Please review Athena’s clinical history.

Attitude/Demeanor: Lethargic
Coughing: Coughing for two weeks
Abnormal Respirations: Increased respiratory effort over the last 2 days
Exercise Tolerance: Refusing to go on normal walks
Sleep Patterns: Prefers to lay in sternal recumbency which is atypical
Weight Change (loss or gain): None
Appetite: Has become very particular about food over the last 2 weeks
Usual Diet: Purina OM™, 4 cups per day
Vomiting: None
Diarrhea: None
Syncope: None
Change in urinary habits: None
Change in drinking habits: None
Other symptoms or signs: None

Please review the results of Athena’s physical exam.

Body Condition: Good
Attitude: Quiet
Mobility | Gait: Ambulating normally
Posture: Standing or sternally recumbent
Hydration: Adequate
Body Temperature: 100.2 F
Arterial Pulse – rate, regularity, intensity: Weak, irregular pulses with a rate of 180/min with pulse deficits
Respiratory Effort: Increased respiratory effort.
Mucous Membranes – Color & CRT: Pale to pink / 3 seconds.
Jugular Venous Pulse & Pressure: No jugular distention
Abdominal Palpatation: Normal
Lymph Nodes: Normal.
Oral Cavity: Normal
Other Abnormalities: None

Let’s auscult Athena’s heart & lungs.

• High (could explain most or all of the signs)
• Possible (less likely to explain most of the signs)
• Unlikely

Please review Athena’s thoracic radiographs

Athena's right lateral view

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Athena's ventral dorsal lateral view

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Please review Athena’s lab results

SERUM CHEMISTRIES
BUN: 24 mg/dL, Normal: 5 – 29 mg/dL
Creatinine: 1.7 mg/dL, Normal: 2.1 mg/dL
Sodium: 140 mmol/L, Normal:138 – 154 mmol/L
Potassium: 3.8 mEq/dL, Normal: 3.6 – 5.2 mEq/dL
Chloride: 115 mEq/dL, Normal: 105- 119 mEq/dL
ALT: 98 IU/dL, Normal: <75 IU/dL
ALP: 58 IU/dL, Normal: <100 IU/dL
Glucose: 140 IU/dL, Normal: 68 – 126 mg/dLHEARTWORM
Heartworm Test Results: NegativeURINALYSIS
Urinalysis – USG: 1.020
Urinalysis – Protein: Negative
Urinalysis – Biochemical: Negative
Urinalysis – Sediment Evaluation: NegativeCBC
White Blood Cells: 12,000/ul
Red Blood Cells: 41%
Platelets: 240,000/ul

Please review the results of Athena’s echo.

Subjective – lesions of valves, myocardium, pericardial space: No valvular degeneration was seen. The left ventricular systolic function is subjectively reduced.
LV chamber size and thickness: There is severe left venticular eccentric dilation.
Left atrial size: The left atrium is moderately to severely enlarged.
LVIDd & LVIDs: Diastole (5.6 cm); Systole (5 cm).
LV shortening fraction: Left ventricular contractility is significantly reduced with a low fractional shortening of 11%.
RA, RV and Pulmonary Artery: Normal.
Effusions: No pleural or pericardial effusion.
Doppler results: There is moderate mitral valve regurgitation associated with geometric ventricular changes (dilation of the mitral valve annulus). Trivial tricuspid regurgitation.
Watch echo #1

Please review Athena’s ECG.

Athena's echocardiogram

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Dilated cardiomyopathy is a common form of heart disease that we see in large breed dogs. Reduced systolic function of the ventricular muscle results in volume overload and congestive heart failure. Arrhythmias are a common finding with dilated cardiomyopathy, and include ventricular tachyarrhythmias, and atrial fibrillation. Furosemide, enalapril, pimobendan have been prescribed to eliminate the cough and respiratory distress. The digoxin and diltiazem are being used to reduce the ventricular response rate to atrial fibrillation to prevent rate induced cardiomyopathy. Dilated cardiomyopathy is usually a progressive disease, with a poor long term prognosis. Dobermans can have a good quality of life for a number of months 3-12 months with appropriate management.

• Furosemide IV 3 mg/kg initial bolus
• Furosemide IV CRI  0.9ml/kg/hr for 4-8 hours until respiratory rate is <50 breaths/min
• Vetmedin 0.25 mg/kg PO q 8hrs

• Diltiazem (Regular) 2 mg/kg PO q8hr

Chronic Treatment: (To Go Home)

• Furosemide 2 mg/kg PO BID
• Enalapril 0.5 mg/kg PO BID
• Vetmedin 0.25 mg/kg PO BID

• Diltiazem XR 3 mg/kg PO BID
• Digoxin 0.003 mg/kg PO BID

7 Day Recheck: Athena was released after diagnostic tests and instituting oral therapy for CHF which included: Furosemide 2 mg/kg PO BID, enalapril 0.5 mg/kg PO BID, Vetmedin 0.25 mg/kg PO BID, and Diltiazem XR 3 mg/kg PO BID, Digoxin 0.003 mg/kg PO BID. She was re-examined 7 days later. The owners have not noticed any coughing or labored breathing since discharge from the hospital. The appetite was reduced for the first 3 days, and is near normal today. Athena ws assessed with a renal panel, 8-hour post-pill serum digoxin concentration, ECG and thoracic radiographs. Renal panel: BUN=37mg/dl; creatinine 1.8mg/dl; phosphorus and electrolytes are within normal limits. Serum digoxin concentration: 0.9ng/dl (sample was drawn 6-8 hours post-pill into a red top tube without a serum separator. Eight-hour post-pill (trough) concentrations between 0.8 and 1.3 ng/dl are ideal to help with rate control and prevent toxicity signs. ECG: Rhythm is still atrial fibrillation, but the rate has been effectively reduced to an average of 150 bpm on the in-hospital rhythm strip. Thoracic radiographs: Left-sided cardiomegaly with a tall, upright heart consistent with left ventricular enlargement with a moderate to severe caudodorsal bulge consistent with left atrial enlargement. However, the caudodorsal interstitial pattern noted previously is absent on today’s films, and there has been improvement in the pulmonary venous distention. An increase in the furosemide dose is not warranted.