So the, the, the, the subject of our little workshop is heart murmurs in cats, and I know that they cause always a lot of, a lot of worries and a lot of problems. I'm not a cardiologist. I have particular interest in feline medicine, and I'm using anything to do with cardiology just to help the cats which I'm treating rather than just working on hearts themselves.

So I've got the pleasure to actually work along Malcolm and whenever I've got trouble with anything, I'll, I'll, I can just ask him, which is brilliant, OK? So, I'm really, really glad that he did our little talk about, about cardiology on shoestring because that mentioned loads of issues which we're going to be discussing. So, What I would like you to do, if you go to your rooms and then you look at the little task list.

I added a task list to the, to the Dropbox, information. You've got 3 little cases and just imagine yourself being in a consulting room and seeing these 3 cats. They're all healthy, as far as you know.

There was no problems reported. Everything is absolutely fine. You're examining them.

I give you a little tiny bit of information. I didn't want to overload you with information. Just because I want to point out towards certain things that we normally would be looking at and how, how to use, things in our history and what we hear as a clue.

Now, I do apologise because it's very difficult to record or lift the recordings of the heart sounds, especially cat heart sounds. So they might be a little bit confusing. And probably I should just mention that it's again, very unfair, especially with case two, that you might not realise not having a live cat to listen in front of you, that this cat is purring.

OK. So there was a little bit of a confusion with sounds because it sounded quite, quite dramatic, but this little guy is just very chilled, and he's sparing. So, What then we're going to do, we're going to close the close the rooms, and we're going to come back and we're going to go through the cases a little tiny bit, asking slightly different questions, and I'm going to just mention a few tips, a few things which, which I've learned along working along loads of very, very, very, very amazing people and hopefully they're going to be useful.

At any stage, if you have any questions, just, just please speak up or, or send a message via chat. and I think we can begin. Does anybody have got any burning questions about the little tiny baby bean?

I apologise that baby bean on the picture might not be necessarily 9 weeks old, but I could not really think about any better picture, which was kind of roughly of that size. They all are very small or slightly bigger. So this is actually one of the little kittens from from a charity I worked with in, in Portugal, helping them with their training, in, in with ISFM.

It's absolutely gorgeous kitten. Right, so the few things which I wanted you to think about the baby bean is, is thinking about the, about the presentation of the, of the patient, because there's a very big difference if we are charity vets working just with the charity and working with shelters and working with animals which are coming from very unprivileged backgrounds or working in, you know, in certain countries which I've seen literally kittens ridden with fleas and ticks. Versus the, you know, the shelters or the charities when we actually have, you know, really nicely taken care of kittens.

So this kitten is actually quite chunky. I thought maybe I was a little bit enthusiastic with 4 out of 9 because that's probably the fattest kitten ever. But what I want you to think is that this kitten is really absolutely happy.

It's not underweight, it's growing really well. Did you all manage to hear and, and hear the heart murmur in this little kitten? This is actually quite difficult exercise when you have recordings because it's very difficult to actually sometimes convince ourselves.

To what is happening. Sorry, I'm just trying to. Trying to get out of my screen, right, could we have a first poll, please?

So out of interest, if you detect this mild systolic heart murmur, in, in, in well-doing kitten, what would you, what would you be your next thought be really? Excellent. There is no right and wrong answers here, really.

I'm just quite interested, you know, how people, what, what sort of the next thought is going to be for every person and every vet, and I think that will very much depends on our, on our circumstances. Sorry, let me just, that's what I'm failing slightly with my skills. So a few things which I wanted to share with you is recommendation of echo, OK.

Now, most commonly when we do have a significant abnormalities, the murmur is going to be very, very pronounced, OK? And I truly believe, and I might be absolutely wrong, but I just really think that you have to be really, really super good to tell the person, what sort of abnormalities are in a little tiny heart. So I think you need to have a, you know, cardiologist or somebody really, really good at echo to be able to detect changes in the heart.

So I normally, personally, unless I can hear something really, really horrendous, I normally do not, do not recommend it, OK? Check if kitten is anaemic. And I think this is actually quite important.

Let's not forget about these little functional murmurs or murmurs related to things which are outside the heart. We know, and that's something which has been reported that if, if the PCV drops below 20%, which we know, all of us know that cats can richly walk quite happily with, with 20% PCV, you might be able to hear a murmur. It is more likely when, when, when we at about 15%, but Nevertheless, it's something worth remembering, especially if you're seeing the kittens that they are not doing very, very well, especially if we're dealing with the population of kittens which might be struggling and suffering with, with severe flea infestation or were infested with fleas.

And innocent, innocent kitten murmur. I think that this is something, something which we, which we hear quite often. A lot of the times it's very difficult to hear unless you really, really have a very good hearing.

And we're thinking that it is related to this, to this disparity between large stroke, not smoke, volume, in relation to the size of the blood vessels in the kitten. And it does become less, less pronounced pronounced as the time progresses. So it's absolutely fine, and that's what I normally do, unless there is any problem with the animal that I wait and listen to it at the second vaccination, and normally they should disappear by 56 months of age.

Now, Iogenic murmurs are actually quite common, and sometimes we actually just make ourselves believe that we're hearing things, and I don't know if you guys have the same thing, but is this, I've got the same feeling with euthanasia when I'm listening, if there is still heart rate there, and I can convince myself sometimes that I can still hear the heart, and I normally ask trusted nurse to listen and just, just reassure me that the heart is gone. I mean, heart rate is gone. And sometimes that's what can happen.

We know that and that's been described in literature and there was, there was something which was published in last year. That we can actually induce the murmurs, and that's something which I was told years ago, that if we're pressing these kittens or cats too hard on the chest, we will be able to induce the murmurs. So it's worth, worth thinking about it.

Now, the difficulty is that we want to have a calm, calm kitten, and that doesn't a lot of the times happen. They are all over the place. They're climbing.

If you imagine having, let's say, 6 kittens for vaccinations, that's, that's even worse. So if you're ever in a situation when you, when you can go to the shelter or you're in the position that you can listen. Sort of in the place where the kittens are, that's what makes it excellent because they can play and then you can every so often as they calm down, listen to all the kittens.

It's much more difficult in your, in your, in your room. And the other thing it's very difficult to find a quiet room, quiet enough room. So the top tip is toilet.

In every practise there's a toilet, and if you're ever struggling rather than looking for the random places, I normally think that actually toilets are the best places because you can close the toilets top, you can put the cat there, they kind of look around. Sometimes they jump up and can put them back on, and you'll be able to listen to the heart. Hopefully nobody's going to disturb you there and you can, you can breathe yourself a little bit better.

Now, the next poll, please. Now, I'm not trying to teach you how to, how to suck eggs, as people say, but I'm just quite curious what people normally do, and I know, you know, how, how I teach my students and how different people describe things and what different people do. So I'm just quite interested to to what you guys are doing.

I think there's definitely disparity, and that's my research, which is, which is completely not not very evidence-based, just anecdotal, that, people who just deal with cats, listen to cat chest very, very differently to people who actually listen, listen to, to both cats and dogs or, or mainly dogs. Excellent. That's, that's really, really, really good.

So, we're going to see shortly how the, how the cat's heart is positioned in the chest, and that's something which we sometimes forget about. And I definitely forgot about it until I've just relearned that for something else. And that started making a sense.

I basically relearned that when I was trying to explain to students where to listen. for a, for a moments in the cat. So, with the dogs, we know that a lot of the times with many, many big chested dogs, you have to really put your hand quite cranially, and the hearts are big enough that, you know, you can actually distinguish between different areas of the heart.

And sometimes with cats, it's not that easy. So, the best location really is to consider actually putting it just on the sternum, and I'll show you the pictures. Sorry, I'm just going to try to get rid of this pole unless, Sorry, sorry, so whoops.

. Now I'm failing again. Right, if we think about the position of the, of the stethoscope where we should be auscultating, there is a, there is a little cat's chest on the left side versus the dog chest on the right hand side, and, and, and they just take it for, you know, just, just to really for the purpose of, of seeing where the things are. So you can really really see how, you know, how we're pulling forward the, the leg in the dog versus cat.

And how far that will go backwards when the cat or the dog is standing. So in a dog, we really have to go underneath, underneath the the leg in the cat, we don't really have to. And also, if you look at that, the, the cat's heart has got a bit more of a slanted angle when how it's like in the chest.

And therefore, especially when you, when you notice how big part of the heart is on the caudal sternum, the The easiest way to listen to, to the heart is really listen to the heart at the caudal sternum, and then just feel, slightly to the side, one side and then the other side. And on the same token, if you're learning to do the scans, the best thing to think about is just feeling the chest, where we can hear, or we can feel the beat the most and putting the probe there. That's, that's one of the easiest way of actually learning to, to locate, the heart.

Don't forget that actually about the angle and the position of the heart and contact with the sternum as the cat is ageing. So if you see the young adult versus older cat, and they're not the best X-rays to, to, to demonstrate, but that's the X-rays which I found in our, in our, in our stock. I didn't want to steal anything from the good cardiology book.

I thought, well, we can definitely manage. So if you see, as the cats are ageing, you can see that this heart is becoming more and more flat lying on the bottom of the chest. So that's another thing which is worth thinking about it when we're listening to the heart where exactly the heart will be compared with the compared with the dog.

Could we please have the next, pill, please? So I do admit that I normally worry very much about, you know, I used to worry a lot about, you know, am I missing something very, very, very obvious in the cat's chest, especially with the young kittens, and I was always very, very petrified thinking, oh my God, there must be something wrong with this kitten, and it can never be insured and oh, what am I going to do? You guys are superstars.

So definitely all the research which recently have been, have been published, investigating the the congenital problems in cats, the VSD was definitely the most, the most commonly reported ones. I think I'm. It sometimes when we're thinking about patent ductus arteriosis or or anything, anything else like aortic stenosis, is it because we really always think about it and we learn about it that that it is actually more common in dogs and then we just applying that to the cats, or is it because we actually had the case and that's why we're remembering about that?

Oops. Holly, can you just get rid of the pole? Sorry.

Oh. If not, I can try to do it differently. Oh, perfect.

I don't know if I did it or she did it, . So interestingly, and there will be few publications, and, and obviously they have their own limitations, but in, in one of the most recent publications, you know, the congenital heart disease in cats that was reported in, in, in a group of cats that they were tested was only 0.2%.

So that always makes me slightly more reassured thinking, well, actually maybe I'm not missing and you know, all these big, all these big problems that the kittens are born with, . And only about 8, 8% on, on, on average, so between 5 and 12% of the cats with heart disease actually, when they, when they presented, there was a cardiac congenital heart disease which was discovered. So it's worth, it's worth thinking about these little statistics.

They might not always apply to us. As you guys actually, you guys actually were quite good with, with, knowing about VSD so this is the most commonly reported congenital abnormality. It's, it's, it's across the studies, not only in the, in the one from 2015.

It's reported that actually about 50% of cases are actually presenting with that. And the most, the most next most common reported is going to be tri or speed valve. And after this 50% of the cases, every other, every other abnormalities is probably less than about 10% of total.

So my top tips for the kittens is trying to get, or for any cat really is trying to get a quiet room and be very, very cat friendly. So, I normally follow the cat around the room when I listen to a cat, and it, I know it's easier said than done, but there's a number of times when, you know, when I'm kind of sitting somewhere and cat is, you know, sitting, sitting on the floor or on the chair and I'm listening to a cat and I'm just giving them a break, just giving myself the best chance. Calm kitten, very, very difficult.

If you're ever in a shelter and if there is a situation that, you know, they, they've beaten, they've played, and they're relaxing, that might be a good time to try to try to listen to them if you get a, get a chance. And remember, just do not apply too much pressure with your stethoscope, because that can induce, induce murmurs. And always, if in doubt, just recheck and you know, for the kittens, rechecking out the next vaccination is, is, is a perfect timing.

Now, this is our little Leon. So did you manage to, to hear murmur through the purring? And I know this is actually a little bit of a curved ball, because if you had the cat in front of you, you would know that the cat is purring.

So, unfortunately, I, I only had a soundtracks. I didn't have actually patient that I could record because they were actually copied from the sound sources. Now, this is always very, very, very, very difficult, and I'm going just to go to the next slide slightly differently.

But if we could have the next poll, how do you guys stop the cats to purr? OK, stop, stop the cats purring? And I always learned the new tips from everybody.

Wherever I go, there's always somebody who's got absolutely amazing tip on how to stop the cats purring. Well, I think everybody is very cat friendly. Nobody's spraying with ethanol-based.

Aerosol near the cat. I'm very impressed. I think Margie is here, so everybody's worried and that she'll be shouting at them.

Superb. So this is actually quite interesting because one of my two favourite methods is either running a tap in close proximity, just to kind of spook the cat or surprise the cat a little tiny bit and, and hoping that they're actually going to stop pairing. And my next thing is to offer them something like a, like a spirit, on the cotton ball or cotton wall, to, to sniff, which probably is not the nicest thing to do.

Blowing at the cats here. I've never had a great success with this one. Right.

So interestingly, actually, there was somebody who decided to test that and see what would be the best method. So they did a little project and they tried three methods running tap, blowing in the cat's ear, and then spray ethanol-based aerosol. And they didn't offer the surgical spirit to sniff.

Now, the most effective out, you know, from what they described was actually running tap proximity. Now, the spray was relatively 2, 2nd most effective, but I think we have to just think about it, you know, is that really kind to a cat and what's going to happen to a cat when you suddenly start spraying around? And I would probably argue that if, you know, if, if sniffing ethanol is bad enough, that probably is going to be enough.

You don't have to scare them with, with hissing, hissing noises, because that might mean that they will not be ideal patients for the next examination or for the next, . For whatever we want to do next. Could we have the next spell, please?

So I'm quite interested in what you guys thinking when you're actually hearing the murmur in a middle-aged cat. So the first thing, and I know a lot of us are quite knowledgeable, and we start having a list of differentials, and that's definitely what I'm thinking now when I'm, when I'm teaching my students that . Because I go through differentials a lot, and suddenly I can produce the big list immediately.

But that's not the real life and not real practise, and that's not, you know, what I would be doing if I was just working all the time in the practise. Excellent. .

Oh, nobody wants to become an orthopaedic surgeon. This is, this is consistent. Nobody does.

Oops. But I don't know. Right.

OK, so this is, this is actually quite, quite interesting because, We know that, that That anemias, especially in, you know, if we're thinking of dealing with our shelter population, the anemias can can present as a heart murmur. Some of these guys with chronic chronic disease, they can literally stroll into our room without, without thinking very much and then just look absolutely normal. There is, unless the anaemia is very severe, there is not really great correlation between the colour of the mucous membranes and And, and you know, and how anaemic the animal is.

So sometimes that can be a little bit of a worrying, but that's actually quite interesting, how we think about that. OK. Could we have the next poll, please?

And I absolutely appreciate that a lot of the times when I'm in charity or shelter settings, some of us have access to absolutely amazing care. We do have ultrasound and that becomes much more common, and that's something which we immediately, you know, immediately can do. And I definitely seen that when I was working in charity practises, .

But sometimes Sometimes what I think that that that, you know, that, that we should be thinking also laterally and trying to look for what else we can do when we don't have access to everything, just in case if somebody stands on the probe and destroys the probe, what will be our next thing to think about. I think that actually, I'm just wondering if if this poll is, is slightly biassed because of the talk, Malcolm's talk this morning, and I think he just rally. Managed to, managed to, to really get the message that sometimes the best thing is to really monitor the patient and reject this patient.

Because I've dealt with quite a few caps which were in, in, in the shelters on a charity situation when there was sort of questionable, worming and flea routine, I normally, I'm a little bit cautious of what might be happening, especially if, you know, if, if we're not sure, what was the vaccination like? Is this kind a complete stray, you know, is there a possibility of Of any, any, any infectious diseases that they are happening. So, interestingly, if we think about it, fela infectious anaemia is definitely is out there.

We do see it. I don't know how often you guys see it, but, it doesn't always present with this, with this horrendous, horrendous yellow cat, but sometimes, you know, sometimes we can just, just start seeing them being, being a little bit anaemic. Now, FELV, and again, I know that we don't see FELV as much in certain circumstances, but it's still out there, and definitely we know that, that, you know, that it is associated with anaemia.

And, you know, the, the study of 8000 cats from 2012. So they've quoted about 11% of of animals, you know, presenting apart from being FELD positive, being also anaemic. So it's just something worth, worth remembering, especially if we're more working with our, with our charity and shelter population.

Now, with the, with the anti-Pro BNP, this is actually definitely something which, which it's going to hopefully become more used and more useful for us as we know more about this test. The only, the only trouble is that it cannot really tell us how severely, you know, how, you know, what type of disease we have. It doesn't distinguish very well between the mild and severe disease.

So it can really tell us a little bit, you know, that, that the cut, it might be, might be normal or with having very mild disease, versus very, very, very severe subclinical disease, but it's, it's, it's not, it's not something which, which can really predict everything. Because of its predictive negative predictive value, the usefulness might be to rule out the disease when you're thinking, right, OK, if I, if I test it and I've got a low value, it is actually quite, you know, quite unlikely that this cat will have severe subclinical disease. Now, monitoring the patient at, at home and recheck.

Sometimes I think where, where we fail in general is how to educate our, our, our clients, the owners, the carers, the foster carers, and, and the members in the staff members in shelter, volunteers on how to monitor. And there was definitely very, very useful paper, which basically looked at sleeping respiratory rates, and kind of described this magic number of 30 breaths per minute, and that's something which actually Malcolm was talking about. And it's definitely worth looking at this, at this paper, but that's my favourite thing to do, teaching clients how to, how to, how to check respiratory rates when they're resting and how to observe them and the way they're breathing.

Now, I'm I'm not the biggest fan of cadalis. I know Malcolm is because it's a small tablet, which is obviously the, the, the right reason to like it. But if you've never seen this, this app, Kalli's app is free, the most useful part of it is that it's making recording respirates very, very easy.

So it's a little app that when you actually open it, it gives you a timer for 30, for 30 seconds, and then you're just touching the big heart every time you see the cat breathing, and that makes it much, much, much easier for the clients to record the respirates. And I really like it because when I do, TPRs on my inpatients, I definitely struggle, and I hate doing them because of the respiration rates. I can, I, I'm always paranoid that I cannot count it properly.

So I would highly recommend, I'm pretty sure that there are other apps, but this one just worked for me. I've downloaded it and I just didn't look for anything else. It's definitely worth thinking about.

Right, a little Porsche. So this is actually my cat. She doesn't have a heart issues, but she's got every other issue in the world.

So I was feeling a little tiny bit guilty this morning when Polly was talking about being an ethical cat owner. Mm, can we have the pole number 7, please? So what I do and when I, when I Consult and when I see the patient.

I, I have got my little tiny go to list in my head of what I want to rule out or what I want to think about when I'm seeing these animals. And definitely when I see the young animal with heart murmur versus middle age versus older, older animal, my list differs very, very, very, very much. So I'm just wondering what would be your next go to?

Great, OK. Perfect. Right.

Systemic hypertension and hyperthyroidism. Excellent. Now, the one of the things which I just want people to remember that, that there are certain extra cardiac reasons for the, for the cats to develop murmurs.

You know, it could be a fever. Obviously, we will know if the has got a fever, you know, they do look miserable when they have fever. They don't just walk through the door, you know, being fine and having fever of over 40 degrees.

But sometimes low proteins and low anaemia, as we were saying already, you know, they can, they can affect that. So it's definitely worth thinking about that. My, my go to think is basically always the same as you guys.

Systemic hypertension, hyperthyroidism, and then, my anaemia. That's, that's my three things that I want to think about immediately. And, and I think, right, OK, how much can I, can I find out now without doing any further tests?

So this is actually definitely very, very, very important lesson that actually having a heart murmur, it doesn't equal having structural cardiac disease. And that's what Malcolm was, was talking about this morning. So it's just, it's just something also to talk to our clients about.

And The, you know, the, the different papers give you a different numbers, but I think generally a big part of our population of cats will have a murmur, and we will never find out any changes to the, to the heart on echo. And that's something, something to remember. And then just thinking about it, what else, does it mean really.

Now, look after. And this is actually quite, quite a nice paper, which they did. So they basically looked at actually induction of the, of the heart murmur in the CATs and they were looking at the at the ultrasound images and basically changing the pressure of the probe and inducing the murmurs.

And the strange thing is or possibly normal things for cats, that the murmur which is induced sounds like any other systolic m. So it's, it's, it's quite difficult sometimes to think about it. So when we have these cats that they're really wriggly, and we have to really try to kind of hold them to us, or they're moving around, and we're pressing, pressing the stethoscopes to the chest, that might actually be something that, that, that might make things, things worse, just something to consider.

Now, obviously, all the cat population, very high. Prevalence of, of, of, of kidney disease. And, OK, this is one study which actually citing quite, you know, the different disparity of the numbers.

But if you think about it, even if just 30% of our, of our chronic kidney disease cats has got anaemia, there might be a very good reason for them to have a heart murmur. So it's worth just thinking about that in, in, in, you know, in that way as well. Now, from this examination, this is my favourite part.

I love teaching that and I really, really wish that all my students would just, if they do one thing, with the cats in the consulting room is to check their eyes. A lot of the times, you know, I think it's very, very, if I can learn it, everybody can learn it. So I, you're very highly, you know, welcome, you know, to come over if you know, if you ever travelling next to Nottingham, and if you want a quick, quick show, if you don't know how to do it, once the COVID is over.

To actually to, to learn that examination, but I would highly, highly recommend to, to start doing it. And it's, it's very, very, very useful and non-specialists with a very quick training can become a really absolutely amazing at it. And obviously part of our clinical examination looking for this Mystical thyroid nodules and looking for the goitre, which, it might be that actually just having a little lump, it doesn't necessarily mean that you do have a thyroid disease, but we have to think about it that actually there was association between the sizes and that they were found in the cats with hyperthyroidism.

So could we have a poll number 8, please? Great. So this is actually very, very interesting because now what I've started doing, I've for quite a few years now, I try to look into every cat's eyes very, very quickly as a part of my examination for the for vaccination.

Whenever I see the cats, I try to look. Now, this is very, very common that a lot of us will actually look for the end organ damage in cats which they, which already have diagnosed hypertension, but I would like to challenge you to actually examine the eyes of the older cats and seeing, can you find out the hypertension before you start seeing. Any changes.

And definitely, definitely, definitely, I can promise you that you will probably find quite a few lesions there, and you'll be able to to tell much faster than than booking the cat for for the blood pressure measurements, which we should be doing, but I know that it's not always possible that there might be a risk to these cats. So it's highly, highly recommended. Every cat.

Absolutely, yes. And you know, that's what I used to do. Now I'm trying to challenge myself to try to go for, for every cat.

It just doesn't take me very long now, so I try to have a very quick, quick look. And if you never do it, if you don't know how to do it, I've got a little link, so it might be something useful to to have a look and that's definitely something to learn. You don't have to have a very expensive 40 to 50 quid lens.

You can have something which is much cheaper. Mine is 20 pounds and it's good enough for me for what I need it for, and I had it for over 15 years, and it's still here, so I think that's the best spend money or maybe actually stolen it from somebody. I don't even remember anymore.

But it's the best, you know, the best investment to have with you, . Now, I really love that girl on the run. I don't know if you know about Justin Lee.

She specialises in critical care. But this is a little, a little tiny, a link to, to a few of her how to blogs. So definitely really easy to perform.

Everybody can do it and is going to provide you a lot of information. So definitely, definitely something worth thinking about. If somebody wants any other links, there's loads of different, a bit more local, information provided, especially Sarah Kaney who specialises in feline medicine.

She's got some really top tip, guides on the YouTube, on how to perform this examination. OK, could we have please question poll number 9? Now if you think about it, assume that this patient doesn't have any signs.

So there's no cardiac signs, there's no dyspinia, there's no increased respiratory rate. And that's just to assure you that this, this is actually, this is the echo image from two weeks ago, which I did on, on, on the cat. And this cat was had a pleural effusion as well.

It was post-training pleural effusion, and she was just sitting there. She didn't need any sedation. And she was sitting external.

And I literally had just somebody stroking her chest so she doesn't move forward for me. OK? So if I can do that, everybody can do that.

There was no clipping involved. It was just really wetting, you know, wetting the coats really well with water and then applying a gel, to the point of maximum intensity. On the right hand side.

Excellent. So this is, this is actually quite interesting because I used to use aspirin for ages, and now, I became a clopidogrel person. I don't know if you ever guys tried clopidogrel.

Like, have you tasted it? And do you know how disgusting that is. It's, it's, I, I've got this, I don't really like any, any, any drugs myself, but, I cannot even take aspirin and, and or ibuprofen and, and paracetamol at the same time.

Because my brain immediately thinks that my liver is failing. But if you, if you, if you ever try anything that cat might be, might be, might be having, it might give you the new appreciation of how easy it's going to be medicating, to medicate these cats. Obviously, cats might have a slightly different Sense when they're testing, tasting things, but, but disgusting is disgusting, so I'm always actually applying a little bit of a benefit of the doubt and clopidogrel is not great.

But definitely new upcoming medication. I'm really, really happy that you guys are actually not starting with diuretics because I think that this is one of the biggest problems which we're having, to know when to use certain medication, and we have to remember that unless we do have evidence of, of, . of edoema.

We shouldn't be, we shouldn't be pulmonary edoema. We shouldn't be really dosing these cats with, with, diuretics because they always, as by nature, are slightly on the edge of dehydration. So trying really hard to hold to the fluids and if we start actually dehydrating them even further, they become really, really miserable, don't want to eat, they're quite unwell.

They lose potassium really, really, really rapidly, and that's what Malcolm was talking about. And this is definitely something, something which is true. We'll also be very, very cautious with the doses of the, of the diuretics.

We just, because we have a, we have an issue with with the cats so that the heart cannot relax to fill in properly. That's the most of the time disease in the cats. If we start really reducing the fluid, that might actually by giving them too high doses of risamide that might actually make it even more difficult for them.

So, as I, as I mentioned already, yes, when to use diuretics and how, that's very, very, very important. If there's no signs, then we wouldn't use it. This particular cat actually did have a pleural fusion, and he had a massive, she had massive numbers of beelines on her, on, on her, on her scan, thoracic scan.

So I did start her on a low dose of furizamide, but otherwise, I'll be really careful. Now, there was a specific trial which was performed, comparing clopidogrel with aspirin. And now, this trial, and that was basically comparing the likelihood of recurrence of the, of the feline, arterial thromboembolic episode.

But it wasn't, it was basically between the episodes. So the cats which presented with the episode then were dosed either with clopidogrel or or aspirin. And what they discovered that the likelihood of recurring of the disease was reduced when, and quite significantly reduced when the cats were actually dosed with the clopidogrel.

And I know that it's not always easy and the cost involved, but definitely now, all the, all the cardiologists would, would recommend and, in fact, the guidelines on, on treatment. And of the cat, cardiac diseases recommend strongly using clopidogrel as a first line unless we, we cannot use it for whatever reason because it's, it's, it's a much better drug, and it gives us much better outcomes. Unfortunately, nobody ever, or it hasn't been done yet.

Nobody did the trials, what's going to happen with the cats before they have episodes, so we're still missing some evidence there. But definitely there's a number of a number of cardiologists who would suggest as soon as we start seeing large, or severely enlarged atrium, to start dosing these cats with clopidogrel, I would start treating them if, if it's possible, if I see positive contrast. I would recommend to clients to use clopidogrel, before, unless it is, very difficult to peel the cat, and there are certain, limitations because of the finances, because, you know, I don't want to induce the heart failure in the cat and push it into, you know, out of, out of being quite stable into this unstable situation just by medicating, medicating the cat.

And starting treatment of ACE inhibitors, we used to use that quite a lot. The problem is that actually when we first started describing the heart disease in cats, we, we, we realised that actually hypertrophic cardiomyopathy was amazingly very similar to the human ones. So we started quite obviously using the evidence from humans, using certain.

In cats, but then we discovered that actually it doesn't work the same way as it does in humans. So, especially this this study and some other, some other, produced studies basically show no evidence of benefit and then we have to decide right, should we be actually dosing these cats with anything. Now, Question 10 Paul please, Holly.

Thank you. And this is always a very contagious issue, and unfortunately we don't have a time because it would be very interesting to run a little bit of a discussion looking at splitting the group into 3, and the new owner, vetting the shelter, and then and then, and then a new vet. In the private practise who might be looking after the patient, to see really what we're thinking and what would be the ideal.

Yeah. So a lot of the times, as Malcolm was saying, and I think this is very important, we had this conversation in clinic with Malcolm multiple times, you know, is it, you know, yes, it's great to see how disease is progressing. But is it really something which is necessary?

Is it something we just we want to know for our information or we're just trying to encourage the clients, so we basically tick the boxes and we're trying to make more money for the practise. And I'm thinking that, that the only, the only concerns which I have with these guys, if the heart is enlarging. And the left side is enlarging, to the point when we start having contrast.

So if I wanted to see them, I would want to see them if something is changing there. But most of the time, what I do, I will, I will see these guys, either routine list of like once a year for the routine vaccination and re-examination. Or if anything, anything changes in clinical presentation.

I do like seeing my older cats every, every 6 months, but I know that it's not always, always as easy to do. I'm hoping that actually, you know, telemedicine might might help with with getting lots of information and and having certain consultations and discussions with the clients over the, over the phone. And then, you know, the ethics of the murmur, and this is, this is actually something which is quite interesting, and I just wonder what you guys are thinking.

I always think when I'm considering how I'm making the plan, I'm thinking about the cat factor. What's this, what's fluffy is going to say about having all this medication and checks and, you know, having the coat shaved and being in the basket swung around. I know it's very traumatic for me to take my cat, to myself, to the clinic.

So it's, you know, it's, if I'm bad, imagine if that's my client who actually cannot go in the building now and they never present when we're doing stuff. I don't know how often you guys are allowing the clients to be there when you're scanning, . On a factor, what clients can do, what they understand, would they be able to do things, you know, if you have somebody who is extremely, extremely athletic, it might really struggle with actually getting the cat and just taking, putting the pill into the mouth, even if the cat is the best in the world.

And obviously the drug factor. So is this drug useful or is it definitely life saving, or is it something which is good to have on board and never forgetting, you know, how easy is it to give, you know, is it, is it disgusting flavour? Is that something which is going to make the cat foam if it stays in the mouth for too long or choke?

And what I think my top tip, and if you don't do that now, that will be something which I would strongly recommend is for all the chronic diseases, especially important with the heart disease, I think, is to give the clients a list of importance. What would be the most important thing that the cat gets, especially when they're getting multiple medications, multiple different Treatments. And, you know, I normally tell them that actually, if they can only give one thing and then they have a bad day or they're going away or something is happening and it's becoming difficult, I just say, that is going to be something which is going to be making the most difference.

And, and most of the time with these cardiac cases, it's going to be rosemide. So, you know, if nothing else, sometimes some of these guys just basically have furosemide, and that's the treatment that they're having. Do you have any questions?

Or anything exciting that you want to share about your cases. Do you think that either this workshop or anything changed or Malcolm's stock changed the way how you're going to approach your patients? I had a question about the pro BMP.

Would that be like the quantitative one or the SAP test useful? OK. So we definitely, so we, we used to use actually snap test quite a lot when we were thinking about, you know, when we had an older cat or cat with a murmur, just to see, you know, what's the chances of this cat having a severe heart disease.

And that's quite a quick thing that can be performed, you know, in the clinic. And I thought that's when it was when it was useful, if we have any doubts. Because if you know, if it is a negative, you know, you're thinking, well, it's unlikely that this cat has got severe, severe heart disease.

So that's, that's how I was utilising it. And I know the problem is with that, that most people would prefer to actually have this the tests done when you can send it away and you can have a definite number rather than just random cutoff point. I think it's, I don't know if I remember correctly, something like 200, when you suddenly, you know, just 199, you're negative and then 201 you're positive and you're just thinking, oh.

But it sounds a little bit, you know, a little bit, a little bit strange. So I don't use it anymore. I think if I had a choice, I probably would, would just, would just put a probe on the cat's, you know, cat's chest and have a look quickly before the anaesthetic, you know, what's happening and, and how, how I feel about it.

You know, is there any enlargement? Is there anything else happening than doing the test? And I'm not really quite sure if I'm answering that well enough.

I think for this, the big changes, it, I think it's supposed to be very useful for, for differentiating between the causes of, of, of dyspinia. Is it, is it related to, to heart or is it related to respiratory, primary respiratory disease? But I most of the time, I don't use it this way.

So, it might be that just that just like I try to save money. How I wanted to use it was in a situation where I just wanted to rule out heart disease basically quickly. So I think, I think, so I think the, the severe heart disease, you know, if you have, if you have a, you know, if you have a, if you have a negative test, then you will think, well, it's unlikely that this cat is in serious trouble.

And basically that's how we, you know, that's how I interpret all the, all the findings which they had. So it's much more useful in the fresh in in telling the difference between these cats which are in severe subclinical disease, because obviously, you know, we all kind of can recognise that the cat is clinically affected by heart. That's, that's, that's not that big deal for us.

. So is that what you mean, what you were thinking about using it when you, when you think, for example, you hear a murmur or you have all the cat and you're thinking, right, should I just, you know, is it safe to anaesthetize this cat? Yeah, that kind of thing. So I think, yeah, so I think with, with, with that, I would just think that actually that might be useful just to say, yeah, OK, it's negative, so it's unlikely that is, you know, that it's going to be severely affected cats, so there's not going to be massive change, but I think if I, yeah, but, but it's, I don't think we actually have any studies yet to tell us usefulness in like prognostics, what's what's happening, and I'm not not a cardiologist and I don't use this test very much, but From what I, from what I read, I believe that troponins are better at at sort of, you know, that sort of telling us about prognosis, what's going to happen and, you know, how severely the muscle is damaged.

That's awesome, thank you. Any other questions? Any thoughts?

Should we euthanize them all? Would you rehome? Would you not rehome some of these cats?

I actually did have another question. I feel like I'm hogging it. When you're turning the tap on to listen to stop and peering, it doesn't turn the tap off again because all I can hear is running water when I do it.

Most of the time what happens if I didn't try this tap before, I actually opened the tap and splashed the cad and myself with water and half of the room. That's the kind of how it normally goes for me. But yes, so what I do, and this is actually quite, quite difficult, because I agree with you.

So I believe, and this is my thinking about it, that it basically spooks the cat a little tiny bit and make them think, oh, something else, and try to get the attention to something else. And in that case, you know, once actually, I, I, I would still be listening whilst I actually open the tap. And then what I do, I see what I can, what I can hear through the tap, and I would reduce the tap slightly, and sometimes it's just a drip, and I continue to listen.

And then I try to close it. Now, the bad news is there are some compulsive and obsessive purrs out there, and it doesn't matter what you do, they'll be pairing through everything. And sometimes, you know, It's, it's just, I don't know if anybody has got any other top tapes for this like the most resistant to any, any tapes.

Maggie, you probably have every tip in the book. I don't know, I, I put down the running tat bomb in question. I have known people, I know that there was an option in your list about blowing the cat's ears, but I've known people to blow on their nose.

Yes, and I wonder if that actually, I, I've never tried that. But I think, personally, the running water one seems to work best, but I just think it's a work in progress and see what works. And sometimes it's not working.

I normally think that most of the time it's me splashing myself with water and then client laughing so loudly that cat is just thinking, ah, what's happening? What's happening here? And they just go, literally, I think that is, I don't know what you guys are finding.

I think that if we stop them pairing, if they are pairing anyway. It's going to be a few seconds that you stop them pairing for. It's not going to be a massive thing.

So it's, it's literally, I think with these milder little tiny murmurs, you're probably going to not hear them, but then I don't really worry. I think if I cannot really hear it, is it that significant? And I can swear that, you can go on the, on, on the YouTube and you can check your hearing.

So there's this little test when You can what you can put, and it basically goes through frequencies and starts very, very, very low, and then we cannot hear it and then you're going, going, going, and you're seeing where you can stop hearing it at which frequency. The only thing is if you're ever doing this test, make sure that you don't put it very loud because you can damage yourself, OK? And then you can suddenly hear what's the difference of the frequencies that you can actually hear.

And obviously, do not share your stethoscopes with anybody. Get yourself a brilliant stethoscope. Do not share it with everybody.

Blame COVID if, if you know, if you think that you cannot blame anything else, to say that, well, sorry, COVID. And just make sure that you actually have very nicely fitted and tight, tight earpieces. And if in doubt, go and check all the ear cleaners for, for the very waxy ears in dogs, but don't use the one which is used on the dogs and dirt.

You just use the clean one to remove the wax from your ears. And see if that helps. So squealing, I think would be my choice.

I know, I, I also did actually a couple of times, every time I put a little bronchoscope on, I've got this urge of checking my ears, and this is I have to really force myself not to. Right, if they know any other questions, there is a little link which we can follow back to, to major, major to the main meeting. If you have any questions, you're very welcome to just, just, just get in touch and, and ask, and, and if you have any top tips, again, this is, this is something which is always recommended.

I think we learn all from each other what people, what people see and also what doesn't work. I think that's even more important than what works.