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

Presentation: June 2009

FLOYD

4 yo GSD NM

Referred for tachycardia (non-responsive to lidocaine)

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

Electrocardiography

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1716 1918 20

Thoracic X-rays

Doppler echocardiography

Doppler echocardiography

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

Palliative abdominocentesis

Respiration rate at home

Body weight!!

Biochemistry: renal function?

Holter monitor: rate control?

Radiographs: Left Side-CHF?

Echo: Pulmonary hypertension

Monitoring

Monitoring

cTroponin I Abdominocentesis Digoxin Holter

Conclusions

Owner commitment

Quality vs. Quantity of Life

Adequate monitoring

Pathophysiology and

therapeutics knowledge

Thank you!