Interview with Dr. Emily Chapel, founder of Pure Animal Cardiology

Table of Contents

• Introduction
• How the clinic works and why owner involvement matters
• Understanding canine mitral valve disease: the big picture
• ACVIM stages explained: A through D
• B1: When not to start medical therapy
• B2: Starting pimobendan and the rationale
• Ruptured chordae tendineae: recognition and implications
• Entresto (sacubitril/valsartan): what it is and how it fits in
• Stage C and D: heart failure, diuretics, and balancing kidneys
• When to consider surgery, and practical preparation
• Practical tips for owners: lifestyle, supplements, and travel
• Monitoring, mobile cardiology, and building a relationship
• Communication and clinical judgment
• FAQ
• Closing thoughts

Introduction

Dr. Emily Chapel is a veterinary cardiologist who opened Pure Animal Cardiology in Culver City, Los Angeles, to provide specialty heart care with transparency and direct owner involvement. This interview-style article captures her practical explanations, clinical judgment, and experience treating canine mitral valve disease. Throughout the conversation, Dr. Emily Chapel emphasizes realistic expectations, individualized decisions, and the importance of close relationships between pet owners and cardiologists.

How the clinic works and why owner involvement matters

Nate: Why did you start Pure Animal Cardiology, and what is different about how you involve owners?

Dr. Emily Chapel opened Pure Animal Cardiology to give owners a clearer window into their pet’s heart. She believes letting owners see the valve anatomy and the echocardiogram in real time reduces fear and improves decision making. When owners are present, dogs are generally calmer. That reduces murmur intensity, heart rate, and blood pressure artifacts that can complicate assessment. More importantly, Dr. Emily Chapel makes the owner a partner in the management plan—whether that means monitoring, medication, or surgical referral—so that the chosen path matches the family’s goals and their pet’s needs.

Understanding canine mitral valve disease: the big picture

Nate: Can you explain the overall disease process in plain terms?

Dr. Emily Chapel describes degenerative mitral valve disease as a genetically influenced, age-related thickening and irregularity of the mitral valve. It is not infection, inflammation, or cancer. As the valve loses its smooth seal, blood leaks backward from the left ventricle into the left atrium. That leak causes the heart to compensate: chambers enlarge to handle the increased volume. Enlargement can be adaptive for a long time, but eventually the added stretch worsens the leak and contributes to the cascade that leads to congestive heart failure.

Michelle: How variable is the disease?

Extremely variable. Dr. Emily Chapel points out that no two mitral valves are identical. Studies in humans show significant anatomic variation even in healthy valves, and dogs show the same diversity. The scalloping of the leaflets, cord attachments, and locations of thickening differ from patient to patient. That variability makes predicting the pace and pattern of progression difficult. The ACVIM staging system helps clinicians communicate, but many dogs fall into gray areas that require judgment and conversation with the owner.

ACVIM stages explained: A through D

Nate: Walk us through the ACVIM stages and what each means for treatment.

Dr. Emily Chapel frames the ACVIM categories simply and practically.

• Stage A — Dogs at risk (small and toy breeds are common). This is a not-yet-detectable risk state; there is no actionable testing or treatment other than awareness.
• Stage B1 — Structural valve changes with a murmur but without significant heart enlargement. Medications are not generally indicated. Dr. Emily Chapel stresses that murmur grade does not equal disease severity: a loud murmur is not always worse disease, and a soft murmur is not always mild disease. Instead, B1 dogs are typically “good enough” for daily life and anesthesia risk remains low.
• Stage B2 — Enlargement of the heart is evident by imaging and the patient faces a higher risk of progressing to heart failure. This is the stage when clinicians usually start medications like pimobendan (Vetmedin) to reduce heart size, decrease functional regurgitation caused by chamber dilation, and delay progression to congestive heart failure.
• Stage C and D — Stage C is symptomatic congestive heart failure with fluid in the lungs, coughing, and difficulty breathing. Diuretics are central to management. Stage D describes advanced, often refractory disease where multiple medications and strategies are required or where quality-of-life decisions must be made.

Across these categories Dr. Emily Chapel emphasizes that staging is a guide, not an absolute. Clinical judgment, owner preferences, and specific echo findings can shift what happens at each stage.

B1: When not to start medical therapy

Michelle: Many owners want to treat early. Why isn’t medication started at B1?

Dr. Emily Chapel explains that current evidence and consensus do not support starting heart-specific medications at B1 in a straightforward, uncomplicated case. Medications such as pimobendan support the heart muscle and reduce the functional contribution to leakage caused by chamber dilation, but they do not reverse valve thickening. The goal is to treat when enlargement indicates the heart is no longer “good enough” and the risk of progression is higher. At B1, the risks and benefits of chronic treatment do not typically favor medication. Exceptions exist: a B1 dog with hypertension or a significant arrhythmia should be treated for those specific problems even if valve-directed medication is not yet required.

B2: Starting pimobendan and the rationale

Michelle: Why is pimobendan used at B2 and how does it help?

Pimobendan (Vetmedin) is used primarily because it addresses the functional consequences of chamber enlargement. It dilates vessels, improves contractility, and shifts blood volume out of the heart chambers so the heart can shrink back toward normal size. This reduces the functional regurgitation that occurs when dilation pulls the valve leaflets apart. The EPIC clinical trial supports the use of pimobendan in delaying heart failure and prolonging good-quality life. Side effects are uncommon but can include gastrointestinal upset in some dogs. Dr. Emily Chapel acknowledges rare severe GI reactions, which may push a team toward earlier surgical consideration for dogs that cannot tolerate medical therapy.

Michelle: How do you approach the gray zone where measurements are borderline?

Dr. Emily Chapel admits that she sometimes starts pimobendan before a dog strictly meets numeric criteria because the valve looks particularly concerning on echo or a ruptured cord is visible. She involves owners in this decision. If the family is comfortable with medication, she will start it and monitor closely. If they prefer watchful waiting, that is also reasonable. The clinician-owner relationship is essential to navigate these gray areas with context and empathy.

Ruptured chordae tendineae: recognition and implications

Michelle: How do you detect a ruptured cord and how does that change management?

On echocardiography Dr. Emily Chapel looks for the small cords that anchor the valve leaflets. She describes the mitral valve as a parachute: when cords are intact the leaflet has a set shape. If one cord is stretched or torn, a segment of the leaflet will flail and project abnormally into the atrium. Seeing a “dangly” piece on echo is a clear sign of chordal rupture. These eyes-on-echo findings change the clinician’s level of concern because ruptured cords are associated with faster progression and larger leaks. When Dr. Emily Chapel visualizes ruptured cords, she tends to be more aggressive about starting pimobendan and considering advanced therapies.

Entresto (sacubitril/valsartan): what it is and how it fits in

Michelle: You discussed Entresto a lot. What should owners know?

Entresto, the combination of sacubitril and valsartan, addresses hormonal pathways that promote fluid retention and vasoconstriction. In human cardiology, it demonstrated superiority over ACE inhibitors in multiple outcome categories: symptoms, survival, and hospitalizations. Veterinary data are limited, small, and early, but Dr. Emily Chapel has used Entresto in select cases and reports good clinical experiences in many dogs.

Key clinical points Dr. Emily Chapel shares about Entresto:

• It replaces ACE inhibitor therapy rather than pimobendan. Do not combine Entresto with an ACE inhibitor; a washout period of three days is typical when switching.
• It can be useful in advanced B2 dogs that are enlarging despite pimobendan, or in frank heart failure as an additional tool to control volume and hormonal overactivation.
• Start low and escalate doses carefully while monitoring kidney function because vasodilator effects can influence renal perfusion.
• Cost used to be a barrier, but Entresto is now available generically in some markets and can be obtained affordably with coupons at common pharmacies; Dr. Emily Chapel shares that an RX coupon coupled with a national pharmacy chain can make Entresto accessible in many cases.

Michelle: Why are some cardiologists cautious about Entresto?

There is limited veterinary literature and a lack of large, long-term trials in dogs at the B2 stage. Some clinicians hesitate until stronger data appear. Dr. Emily Chapel recommends informed discussions: owners can request the medication after acknowledging the limitations of the evidence. Second opinions are reasonable if a cardiologist is uncomfortable prescribing Entresto. She stresses transparency about risks, monitoring, and expectations.

Stage C and D: heart failure, diuretics, and balancing kidneys

Michelle: What defines stage C and how is it managed?

Stage C is congestive heart failure with fluid accumulation in the lungs. Microscopically, pulmonary vessels become engorged and leak, causing fluid in lung fields. Clinically, dogs have heavy breathing, coughing, and decreased appetite because breathing requires most of their effort. Stage C is often an emergency and requires diuretics such as furosemide to remove excess fluid rapidly. IV diuretics and oxygen are common in emergency clinics to stabilize the pet.

Michelle: How do you balance diuretics and kidney health?

Treatment for heart failure inevitably stresses the kidneys. Many dogs will show increased kidney values during therapy. Dr. Emily Chapel points out that roughly half of dogs with heart failure will develop some degree of kidney injury from diuretics, but death from uncontrolled heart failure is more common than death from diuretic-induced kidney failure. The clinical approach is to relieve pulmonary congestion and then reduce medications to the lowest effective doses while closely monitoring bloodwork. If kidney values become intolerably high and the dog feels unwell, clinicians may be forced to accept greater cardiac congestion or consider advanced therapies or quality-of-life decisions.

When to consider surgery, and practical preparation

Michelle: Surgery for mitral valve disease is becoming more available. When should owners start thinking about it?

Surgical repair is an important option for appropriate candidates. Dr. Emily Chapel encourages early conversations about surgery during advanced B2 rather than waiting until full decompensated heart failure. Preparing ahead reduces the scramble that can occur if a dog develops symptoms quickly. For surgical centers, dogs that are too far advanced or have severely degraded tissue may be poor candidates. Conversely, dogs that are moderately enlarged but otherwise stable are often the best surgical candidates because the valve and surrounding tissue provide the surgeon with material to repair.

Michelle: Is there an age cutoff for surgery?

Not strictly. Some centers have operated on dogs 15 years old when the overall health and comorbid conditions supported a favorable outcome. The decision is case by case. Clients should weigh surgical risks, recovery demands, cost, and personal goals for their pet’s future. Dr. Emily Chapel stresses that no clinician should judge a family’s choice: both surgical and conservative paths can be appropriate depending on context.

Practical tips for owners: lifestyle, supplements, and travel

Michelle: What lifestyle changes are advisable for dogs with valve disease?

Dr. Emily Chapel recommends moderation rather than restriction. Dogs with B2 disease should avoid excess salt and not be pushed into high-intensity exercise. Regular walks and normal activity are fine; avoid marathon running, extreme heat, or strenuous hikes at high altitude. Stressful events like vet visits or grooming can sometimes trigger clinical deterioration, so minimizing stress and using calming strategies is sensible. For dogs with documented pulmonary hypertension, extra caution around altitude or exertional stress is warranted.

Michelle: Are supplements helpful?

There is limited evidence that supplements materially alter the course of degenerative mitral valve disease, but many are benign and potentially supportive. Dr. Emily Chapel sees no problem with supplements such as CoQ10, fish oil, taurine, carnitine, arginine, and medium-chain triglycerides when used thoughtfully. Nutrition matters: the heart uses fatty acids for energy, and a balanced, complete diet developed with a veterinary nutritionist is important, especially when owners prepare home-cooked meals.

Monitoring, mobile cardiology, and building a relationship

Michelle: How often should owners monitor their dog, and what about mobile cardiology services?

Monitoring frequency depends on stage and clinical trajectory. Some cardiologists rely more heavily on repeated echocardiography; others emphasize clinical follow-up and targeted imaging. Key is having a relationship with a cardiologist who will answer questions, review videos of coughing episodes, and guide decisions. When using mobile cardiology or in-house echo services, Dr. Emily Chapel urges owners to confirm whether the service includes a direct consultation with the cardiologist. Paying for an echo that yields only a report without the chance to discuss management can leave owners frustrated when they need to act on findings.

Communication and clinical judgment

Michelle: How do you counsel anxious owners and manage expectations?

Dr. Emily Chapel prioritizes emotional validation and clear plans. She meets owners where they are, explains the condition in accessible terms, and outlines concrete steps for the near future. She stresses that mitral valve disease is not fully controllable, but there are many measures to preserve quality of life for months to years. When decisions become complex—such as choosing between escalating medical therapy, pursuing surgery, or prioritizing comfort—she helps families weigh tradeoffs, costs, and logistics. Second opinions are encouraged when controversy arises about treatment options like Entresto.

FAQ

What are the ACVIM stages of mitral valve disease and why are they useful?

The ACVIM staging system groups dogs into A (at risk), B1 (murmur without significant enlargement), B2 (enlargement without heart failure), C (congestive heart failure), and D (end-stage or refractory disease). The system helps clinicians communicate risk and treatment thresholds, but many dogs fall into gray zones that require individualized judgment and owner discussion.

When is pimobendan recommended?

Pimobendan is recommended when a dog reaches stage B2—when echocardiographic measurements show enlargement—or earlier in some borderline cases where the valve appearance or a ruptured cord suggests rapid progression. It reduces chamber size, improves contractility, and delays congestive heart failure.

What is Entresto and when might it be used?

Entresto is a combination of sacubitril and valsartan that counteracts hormonal drivers of fluid retention and vasoconstriction. It replaces ACE inhibitors, not pimobendan, and can be considered for advanced B2 dogs or heart failure cases where hormonal modulation may help control volume and symptoms. Veterinary evidence is limited, so clinicians weigh risks and monitor carefully.

Can a ruptured chord be seen on echocardiography?

Yes. A ruptured chord appears as a flail or dangly segment of the valve leaflet that moves abnormally into the atrium when the valve closes. Seeing a rupture increases concern because these cases often progress faster.

Are there activity restrictions for dogs with valve disease?

Owners should avoid high-intensity exertion, extreme heat, and strenuous hikes at altitude. Normal walks and moderate play are acceptable. Reduce stress during vet visits and grooming. For dogs with pulmonary hypertension, limit exertion further and avoid high-altitude travel when possible.

Will diuretics cause kidney failure?

Diuretics can raise kidney values in many dogs; about half of dogs treated for heart failure will develop some kidney injury. Clinicians monitor bloodwork and aim to use the lowest effective diuretic dose. Most dogs die from uncontrolled heart failure rather than diuretic-induced kidney failure, but careful balancing is essential.

When should owners consider surgery?

Surgery is considered for dogs who are worsening despite aggressive medical therapy or for those in advanced B2 who are good surgical candidates. Earlier planning and prequalification reduce emergency pressure when heart failure develops. Age alone is not an absolute barrier; overall health and comorbidities determine candidacy.

How should owners approach mobile echo services?

Ask whether the mobile service includes a consultation with the cardiologist who interprets the echo. A written report alone may not be enough; owners often need a direct discussion to interpret findings and decide on next steps.

Closing thoughts

Dr. Emily Chapel’s approach blends evidence-based medicine with humane, individualized care. She advocates for clear communication, realistic expectations, thoughtful use of medication like pimobendan, selective use of new tools such as Entresto when appropriate, and careful monitoring in heart failure. Most of all, she underscores the value of a collaborative relationship between owners and cardiologists. For families facing mitral valve disease, that relationship brings clarity, comfort, and options—and often extends quality time with beloved pets.

References and further reading are available through specialist cardiology resources and veterinary guidelines. For owners considering advanced options, a direct consultation with a cardiologist ensures the best interpretation of diagnostics and the most appropriate, personalized plan for each pet.

This article was created from the video Dr Emily Chapel – Pure Animal Cardiology.