Case Studies In Small Animal

Cardiovascular Medicine

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Pathology

Case 5

Recheck Examinations

10/14/98

bulletA telephone conversation with the owner revealed that Alice was doing very well (acting like a kitten). She is drinking a lot according to the owner but she urinates outside so she is unable to monitor this. Her Lasix dose was increased over the phone because of persistent tachypnea. She is now on 1.5 of the 12.5 mg Lasix tablets morning and night and 1 tablet in the middle of the day (50 mg per day) along with 7.5 mg diltiazem q8 hours and 1 mg enalapril once a day.

4/16/99

bulletAlice is still doing well! On a phone conversation her owner indicated that the doses of the medications haven't changed at all in the last 6 months and that Alice still feels like a kitten. At last report she was chasing her brother around the house! Hopefully we won't hear anything from her for another 6 months. The general impression is that cats with HCM are doing better since we started using an ACE inhibitor, such as enalapril, to treat them. Alice may be living proof.

1/15/00

bulletAlice's owner called today for a refill on her medications. We called her back and she is still doing well! We told her that we should recheck Alice in the near future to see if we can discover why she has done so well for so long.

3/29/01

Presenting Complaints

bulletRecheck HCM

Pertinent History

bullet6/98- Alice presented to the VMTH Emergency Service for dyspnea, and was diagnosed with hypertrophic cardiomyopathy and severe congestive heart failure. She was hospitalized and given intravenous Lasix. She was eventually sent home with diltiazem 7.5 mg PO TID, enalapril 1 mg PO q 24h, and Lasix 12.5 mg (1.5 tabs PO q 12h with 1 tab PO in the middle of the day).
bulletAlice has not returned to the Cardiology Service for a recheck in the past 2.5 years. She has been eupneic with no episodes of distress. She has been on the same medications at the same dosages for this entire time. The client reports that Alice has been doing well and appears to be an active healthy cat. Alice has not had any V/D/C/S but occasionally regurgitates after eating too quickly. The client reports that a litter box had to be placed inside the house this past winter since Alice would not bother to go outside to urinate. She no longer has this problem.

Physical Examination

bulletGeneral: BARH, BCS 5/9, P 192, R 52
bulletIntegument: Healthy coat
bulletEENT: Eyes- Clear anterior chamber, no discharge, mild episcleral injection. Ears- Clean. Nose- Moist, lacks discharge. Throat- Pink mucus membranes, no oral lesions.
bulletMS: No lameness.
bulletCV: IV/VI left apical systolic murmur. No gallop or arrhythmia present. Strong femoral pulses. CRT < 1 sec.
bulletResp: All lung fields clear.
bulletGI: No masses palpated.
bulletGU: Smooth kidneys.
bulletNS: No obvious deficits though not thoroughly examined.
bulletLN: WNL

Problems

bulletHypertrophic cardiomyopathy (historical secondary pulmonary edema)

Clinical Diagnoses

bulletSevere hypertrophic cardiomyopathy

Comments

bulletEcho: IVSd 6.9 mm, LVFWd 7.4 mm, LVIDd 16.3 mm, LVIDs 6.4 mm, Ao root diameter 9.3 mm, LA dimension 11.5 mm, FS 60 %. Severe progressive global left ventricular hypertrophy and severe papillary hypertrophy. Left ventricular myocardium is hyperechoic. Mild SAM seen on 2-D and color flow Doppler; maximal aortic blood flow velocity is 3 m/s with pressure gradient of 36 mmHg. Normal left atrial size. Conclusion: Severe hypertrophic cardiomyopathy with mild SAM. The left ventricular hypertrophy has progressed since 2.5 years ago, but most importantly the left atrial size is now normal. She is a unique and fortunate patient to have compensated for 2.5 years. The severe CHF may have been precipitated by an acute stressor event, and with treatment she has compensated. She is still at risk for recurrent CHF, but at this time probably does not need to be on such high diuretic doses. We have recommended a slow decrease in dose of Lasix to 12.5 mg PO BID over 2 weeks. We also recommend continuing the diltiazem 30 mg, 1/4 tab PO TID and enalapril 1.25 mg PO SID (although often we are prescribing enalapril BID now).
bulletRecheck echocardiogram in a year or earlier if she has breathing difficulties.

4/25/01; 5/10/01; 7/03/01; 8/08/01; 10/16/01; 01/10/02

bulletMedication refills are recorded for each of the above dates.
bulletThree and one-half years and counting!!

2/07/02

bulletAlice's owner called this morning to let us know that Alice died. She didn't see her last night and this morning when she didn't show up for her food she went looking and found her lying on the porch, as if she was sunning herself there. Apparently she died suddenly in her sleep. It was something that wasn't totally unexpected but the news still shocked all of us to hear it. The owners offered to have a cosmetic necropsy performed. This was done and Alice's body was returned to her owners, who buried her in their back yard.

Mark D. Kittleson, D.V.M., Ph.D. All rights reserved.