Question: Hello Dr. Richards,
I have a poodle mix, Bonni, that is 11 years old. She is my baby and I am very concerned about her. I adopted her (at 6-8 months) from the Humane Society in Texas, she had been abused and was aggressive towards men, but they were doing their best to find a suitable home for her. As a puppy she was diagnosed with a mild heart murmur and her only other problem until recently was skin allergies. Noticing that she hasn't been feeling good lately (she had been really chewing on the same spot on her right hip and been hobbling a bit), I took her to my vet for a geriatric exam, where the vet did a series of tests. The blood tests revealed that all of her levels were within acceptable standards except for the LDH or LHD (?), the vet explained it as a "feel good" level. The norm, I believe, was 300 - 800, and she was at 1200. Her x-ray also showed mild enlargement of her heart, and he noticed that she was favoring her front legs. This led to a diagnosis of enlargement of the heart and osteoarthritis of the hip. The vet placed her on Rimadyl and Enacard, in addition to the Benedryl I give her occasionally for itchy skin. Here are my questions:
Is it safe to mix these medications?
Is there anything I can do without medication to help her feel better?
Can you estimate her life expectancy with these health problems?
Would you recommend a different course of treatment?
I think my vet is great, but am just interested in another opinion. Thanks for your service. Leslie
I do not know of any reason not to use carprofen (Rimadyl Rx), diphenhydramine (Bendryl Rx) and enalapril (Enacard Rx) together.
Weight control is the best non-medical treatment for both arthritis and heart disease. If Bonni is overweight, even a little, weight control would benefit her. We recommend trying glucosamine and chondroitin to see if they are helpful. These are available over the counter at most pharmacies and health food stores.
We have lots of small poodles in our practice with heart murmurs that do not cause problems for years or even never cause problems, in some cases. I usually wait until there are clinical signs prior to using enalapril but many vets think it helps to use this as soon as a murmur is audible. If and when the heart disease gets worse there are other medications that may be helpful. Trying to keep extra salt out of the diet is helpful and I think that moderate exercise is beneficial, especially early in heart disease.
All the things that help with arthritis such as massage, heat therapy, comfortable beds and adequate rest probably help dogs, too. Dogs don't always like this kind of attention but you might find some aspect of this sort of nursing care that helps a lot.
Mike Richards, DVM 3/21/2001
Question: Hello Dr. Richards: Once more, I find it a great resource to have this internet service from you. The reason I'm writing concerns an 8 week old OES puppy that the vet feels may have a heart murmur and has suggested a number of possible options including submitting the pup to an EKG, all of which represent substantial costs, in order to ascertain the seriousness and type of the cause producing the murmur. As some murmurs can be rectified through early surgery the breed owner of this pup is feeling pressured to act on their suggestions immediately. My involvement in this case is as the owner of the litter's stud dog and mentor to the breeder involved, having been a successful and internationally recognized breeder of OES myself for 25 years. In that time we have experienced the occasional puppy who at two months has indicated having a heart murmur but, in each case this has resolved itself on its own as the pup matures and leaving no side effects as a result. From my discussions with other breeders on this subject some have also produced pups with murmurs that do not rectify on their own yet, for the most part it seems that though the murmurs persist through the life of these dog, generally it is without any dicernable ill effects to their outward health nor do they seem short changed by it either in their growth or life span. Could you provide me with some current information relevant to heart murmurs in young pups and recommended avenues of suggested treatment or non treatment?
Thank you. Toni
When it is possible, economically, for the owner of a puppy with a heart murmur to have a cardiac ultrasound exam done, I think that is the best course of action. It is unquestionable that many murmurs that are present congenitally will never cause any problem during a dog's lifetime. However, it is also definitely true that some do. Ultrasound exam is the best way to evaluate heart murmurs because it gives a good idea of how much of the blood flow in the heart is being misdirected and also identifies readily where the defect is that is allowing the blood flow to produce a murmur.
When it isn't possible for a pet owner to comfortably pay for cardiac ultrasound exam, we do our best to evaluate the overall situation and advise the owner based on clinical signs present. If a puppy is gaining weight normally, is active and doesn't tire readily, has a normal red blood cell count adjusted for his or her age and isn't showing any other signs of heart disease, we advise just waiting to see what happens. If there are definite clinical signs of heart disease, in addition to the murmur, we push much more strongly for advanced testing.
Since cardiac ultrasound exam is by far the most effective method of evaluating heart murmurs, I'd skip things like ECGs to get the ultrasound exam, if a choice has to be made between tests.
Hope this helps some.
Mike Richards, DVM 2/10/2000
Q: Hi Dr. Richards I was wondering if there are any unusual concerns when planning to have my JR terriers teeth cleaned by my vet. She is 9 years old and has a grade III heart murmer that we monitor on a regular basis. Would this procedure be safe to perform? Thanks for your great service, Maureen
I know of no special anesthetic requirements pertaining to Jack Russells. We are comfortable anesthetizing dogs with heart murmurs if clinical signs are stable but you might consider preanesthetic labwork, possibly including an ECG, if you wish to be cautious. We anesthetize most of our dental patients by mask induction with isoflurane after sedation and we have had no major problems with this combination. (sometimes we do have minor problems like dogs or cats getting excited during induction and requiring a different anesthetic approach). Dental work does not require great anesthetic depth which makes the anesthesia less of a risk.
Hope this helps.
Mike Richards, DVM 3/21/99
Q: Dr. Richards I have been reading your posted info on heart murmurs in dogs, but I didn't see the answer to my particular question. My female terrier is 8 years old and has developed a murmur that my vet wants to investigate. Can you tell me what the order of tests would be to check this condition? Is blood work necessary? Are chest films necessary? I can understand ultrasound, but don't see the necessity of the other tests. Since ultrasonography is not really inexpensive, could enough information be collected via this one test?
I will follow the advice of my vet on treatment of this condition as the quality of my pets life is foremost in importance, but I want to spend my money wisely so that I can afford the follow-up management.
Thanks for your help. Maureen
I would be content in most cases with an ultrasound exam alone. It is the most useful test for determining the cause of a murmur and the significance of the murmur. While I am not an expert on ultrasonagraphy it does seem like it requires some expertise in positioning the patient and the probes to obtain a standardized image that can be used to accurately assess the heart's condition. We try to refer to veterinary cardiologists on the theory that most of them, or at least their technicians, have more experience in getting the technical aspects of the imaging done properly. Plus the cardiologist interprets the results more often than most vets, too. Most cardiologists seem to like to run an electrocardiogram and to have X-rays taken too, though.
I have many clients who would have to be careful making a choice between diagnostic techniques when determining what to do for a pet with a heart murmur. There are basically three choices, electrocardiograms (ECG), radiographs (X-rays) and ultrasound. Many veterinary practices have the capability of doing ECGs and X-rays and fewer have the capability of doing ultrasound exams.
I have an ECG machine. I almost never use it. While there would be a lot of argument from many vets I think that ECGs do not offer enough information in the case of a murmur to make it a justifiable expense when the cost of diagnostic testing is a factor. If a dog has an arrhythmia an ECG is much more useful but most dogs with heart murmurs do not have concurrent arrhytmias.
X-rays are more useful in helping to determine how serious the effects of the murmur are than in assessing the type of murmur. In many cases a veterinarian has a pretty good idea of what type of murmur is present based on the type of sound it makes and the location of the sound when listening to the heart. This is particularly true of murmurs that occur in aging dogs since most of them are valve failures. Often, using X-rays to determine when the heart is enlarging and when fluid accumulation in the lungs (pulmonary edema) is beginning to occur is sufficient to make treatment decisions in dogs. It is not as accurate as ultrasound examination in many ways but it is accurate enough to allow successful management of the heart problems associated with murmurs in many dogs.
Ultrasound exam allows visualization of the heart valves, which allows accurate confirmation that the valve is the problem. The amount of reflux blood flow through the valve is measurable with some forms of ultrasonagraphy. This is useful information and worth having if the cost of testing is not prohibitive for a pet owner. Ultrasound exam can help to rule out causes of heart murmurs in which the damage to the valves is occurring due to a cause such as cancer or bacterial infection of the heart lining that would not show up using X-rays or ECG alone. Cardiomyopathy is usually identifiable on ultrasound exam as well and this is an important "rule-out" in many cases of heart failure. This is especially true in cats.
If you have to choose between tests, I think the ultrasound exam is the most useful in the case of a heart murmur. It's major problem is that it is not available without referral in many cases. Therefore, it may not be the best test to keep repeating to manage the case. Your vet can take X-rays and can do follow-up comparison X-rays. Once a diagnosis is firmly established, it may be necessary to use X-rays to for long term management of the problems associated with heart murmurs since it is more convenient, unless your vet does the ultrasound exams or has a specialist who comes to the practice. Personally, unless an arrhythmia is present, I don't see much use in an ECG.
I think that your plan to follow your vet's advice is best. Different vets need different levels of information in order to comfortably manage a case. While I might be content with auscultation and X-rays, your vet may really need the ECG results and ultrasound exam in order to feel comfortable in making decisions about managing the heart problems in your dog. If this is the case it is best to allow those tests, if possible.
Mike Richards, DVM
Q: I have a 4 month old female pup with a significant heart murmur. She has no signs of heart failure and seems normal in every other way. I want to have her spayed but am nervous about the risks associated with the anesthesia. Is this something to be concerned about? Do we have other options? Thanks for your help.
Answer: The best approach to assessing the risk of anesthesia would be to have your puppy examined by a cardiologist or internal medicine specialist who can do an ultrasound exam of the heart. Knowing what is causing the murmur and how much change there is in cardiovascular function due to the murmur would be very helpful. Some murmurs are quiet loud but still very benign. Other murmurs are barely audible but pose a significant risk when anesthesia is anticipated. If this is not possible a careful assessment of the sounds, combined with a knowledge of the likelihood of a various causes by breed may make it possible for your vet to at least give you a rough idea of the potential risk. This won't be as accurate as can be achieved but in some cases it is all that is possible for an owner.
I do not know of a really good alternative to spaying a female dog. There are contraceptive compounds for dogs but the overall risk of uterine infection and mammary cancers is so high in unspayed females that I have a very hard time recommending this approach. I am nearly certain that the long term health risks outweigh the risk of anesthesia by a long shot in most female dogs. While the difference may be smaller in your dog who has a murmur I still tend to think it is safer to spay her unless your vet believes that this murmur is from a patent ductus arteriosis or from another significant congenital heart defect.
Please consider asking for referral to a cardiologist. Your dog is young and has the potential for a long lifespan in which to live with this problem. Identifying the cause may make decision making much easier throughout her lifetime.
Mike Richards, DVM
Q: I have just acquired a 8 to 10 week old puppy. She is the runt of the litter and has a significant heart murmur. You can actually feel the murmur when you hold her. She seems healthy, happy and hungry. My vet has checked her and told me to come back in a week. He said that sometimes these murmurs disappear as the pup grows older. My questions are what happens if the murmur does not go away? What can I expect? Surgery? Drugs? Death? Thanks for your help. Anita.
A: Anita- Heart murmurs occur for a variety of reasons. The loudness of the murmur does not always correlate well with its seriousness. A small defect in the wall between the heart chambers may produce a very loud murmur that will not be much of a problem. On the other hand, murmur from a patent ductus arteriosus are loud in many cases and they are serious. If the murmur persists your vet will probably either recommend a work-up of the murmur at his or her hospital if possible or refer you to a cardiologist if that is necessary. It would be best to go to the cardiologist if your vet remains worried about this murmur or if your puppy is not growing normally and playing like a normal puppy. Hopefully she is OK. In that case it may be OK to adopt a "wait and see" attitude -- but it still wouldn't hurt to see a veterinary cardiologist if there is one in your area.
Mike Richards, DVM
Q: Dear Doctor Richards, I have a five year old Border Collie, (Goldie) she just had her yearly examination and passed with flying colors except the doctor mentioned she has a slight heart murmur. He wants to see her in six months. Could this conditioned be caused by drinking coffee which my dog does, or could it be caused from her vitamins or some outside source, ie allergies. I don't know. What I should do. Thank you for this forum ,Matthew
A: Matthew-I don't think that drinking coffee will lead to heart murmurs in dogs, nor will use of vitamins or allergies, to the best of my knowledge. If your dog seems normal in all other aspects and is negative on a heartworm exam it seems reasonable to me to wait and see what happens. Many murmurs do not cause problems.
Mike Richards, DVM
Q: We have a 2 year old male American cocker spaniel. Recently, during his yearly examination, the vet mentioned he may have a heart murmur. She suggested that we return in a month to confirm this prognosis, because at the time he was very excited. Is this a common problem in spaniels his age? Is this a problem that must be attended to, or can he live with this problem? What are some of the potential treatments? Thank you for your consideration of our questions.
A: Stephen- It can be very hard to determine if a heart murmur is present when listening to the chest of an excited dog. Respiratory sounds can mimic a heart murmur when respiration is rapid enough to approximate the heartrate. Your vet has given you good advice in that a re-exam to see if there really is a problem is the correct first step.
Heart murmurs vary widely in their importance. Hearing a heart murmur in a dog that seems normal in all other respects doesn't usually make me want to pursue a lot of immediate testing to determine the cause but it does make it important for the dog owner to watch carefully for signs of heart failure, such as tiring easily, coughing, weight loss and difficulty breathing. If any of these signs are present then it is much more important to try to identify the cause. Cockers are one of the breeds in which cardiomyopathy occurs more commonly than the "average" breed. Since this is a serious problem it may be worth being a little more cautious and checking for this problem with an ultrasound exam if that is possible to arrange in your area.
Hope all is well. The first step, before worrying too much, is to be sure that a problem really exists.
Mike Richards, DVM
Q: I would greatly appreciate any information you can provide: I recently acquired a shah tzu pup, born 1-29-97, so he about 5 months now. Upon our 2nd vet visit together, it was found that he lost his bottom front baby teeth but no adults were coming up and we touched the gums and couldn't feel any, but is also didn't hurt him so most likely they weren't impounded. He does have a undershot jaw, what do you think is going on here? How will it affect him if his adult teeth don't come...do you think he could be a "late bloomer" and that's why. FYI:The breeder told me he was the smallest in the litter. The vet also found a heart murmur and told me not to get him neutered unless I went to cardiologist for dogs. I can't afford this currently, any advice? He said that its odd b/c usually pups get them young & then they go away as they mature, but in this case it wasn't noted on the 1st visit so it may be a newly acquired murmur. He also said that the pup should weigh 9lbs and he weighs around 8. I feed him Eukanuba small breed puppy hard pellets, any change in diet based on this new info? I'll take ANY advice or suggestions you can offer me and my new friend, Casper. THANK YOU SO MUCH! Amy
Q: Amy- It is usually possible to tell if the permanent teeth are present, even if they haven't erupted, using X-rays. It is acceptable just to wait and see if they come in if paying for X-rays is difficult for you right now. I have two or three patients who are missing some (and one who is missing most) of the permanent teeth because they just didn't come it. This has not caused them much problem.
I am more willing than your vet to operate on dogs (even puppies) with heart murmurs as long as I feel that their physical condition is satisfactory overall. If there are signs of problems related to the heart murmur, such as stunted growth, coughing, breathing difficulties, tiring easily, etc. then I am less willing to do so. Your vet may be seeing one or more of these signs and that may be the cause for the reluctance to consider surgery. Neutering is optional so it is reasonable to be cautious. A cardiologist is the best person to evaluate the importance of the murmur and when it is possible to make a visit to the cardiologist it would be a good idea.
I can't think of a reason to make dietary changes. Please don't take any advice about Casper without thinking about whether it makes sense --- even from a generally reliable source like me!Mike Richards, DVM
Michael Richards, D.V.M. co-owns a small animal general veterinary practice in rural tidewater Virginia. Dr. Richards graduated from Iowa State University's College of Veterinary Medicine in 1979, and has been in private practice ever since. Dr. Richards has been the director of the PetCare Forum...