1. health and fitness
2. disease

When to treat and what to use
cardiac disease
Mark Patteson
MA VetMB PhD DVC CertVR MRCVS
Jo Harris BVSc CertVC MRCVS
HeartVets
Vale Referrals, The Animal Hospital, Stinchcombe, Dursley,
Gloucestershire 01453 547934
clinics @, South Devon Referrals in Newton Abbot,
A30 referrals @ Penmellyn Vets, Newquay
E-mail [email protected] tel. 07970 956689
Why do we chose a drug ?
I will cover
• some principles of drug use – why do we use them
• canine mitral valve disease
• canine dilated cardiomyopathy
• feline cardiomyopathy
• what evidence is there that a drug works
• what practical limitations may there be to its use
• which drugs to use and when to use them
HeartVets
Treatment
things change
HeartVets
Background
What we were told just a few years ago
no more boom and bust
Things have moved on
in the last few years
Treatment – choice of drug
Why do we chose a drug?
• everyone who works here uses it
•
•
•
•
the rep told me to
the owner suggested it because her last dog had it
I get a turnover related bonus
its worth a go, I will try it for a week or so
and see what happens
HeartVets
Why do we chose a drug ?
We only use drugs for two reasons
• to improve quality of life
• to increase longevity
and this is by one of the following means:
• prevent disease developing
• slow disease progression
• alleviate clinical signs
HeartVets
Why do we chose a drug ?
what is our rationale based on?
• evidence based medicine
• what we were taught
• what happened last time
• who I spoke to last
• what I read last
• personal experience
• what drugs I have available
• cost
HeartVets
Why do we chose a drug ?
Which drugs to use based on EBM:
Consider:
• evidence that they are helpful
• evidence that they may be harmful
• theoretic reasons that they may be helpful
• theoretic reasons that they may be harmful
• complications from concurrent disease
• complications from concurrent drugs
• factors that affect their bioavailability or phaemacokinetics
HeartVets
CDMVD - diagnosis
• what evidence is that the dog has disease
•
– clinical signs, signalment, physical findings
how bad is the disease
– clinical signs, physical findings
CDMVD - diagnosis
• Clinical signs
– cough, exercise intolerance, incidental
• Physical findings
– respiratory rate
– heart rate
– murmur intensity
– hyperdynamic apex beat and increased heart sound intensity
– ascites, jugular distension, arrhythmias, concomitant disease
• Further investigations
– echocardiography, radiography, (pro-BNP, BP, ECG)
– coughing, exercise intolerance
HeartVets
Buchanan “heart-score” method
T4
x + y = ht score
Maximal width
x
y
Base-apex
HeartVets
Buchanan “heart-size” method
•
normal heart size
Dogs
< 10.7 ics from T4
Cats
< 9.5 ics from T4
HeartVets
LA
HeartVets
Interstitial pattern in hilar
region, + big LA = oedema
(probably)
HeartVets
Measurement of LV size M-mode
HeartVets
Measurement of LA size
HeartVets
Treatment – choice of drug
Why do we chose a drug
•
there is evidence based medicine to support
its use?
• there is a sound theoretical basis to use it?
•
•
•
there is no evidence that it is harmful?
there is a wealth of experience
optimistic uncertainty
• cost / ease of administration
HeartVets
ACVIM Consensus statement 2009
Table 1
Stage
A
Guidelines for the diagnosis of CHCV
Criteria
At risk but no evidence of disease (eg predisposition of breed such as
CKCS). No murmur
B1
Asymptomatic – have murmur of MR resulting from CVHD but have no
radiographic or echocardiographic evidence of cardiac remodelling
B2
Asymptomatic – have murmur of MR resulting from CVHD and
radiographic or echocardiographic evidence of cardiac remodelling
C
Patients with current or past clinical signs of heart failure with structural
CVHD. Some of these will be presenting for the first time, some have
relapsed following treatment hence treatment may differ. Typically
managed as outpatients.
D
Patients with clinical signs of heart failure with structural CVHD which are
refractory to “conventional” treatment or are “end stage”. Require hospital
treatment.
ACVIM Consensus statement 2009
Table
1
Stage
A
Guidelines for the diagnosis of CHCV
Criteria
At risk but no evidence of disease (eg predisposition of breed such as CKCS). No murmur
B1
Asymptomatic – have murmur of MR resulting from CVHD but have no radiographic or
echocardiographic evidence of cardiac remodelling
B2
Asymptomatic – have murmur of MR resulting from
CVHD and radiographic or echocardiographic
evidence of cardiac remodelling
C
Patients with current or past clinical signs of heart failure with structural CVHD. Some of
these will be presenting for the first time, some have relapsed following treatment hence
treatment may differ. Typically managed as outpatients.
D
Patients with clinical signs of heart failure with structural CVHD which are refractory to
“conventional” treatment or are “end stage”. Require hospital treatment.
ACVIM Consensus statement 2009
B2 - No consensus
•Monitor the progression of underlying disease looking for
clinical signs of exercise intolerance and coughing. Train
owner in recognising respiratory rate and look for an upward
trend that may indicate onset of congestive failure
•Ongoing clinical trial looking at whether there is an
indication for using drugs such as pimobendan at a stage
earlier than C.
HeartVets
ACVIM Consensus statement 2009
B2 - No consensus
•Difficult to determine a level at which drugs can be
introduced and difficult to run clinical trials to establish EBM
without a landmark other than clinical signs.
•Currently, 2D echocardiography or radiography are gold
standards in establishing the severity of disease but there is a
possible future role for proBNP measurement in addition to
radiography and echocardiography (studies are ongoing)
HeartVets
ACVIM Consensus statement 2009
B2 - No consensus
•ACE inhibitors are recommended by some cardiologists for
dogs with clinically relevant enlargement of the LA or
dramatic increase in the size of the LA
•A few ACVIM panellists considered the use of pimobendan,
digoxin, amlodipine, spironolactone, in general with a view
that additional data on efficacy and safety are needed
HeartVets
Benazepril drug data (BENCH)
% mortality rate in dogs treated with
benazepril or placebo (P< 0.05)
40
placebo
30
20
benazepril
10
0
0
10
20
30
40
days from start
50
60
HeartVets
IMPROVE study - Pulmonary oedema
% reduction in pulmonary wedge pressure in dogs treated with
ACE inhibitor or placebo, and standard treatment (P< 0.05)
60
ACE
inhibitor
50
40
placebo
30
20
10
0
day 2
day 20
HeartVets
SVEP trial
(Scandinavia, enalapril, not drug sponosred, CKCS only)
• Efficacy of enalapril for prevention of congestive heart failure in dogs
•
•
•
•
with myxomatous valve disease and asymptomatic mitral regurgitation.
Kvart C, et al J Vet Intern Med. 2002 16(1):80-8.
Multivariate analysis showed that enalapril had no significant effect
on the time from initiation of therapy to heart failure (P = .86).
When absence or presence of cardiomegaly at the entrance of the trial
was considered, still no differences between the treatment and placebo
groups (P = .98 and .51, respectively).
Long-term treatment with enalapril in asymptomatic dogs with MVD and
MR did not delay the onset of CHF regardless of whether or not
cardiomegaly was present at initiation of the study.
HeartVets
ICVS 08 Stockholm
Paul Pion: Evidence based review of survival
studies in Canine Myxomatous valve disease
Quotes of insight:
“Based on the current evidence provided by the
SVEP and VETPROOF trials, we believe that there is
adequate data to conclude that, prior to the onset of
CHF, we can discount ACE-inhibitors as the “silver
bullet”
HeartVets
HeartVets
•
The study compared Pimo vs Benazepril, this
does not mean that dogs don’t benefit from both
•
•
•
It doesn’t mean that they do either
But that’s what I do
It doesn’t mean that they don’t benefit from
mineralocortocoid blockers like spironolactone
HeartVets
Quotations from Mark Oyama
editorial JVIM Sept 08
•
Treatment of this highly prevalent condition
remains an immense challenge
•
Despite myriad advances in the diagnosis,
imaging, and pharmaceutics, morbidity and case
fatality rate of dogs with congestive heart failure
remain surprisingly high.
HeartVets
Quotations from Mark Oyama
editorial JVIM Sept 08
the ‘‘ideal’’ treatment of heart failure in dogs with
DMVD likely involves a combination of several
agents, some of which offer hemodynamic benefits (ie,
diuretics, positive inotropes, vasodilators)
and some of which (ie, ACE inhibitors, b-blockers,
and so on) tilt the balance of neurohormonal activity
toward a more favorable equilibrium.
HeartVets
Quotations from Mark Oyama
editorial JVIM Sept 08
• In cases where circumstances dictate an ‘‘either-or’’ approach
(ie, financial restraints, recalcitrant pets who are difficult to medicate),
the data from Haggstrom et al clearly favor the use of pimobendan.
• In all other cases of dogs with heart failure caused by DMVD, the
most reasonable course of action is combined therapy with pimobendan,
ACE inhibitor, and diuretics.
• Just how much greater effectiveness this combination might have over
the either-or approach requires further trials, but in the absence of these
data, there is every theoretic and practical reason to assume that these
agents retain their individual beneficial effects when co-administered.
HeartVets
Efficacy of Spironolactone on Survival in dogs with
naturally occurring mitral regurgitation caused by
Myxomatous Mitral Valve Disease.
Bernay, Bland, Haagstrom et al
Journal of Veterinary Internal Medicine 2010
214 dogs with mitral valve disease
• Exercise intolerance
• Dyspnoea, cough and/or syncope
• Evidence of mitral regurgitation on echocardiography
• Cardiomegaly on X-ray (VHS>10.5)
i.e. congestive heart failure cases
HeartVets
Efficacy of Spironolactone on Survival in dogs with
naturally occurring MR caused by MVD.
Bernay, Bland, Haagstrom et al Journal of Veterinary Internal Medicine 2010
• Double-blind
• Placebo controlled
• Continued for 15 months
• Dogs given:
ACE inhibitor +/- furosemide + placebo
or
ACE inhibitor +/- furosemide + Prilactone®
(Digoxin and L-carnitine also authorised)
HeartVets
Results
- Survival benefits:
• End point reached - 10.8% (Prilactone® group) versus 25.5%
•
(placebo group)
55% reduction in the risk of mortality in the spironolactone
group (p=0.017)
HeartVets
Spironolactone in CHF dogs
significant improvement in quality
of life in spironolactone group vs placebo
ACVIM Consensus statement 2009
B2 - No consensus
•Beta-blockers are not recommended by many cardiologists
but some are recommended for dogs with clinically relevant
enlargement of the LA or dramatic increase in the size of the
LA. A low dose is recommended with upward titration over a
one to two months
•Dietary changes with a highly palatable diet, mild sodium
restriction and adequate protein and calories recommended by
some cardiologists
HeartVets
Treatment of CDMVD with failure
Now general agreement that when CHF is present the following
have a strong case for use:
• Furosemide
• Pimobendan
• ACE inhibitors – no case for one vs another although price,
palatability and consistency are important
•
•
•
spironolactone
other decisions are owner management
client compliance is essential and education is required
HeartVets
ACVIM Consensus statement 2009
C2 acute – largely consensus
•Aim to mitigate heart failure by optimising preload, afterload,
heart rate and contractility to maintain cardiac output. Reduce
MR if possible:
•Furosemide. Wide range of doses (1-4 mg/kg) ranging from
oral to IV boluses or infusion. CRI recommended at
1mg/kg/hr for life threatening pulmonary oedema
(no EMB)
•Free access to water once diuresis has started
•Pimobendan 0.25 – 0.3 mg/kg every 12 hours
•Oxygen supplementation if needed
HeartVets
ACVIM Consensus statement 2009
C2 acute – largely consensus
•Drain effusions if affecting breathing
•Optimal nursing care
•Sedation if anxiety exacerbating dyspnoea (typically
narcotics with anxiolytics [eg, 0.0075-0.01 mg/kg
buprenorphine and 0.01-0.03 mg/kg ACP])
•CRI of sodium nitroprusside for up to 48 hours in dogs with
poorly responsive pulmonary oedema
HeartVets
ACVIM Consensus statement 2009
C2 acute – largely consensus
•ACE inhibition is clearly indicated in chronic therapy but no
definitive proof of efficacy in acute therapy, although it has
been shown to reduce pulmonary capillary wedge pressure
•Nitroglycerine 2 per cent ointment approximately _ inch per
10 kg every 12 hours for 24 to 36 hours (relative strength of
opinion is unclear)
HeartVets
ACVIM Consensus statement 2009
C2 chronic – largely consensus but different tricks
•Furosemide orally to effect, often 2mg/kg every 12 hours.
Wide range of doses (1-2 mg/kg every 12 hours to 4-6 mg/kg
every eight hours).
Doses in excess of these mean move to stage D.
•Pimobendan 0.25 – 0.3 mg/kg every 12 hours
•ACE inhibitor. Most panellists used enalapril at the upper
end of its published range (0.25-0.5 mg/kg every 24 hours)
HeartVets
ACVIM Consensus statement 2009
C2 chronic – largely consensus but different tricks
•Monitor creatinine
•No beta-blockers or nitroglycerine ointment
•Monitor weight, appetite, respiratory and heart rates at home
•Diet: accurately monitor weight, sustain calorific intake,
ensure adequate protein intake and avoid low-protein diets,
modestly reduce sodium intake (including treats and food use
to help give medication), monitor K+, address anorexia where
possible
HeartVets
ACVIM Consensus statement 2009
C2 chronic – different views
•Spironolactone, 0.25-2.0 mg/kg every 12 to 24 hours, (2.0
mg/kg every 24 hours with food; (licensed in Europe but not
in the USA). Mineralocorticoid blocker with no significant
diuretic effect
•Digoxin, 0.22 mg/m2 every 12 hours, aiming for eight-hour
post-pill plasma level of 0.8-1.5 mg/litre. Indicated in cases
with atrial fibrillation to reduce heart the rate. Some
cardiologists use digoxin in the absence of SV arrhythmia
provided that there is no contraindication (eg. raised creatinine,
ventricular ectopy, owner compliance)
HeartVets
ACVIM Consensus statement 2009
C2 chronic – different views
•Diltiazem to control the heart rate, especially in larger dogs
•Continued used of beta-blockers if used in stage B2
•Diet: monitor magnesium and add omega-3 fatty acids,
especially in dogs with arrhythmias, reduced appetite or
weight loss
•Cough suppressants eg codeine or inhaled steroids
•Bronchodilators eg theophylline
HeartVets
ACVIM Consensus statement 2009
D chronic – largely consensus
•Furosemide. Wide range of doses. Every eight hours
preferable to every 12, with SQ doses periodically (every 48
hours is useful). Dose may be titrated to the respiratory rate
measured at home, aiming for below 30 breaths per minute, or
increase the dose if there is a persistently increased rate
•Spiroloactone if not added at stage
•Do not add beta-blockers
HeartVets
ACVIM Consensus statement 2009
D chronic – different views
•Amlodipine or hydrochlorothoazine as an adjunct to
furosemide
•Increase pimobendan dose
•Digoxin for dogs with atrial fibrillation and to control the
heart rate
•Sildenafil 1-2 mg/kg every 12 hours
•Cough suppressants
•Bronchodilators
•Some cardiologists do not discontinue beta-blockers
•Beta-blockers to control rate (care)
HeartVets
ACVIM Consensus statement 2009
Table
1
Stage
A
Guidelines for the diagnosis of CHCV
Criteria
At risk but no evidence of disease (eg predisposition of breed such as CKCS). No murmur
B1
Asymptomatic – have murmur of MR resulting from CVHD but have no radiographic or
echocardiographic evidence of cardiac remodelling
B2
Asymptomatic – have murmur of MR resulting from
CVHD and radiographic or echocardiographic
evidence of cardiac remodelling
C
Patients with current or past clinical signs of heart failure with structural CVHD. Some of
these will be presenting for the first time, some have relapsed following treatment hence
treatment may differ. Typically managed as outpatients.
D
Patients with clinical signs of heart failure with structural CVHD which are refractory to
“conventional” treatment or are “end stage”. Require hospital treatment.
The EPIC Scientific Objective
Study Objective:
To determine whether chronic oral
administration of pimobendan in dogs with
evidence of increased heart size secondary
to preclinical myxomatous mitral valve
disease, can delay the onset of signs of
congestive heart failure.
HeartVets
Enrolment into EPIC
•
•
•
•
•
•
6 years of age or older
4.1-15 kg
No other significant disease
No previous treatment with cardiac drugs
Have a loud heart murmur
Have cardiomegaly (VHS > 10.5, echo LA:AO
> 1.6:1). LVDd Cornell formula > 1.7
• Not be in CHF
HeartVets
What happens in EPIC
•
•
•
•
•
•
client questionnaire
physical exam
basic blood tests
blood pressure
echocardiogram (LA:AO, LVDd, TR velocity)
Chest radiographs
HeartVets
What happens in EPIC
• 1 month, 4 months and every 4 months
• primary end-point CHF (proven by radiographs)
• secondary end-point death
• free exams, placebo/Vetmedin (blinded)
• free Vetmedin after the trial (but not other drugs
or investigations)
HeartVets
Significance of EPIC
EPIC is the largest prospective cardiology study ever
conducted in dogs:
•
•
•
•
360 dogs
36 centres
11 countries
4 continents
Bailey, a 6 year old MN Boxer
•
•
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•
•
•
two episodes of syncope during excitement
some exercise intolerance
rapid sometimes irregular rhythm
some weight loss
grade 2/6 left basal ejection murmur
quiet gallop sound
no cough
HeartVets
Bailey, a 6 year old MN Boxer
HeartVets
Treating of DCM
DCM
– arrhythmias are common in DCM but are often intermittent
variable and multiple
• quiet heart sounds, +/- murmur, +/- gallop
• weak apex beat and weak pulse
• breed predispositions
• many have arrhythmias, SVT or VT
• some have ascites
HeartVets
Bailey, a 6 year old MN Boxer
HeartVets
Bailey, a 6 year old MN Boxer
SVT
rate 220
3 sec
Bigeminal
VPCs
Instantaneous
rate 130
6 sec
NSR
rate 130
HeartVets
Bailey, a 6 year old MN Boxer
HeartVets
Bailey, a 6 year old MN Boxer
2 months later Bailey developed a chaotic rhythm
HeartVets
Treatment of DCM - negative chronotropes
•
•
•
what is the real rate – Holters very useful
arrhythmia or sinus tachycardia
control CHF may be sufficient. Do this first and then
re-evaluate unless tachycardia is severe
Treatment of DCM:
•
•
•
•
•
diuretics - if there is CHF
pimobendan
ACE inhibitors
negative chronotropes / antiarrhythmics
• digoxin
Is there output failure?
• diltiazem
• propanolol
• sotalol / amiodarone
dietary supplements
HeartVets
Treatment of DCM - negative chronotropes
• I sometime use diltiazem in big dogs with AF and a
rate that is too high when on digoxin
•
I sometime use sotalol when the rate is too high,
systolic function is OK, and there is a ventricular
arrhythmia
• I use Amiodarone for selected cases with terrible
systolic function and VT but it is a tricky drug to use
HeartVets
Bailey, a 6 year old MN Boxer - Treatment
but what disease are we calling this ?
• Boxer cardiomyopathy, ARVC (arrhythmogenic
right ventricular cardiomyopathy,
cardiomyopathy)
• Focus on dog’s problems
• – systolic/diastolic failure, CHF, arrhythmias
• What evidence based medicine have we got for
treating these dogs
HeartVets
Which of the following are of proven
benefit in canine DCM:
1.
Omega 3 supplements
2.
carnitine
3.
Taurine
4.
low salt diet
5.
homeopathy
6.
very dilute extract of dragon tongue
No EBM for my
view or others
HeartVets
When do dogs develop DM?
Pre-clinical phase
• Probably lasts 1-2 years
• No clinical signs
• Sudden death (25-30% of affected dogs)
• ? what benefit to identifying, should we treat these
• ? how best to screen these cases
• echo, Holter, biomarkers, standard ECG,
radiography
HeartVets
Pimobendan randomised occult DCM trial to
evaluate clinical symptoms and time to heart failure
Study Hypothesis
That the administration of pimobendan to Doberman
Pinschers with occult dilated cardiomyopathy will delay
the onset of heart failure and in doing so, prolong the
period between diagnosis and the death of the patient
HeartVets
• No previous prospective study has evaluated the
•
•
•
effectiveness of any medication for the treatment of
preclinical DCM in the Doberman
Pimobendan treatment has been proven to significantly
reduce mortality and morbidity in Dobermans with CHF
secondary to DCM
There is reason to believe some of the known effects of
pimobendan could be of benefit in the preclinical stage of the
disease
The potential benefit of pimobendan therapy in delaying the
progression of preclinical DCM in Dobermans has not
previously been evaluated
HeartVets
Protocol Design
• The trial protocol was prepared by independent cardiologists in
conjunction with the sponsor and was approved by an ethical
review committee at all sites where this was required
• The contract between the sponsor and the investigators
stipulated that the latter group have full access to all results and
the right to independently publish regardless of the trial
outcome
HeartVets
The study
Results
•the data show that treating Dobermans with pre-clinical DCM
with Vetmedin results in several months longer to onset of heart
failure or death compared to dogs left untreated.
•Look out in JVIM for publication hopefully in the next few
months
HeartVets
Preclinical cardiomyopathy?
How should we screen ?
•
•
•
•
•
•
Auscultation
Biomarkers
Echocardiography
ECG
Holter ECG
Radiography
HeartVets
Feline Cardiology
Myocardial diseases classified as:
• Hypertrophic cardiomyopathy (HCM)
•
•
•
•
•
•
Dilated cardiomyopathy (DCM)
Restrictive cardiomyopathy (RCM)
Unclassified cardiomyopathy (FUCM)
Moderator band cardiomyopathy (MBCM)
Arrhythmogenic right ventricular cardiomyopathy (ARVC)
Endomyocardial fibroelastosis
HeartVets
Feline Cardiology
• Why do we classify
•
diseases?
Pathological
documentation
Structural description
•
• To aid treatment
• To aid prognostication
HeartVets
Feline Cardiology
Be clear about definitions
Why do we chose a drug ?
what is our rationale based on?
• evidence based medicine
• what we were taught
• what happened last time
• who I spoke to last
• what I read last
• personal experience
• what drugs I have available
• cost
HeartVets
Cat the owner give the cat tablets?
Feline Cardiology
Myocardial diseases could be classified as:
• I can hear a murmur / gallop / arrhythmia but the echo
looks pretty normal to me
• I can hear a murmur / gallop / arrhythmia but the echo
looks a little bit odd
• Wow that’s a thick left ventricle
•
•
•
Gosh what a massive left atrium
Gee, it’s got a pericardial effusion / pleural effusion too
oh deary me ! there is a bloody great thrombus in the LA
HeartVets
Feline Cardiology
Myocardial diseases can be difficult to classify:
• “fortunately strict echocardiographic characterisation of the
type of cardiomyopathy may be less valuable for prognosis
than other echocardiographic factors”
Virginia Luis-Fuentes BSAVA 2011
classify on a functional basis
•
•
•
•
is there a big enough LA for failure to be possible
is there evidence of diastolic dysfunction?
is there evidence of systolic dysfunction?
what is the rate and rhythm?
HeartVets
Treatment of Feline Cardiomyopathy
Options
•
•
•
•
•
•
diuretics
beta blocker (atenolol)
calcium channel blocker (diltiazem)
ACE inhibitors
positive inotropes (pimobendan)
anticoagulants
– aspirin 30-75 mg every 2-3 days, clopidogrel _ x 75 mg sid
HeartVets
Feline Cardiology
What I do next:
Murmur, gallop or arrhythmia but marked
hypertrophic changes
• Check T4, blood pressure, renal parameters
• if no failure, marked LVH +/- outflow obstruction
and no LA enlargement I prescribe atenolol
• No LVH do nothing but repeat scan in 3 months
HeartVets
Feline Cardiology
What I do next:
tachyarrhythmias / bradyarrhythmias
• Echo and assess as before
• Check full biochemistry, electrolytes, T4, blood pressure,
urine s.g.
• if no failure I prescribe atenolol for tachyarrhythmias
(either supraventricular or ventricular)
• If failure and supraventricular I use diltiazem
• For bradycardias treat underlying disease and consider
treatments such as beta-agonists (eg terbutolene) or
pacemaker only if symptomatic
HeartVets
Feline Cardiology
What I do next: (all without evidence of CHF)
• mild LA enlargement:
• Add benazepril but not aspirin
• +/- frusemide if in failure
• moderate / severe LA enlargement
• add aspirin and withdraw atenolol
• humungous LA enlargement
• add clopidogrel (18.75 mg ie _ x 75 mg PO q 24 hours)
• withdraw atenolol
HeartVets
Feline Cardiology
What I do next: :
• congestive heart failure
• frusemide
• +/- spironolactone
• benazepril
• stop atenolol
• consider whether diltiazem is practical and try to manage
•
•
without it
usually have LA enlargement therefore I use aspirin
consider use of clopidogrel
HeartVets
Feline Cardiology
What I do next:
• Pleural effusion
• Drain if dyspnoeic
• make sure that CHF is the cause
• company it keep
• cytology / bioch on fluid
• other lab data
• Treat as for CHF
Feline Cardiology
What I do next:
• Systolic failure
• often these are RCM and FUCM cases rather that
•
•
clear DCM
• changes may be subtle and dyskinetic, furthermore
FS% can be difficult to interpret (one dimensional)
• LA usually large and are at risk of CHF
I add pimobendan at 0.75 -1.25 mg bid per cat.
This is off licence.
I also use pimo when I have run out of options in CHF
HeartVets