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Chasing fluid away… case report

This case report discusses the diagnosis and treatment of a German Shepherd dog with myxomatous degenerative valvular disease and congestive heart failure. The report covers diagnostic work-up, treatment options, and monitoring strategies.

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Chasing fluid away… case report

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  1. Chasing fluid away…case report Mr Jordi López-Alvarez LltVet MRCVS Resident in Internal Medicine (Cardiology) Small Animal Teaching Hospital, University of Liverpool Leahurst, Chester High Road, Neston Cheshire CH64 7TE, United Kingdom

  2. FLOYD 4 yo GSD NM Referred for tachycardia (non-responsive to lidocaine) Presentation: June 2009

  3. Presentation: June 2009 Anamnesis: • Progressive (over 1 month): • exercise intolerance • tachypnoea • No history of previous illnesses was reported • Up-to-date with worming and vaccinations

  4. Presentation: June 2009 Physical examination: • 36.4 kg • Tachypnoea (44 rpm) • Mild abdominal distension with fluid thrill • Positive hepatojugular reflux • Chaotic rhythm and rate at 240 bpm • Marked pulse deficits at 100/min • Variable 2-3/6 left apical systolic murmur

  5. Diagnostic work-up • Haematology and biochemistry: NAD • Cardiac troponin I: 1.18 ng/mL (ref. value <0.15) • Blood pressure:150 mmHg

  6. Electrocardiography 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

  7. Thoracic X-rays

  8. Doppler echocardiography

  9. Doppler echocardiography

  10. Diagnosis Myxomatous degenerative valvular disease1 • secondary myocardial failure • atrial fibrillation • congestive heart failure 1 Borgarelli M, Zini E, D'Agnolo G, et al. Comparison of primary mitral valve disease in German Shepherd dogs and in small breeds. J Vet Cardiol 2004;6:27-34.

  11. CHF Treatment • Diuresis: sequential nephron blockade • ACEi • Pimobendan • Spironolactone • Others: antiarrhythmics, afterload reduction...

  12. Treatment • Hospitalisation over the week-end: • IV furosemide q 2-4h (until RR<40bpm) • Rate control: digoxin and diltiazem • At discharge • CHF: • Furosemide 1.5 mg/kg TID • Pimobendan 0.3 mg/kg BID • Benazepril 0.5 mg/kg SID • Spironolactone 1 mg/kg SID • Rate control: • Digoxin 0.125 mg/dog BID (0.003 mg/kg BID!!) • Diltiazem 2 mg/kg TID

  13. Sequential nephron blockade • Sodium transport: • Proximal tubule: 60% (cotransported with glucose, amino acids or phosphate) • Loop of Henle: 30% (Na+-K+-2Cl- carrier) • Distal convoluted tubule: 7% (Na+-Cl-cotransporter) • Collecting duct: 3% (aldosterone) NaCl Thiazides Na Na 2Cl Na K Aldosterone inhibitors Loop diuretics

  14. Spironolactone • Weak diuretic effect • Anti-aldosterone: • Potassium sparing effect • Anti-remodelling • Reduces cardiac morbidity and mortality2 2 Bernay F, Bland JM, Häggström J, et al. Efficacy of spironolactone on survival in dogs with naturally occurring mitral regurgitation caused by myxomatous mitral valve disease. J Vet Intern Med 2010;24:331-341.

  15. Torasemide vs. Furosemide • Longer half life (6h vs 4h) • More potent diuretic effect • Anti-aldosterone: • Potassium sparing effect • Anti-remodelling • Better oral absorption (absorption of furosemide but not torasemide is delayed in CHF) • No Clinical trials in Veterinary medicine

  16. CHF Treatment • Furosemide 2 mg/kg QID • Spironolactone 1 mg/kg SID • Hydrochlorthiazide + Amiloride 0.5 mg/kg BID • Torasemide 0.25 mg/kg BID

  17. RATE vs RYTHM Control • DIGOXIN • +/- DILTIAZEM • Recommendation: • 0.003 mg/kg BID and check the trough levels 1 week after • Lab ref: 1.0 - 2.4 • Aimed levels 0.5 – 1.2

  18. AMLODIPINE Dihydropyridine class calcium channel blocker Peripheral vasodilation  antihypertensive Ao = 80% Ao = 50% • Risk If hypotension: • Tachycardia • RAAS activation MR = 50% MR = 20%

  19. Palliative abdominocentesis

  20. Monitoring • Respiration rate at home • Body weight!! • Biochemistry: renal function? • Holter monitor: rate control? • Radiographs: Left Side-CHF? • Echo: Pulmonary hypertension

  21. Monitoring cTroponin I Abdominocentesis Digoxin Holter

  22. Conclusions • Owner commitment • Quality vs. Quantity of Life • Adequate monitoring • Pathophysiology and therapeutics knowledge

  23. Thank you!

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