|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.
|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|
|Usual Diet||Purina® OM™, 4 cups per day|
|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|
|Mobility | Gait||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|
Let's auscult Jake's heart & lungs.
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 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.
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.
Please review Jake's thoracic radiographs
Please review Jake's lab results
|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 Test Results||Not performed|
|Urinalysis - USG||Not performed|
|Urinalysis - Protein||Not performed|
|Urinalysis - Biochemical||Not performed|
|Urinalysis - Sediment Evaluation||Not performed|
|White Blood Cells||Not evaluated|
|Red Blood Cells||51.4%|
Please review the results of Jake's echo.
|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.|
|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
|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 Duration||17 hours, 49 minutes|
|Average HR||105 bpm|
|Pauses||# pauses > 3.5 sec = 0|
|# 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|
|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.
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.
|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.