feel free to return to our conversation - even after rating - prior to my contacting you if you wish.
Dr. Michael Salkin, Veterinarian
Category: Dog Veterinary
Satisfied Customers: 12711
Experience: University of California at Davis graduate veterinarian with 42 years of experience
Dr. Michael Salkin and 6 other Dog Veterinary Specialists are ready to help you
Expert:  Dr. Michael Salkin replied 1 year ago.
Thank you once again. I'll speak to you soon.

Please disregard the info request.
Customer: replied 1 year ago.

Toby died tonight. Thank you for all your help.

Expert:  Dr. Michael Salkin replied 1 year ago.
Oh dear. My condolences for your loss of Toby. Thank you for letting me know.

Toby was lucky to have you.

You may receive an inappropriate follow-up from the site ostensibly sent by me. It wasn't and I apologize in advance should you receive it.

Please disregard the info request.

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