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Our Cavalier has been diagnosed with heart trouble

Quick update: Freckles had another set of x-rays taken on Friday. The vet said that Freckles' heart is noticeably less enlarged than it was a few weeks ago (her cough is less noticeable, too); the medication appears to be helping. She didn't mention fluid...and I forgot to ask. The vet is forwarding the x-rays to a radiologist and to the cardiologist.

The vet said that Freckles' sneezing could be allergy-related; unless we notice it occurring frequently, however, she suggested we not worry about it.
 
That's great news. Heart disease is such an up and down journey. We're fortunate in that the treatment options are well known and that there are quite a few directions that can be taken over time. Many cavaliers can be amazingly resilient once started on meds so fingers and paws crossed you'll have many years ahead together.
 
My Pippin is doing very well on heart meds even though he has CHF diagnosed last Sept...we just take it one day at a time with him, at the moment his heart is stable.

Dj another of my dogs has a grade 3 murmur but no symptoms and no medications yet.

I hope you have many years left with freckles xx
 
Thanks for the kind words, Karlin and pippa.

The vet just called to say that the cardiologist reviewed the x-rays, acknowledged that Freckles' heart is less enlarged, but that it hasn't reduced in size as much as she hoped it would. She also commented that the fluid in Freckles' lungs hasn't been reduced as much as she would like it to. Freckles breathing rate is still good; given her condition and the breed, however, the cardiologist recommends starting Freckles on VetMedin--in addition to keeping her on the same dosage of Furosemide and Enalapril. She says she is recommending this so as to keep the disease manageable for as long as possible. After hearing the vet's good news two weeks ago, I'm a bit discouraged about this.

Appreciate hearing any comments or experiences.
 
My Leo was diagnosed with CHF last December. He has been on 1.25mg of Vetmedin twice a day since and he's doing great :) He is also on Cardalis and 10mg of frusemide twice a day.
Like Pippa we take one day at a time, that's all you can do.
Leo is really good at the moment. He had a cardio check last week and the vet was delighted. His heart rate was good and his chest clear....she wants to see him again in October unless we're worried. Im sure there will be ups and downs so we just go with it and as its been said to me many times...remember Freckles doesn't know she's ill :)
 
Thanks, Mel. Yes, Freckles still seems to enjoy life very much! And naps, too!

The cardiologist wants to see Freckles again in early September.

I had a conversation with Freckles' vet about VetMedin. She told me she has seen good results of its use (prescribed by cardiologists) with many breeds (including Cavaliers), at various levels of MVD. She has seen none of the occasional hazards I mentioned on the excellent cavalierhealth.org. She has seen diarrhea and suppressed appetite in a few dogs.

Have anyone's Cavalier, on VetMedin, exhibited diarrhea or suppressed appetite? Any suggestions on how to avoid that? We administer Freckles' medications with food and/or small snacks.
 
Vetmedin has to be given 1 hour before food so you cant hide it in anything......not a problem with Leo as he thinks he's getting an extra treat for being such a good boyicon_whistling

We've been lucky he hasn't had any side effects with it...no diarrhoea or loss of appetite
 
Vetmedin has to be given 1 hour before food so you cant hide it in anything......not a problem with Leo as he thinks he's getting an extra treat for being such a good boyicon_whistling

We've been lucky he hasn't had any side effects with it...no diarrhoea or loss of appetite
Surprised to hear that about the instructions! The bottle makes no mention of it. May I ask where you heard that? *Must* food be given an hour later? I ask because Freckles had a snack just now and, although we keep her food dish out all the time, she probably won't eat anything the rest of the night.

Freckles' vet told me the VetMedin could be given at the same time I administer her other medications and with food, if desired. Currently, Freckles gets her Furosemide and Enalapril pills in the morning, with food (followed by a Dasuquin pill, a Vetri-Science Cardio Chew, a walk, and a Crananidin pill); an Enalapril pill in the evening, with a dab of peanut butter.

I just got back from picking up the VetMedin. Similar to your comment about your Leo, the clerk said Freckles would likely not need any coaxing to take the VetMedin; she would view it as a treat.
 
When my Sydney was taking Vetmedin, our instructions were 1 hour before a meal or 2 hours after a meal, so basically, on an empty stomach. I did wrap his pill in a small amount of sliced ham and there was never an issue.
 
I picked up the VetMedin last night but have not yet begun administering it. I'm unsure it's the right thing to do because, while reviewing this thread for any mention of how others administer VetMedin to their Cavaliers, I noticed the following comment from Rod:

"Freckles fortunately is not in CHF, so she should not be taking pimo (according to the ACVIM's Consensus Statement and the manufacturer's warnings and the FDA's statement approving pimo for dogs)."

I want to believe that the cardiologist and the vet know what's best for Freckles, but I don't want to administer VetMedin if it is premature to do so and if it could, therefore, be harmful to her.

What do you think? How can I reconcile this?

Update: From reviewing other threads on this forum, it appears that there are differing opinions as to when to begin administering VetMedin. Here's my dilemma: Since the combination of Furosemide and Enalapril have not, in the cardiologist's expert opinion, sufficiently reduced the enlargement of Freckles heart and the accumulation of fluid, is there any reason why I *shouldn't* start administering VetMedin, even though she may not technically be in CHF yet?
 
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Whether Vetmedin could be damaging or not depends upon the dog's condition. Some dogs in CHF cannot tolerate Vetmedin because one consequence of Vetmedin is that it strengthens the heart muscle and enables it to pump harder. If the dog in CHF still has a strong heart muscle, it does not need to be strengthened, and the Vetmedin forces the heart to work much harder than it should. This is what happened to one of our cavaliers. We noticed that his heart was beating so hard after being given Vetmedin that we could see the beats causing his chest hair to vibrate. So we cut back the dosage by half, and then by half again, so that he was getting a quarter of the typical dosage. Finally we discontinued it completely. He had an enlarged heart and he was in CHF, but the heart muscle remained strong and was doing its job.

My major concern about the premature administration of Vetmedin is that it can overwork the heart to the point of shredding the chordae tendineae and causing instant death. I know of a cardiologist who prescribed it too early and the end result was exactly that. (BTW, that cardiologist is no longer included on the list of board certified cardiologists on http://cavalierhealth.org/Cardiologists.htm)

As for Freckles, if she was mine and the cardiologist recommended Vetmedin at a point when he and I both knew that she was not in CHF, the first thing I would do is ask him "Why?". And, I would show him the manufacturer's warning on the box about not prescribing it prior to CHF. It states:

"Contraindications: Vetmedin should not be given in cases of hypertrophic cardiomyopathy, aortic stenosis, or any other clinical condition where an augmentation of cardiac output is inappropriate for functional or anatomical reasons.

Warnings: Only for use in dogs with clinical evidence of heart failure." See the box label for yourself: http://www.drugcore.com/fujian/20111207/2011120714214911636.jpg

And, I would point out that on Vetmedin's website -- http://vetmedin.com -- it has this warning:

"The safety of VETMEDIN has not been established in dogs with:

●Asymptomatic heart disease
●Heart failure caused by etiologies other than atrioventricular valvular insufficiency or dilated cardiomyopathy
●Dogs younger than 6 months of age
●Dogs with congenital heart defects
●Dogs with diabetes mellitus or other serious metabolic diseases
●Dogs used for breeding or pregnant or lactating bitches.

"Use only in dogs with clinical evidence of heart failure."

And, I would show him the ACVIM consensus statement -- http://cavalierhealth.org/images/acvim_guidelines_ccvhd_2009.pdf (see page 1145, top of second column) -- which states:

"A few panelists considered the use of the following medications for patients in Stage B2 under specific circumstances: pimobendan [Vetmedin], digoxin, amlodipine, and spironolactone. The panel felt in general that these treatment strategies needed additional investigation into their efficacy and safety in this patient population before a consensus recommendation could be made."

And, I would ask him about the current "EPIC study" of 360 pre-CHF dogs, being sponsored by Vetmedin's manufacturer and not due to end until 2015, to determine whether or not Vetmedin should be given to pre-CHF-dogs. https://www.epictrial.com/

In other words, ask him to satisfy you that his way is better than all of the evidence against premature dosing of Vetmedin.
 
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Thanks, Rod. I recall a comment you made earlier in this thread:

"It sounds like she is not in CHF. based upon what you quoted from the cardiologist's report. Stage B2 is not CHF. Stage C is CHF."

I'm going to ask the cardiologist to tell me if she is of the opinion that Freckles is in CHF. Perhaps she is closer to Stage C than Stage B2.

Is there any debate as to whether Stage B2 is *not* CHF?

I'm torn between this information and with Freckles' vet telling me she has seen good results of VetMedin with many breeds (including Cavaliers), at various levels of MVD, and that, after reviewing the VetMedin section on cavalierhealth.org, she hasn't observed any of these warnings in her office's patients.

Obviously, I don't want to wait *too* long to begin administering VetMedin.
 
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I would just like to hear her answers to those questions about all of the other authorities, including the manufacturer and the EPIC trial, and one I left out so far: The US Food & Drug Administration, which warned that the drug not be prescribed for dogs which are not in congestive heart failure. http://cavalierhealth.org/images/CavalierHealth.org.FDA.141-273o043007.pdf

Stage B2 is not heart failure. Stage C is heart failure. That is the difference.
 
Thanks for the US FDA reference. I perused much of it, but didn't see a warning. The "Conclusion" section states that VetMedin is effective in "the management of the signs of mild, moderate, or severe (modified NYHA Class II, III, or IV) congestive heart failure in dogs due to AVVI or DCM, when used in combination with other appropriate congestive heart failure therapy." Are you suggesting this being a warning for dogs not yet in CHF?

I have a call into the cardiologist. I anticipate she will say she believes Vetmedin is warranted for Freckles, given her Stage B2 condition, even with those references. (This is what the vet told me, based on her experience with Cavaliers, even after perusing, at my request, the "A Few Words About Pimobendan" section of http://cavalierhealth.org/mitral_valve_disease.htm. The vet also told me that she has seen Cavaliers go from what appeared to be a mild murmur to full CHF in just a few weeks and, therefore, that she can understand why the cardiologist wants to put Freckles on Vetmedin.) What are my options then? Go against the cardiologist's recommendation? Consulting with another cardiologist would likely take some weeks to get an appointment with.

I wish I knew the best course to take.

Update: I re-read the "A Few Words About Pinobendan" section. It states: "The FDA report states that pimobendan "is indicated for use with concurrent therapy for congestive heart failure (e.g., furosemide, etc.) as appropriate on a case-by-case basis." Furosemide is a diuretic." That sounds as though Furosemide is meant only for dogs in CHF, too, doesn't it? (As I've mentioned, Freckles is already taking Furosemide and Enalapril.) It also states: "the drug should not be prescribed for dogs whose hearts have remained strong despite the MVD". How can I know whether Freckles' heart has "remained strong" despite the MVD? Lastly, it states: "Bottom line: pimobendan is hazardous to the health of cavaliers with MVD murmurs but no symptoms." Doesn't Freckles' enlarged heart and the presence of fluid indicate she has the symptoms they're referring to?
 
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Thanks for the US FDA reference. I perused much of it, but didn't see a warning. The "Conclusion" section states that VetMedin is effective in "the management of the signs of mild, moderate, or severe (modified NYHA Class II, III, or IV) congestive heart failure in dogs due to AVVI or DCM, when used in combination with other appropriate congestive heart failure therapy." Are you suggesting this being a warning for dogs not yet in CHF?

Yes. FDA approved pimo for dogs in CHF. FDA did not approve pimo for dogs not in CHF. FDA found that:

"VETMEDIN administered to healthy Beagles at three and five times the recommended dose caused severe left ventricular hypertrophy with multifocal subendocardial ischemic lesions, myxomatous thickening of the mitral valves, mitral valve insufficiency murmurs, left atrial jet lesions, endocardial thickening of the left ventricular outflow tract, a granulomatous lesion within the right atrial myocardium, decreased blood pressure, increased heart rate, and a subtle increase in ventricular premature contractions. These effects are typical of positive inotropic and vasodilator drug toxicity in normal dogs."

This means the healthy lab dogs -- those not in CHF -- suffered severe damage to their hearts as a result of taking pimo.

I have a call into the cardiologist. I anticipate she will say she believes Vetmedin is warranted for Freckles, given her Stage B2 condition, even with those references. (This is what the vet told me, based on her experience with Cavaliers, even after perusing, at my request, the "A Few Words About Pimobendan" section of http://cavalierhealth.org/mitral_valve_disease.htm.) What then? Consult with another cardiologist (which will likely take some weeks to get an appointment with)?

It is up to you. If it was my dog, I would not give pimo prior to CHF. Been there; done that; won't ever do it again.

Update: I re-read the "A Few Words About Pinobendan" section. It states: "The FDA report states that pimobendan "is indicated for use with concurrent therapy for congestive heart failure (e.g., furosemide, etc.) as appropriate on a case-by-case basis." Furosemide is a diuretic." That sounds as though Furosemide is meant only for dogs in CHF, too, doesn't it? (As I've mentioned, Freckles is already taking Furosemide and Enalapril.)

Diuretics like furosemide are separate drugs from pimo, so different protocols apply to them. The ACVIM Consensus Statement -- http://www.cavalierhealth.org/images/acvim_guidelines_ccvhd_2009.pdf -- does not mention the use of furosemide for Stage B2 dogs. It does list it for Stage C dogs, meaning dogs in CHF. And this makes sense, because diuretics are given to reduce excess fluid, which is what "congested" means, in terms of fluid in the lungs due to heart failure.

Why is Freckles being given a diuretic if she is not in CHF? If she has fluid in the lungs, then she may be in Stage C, in which case this whole thread about no pimo before CHF may be moot.

As for the enalapril, which is an ACE-Inhibitor, the ACVIM Consensus Statement has not endorsed ACE-I therapy of MVD dogs at Stage B2 MVD. Further, ACE-inhibitors have not been approved for veterinary medicine for MVD dogs in Stage B2 by regulating authorities. Therefore, giving a non-CHF dog enalapril is called an "off label" prescription.

An additional reason for not prescribing ACE-inhibitors prior to congestive heart failure is a 2002 Scandinavian study (the "Scandinavian Veterinary Enalapril Prevention [SVEP] Trial") of 229 asymptomatic cavalier King Charles spaniels with mild MVD murmurs, which has shown that ACE-inhibitors had no significant affect upon the time from the initiation of ACE-I therapy to the point of heart failure. A 2007 study (the "VETPROOF Trial"), sponsored by a drug manufacturer and involving 124 dogs of several breeds (including only 10 cavaliers), showed that enalapril given to dogs with only mild MVD murmurs and some enlargement of the heart but which otherwise are symptomless, "modestly delayed" the onset of CHF. Further, in a 2013 study by Thai graduate students, of twenty dogs (none CKCS) in Stage B2, they found that ramipril did not affect cardiac chamber size, mitral regurgitation severity and systolic function assessed by echocardiography in 91-day period of treatment.

Based upon the SVEP study mentioned above, Dr. Mark Oyama, a board certified veterinary cardiologist at the University of Pennsylvania, told me that it is "a no-brainer" to hold off on giving cavaliers enalapril prior to CHF.

It also states: "the drug should not be prescribed for dogs whose hearts have remained strong despite the MVD". How can I know whether Freckles' heart has "remained strong" despite the MVD?

An ultrasound should enable the cardiologist to determine the strength of the heart muscle.

Lastly, it states: "Bottom line: pimobendan is hazardous to the health of cavaliers with MVD murmurs but no symptoms." Doesn't Freckles' enlarged heart and the presence of fluid indicate she has the symptoms they're referring to?

An enlarged heart is not a symptom. That would be a Stage B2 dog. The presence of fluid may be part of a symptom. Symptoms are such things as:

-- Class II: fatigue, shortness of breath, coughing, apparent when ordinary exercise is exceeded.

-- Class III: exercise capacity is minimal.

-- Class IV: no capacity for exercise and disabling clinical signs are present even at rest
 
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I noticed on the EPIC site that for "What are the clinical signs of Congestive Heart Failure (CHF)?" it states: "The most common signs of CHF include Coughing*, Changes in breathing (...), Changes in behaviour* (...Slowing down/lack of energy*), Poor appetite, Weight loss, Fainting/collapsing, Weakness, Restlessness*, especially at night." (I starred the signs Freckles is showing.) I'm curious why the signs don't include mention of MVD stages (i.e., > B2 = CHF, etc.). Since Freckles is manifesting some of these signs, doesn't that make her an appropriate candidate for Vetmedin? OTOH, the site *is* associated with the manufacturer of the drug.

As for the enalapril....An additional reason for not prescribing ACE-inhibitors prior to congestive heart failure is a 2002 Scandinavian study...which has shown that ACE-inhibitors had no significant affect upon the time from the initiation of ACE-I therapy to the point of heart failure. A 2007 study...showed that enalapril given to dogs with only mild MVD murmurs and some enlargement of the heart but which otherwise are symptomless, "modestly delayed" the onset of CHF. Further, in a 2013 study by Thai graduate students, of twenty dogs (none CKCS) in Stage B2, they found that ramipril did not affect cardiac chamber size, mitral regurgitation severity and systolic function assessed by echocardiography in 91-day period of treatment....Dr. Mark Oyama, a board certified veterinary cardiologist at the University of Pennsylvania, told me that it is "a no-brainer" to hold off on giving cavaliers enalapril prior to CHF.

Interesting. What about Furosemide? Like ACE-inhibitors, is it usually not prescribed prior to CHF?

Why is Freckles being given a diuretic if she is not in CHF? If she has fluid in the lungs, then she may be in Stage C, in which case this whole thread about no pimo before CHF may be moot.

The cardiologist diagnosed Freckles as being 'only' Stage B2 30 days ago, even though she saw an enlarged heart and some fluid in the lungs (and still sees them). This led her to prescribe Furosemide and Enalapril. Could that have been premature? OTOH, these medications neither hasten nor prevent CHF, do they? They simply treat the symptoms.

An ultrasound should enable the cardiologist to determine the strength of the heart muscle.

I will *definitely* ask that question.

Suppose the cardiologist says Freckles is not yet in CHF. If I decide to go against her recommendation and not administer the Vetmedin at this time, do I simply continue to administer the Furosemide and Enalapril...and wait for her to enter CHF--detected either at a future examination or via a significant change in her breathing at rest?
 
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I noticed on the EPIC site that for "What are the clinical signs of Congestive Heart Failure (CHF)?" it states: "The most common signs of CHF include Coughing*, Changes in breathing (...), Changes in behaviour* (...Slowing down/lack of energy*), Poor appetite, Weight loss, Fainting/collapsing, Weakness, Restlessness*, especially at night." (I starred the signs Freckles is showing.) I'm curious why the signs don't include mention of MVD stages (i.e., > B2 = CHF, etc.).

The "stages" were introduced in ACVIM's 2009 Consensus Statement, primarily for other veterinarians. I suspect the EPIC Trial website, which was introduced in 2010, is more for the information of dog owners, and referring to stages may be of no value to them unless their vets already had used those terms.

Interesting. What about Furosemide? Like ACE-inhibitors, is it usually not prescribed prior to CHF?

I would think that diuretics would be prescribed once fluid was detected in the lungs.

The cardiologist diagnosed Freckles as being 'only' Stage B2 30 days ago, even though she saw an enlarged heart and some fluid in the lungs (and still sees them). This led her to prescribe Furosemide and Enalapril. Could that have been premature? OTOH, these medications neither hasten nor prevent CHF, do they? They simply treat the symptoms.

According to the Consensus Statement, if the dog is in Stage B2, diuretics don't seem to be mentioned at all (unless I missed it). But I would think that if the dog has fluid in the lungs due to MVD, the vet would prescribe a diuretic. It would not prevent CHF.

As for enalapril, at Stage B2, as I mentioned in a post yesterday, studies show it is of little value or none at all for cavaliers in preventing or delaying the onset of CHF.

Suppose the cardiologist says Freckles is not yet in CHF. If I decide to go against her recommendation and not administer the Vetmedin at this time, do I simply continue to administer the Furosemide and Enalapril...and wait for her to enter CHF--either at a future examination or via a significant change in her breathing at rest?

At this point, with fluid in the lungs, Freckles may already be in CHF. I would ask the cardiologist whether she thinks that fluid in the lungs changes the diagnosis from Stage B2 to Stage C or not. If and when any of our cavaliers are in CHF and the cardiologist prescribes Vetmedin, I would first ask about starting at a lower dose than recommended, or at least schedule a follow-up appointment with the cardiologist for no longer than three days after starting the Vetmedin. I might even suggest that the dog be given the first tablet during our visit, and wait an hour for the cardiologist to re-examine the dog to be sure the Vetmedin is not over-working the heart. If after the visit I sense that the dog "is not right" -- the heart seems to be working overtime, for example -- I would discontinue the Vetmedin until I could talk to the cardiologist about lowering the dosage.

As I mentioned yesterday, with our dog in CHF which was given a standard dose of Vetmedin, as soon as we noticed that his heart was going wild, we cut back the dose, and then we cut it back again. And finally we eliminated it.
 
Earlier this evening, I had a long conversation with Freckles' cardiologist. We talked about the various clinical studies. She agrees that Vetmedin shouldn't be administered until CHF is diagnosed. OTOH, she didn't think it would have been harmful had I already administered some of it. Go figure.

There seems to have been a breakdown in communication between the cardiologist and the vet; she will have another discussion with the vet tomorrow. Bottom line: Based on Freckles' examination last month as well as her continued excellent breathing rate at rest, she says it likely Freckles is still Stage B2. Freckles has a strong heart, with good contractility. She agrees that it would, therefore, be premature to begin administering Vetmedin.

The cardiologist *is* a bit confused that Freckles' coughing hasn't improved and that the x-rays still show some pulmonary infiltrates (i.e., fluid) (and, of course, the enlarged heart, due to MVD). She wonders if something else is causing the coughing; perhaps chronic bronchitis or allergies. As long as it isn't more of a nuisance, however, she believes I shouldn't be too concerned about it. To that end, she questions whether the Furosemide and Enalapril are accomplishing anything. To test that theory, she recommends I stop administering Furosemide and then monitor the results for the next week. If her condition remains unchanged (i.e., no increased coughing, nor increased breathing rate), she may recommend I stop administering Enalapril, too. If her condition worsens, it would indicate the coughing *is* being caused by MVD and that she needs to be on the medication--perhaps with further adjustments. Personally, I'll be surprised if any change is seen in as little as a week. Regardless, Freckles has another appointment with the cardiologist in two months.
 
Rod, interesting that you note the contractibility aspect in post #31. My Leo has gone downhill very quickly with MVD, but am wondering if he should just be on frusemide and fortekor (actually he's on Nelio, benazepril). He has started vibrating too with his heartbeat very noticeable, shaking him when at rest. He's only on 1.25 mg of Cardisure 2x but don;t remember him having this noticeable a heartbeat. I am away with the dogs in the UK and making an appt with the cardio for as soon as possible next week when I am back but perhaps on this basis should try halving the cardisure... He is now exercise intolerant and has strong exhalations though resting resp rate is 30ish or below. I wonder if he is on the wrong mix.
 
And thanks for your last post cwaters. This sounds very much like my Leo -- started him on meds because of coughing, but am not sure I think it is entirely due to MVD. I wonder if the meds are actually making it harder for him to function... anxious now to get him to the cardio.
 
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