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Chasing fluid away case reportMr Jordi Lpez-Alvarez LltVet
MRCVSResident in Internal Medicine (Cardiology)
Small Animal Teaching Hospital, University of LiverpoolLeahurst,
Chester High Road, NestonCheshire CH64 7TE, United Kingdom
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Presentation: June 2009FLOYD
4 yo GSD NM
Referred for tachycardia (non-responsive to lidocaine)
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Anamnesis:Progressive (over 1 month):exercise
intolerancetachypnoea
No history of previous illnesses was reportedUp-to-date with
worming and vaccinationsPresentation: June 2009
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Physical examination:36.4 kgTachypnoea (44 rpm)Mild abdominal
distension with fluid thrillPositive hepatojugular refluxChaotic
rhythm and rate at 240 bpmMarked pulse deficits at 100/minVariable
2-3/6 left apical systolic murmurPresentation: June 2009
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Diagnostic work-upHaematology and biochemistry: NAD
Cardiac troponin I: 1.18 ng/mL (ref. value
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Electrocardiography
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Thoracic X-rays
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Doppler echocardiography
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Doppler echocardiography
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DiagnosisMyxomatous degenerative valvular disease1secondary
myocardial failureatrial fibrillationcongestive heart failure1
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.
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Diuresis: sequential nephron
blockadeACEiPimobendanSpironolactoneOthers: antiarrhythmics,
afterload reduction...
CHF Treatment
- TreatmentHospitalisation over the week-end:IV furosemide q 2-4h
(until RR
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Sequential nephron blockadeSodium 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)
Na2ClNaNaClNaKLoopdiureticsAldosteroneinhibitorsThiazides
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SpironolactoneWeak diuretic effectAnti-aldosterone:Potassium
sparing effectAnti-remodellingReduces cardiac morbidity and
mortality22 Bernay F, Bland JM, Hggstrm 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.
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Torasemide vs. FurosemideLonger half life (6h vs 4h)More potent
diuretic effectAnti-aldosterone:Potassium sparing
effectAnti-remodellingBetter oral absorption (absorption of
furosemide but not torasemide is delayed in CHF)No Clinical trials
in Veterinary medicine
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Furosemide 2 mg/kg QIDSpironolactone 1 mg/kg
SIDHydrochlorthiazide + Amiloride 0.5 mg/kg BIDTorasemide 0.25
mg/kg BIDCHF Treatment
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DIGOXIN+/- DILTIAZEMRecommendation:0.003 mg/kg BID and check the
trough levels 1 week afterLab ref: 1.0 - 2.4Aimed levels 0.5
1.2RATE vs RYTHM Control
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AMLODIPINEDihydropyridine class calcium channel
blockerPeripheral vasodilation antihypertensiveAo = 50%MR = 50%Ao =
80%MR = 20%Risk If hypotension:TachycardiaRAAS activation
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Palliative abdominocentesis
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Respiration rate at homeBody weight!!Biochemistry: renal
function?Holter monitor: rate control?Radiographs: Left
Side-CHF?Echo: Pulmonary hypertension
Monitoring
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Monitoring
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ConclusionsOwner commitmentQuality vs. Quantity of LifeAdequate
monitoringPathophysiology and therapeutics knowledge
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Thank you!
