Case Studies

These case studies contain detailed information on the diagnostic and treatment process for each individual animal.

Jake

Case 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

Clinical History

Please review Jake’s clinical history.

Attitude/demeanor: Normal
Coughing: None
Respirations: Normal rate and effort (owner does not count rate)
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

Physical Exam - General

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

Physical Exam - Auscultation

Let’s auscult Jake’s heart & lungs. (Recommend high-end headphones)

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?
Pick the most likely etiology of Jake's heart murmur
Direct HR: 130 beats/min
Heart rhythm: Normal
Intensity of heart sound: Normal
Extra sounds – clicks or gallops: None
Precordial palpation: Normal

Physical Exam - Differential Diagnosis

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
Stage B CVD
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) 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, including Dobermans.

Diagnostic Test Selection

BLOOD PRESSURE

Non-invasive blood pressure

CLINICAL LABORATORY TESTS

CBC with platelet count
CLINICAL LABORATORY
Serum biochemical profile (includes electrolytes)
Urinalysis
Serum thyroxine (T4)
Heartworm antigen test
NT-ProBNP
Cardiac troponin-I

DIAGNOSTIC IMAGING (some may require a referral)

Thoracic radiographs
Echocardiogram

ELECTRODIAGNOSTICS (some may require a referral)

ECG rhythm strip or 6 lead ECG
Ambulatory ECG - holter ECG or event monitor
The CEG considers the following diagnostic tests as the highest priority: Echocardiogram, Holter. Lower priority tests include a 3-5 minute ECG (if Holter declined or unavailable) and an NT-proBNP if and echocrdiogram is declined or unavailable) and blood pressure.
High priority tests are those that should be considered the most accurate and cost effective tests to establish a diagnosis and stage the disease if present and may require referral to a cardiologist or other specialists. Low priority tests are those that have value if a scaled down approached is required due to availability or budgetary retraint. For example: serum biochemistry and blood pressure.
In Jake’s case, if an echocardiogram is declined an NTproBNP should be considered to better assess his risk of having structural DCM (an abnormal echocardiogram). If the NTproBNP is elevated then an echocardiogram could be recommended again. Likewise, if Jake’s owner declines a Holter then a 3-5 minute ECG should be considered, because any VPCs on a 3-5 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 not indicated if high priority tests are avaiable but can be consiered if high and lower priority tests are declined/unavailable. Radiographs cannot be used to rule out DCM 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 urinalysis are reasonable baseline tests in any older dog suspected or known to have heart disease, particularly if treatment is being considered.

Blood Pressure

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) provide the veterinary community with up-to-date information on the pathophysiology, diagnosis, and treatment of clinically important animal diseases. In 2018, ACVIM updated 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.

Radiography

Please review Jake’s thoracic radiographs Click here for Jake’s radiograph viewer (measure VHS and VLAS here) View the right lateral radiograph View the ventral dorsal radiograph Click here to see the CEG’s recommendation on evaluating heart size on radiographs
What is the vertebral heart size?
What is the VLAS
Is Jake's heart enlarged?
Is there evidence of congestive heart failure present (pleural effusion or pulmonary edema)?

Clinical Labs

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

Echocardiography

Please review the results of Jake’s echo

Watch echo #1 Watch echo #2 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.
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% (breed specific normal 20-35%).
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 tricuspid regurgitation and pulmonic insufficiency are documented which are normal findings in the majority of dogs and do not result in murmurs.

ECG

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: 750
# 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 arrhythmia, sinus tachycardia and sinus rhythm with occasional VPCs. The ventricular arrhythmias overall were not considered severe but 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.

Diagnosis & Treatment

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?
What treatment(s) would you recommend for Jake? Jake weighs 35.3kg.
THE CEG recommendation:
The CEG recommends treatment with pimobendan with or without an ACE inhibitor in confirmed cases of Stage B2 DCM based on echocardiography in Dobermans such as Jake. In addition sotalol treatment can be considered for treatment of the complex venntricular arrhythnias confirmed by Holter. Consult with a cardiologist regarding the use of pimobendan in Stage B2 DCM in breeds other than Dobermans may be useful. Consult a cardiologist regarding the use of other novel treatments may also be warranted.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. Diets manufactured by a company that meets World Small Animal Veternarian Association (WSAVA) is always recommended.
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 and potassium-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 if ACEi was initiated. At this time the kidney values should be rechecked. This is a standard recommendation after initiating enalapril. Otherwise a followup should occur every 4-6 months or sooner if clinical signs develop.No exercise restriction is warranted at this time but sustained durations of strenuous activity should be abbreviated.

    The CEG is funded through an educational grant from Boehringer Ingelheim Vetmedica, Inc., IDEXX Laboratories, Inc. and Nestle Purina PetCare.

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