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why would you avoid using ACEi in acute renal failure?
- in acute renal failure you are going to see hypotension, and ACEi can exacerbate this
what is DCM and in which animals is it commonly seen?
- dilated cardiomyopathy
- primarily dogs
what is MVD and in which animals is it commonly seen?
- mitral valve disease; primarily dogs
what is HCM and in which animals is it primarily seen?
hypertrophic cardiomyopathy, cats
what is VTach and in which animals is it primarily seen?
- ventricular tachycardia, all species
what is AF and in which animals is it commonly seen?
- atrial fibrillation; dogs and horses
what are the five therapeutic goals?
1) manage congestive heart failure, or reduce progression of disease
2) improve the quality of life (ameliorate distressing clinical signs and reduce the risk of morbid events)
3) extend survival
4) identify and treat any precipitating or underlying cause of heart disease or failure
- anatomical, medication, infections
5) management of CV disease often relies on combination therapy
describe what happens in congestive heart failure
another look at what happens in congestive heart failure
a conceptual look at Tx of shock
hypovolemia is a pre or after load problem?
T/F: Assessment of patient is important
how should you choose drugs?
- evidence based selection of drugs based on therapeutic Goal for the disease, the stage of cardiac disease, and current clinical signs
adjust the dose based on what?
patient status, pharmacokinetic characteristics, and response to maximize efficacy
T/F: acute followed by chronic treatment
staging of CHF
- it is useful to think of CHF as a syndrome, not a disease; as such, it represents a continuum that may progress from (look at image)
describe stage A
- patients at risk (ex: breed disposition) but patients are normal (asymptomatic and with no identifiable structural disorder of the heart)
- no treatment
describe stage B
- pre-clinical, asymptomatic heart disease
- have anatomic or physiologic changes but no overt clinical signs of CHF - murmur; occasional arrhythmias
- no radiographic or echocardiographic signs of cardiac remodeling
describe stage B2
- pre-clinical stage: hemodynamic and metabolic disturbances balanced by compensatory mechanisms which inhibits development of clinical signs
- but demonstrate cardiac remodeling based on radiographic (ex: enlarged heart) or echocardiographic evaluation (decreased fractional shortening) and/or in some cases complex, more severe arrhythmias
will we treat animals in B2
what do you do with animals with MVD and DCM in stage B2?
- initiate pimobendan therapy
- mild sodium restriction in diet
- no data supporting use of ACEi therapy in dogs without clinical signs - still recommended by some cardiologists
what do you do with cats with HCM in stage B2?
- no clear recommendations
what do you do with pimobendan?
- delay the onset of the disease and they will live longer
- it is an inodilator
T/F: combining pimobendan and ACEi will lead to extended life of the animal
F, we do not have that data
T/F: principles of stage D and C are the same
describe stage C
- patients with past or current clinical signs of heart failure associated with structural heart disease
- can't revert back to stage B because you treat signs
- coughing, dyspnea, pulmonary edema, syncope, exercise intolerance, etc.
- these are the major group of patents that you will treat
- target the signs that indicate the need to address the problem
describe stage D
- end stage heart failure
- clinical signs that are refractor to standard therapy
- these patients require advanced or specialized treatment strategies to remain clinically comfortable with their disease
what drug do you give for acute therapy to reduce pulmonary edema in dogs?
- start with doses of 1-2 mg/kg IV, IM and repeat as needed every 1-2 hours
- 20-30 min till response for IM, 5 min for IV, 1 hour for oral
- can try to go to CRI if needed (0.66 - 1 mg/kg/h) after bolus
- can go as high as 4-6 mg/kg IV per dose, but do not exceed 8 mg/kg over 4 h
pulmonary edema means that there is a pre or after load problem?
what will furosemide do?
- cause diuresis, which will shrink the BV decreasing the BP, and decreasing th oncotic pressure
what dose of furosemide should you not exceed?
8 mg/kg over 4 hours
what drug do you give for acute therapy to reduce pulmonary edema in cats?
- 2-4 mg/kg IV q 1-2 h PRN of furosemide, but best to stay lower end of dose - toxicity
- onset is about 30 minutes
- repeat and lower dose as required over first 24-36 hours then switch to oral
- cats are more susceptible to adverse effects than dogs
what is important in chronic therapy?
to get to a dose and maintain it
chronic therapy for pulmonary edema
- furosemide or torsemide (oral only; 10-20 x as potent)
- important to arrive at a dose and maintain constant dose
- keep food the same (Salt)
describe the doses of furosemide you would use chronically
drug interactions seen with furosemide
- ACEi: decrease dose of furosemide 25-50% when starting ACEi if animal was on a stable dose
- aminoglycosides: increased risk of ototoxicity
- digoxin: furosemide-induced hypokalemia may aggravate CV toxicity (arrhythmias)
- NSAIDs: may block some of furosemide's diuretic effect - impact on prostaglandins
food interaction seen with furosemide
- sodium in diet
- low potassium if they do not eat
adverse effects of furosemide
- over diuresis
what is the chronic response is insufficient?
- diet: check for salt intake
- drug interactions: NSAIDs
- combination diuretics
what are some combination diuretics?
what to use for sedation - anxiety associated with dyspnea? What should you monitor?
- narcotics or a narcotic combined with an anxiolytic
- monitor the BP and respiratory response, no specific treatment or dosage
- butorphanol: 0.2 to 0.25 mg/kg administered IM or IV
- buprenorphine 0.0075-0.01 mg/kg and acepromazine 0.01-0.03 mg/kg IV, IM, SC
what is the drug of choice for increased inotropy orally?
if in stage C, when should you start pimobendan?
what does pimobendan do?
it is an inodilator
when to use pimobendan in DCM, MVI, and FHM
explain the use of pimobendan in DCM in dogs
- increasing the survival from about 14-50 days to 130-330 days in dobermans
- extends time to onset of CHF and sudden death when used in preclinical phases of DCM - median goes from 450-700 days
explain the use of pimobendan in MVI in dogs
T/F: pimobendan is now recommended for all stage B2 dogs
describe pimobendan use in cats
- has been used in cats, but data is limited
- recent case-control study suggested that in cats with overt congestive heart failure, pimobendan may have a positive effect when added to traditional treatment
- median survival was increased from ~100 days to ~600 days
- similar results were seen in FDCM, but median survival increased from 12-50 days
- limited data
what drugs can you use to decrease afterload (causing vasodilation) acutely?
- nitroglycerine: - IV, cream
- sodium nitroprusside: IV, CRI
how do you give nitroglycerin?
- half an inch paste/10kg BW, applied to an unaired or shaved area of skin, can be used for the first 24-36 hours
how do you give sodium nitroprusside?
- constant IV infusion at dosages ranging from 1-15 ug/kg/min for up to 48 hours
what drugs can you use to decrease afterload (causing vasodilation) chronically?
1) pimobendan: inodilator (add on ASAP)
2) ACEi: stop angiotensin 2 so has some vasodilation effect
3) hydralazine: peripheral vasodilation
4) prazosin: alpha 1 antagonist
5) amlodipine: calcium channel blocker
what are the primary ACEi used?
- enalapril and benazepril - human products
- equally effective
- they are approved vet products but off market
what do the clinically important ACEi do?
- increase lifespan by ~50% in CHF due to MVD and DCM
- no additive with PIMO
- no protectief effect
will you get a response right away with ACEi?
no, it takes about 1-2 weeks to get a response in part due to their conversion to active metabolites with a longer half life than the parent
why do some clinicians prefer benazepril?
no need to adjust dose in face of declining renal function
what are the important pro-drugs and active metabolites of enalapril and benazepril?
are ACEi for acute therapy?
no, but they are for long term management
when should you start ACEi?
- after one day of standard therapy to stabilize patient as required
- if dosing q24h, PK-PD analysis suggests that optimal effect will be achieved with bedtime dosing
enalapril and benazepril in dogs
- recommended dose ranges similar now
- 0.25 - 0.5 mg/kg PO q12-24 h
- start at 0.5 mg/kg q12 h and adjust based on response
enalapril and benazepril use in cats
- with HMC if signs of CHF; monitor carefully
- 1.25 - 2.5 mg/cat q24h or 0.25-0.5 mg/kg q12-24 h
what are the adverse effects of ACEi?
- decrease afterload and usually do not see reflex tachycardia (because of inhibition of sympathetic output) but can see hypotension
- exacerbation of renal insufficiency:
1) decrease aldosterone (Na/K exchanger)
2) hyperkalemia - if in combination with spironolactone - stop excretion of potassium
3) enhanced efficacy of furosemide may lead to volume depletion, hypotension, and subsequent renal insufficiency
what should you do with furosemide when you start ACEi?
decrease the dose 25-50%
summarize which drugs to use in stage C and D
- pimobendan: inodilator, extended lifespan
- furosemide - for pre-load
- ACEi - for after-load
- spironolactone - bigger diuretic effect
- additional anti-arrhythmics as required
what is the problem here and which drug do you want to use?
- use lidocaine
describe lidocaine use in horses
what should you use for VTach in any animal?
what is this an image of?
what is different about a horse and a dog with atrial fibrillation?
- dog: has an underlying cardiac disease, sick muscle, cannot get rid of the problem completely
- Horse: slow HR and big atria, we can get rid of the atrial fibrillation in horses and return it to normal
what are you going to use to treat atrial fibrillation in a horse?
what are you doing to use to treat atrial fibrillation in a dog?
how does quinidine work?
- class 1A sodium channel blocker
- blocks open Na channels and has a slow off rate
- increases ERP , has a significant vagolytic effects and is an alpha 1 blocker
what is the primary treatment choice in atrial fibrillation in horses?
- quinidine, can reverse atrial fibrillation in the horse
what are the potential adverse effects of quinidine?
- anaphylactoid reaction (histamine release) - in horses
- hypotension (alpha-blockade)
- paradoxical ventricular tachycardia in horse with AF can occur
- as heart rate slows, you get leak through AV node
- control with digoxin - increased vagal tone
dosing regimen for quinidine in horses
what to use for stage C/D dogs and cats with tachycardia?
- beta blockers - non selective versus selective
what to use for stage C/D dogs and cats with atrial fibrillation?
- you will not get rid of it but you will slow the response rate
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