CVCA-Cardiac Care for Pets 2/3/2019 Feline Diagnostics (there is no one Update on the Treatment of good test in the cat…) CHF in the Cat and Dog • Good history – Signalment – BNP/SNAP test Bill Tyrrell, DVM, DACVIM- – Stressful event? cardiology – Depo? VVMA VVC February 2019 – Thyroid status? 1 4 Agenda Physical Examination: Auscultation • Murmur = Pay attention • Feline CHF – Diagnosis – 43% of control cats and 80% of cats with occult disease – Treatment had murmurs – Prognosis and Complications – 2x probability of HCM (JVIM 2011) • Canine • Arrhythmia and Gallop = Concern – Diagnosis/Point of care US – Treatment - Risk of cardiac related death – Prognosis and Complications - Hazard ratio 1.8 – Gallop • Cases - Hazard ratio 3.2 – Arrhythmia ( JVIM 2013) 2 5 Cardiac Auscultation: Tips Congestive Heart Failure • Take your time • Adequately restrain • Clinical syndrome from a • Minimize panting, growling, purring structural or functional disorder • Focus on heart sounds first, then breath sounds • Develop a consistent and repeatable pattern that impairs the ventricle’s • Listen for 3rd heart sounds (clicks vs. gallops) ability to either eject or fill with • Consider the signalment of the patient blood. – Common things happen commonly – Congenital vs. Acquired – Breed-specific defects 3 6 Bill Tyrrell, DVM, DACVIM-cardiology 1
CVCA-Cardiac Care for Pets 2/3/2019 Feline Chest Radiographs: Quick Seemed fine yesterday… Review • VHS L 4 5 6 7 8 9 10 6.7-8.1 (mean 7.5) • JAVMA 2013: VHS > 9.3 is likely cardiac cause for dyspnea ( N= 7.5) 7 10 Cat in a Box Radiograph Trick Rule Outs: Feline • Causes of Dyspnea (Big 3) – CHF – Asthma / Inflammatory bronchial disease – Pneumonia/infectious • Pleural effusion – R or L sided (parietal vs. visceral) – R/O Neoplastic • CHF Pulmonary Infiltrates – Cardiomegaly – Diffuse and variable 8 11 We have diagnosed heart DIAGNOSTICS disease…now what?...therapy in feline acute CHF • PE • Treat pulmonary edema and/or pleural effusion – O2 support (cage vs. nasal canula) • Rads – Furosemide (2-4 mg/kg) IM vs. IV – Thoracocentesis • +/- ECG • Maintain BP/CO – Pimobendan 0.25-.03 mg/kg PO BID • Labwork incl. T4 – Dobutamine CRI 1-5 mcg/kg/min • Unlikely as needed adjunctive Meds: • NT-ProBNP – Sedation – Butorphanol 0.2 mg/kg – Nitroprusside CRI 0.5 – 2 mcg/kg/min 9 12 Bill Tyrrell, DVM, DACVIM-cardiology 2
CVCA-Cardiac Care for Pets 2/3/2019 Worst case scenario? Supportive Care is Crucial to Survival • Silent/occult cardiomyopathies • Heat • NE tube • 250 FATE cases • Anti-thrombotics – Only 11% had previous diagnosis of heart disease – Heparin vs. Clopidogrel • JVIM 2013 • Basic monitoring • Mirtazapine/Cerenia, etc. • No IV fluids 13 16 FATCAT study– Plavix/Clopidogrel vs. In Hospital Monitoring ASA • BP – q 6 hours, q 1hr if hypotensive • Prospective, 72 cats – 50% ASA/50% Plavix • Looked at cats that had survived FATE • Renal panel with lytes q 24 hours • On Plavix, MST 443 days • Rads q 24-48 hours. • On ASA, MST 192 days • Individualize • Body temperature MST progression 500 400 300 200 100 0 MST 14 17 New Generation Anti Xa Drugs Prognosis of CHF and Cats • Xarelto (rivaroxaban) 2.5 mg SID PO per cat • Eliquis (apixaban) (BID dosing) • Hypotensive + Hypothermic + Dehydrated = – VERY EXPENSIVE MEDS! Poor Prognosis – Need NE tube for caloric and rehydration needs • Cats that do not respond to standard therapy = Poor Prognosis – Cats are more sensitive to CRI – Nitroprusside can be very useful (if BP is normal) 15 18 Bill Tyrrell, DVM, DACVIM-cardiology 3
CVCA-Cardiac Care for Pets 2/3/2019 Questions ? Other Meds While in Hospital? • ACE inhibitor? • Spironolactone? 19 22 Chronic monitoring Case: Tut • 12 year old MC DSH • Blood pressure, chem +/- T4 and +/- rads in 2 • 11 lbs. weeks and then every 4-6 months • Off for the past 2-3 weeks with slight decreased • Appetite, vomiting, maintain body weight appetite • PE – New arrhythmia/gallop/loss of murmur • Presented to neighboring ER with dyspnea • At home RR monitoring • Transferred to our ER for further therapy and diagnostics • Normal renal values from ER 20 23 Take Home Feline Pearls Physical Examination • Thoracocentesis • Heart/breath sounds muffled bilaterally • Judicious Lasix (Start at 2 mg/kg parenteral) • Increased WOB • NE tube • HR 220 with extrasystolic beats • Pimobendan • Gallop • Clopidogrel • No murmur • ACE inhibitors are not intended for acute tx • T nodule 21 24 Bill Tyrrell, DVM, DACVIM-cardiology 4
CVCA-Cardiac Care for Pets 2/3/2019 Echo Radiographs 25 28 Echo 26 29 Echo EKG 27 30 Bill Tyrrell, DVM, DACVIM-cardiology 5
CVCA-Cardiac Care for Pets 2/3/2019 Echo Discharge/At Home Therapy • Pimobendan 1.25 mg PO BID(0.25-0.3 mg/kg bid) • Methimazole 2.5 mg PO BID • Furosemide 10 mg PO TID for 3 days, then decrease to BID provided doing well • Clopidogrel 18.75 mg PO (Total dosage) • In 4-5 days, titrate Benazepril up to 2.5 mg PO SID (0.5 mg/kg SID) 31 34 Treatment—In Hospital Further Recommendations • Thoracocentesis • Owner to monitor resting RR/RE at home • Lasix 2 mg/kg IV TID • Recheck CBC/Chem/T4 in 2-3 weeks • Pimobendan 0.25-0.3 mg/kg PO BID • Recheck echocardiogram in 4-6 months – Often use TinyTabs/Compressed Tabs for cats • Prognosis? • Clopidogrel 18.75 mg total PO 32 35 Canine CHF Other Diagnostics • T4=6.0 • Repeat renal/lytes—all WNL • Began to eat post thoracocentesis so no need for NE tube 33 36 Bill Tyrrell, DVM, DACVIM-cardiology 6
CVCA-Cardiac Care for Pets 2/3/2019 Rads Diagnosis • Normal dogs: • History 8.5-10.7 – Presence of a murmur (9.7 +/- 0.5) – Duration of symptoms • Boxers: • PE 10.3-12.6 – Heart rate • Labrador – BCS Retrievers: 9.7- • NT-proBNP? 11.7 • Rads/Echo • CKCS: • Furosemide trial 9.9-11.7 37 40 Crackles Do Not Always Indicate CHF Cardiac Respiratory +/- Exercise intolerance Activity Normal Weight/BCS +/- Weight loss +/- Obese Normal to BV sounds Normal to BV sounds Lungs Sounds +/- Soft crackles +/- Loud crackles +/- Wheezes RR/RE/Pattern Usually short, rapid,+/- Exaggerated expiration +/- exp abdominal effort abdominal push HR/Rhythm Normal to Tachycardia Normal +/- RSA CXR VHS High Bronchial, Broncho-interstitial pattern, Peri-bronchial enhancement 38 41 Lung ultrasound Signalment Positioning: sternal or standing Transducer sites: Vet BLUE protocol 8 transducer positions • Right and left caudal lung lobe • Right and left perihilar lung lobe • Right and left middle lung lobe • History • Right and left cranial • Older, small breeds lung lobe • Chronic, loud murmur • Recent signs Ward et al. JAVMA 2017 39 42 Bill Tyrrell, DVM, DACVIM-cardiology 7
CVCA-Cardiac Care for Pets 2/3/2019 Lung ultrasound B-lines (lung rockets) Air attenuates ultrasound waves High acoustic impedance = difficult to image lungs Lung US looks at ARTIFACTS, not lung itself Normal: see reverberation artifacts under lung surface Disease: reflect pathology that extends to lung surface Normal Lung Ultrasound Lisciandro 2014 A-lines Slide credit to Jessica Ward, DVM, DACVIM-Cardiology; Horizontal lines represent reflection of interlobular septae Iowa State University Slide credit to Jessica Ward, DVM, DACVIM- cardiology Iowa State University 43 46 Normal Lung Ultrasound B-lines (lung rockets) A-lines and Glide sign QUANTIFY B-LINES: 0, 1, 2, 3, >3, INFINITY Lisciandro 2014 Ward et al. JAVMA 2017 Slide credit to Jessica Ward, DVM, DACVIM-cardiology Iowa State University Slide credit to Jessica Ward, DVM, DACVIM-cardiology Iowa State University 44 47 Lung ultrasound Normal LUS vs. B-lines Abnormal Lung Ultrasound Lisciandro 2014 B-lines (lung rockets, comet tails) o Small fluid-filled alveoli below resolution threshold of US o Surrounded by air = high impedance gradient o Discrete, narrow, hyperechoic, vertical, “laser-like” o Extend from pulmonary to pleural interface to far edge of screen w/o fading o Move synchronously with respiration Slide credit to Jessica Ward, DVM, DACVIM-cardiology Iowa State University Slide credit to Jessica Ward, DVM, DACVIM-cardiology Iowa State University 45 48 Bill Tyrrell, DVM, DACVIM-cardiology 8
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