INTERACTIVE CASE STUDIES

 
 

JakeCase Background

 
Name Jake
Age 7 years
Sex Male, neutered
Breed Doberman
Weight 35.3 kg (77.7 lbs)
Reason for Visit Annual health evaluation
Medications Heartworm prevention, fish oil supplementation
     

Please review Jake's clinical history.

 
Attitude/Demeanor Normal
Coughing None
Respirations Normal rate and effort
Exercise Tolerance Normal, walks 3 miles daily with owner
Sleep Patterns Normal, sleeps in bed with owner
Weight Change (loss or gain) None according to owner but according to hospital records there is a 0.5 kg increase since the last exam 12 months ago
Appetite Normal appetite
Usual Diet Purina® OM™, 4 cups per day
Vomiting None
Diarrhea None
Syncope None
Change in urinary habits None, normal
Change in drinking habits None, normal
Other symptoms or signs None, normal
 

Please review the results of Jake's physical exam.

Body Condition Normal, BCS 4.5/9
Attitude Normal
Mobility | Gait Normal
Posture Normal
Hydration Normal
Body Temperature 101.8 F
Arterial pulse - rate, regularity, intensity 130 beats/min, regular, synchronous, normal amplitude
Respiratory Effort 18 breaths per minute
Mucous Membranes - Color & CRT Pink, <1.5 sec
Jugular Venous Pulse & Pressure Not examined
Abdominal Palpatation Normal
Lymph Nodes Normal
Oral Cavity Normal
Other abnormalities None
 

Let's auscult Jake's heart & lungs.

Palpitation of the chest wall overlying the heart (precordial palpitation) was normal. Jake's lung sounds are normal. These heart sounds were heard when the stethoscope was positioned over Jake's left apex.

What do you hear?

Please select another answer
Correct
Grade 5/6 murmurs are loud, are not focal and are associated with a precordial thrill
There are no gallop heart sounds
The murmur is systolic. Diastolic heart murmurs are rare and when present in the dog are typically heard best at the left base.
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Pick the most likely etiology of Jake's heart murmur

MR typically causes a left apical systolic murmur and in some cases a right midheart systolic murmur
This causes a left base systolic murmur
This leak typically causes a right mid-heart systolic murmur
This causes a left base diastolic murmur
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Direct HR: 130 bpm

Heart Rhythm: Normal

Intensity of Sounds: Normal, partially obscured by holosystolic heart murmur, grade III/VI

Extra Sounds - Clicks or Gallops: None

Precordial Palpation: Normal

The following are potential diagnosis for you to consider at this time. Based on the history and the physical examination, please indicate the likelihood of each as:
  • High (could explain most or all of the signs)
  • Possible (less likely to explain most of the signs)
  • Unlikely

Stage B DCM

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Stage B CVD

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The CEG considers the following differential diagnosis as most likely (and why):

Based on breed and age dilated cardiomyopathy (DCM) is the most probable underlying etiology of the mitral regurgitation (MR). Myxomatous mitral valve disease (MMVD, also called chronic valvular disease [CVD]) is possible but much less likely. Note; the life time risk for developing DCM in Dobermans is 25-66%. DCM is rare before the age of 4 years in all breeds.

BLOOD PRESSURE

Non-invasive blood pressure

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CLINICAL LABORATORY

CBC with platelet count

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Coagulation profile

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Serum biochemical profile (includes electrolytes)

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Urinalysis

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Serum thyroxine (T4)

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Heartworm antigen test

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Heartworm antibody test

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Heartworm microfilaria test

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NT-proBNP

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Cardiac troponin-I

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Blood culture

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Thoracocentesis or abdominocentesis for diagnosis or therapy

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DIAGNOSTIC IMAGING (some may require a referral)

Thoracic radiographs

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Abdominal radiographs

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Echocardiogram Doppler studies

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Abdominal ultrasound

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ELECTRODIAGNOSTICS (some may require a referral)

ECG rhythm strip or 6 lead ECG

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Ambulatory ECG - Holter ECG or event monitor

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  • You considered the following to be higher priority
    • You considered the following to be lower priority
      • You considered the following to be not indicated

        The CEG considers the following diagnostic tests as the highest priority: 

        High priority tests for Jake include echo, Holter and BP. Lower priority tests include a 5 minute ECG and an NT-proBNP.

        High priority tests are those that should be considered the most cost effective tests to establish a diagnosis and stage the disease and may require referral to a cardiologist or other specialists. Low priority tests are those that have value and should be included as part of an ideal work-up but if a scaled down approached is required, then they may be excluded or delayed. In addition, some low priority tests may be more valuable when the recommended high priority tests are not available or declined.

        In Jake's case, if an echocardiogram is declined an NT-proBNP should be considered to better assess his risk of having structural DCM (an abnormal echocardiogram). If the NT-proBNP is elevated then an echocardiogram could be recommended again. Likewise, if Jake's owner declines a Holter then a 5 minute ECG should be considered, because any VPCs on a 5 minute ECG are highly suggestive of a diagnosis of DCM and should be used to encourage owners to undergo the high priority tests. Radiographs are low priority at this time because DCM cannot be ruled out based on a normal VHS. However, if a diagnosis of DCM is confirmed, baseline radiographs may be valuable to help establish a diagnosis of CHF if and when signs develop.

        Systemic BP is indicated in all dogs with heart disease to rule out systemic hypertension. A minimum database including a CBC, chemistries and UA are reasonable baseline tests in any older dog suspected or known to have heart disease, particularly if treatment is being considered.

        Systolic Blood Pressure: 132mmHg, (this is the average of 5 readings)
        Diastolic Blood Pressure: Not available for this case
        Mean Blood Pressure: Not available for this case
        Consensus Statements of the American College of Veterinary Internal Medicine (ACVIM) provides the veterinary community with up-to-date information on the pathophysiology, diagnosis, and treatment of clinically important animal diseases. In 2007, ACVIM published guidelines for the Identification, Evaluation, and Management of Systemic Hypertension in Dogs and Cats in the the Journal of Veterinary Internal Medicine.
        Click here to view and download a PDF of the ACVIM Consensus Statement, Guidelines for the Identification, Evaluation, and Management of Systemic Hypertension in Dogs and Cats.  

        Please review Jake's thoracic radiographs

        Click here for the right lateral view
        Click here for the ventral dorsal view
        Click here to see the CEG's recommendation on Evaluating Heart Size on Radiographs   Click here to view the annotated radiograph

        What is the vertebral heart score?

        Jake's vertebral heart score is 9.7
        Review the landmarks for determination of VHS and repeat measurement. For more information, please click the link above to review the CEG's recommendation for evaluating heart size on radiographs
        Review the landmarks for determination of VHS and repeat measurement. For more information, please click the link above to review the CEG's recommendation for evaluating heart size on radiographs
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        Is Jake's heart enlarged?

        The VHS is within the normal range (≤10.5). However, LV dilation and systolic dysfunction (e.g. DCM) cannot be ruled out based on a normal VHS. Thoracic radiographs have limited utility in screening for DCM in the dog. Additional testing would still be indicated in this case even though the VHS was normal. If the VHS was enlarged the test would have clinical value but a more specific test like echocardiography would still be required to confirm the diagnosis
        The VHS is within the normal range (≤10.5)
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        Is there evidence of congestive heart failure present (pleural effusion or pulmonary edema)?

        There is no pleural effusion or pulmonary edema present
        There is no radiographic evidence of pleural effusion or pulmonary edema
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        Please review Jake's lab results

        SERUM CHEMISTRIES
        BUN 14 mg/dL, Normal: 5 - 29 mg/dL
        Creatinine 1 mg/dL, Normal: 0.3 - 2.0 mg/dL
        Sodium 148 mm0l/L, Normal:138 - 154 mm0l/L
        Potassium 3.8 mm0l/L, Normal: 3.6 - 5.2 mm0l/L
        Chloride 114 mm0l/L, Normal: 114 - 126 mm0l/L
        ALT 89 IU/dL, Normal: 10 - 130 U/dL
        ALP 80 IU/dL, Normal: 24 - 147 U/dL
        Glucose 118 mg/dL, Normal: <68 - 126 mg/dL
        HEARTWORM
        Heartworm Test Results Not performed
        URINALYSIS
        Urinalysis - USG Not performed
        Urinalysis - Protein Not performed
        Urinalysis - Biochemical Not performed
        Urinalysis - Sediment Evaluation Not performed
        CBC
        White Blood Cells Not evaluated
        Red Blood Cells 51.4%
        Platelets Not Evaluated

        Please review the results of Jake's echo.

        Please view the video and interpretations that follow.
        Watch echo #1
        Watch echo #2
        Click here for Jake's right parasternal 4-chamber view
        Click here for Jake's LV M Mode View
        Click here for Jake's LA:Ao M Mode View
        Subjective - lesions of valves, myocardium, pericardial space Normal morphology of all valves. Normal myocardial echogenicity. No pericardial effusion.
         LV chamber size and thickness LV dilated. Normal thickness.
         Left atrial size Normal
         LVIDd & LVIDs Increased
         LV shortening fraction Subjectively reduced and measures low at 9.26% (normal 25-35%).
         RA, RV and Pulmonary Artery Normal RA, RV and pulmonary artery.
         Effusions None.
         Doppler results Mild mitral regurgitation is documented which is the most likely cause of the murmur. In addition, mild TR and PI are documented which are normal findings in the majority of dogs and do not result in murmurs.

        Please review Jake's ECG

        An ECG is not a first priority test for Jake at this time because his rhythm based on auscultation was regular.  However, intermittent arrhythmias are common in dilated cardiomyopathy and thus Jake would benefit from a Holter examination (A 24-hour ambulatory ECG). The results of Jake's Holter can be found below. Click here to view Jake's ECG
        Technical Quality, Leads, Paper Speed, Calibrations  Adequate, 6 lead, 25 mm/sec
         Artifacts Intermittent 60 cycle electrical interference artifact
         Rhythm - Regular or Irregular, Patterns Sinus
         Heart Rhythm Disturbances None
         P Wave Abnormalities - morphology, amplitude,  duration None
         QRS Abnormalities - axis, morphology, amplitude,  duration None
          HOLTER EXAMINATION REPORT
         Holter Duration  17 hours, 49 minutes
         Average HR  105 bpm
         Pauses  # pauses > 3.5 sec = 0
         Longest Pause  n/a
         # Single VPC  32
         # VPC Couplets 1
         # VPC Triplets 3
         Run of V Tach 1
         Longest Run of V Tach 6 beats
         # Single SVPB 0
         # SVPB Couplets 0
         # SVPB Triplets 0
         Run of SVT 0
         Longest Run of SVT n/a
         SVT HR n/a
         Interpretive Summary: The recording quality was good. They underlying rhythm was sinus arrhythmias, sinus tachycardia and sinus rhythm with occasional VPCs. The ventricular arrhythmias overall were not considered severe are considered complex because repetitive forms (couplets, triplets and short runs of ventricular tachycardia) were noted. These findings are consistent with a diagnosis of DCM in the Doberman.

        You're ready to form a diagnosis and treatment plan for Jake! Please select your answer to each question below.

        What stage is Jake's DCM?

        Although Jake is an older dog and an at-risk breed, he has echocardiographic evidence of DCM and ventricular arrythmias. Stage A dogs are at risk for developing DCM but are currently normal. Jake has echocardiographic evidence of DCM and arrhythmias with no evidence of CHF.
        Jake has DCM with no evidence of CHF. The following support your diagnosis: older age; at risk breed with mild cardiomegaly but no evidence of clinical signs associated with his heart disease. Stage C DCM is diagnosed when patients have a confirmed diagnosis of DCM and past or current clinical signs of heart failure that are caused by the underlying DCM. e.g. past or current dyspnea, tachypnea and radiograpic evidence of cardiogenic pulmonary edema in a dog known to have DCM.
        Jake has a confirmed diagnosis of DCM (remodeling and systolic dysfunction of the LV based on echocardiography) with no past or current evidence of CHF. The following support your diagnosis: Older age; at risk breed with mild cardiomegaly and systolic dysfunction but no past or current evidence of clinical signs associated with his heart disease. Jake also has clinically silent ventricular arrhythmias, a common finding in Doberman pinschers with DCM.
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        Click here to learn more about the stages of heart disease (ABCD Brochure)

        What treatment(s) would you recommend for Jake? Jake weighs 35.3kg.

        Submit

        THE CEG RECOMMENDS:

        The CEG recommends treatment with pimobendan and an ACE inhibitor in confirmed cases of Stage B2 DCM in Dobermans such as Jake.  Consult a cardiologist regarding the use of pimobendan in Stage B2 DCM in breeds other than Dobermans. Consult a cardiologist regarding the use of a beta blockers or other novel treatments.

         ACTUAL TREATMENT
         Initial Therapy Pimobendan - 10mg BID, Enalapril - 10mg BID
         Diet No change required as Jake is in good body condition and on a prescription diet for another indication.  If a prescription diet were selected, the Royal Canin® EC™ diet would be appropriate.  Severely restricted Na diets like the Hills® HD should be avoided in Stage A and B DCM.
         Other Points The initiation of pimobendan in stage B2 DCM in Dobermans has been shown to prolong overall survival and more specifically symptom free survival by greater than 60% (median of 9 months).

        No medication was definitively indicated at this time for the ventricular arrhythmias but initiation of sotalol now or at some point in the future may be beneficial given the current Holter results.  Sotalol has beta-blocking properties and a gradual dose increase may be needed when sotalol is initiated in dogs with Stage B, C, or D DCM. For example, Jake could initially be givin 20 mg every 12 hours, with an increase to 40mg ever 12 hours in two weeks if the initial dose was well tolerated. A Holter evaluation could be repeated in 3-4 months to check for efficacy, or sooner if signs of progressive arrhythmias develop, such as exercise intolerance or collapse.

        The owner needs to be aware that DCM is a progressive disease and that Jake is a risk for CHF and sudden death. The average time for a Doberman with stage B2 DCM to develop CHF or die suddenly is approximately 24 months with the therapy outlined above. This is a good time to have the owner learn how to count the home resting respiration rate weekly and that if the rate increases above 35/min it should be repeated to confirm it is truly elevated.  If it is truly elevated, owners should be instructed to contact the veterinarian to make an appointment as soon as possible. In addition if a new cough, breathing difficulty, restlessness during sleeping, weakness, collapse, exercise intolerance, or reductions in appetite or body weight develop, the patient should be re-evaluated as soon as possible, otherwise, a routine recheck can be scheduled in 4-6 months.  At this time, a good history and physical exam including auscultation, thoracic radiographs, biochemistry panel, and Holter (+/- echocardiophraphy and ECG) are indicated.

        Recommended Follow-up The first follow-up evaluation for Jake should be scheduled in about 2 weeks.  At this time the kidney values should be rechecked.  This is a standard recommendation after initiating enalapril.

        No exercise restriction is warranted at this time but sustained durations of strenuous activity should be abbreviated.

         

        To qualify for CE credit, please answer the following 5 questions.

        The most likely rule-out for a grade 2/6 (soft) left apical systolic murmur in an asymptomatic 6-year-old MN Doberman is:

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        Dilated cardiomyopathy is correct
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        The best recommended single screening test for occult DCM in Dobermans is:

        Echocardiography is correct
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        Clinical signs that the owners should be directed to watch for in Dobermans with Stage B2 DCM include:

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        All of the above is the correct answer.
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        The treatment that has been proven to delay the onset of congestive heart failure and sudden death in Dobermans with stage B2 DCM is:

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        Pimobendan is correct
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        The best chronic oral treatment for significant numbers of ventricular premature beats in Dobermans with Stage B2 or C DCM is:

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        Sotalol is correct
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