Incredible Presentation on How To Treat Cardiac Disease

I've been doing some research as I determine how or if to respond to the warnings about pimobendan blog.....and I found this amazing presentation that summarizes recent research, offers treatment recommendations, and ties in to the 2009 ACVIM consensus paper. This is probably the best resource that I've seen in a long time, and I'm so impressed that it was done by UK vets.

I have now downloaded this pdf to save on my hard drive in case this link disappears. I'd advise others to do the same because it takes some time to process all of the great info. It is 85 slides, but only the first 53 deal with MVD and the rest deal with DCM and feline cardiology.

Slides 19-22 and slide 36 deal directly with topics in the recent thread about whether to start meds for stage B2. Note the prominent statement "NO CONSENSUS" at the top of each of these slides; this explains the different recommendations by different cardiologists (not to mention GP vets) and the resultant confusion for clients/pet owners. (My personal experience is that this is a gray area rather than being black and white. I consider the individual dog's situation rather than following the exact same treatment strategy for every one of my dogs. Part of this dilemma is identifying exactly when a dog moves from B2 to C, and this can be nebulous. And a dog which has had an acute stage C episode is still in stage C even if it appears to move back into compensated B2.)

Some key slides for me are 28, 30, 31, 36, and 37.

Slides about spironolactone benefits are 32-35.

There are very helpful "tricks" and recommendations about treating acute decompensated heart failure, emergency treatment, and late stage failure. This is just a terrific resource, and I'm so pleased that I found it.

http://www.valevetsreferrals.co.uk/imports/How_to_Treat_Cardiac_Disease.pdf

Pat

P.S. I love the cartoon on slide 3 - I think I would very much like the person who prepared this presentation!

Thank You Pat,
That was interesting and very education too......

Mel

While Dr. Patteson's Stage B2 slides all are headed "NO CONSENSUS", there really is a consensus of sorts regarding prescribing ACE-inhibitors and/or pimobendan and/or diuretics and/or spironolactone under Stage B2, and that consensus is to NOT administer any of those drugs.

ACE-Inhibitors: The SVEP Trial (Slide 25) involved 225 cavaliers and no other breed. The finding was that "enalapril had no significant effect on the time from initiation of therapy to heart failure". Dr. Mark Oyama has stated that, based upon this trial, the decision to not prescribe enalapril to CKCSs in Stage B2 is "a no-brainer", meaning he would not do it. Further, in the USA, ACE-Inhibitors are not approved for Stage B2 dogs. So, any use of it at that stage is "off-label".

Pimobendan: There is NO study finding that pimo should be given to any dog in Stage B2. The QUEST Trial was of dogs in CHF. The FDA has not approved pimo for dogs prior to CHF. The Vetmedin package contains a warning that it is not to be prescribed for dogs prior to CHF. The Vetmedin website warns viewers that it has not been approved for dogs prior to CHF. A 5-year study is on-going, called the EPIC Trial, to determine if pimo could aid dogs prior to CHF, and it will not conclude until late next year. There have been studies showing that premature administration of pimo can worsen the dogs' MVD.

Diuretics: These are to remove unwanted fluids from the body. Stage B2 dogs apparently do not have congestion in their lungs, and so, there should be no need to administer diuretics to dogs in Stage B2 for MVD-related fluids.

Spironolactone: The study at Slide 32 was of CHF dogs (hence Stage C), and NOT Stage B2 dogs.

Caveat: If a dog has been in Stage C but, because of the success of the pimo and/or ACE-Inhibitor, the heart size has reduced, the dog does not thereby move back to Stage B2. By definition, once a dog reaches Stage C, it cannot drop back to Stage B2. So, even though the CHF symptoms have disappeared, the dog still should be treated as if it is in Stage C.