https://doi.org/10.1111/jvim.15126 Dogs that were hospitalized on the day of diagnosis of advanced heart failure had a shorter survival time (median survival=163 days [range 3464 days]; compared to dogs treated as outpatients (median survival=318 days [range, 9885 days]; P=.011; Figure Figure22 Date of death was recorded. The variability in doses was related to disease severity and clinical signs, as well as the wide range in number and types of medications each dog was receiving. Although the ACVIM Consensus Statement did not reach agreement on spironolactone and recommended a furosemide dose 6 mg/kg q12h to identify dogs in Stage D heart failure, the authors of our study rarely allow the furosemide dose to rise above 4 mg/kg/day before adding in additional drugs, such as spironolactone or an offlabel dose of pimobendan. Guidelines for the diagnosis and treatment of canine chronic valvular heart disease. J Vet Intern Med. The relatively small number of cases also limited the statistical power to find other potential associations with survival. How are the dogs appetite and activity level? In general, dogs with heart enlargement are at greater risk for heart failure, but only 30% of dogs with asymptomatic DMVD develop clinical signs and require heart failure therapy. There is pulmonary venous enlargement (arrow) and an interstitial pattern consistent with pulmonary edema as evidence of CHF. This complex pathophysiology leads to increased: DMVD is the most common acquired heart disease in dogs. Our study has a number of important limitations that must be considered. Congestion and pulmonary edema (left-sided heart failure). Scenario 2demonstrating increased heart and respiratory rates compared with Scenario 1is consistent with CHF in this coughing dog with a heart murmur. The most common breeds represented were cavalier King Charles spaniel (n=9), Dachshund (n=5), Chihuahua (n=5), Shih Tzu (n=5), Maltese (n=4), Havanese (n=2), Papillon (n=2), Pomeranian (n=2), and Miniature Schnauzer (n=2). To describe clinical findings and outcome of dogs with advanced heart failure caused by degenerative mitral valve disease (DMVD). Historical review, epidemiology and natural history of degenerative mitral valve disease. Sonya G. Gordon, DVM, DVSc, DACVIM (Cardiology), is an associate professor of cardiology in the Department of Small Animal Clinical Sciences at Texas A&M University College of Veterinary Medicine and Biomedical Sciences where she is part of a busy progressive cardiology program. In human patients with advanced heart failure, several studies have reported a negative association between a higher dose of loop diuretics and survival.10, 11, 12 In addition to being in a different species, other study design differences make direct comparison with this study difficult. The highest BUN, creatinine, and potassium concentration, and the lowest potassium, sodium, chloride, albumin, and hematocrit after the diagnosis of advanced heart failure were also recorded and the number of dogs with abnormalities for each analyte was determined. How long has the cough or respiratory signs been present? Radiographs can also indicate bronchial compression due to an enlarged left atrium and rule out alternate diagnoses, such as pneumonia or pulmonary neoplasia. For study purposes, advanced heart failure was defined as recurrence of congestive heart failure signs despite receiving the initially prescribed dose of pimobendan, angiotensinconvertingenzyme inhibitor (ACEI), and furosemide >4 mg/kg/day. Effects of enalapril maleate on survival of dogs with naturally occurring acquired heart failure. Three dogs had both a medication addition and an increase in the pimobendan dose. See, A rapid heart rate, most often a sinus tachycardia (. Dogs receiving a total daily dose of furosemide 4 mg/kg/day while receiving pimobendan and an ACEI with recurrent signs of congestive heart failure were included only if the total daily dose of furosemide was increased to >4 mg/kg/day, and if either at least 1 additional cardiac medication was introduced or if the dose of pimobendan was increased to an offlabel dose. Mainstem bronchial compression (arrow) was documented. This could suggest that dogs requiring hospitalization for advanced heart failure have more severe or advanced disease. Abnormalities that support CHF include: During initial presentation for coughing or decreased exercise tolerance, radiographs are the best way to confirm presence of venous congestion and pulmonary edema. Consider the following scenario: An 8-year-old castrated male bichon frise has a 6-month history of exercise-induced cough and a grade 3/6 systolic left-sided heart murmur. Cough is a common complaint that does not necessarily indicate heart failure. Akshay S, et al. Ruiz D, Median body weight was 6.7 kg (range, 2.468.3 kg) and median body condition score was 5 (range, 28; Table 1). Kapelios C, At the time of analysis, 37 dogs had died and 17 were still alive; no dogs were lost to followup. Advanced heart failure was defined as the persistence of congestive heart failure despite a daily dose of furosemide >4 mg/kg/day, a recommended dose of pimobendan (0.50.6 mg/kg/day), and a maximally tolerated dose of ACEI. Yang VK, Severo M, Body weight, body condition score, and muscle condition score in 54 dogs with advanced heart failure secondary to DMVD. The signalment, combined with a heart murmur and cough, suggests that heart failure is possible; however, additional information from the history, physical examination, and diagnostic tests is needed to confirm whether the diagnosis is CHF. An official website of the United States government. Body weight and body composition changes also were common in this population of dogs with advanced heart failure. Degenerative mitral valve disease (DMVD) or chronic valvular disease is the most common canine acquired heart disease in dogs, and often leads to congestive heart failure.1 Although other classification systems have been used to stratify the severity of disease, the 2009 ACVIM Consensus Statement on the diagnosis and treatment of DMVD provided a new system which has been incorporated into practice.1 In this 4stage system, dogs with DMVD with endstage disease and clinical signs of congestive heart failure that are refractory to standard therapy (ie, furosemide, an angiotensin converting enzyme inhibitor [ACEI], and Pimobendan, [Vetmedin, Boehringer Ingelheim Vetmedica, Inc, St. Joseph, Missouri]) were classified as Stage D heart failure. In a dog with a good appetite and normal activity level, a chronic, harsh cough that ends with a gag is less likely to be associated with heart failure. Median survival time after diagnosis of advanced heart failure was 281 days (range, 3885 days). Torres O, Defining advanced heart failure: a systematic review of criteria used in clinical trials, Advanced (Stage D) heart failure: a statement from the Heart Failure Society of America Guidelines Committee. However, the owner remembered that the dog had a murmur as a puppy. Medical records for all eligible dogs were reviewed. Freeman LM. Fiftyfour dogs (29 male [27 castrated], 25 female [all spayed]) met the study inclusion criteria. Stay current with the latest techniques and information sign up below to start your FREE Todays Veterinary Practice subscription today. Multiple medication changes were made at the time of diagnosis of advanced heart failure, with 85% having dose adjustments and 76% having new medications added. Enalapril was the most commonly used ACEI (n=50), followed by benazepril (n=3), and lisinopril (n=1). The median number of reevaluations after diagnosis of advanced heart failure was 1 (range, 0 30). Laboratory abnormalities found after the diagnosis of advanced heart failure, based on the dogs' highest or lowest recorded value, included increased BUN concentration (35/43; 81%), hypochloremia (31/41; 76%), hyponatremia (18/41; 44%), hypokalemia (15/41; 37%), increased creatinine concentration (10/43; 23%), anemia (7/35; 20%), and hyperkalemia (0/41; 0%). Lead II electrocardiogram demonstrating sinus tachycardia with a regular rhythm and heart rate of 175 beats/min in a dog with CHF (25 mm/s; 10 mm/mV). Learn more Exercise restriction was recommended for 33 dogs. Atkins C, Bonagura J, Ettinger S, et al. Harpster NK, et al. Muscle condition score was recorded in 42 dogs, with 29/42 dogs (69%) having some muscle loss recorded and 5/42 dogs having severe muscle loss (Table 1). DCM is a primary disease of the heart muscle, characterized by a relatively long asymptomatic stage (12 years) followed by sudden death (due to arrhythmias) or heart failure. Received 2017 Aug 31; Revised 2018 Feb 21; Accepted 2018 Mar 5. The new PMC design is here! It is unclear whether the azotemia was prerenal secondary to diuretic therapy, because of worsening heart disease and reduced cardiac output, or the result of primary renal disease. Varney S, et al. A singlecentre analysis. Wasting as independent risk factor for mortality in chronic heart failure, Nutritional alterations and the effect of fish oil supplementation in dogs with heart failure, http://creativecommons.org/licenses/by-nc/4.0/. Nonetheless, these findings could assist clinicians during communications regarding prognosis with owners of dogs with advanced heart failure because of DMVD. With good management, many dogs with progressive heart failure can have a good quality of life as well as improved survival times. Are there other signs of potential heart disease, including a gallop or arrhythmia? Overall, medication doses were adjusted in 46 dogs (85%) at the time of diagnosis of advanced heart failure and medications were added to the regimen in 41 dogs (76%). Prevalence of dilated cardiomyopathy in Doberman Pinschers in various age groups. Following progressive enlargement of the left atrium, a cough from mainstem bronchial compression can develop before heart failure, and persist after initiation of heart failure therapy. Prescription of other cardiac medications such as spironolactone, amlodipine, torsemide, or sildenafil before the date of the first recurrent episode of heart failure was permitted although dogs were classified in advanced heart failure only once they had recurrent congestive heart failure despite having been on these medications in addition to the previously described combination of furosemide (>4 mg/kg/day), pimobendan, and ACEI (ie, dogs that were receiving these other medications but were not receiving >4 mg/kg/day of furosemide were not enrolled). Following are 6 practical tips for optimizing heart failure diagnosis and management in dogs. Right lateral thoracic radiographs in 2 dogs with DMVD and radiographic cardiomegaly, including left atrial enlargement (LA): A 14-year-old shih tzu (A) was receiving heart failure medications (enalapril, furosemide, pimobendan), but still had a chronic, harsh cough that had been present for several months despite administration of cardiac drugs. Heart failure in dogs is a complex condition, but successful management is possible. The diagnosis of congestive heart failure was based on the presence of clinical signs, such as ascites attributed to DMVD, radiographic evidence of pulmonary edema or pleural effusion, or responsiveness to escalation of drug number or dose in dogs with prior documented pulmonary edema or ascites and recurrent dyspnea. Ponikowski P, The dog had a good appetite and activity level, with an at-home resting breathing rate of 24 breaths/min. Owners or primary care veterinarians were contacted if no information was available in the medical record regarding the dogs' outcome. Dogs receiving a total daily dose of furosemide 4 mg/kg/day while receiving pimobendan and an ACEI with recurrent signs of congestive heart failure were included only if the total daily dose of furosemide was increased to >4 mg/kg/day, and if either at least 1 additional cardiac medication was introduced, or if the dose of pimobendan was increased to an offlabel dose. Depending on the specific disease process, it can affect the left and right sides of the heart, manifesting in respiratory signs and weakness due to: While the underlying heart disease can vary depending on age and breed, chronic heart failure management for degenerative mitral valve disease (DMVD) and dilated cardiomyopathy (DCM) initially relies on a combination of a diuretic, angiotensin-converting enzyme (ACE) inhibitor, and pimobendan, with additional medications added as necessary. Borgarelli M, Buchanan JW. Another limitation is the retrospective nature of our study, so not all information was available for all dogs at the same timepoints. Is there a history of heart disease in a relative or littermate? Benitz A, Cummings School of Veterinary Medicine at Tufts University, Clinical findings and survival time in dogs with advanced heart failure. Therefore, they might not be representative of the general population of dogs with advanced heart failure since the treatment of these challenging cases can vary among different clinicians. The number of medications added varied: 1 medication added (n=33), 2 medications added (n=6), 3 medications added (n=1), and 4 medications added (n=1; Table 2). While only 33% of dogs were hospitalized at the time of diagnosis of advanced heart failure, this was associated with a shorter survival time compared to dogs that were treated as outpatients. This accounts for the high end of the dosage range shown in Table 2. FOIA This included increases or decreases in the medication dose, addition of medications, and, in some cases, discontinuation of medications. See, Does the history of clinical sign progression support heart failure? As a result of our deviation from the ACVIM Consensus definition of Stage D heart failure, we felt that avoiding the term Stage D heart failure and using a more general term of advanced heart failure would be more accurate. Echocardiography can also identify anatomic abnormalities and assess function, but it cannot specifically diagnose the presence of CHF. Factors contributing to the euthanasia decision in dogs with congestive heart failure. The https:// ensures that you are connecting to the Higher furosemide dose and nonhospitalization were associated with longer survival. It is useful to ask the following questions about a cough: FIGURE 1A. , Electrolyte concentrations are affected by ACE inhibitors and diuretics. Advanced heart failure is challenging to manage because of the complexity of treatment, the systemic impact of cardiac medications, and important issues such as cost of care, quality of life, and individual owner preferences. 2018;32:944950. Periodic biochemistry monitoring is important in dogs receiving diuretics and ACE inhibitors or those with comorbid conditions, such as kidney disease. She is routinely an invited speaker at local, national and international veterinary meetings. Case #2: Consider the case presented in A Case to Consider abovethe 8-year-old castrated male bichon frise with 6-month history of exercise-induced cough and a grade 3/6 systolic left-sided heart murmur, whose owner reported coughing during the night and labored breathing. Dogs were eligible for inclusion in this retrospective study if they had been evaluated by the Cardiology Service at the Cummings Veterinary Medical Center at Tufts University between January 2010 and February 2016, were diagnosed with DMVD, and had advanced heart failure. Thus, we defined advanced heart failure as the recurrence of congestive heart failure despite a daily dose of furosemide >4 mg/kg/day, a recommended dose of pimobendan (0.50.6 mg/kg/day), and a maximally tolerated dose of ACEI. The number of dogs and the ultimate dosage of medications are shown in Table 2. Incidence of DMVD in Cavalier King Charles spaniels increases with age but, in general, DMVD occurs at a younger age in this breed compared with other breeds. Additional information from clinical trials continues to become available. Although not all cardiologists will agree on our definition, we hope that these results from dogs with advanced heart failure provide a first step towards optimizing treatment for this population. Muscle condition (n=24) was scored as normal (n=11), mild muscle loss (n=11), or moderate muscle loss (n=2; Table 1). HHS Vulnerability Disclosure, Help Identifying an individual dogs type of heart disease helps guide assessment and treatment recommendations. She has published numerous manuscripts and book chapters and co-authored a practical small animal clinical cardiology book entitled The ABCDs of Small Animal Cardiology.
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