Page 155 - Small Animal Internal Medicine, 6th Edition

CHAPTER 6 Acquired Valvular and Endocardial Disease 127

BOX 6.2
VetBooks.ir Treatment Guidelines for Chronic Mitral Valve Disease

Stage B1 (Asymptomatic, No or Minimal
Cardiac Enlargement) Stage C (Acute/Hospitalized Care Needed; Severe CHF
Signs [Stage C3])*
Client education (about disease process and early heart Supplemental O 2
failure signs) Cage rest and minimal patient handling
Routine health maintenance Furosemide (more aggressive doses, parenteral)
Blood pressure measurement Pimobendan (continue or add as soon as PO
Baseline chest radiographs, ±echocardiogram or administration possible; or use IV, if available)
NT-proBNP, and yearly rechecks Vasodilator therapy (consider intravenous [IV] nitroprusside
Maintain normal body weight/condition or (IV or PO) hydralazine, ± topical nitroglycerin
Regular exercise, as tolerated ±Sedation, as needed
Heartworm testing and prophylaxis in endemic areas Antiarrhythmic therapy, if necessary
Manage other medical problems (including mild/moderate See Box 3.1 for other recommendations
hypertension!) Thoracocentesis, if moderate- to large-volume pleural
Avoid high-salt foods effusion
Have client begin monitoring RRR to establish normal
baseline for that animal (see Box 3.2, p. 74) Stage D (Chronic Recurrent or Refractory Heart Failure)
Strategies for in-Hospital or Outpatient Care as Needed)*
Stage B2 (Asymptomatic, Progressive Cardiac Ensure that standard therapies for stage C are being given
Enlargement Evident) at optimal doses and intervals, including furosemide,
Client education (see stage B1) ACEI (q12h), pimobendan, spironolactone (see Chapter
Routine health maintenance 3, p. 74)
Blood pressure measurement Rule out systemic arterial hypertension, arrhythmias,
Chest radiographs, echocardiogram, or NT-proBNP anemia, and other complications
yearly (or every 6 months, if advanced disease or Increase furosemide dose/frequency as needed (check
large-breed dog) renal function and electrolyte status); may be able to
Maintain normal body weight/condition decrease somewhat in several days after signs resolve
Regular mild to moderate activity, as tolerated Enforced rest until after signs abate
Avoid excessively strenuous activity Additional afterload reduction (such as amlodipine [or
Heartworm testing and prophylaxis in endemic areas hydralazine]); monitor blood pressure
Manage other medical problems (if arterial blood pressure Other strategies to consider:
elevated, institute ACEI therapy) Increase pimobendan dosage (up to q8h frequency,
Avoid high-salt foods; consider introducing moderately +/or up to 0.4-0.5 mg/dose)
salt-restricted diet now Switch from furosemide to torsemide (initial dose at
**New recommendation: institute pimobendan therapy 1 10 - 1 12 of total daily furosemide dose, divided)
(0.2-0.3 mg/kg q12h) in stage B2 ± Add a thiazide diuretic (if not using torsemide) – use
Have client continue monitoring RRR periodically to low dose, monitor renal function and electrolytes
help detect onset of early CHF signs (see Box 3.2, closely!
p. 74) ± Add digoxin, if not currently prescribed; monitor
serum concentration
Stage C (Chronic/Outpatient Care; No Current CHF Signs Antiarrhythmic therapy, if indicated (see Chapter 4)
[Stage C1] or Mild to Moderate CHF Signs [Stage C2])* If pulmonary hypertension with signs of R-CHF or collapse,
Considerations as previously noted add sildenafil (1-3 mg/kg q8-12h PO)
Furosemide, as needed Add (or increase dose of) second diuretic (e.g.,
Pimobendan spironolactone, hydrochlorothiazide)
ACEI Thoracocentesis (or abdominocentesis) as needed
Spironolactone Consider bronchodilator trial or cough suppressant for
Antiarrhythmic therapy, if necessary (see Chapter 4) persistent dry cough
If CHF signs: complete exercise restriction until after signs Further restrict dietary salt intake; verify that drinking water
fully resolve is low in sodium
If no current CHF signs: regular mild (to moderate) activity,
as tolerated; avoid strenuous exercise
Moderate dietary salt restriction
Continue home monitoring of RRR to help detect early
signs of CHF decompensation (see Box 3.2, p. 74)
*See Tables 3.2 and 3.3 and Box 3.1, pp. 60, 62, and 64, for further details and doses.