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Chasing fluid away…Chasing fluid away…case reportcase report
Mr Jordi López-Alvarez LltVet MRCVSResident in Internal Medicine (Cardiology)
Small Animal Teaching Hospital, University of LiverpoolLeahurst, Chester High Road, NestonCheshire CH64 7TE, United Kingdom
Anamnesis:
Progressive (over 1 month):exercise intolerance
tachypnoea
No history of previous illnesses was reported
Up-to-date with worming and vaccinations
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
Presentation: June 2009
Diagnostic work-up
Haematology and biochemistry: NAD
Cardiac troponin I: 1.18 ng/mL (ref. value <0.15)
Blood pressure: 150 mmHg
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.
Diuresis: sequential nephron blockade
ACEi
Pimobendan
Spironolactone
Others: antiarrhythmics, afterload
reduction...
CHF Treatment
Treatment
Hospitalisation over the week-end:
IV furosemide q 2-4h (until RR<40bpm)
Rate control: digoxin and diltiazem
At dischargeCHF:
Furosemide 1.5 mg/kg TID
Pimobendan 0.3 mg/kg BID
Benazepril 0.5 mg/kg SID
Spironolactone 1 mg/kg SIDRate control:
Digoxin 0.125 mg/dog BID (0.003 mg/kg BID!!)
Diltiazem 2 mg/kg TID
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)
Na2Cl
Na
NaCl
NaK
Loopdiuretics
Aldosteroneinhibitors
Thiazides
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.
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
Furosemide 2 mg/kg QID
Spironolactone 1 mg/kg SID
Hydrochlorthiazide + Amiloride 0.5 mg/kg
BID
Torasemide 0.25 mg/kg BID
CHF Treatment
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
RATE vs RYTHM Control
AMLODIPINE
Dihydropyridine class calcium channel blockerPeripheral vasodilation antihypertensive
Ao = 50%
MR = 50%
Ao = 80%
MR = 20%
• Risk
If hypotension:• Tachycardia
• RAAS activation
Respiration rate at home
Body weight!!
Biochemistry: renal function?
Holter monitor: rate control?
Radiographs: Left Side-CHF?
Echo: Pulmonary hypertension
Monitoring
Conclusions
Owner commitment
Quality vs. Quantity of Life
Adequate monitoring
Pathophysiology and
therapeutics knowledge