1 / 23

Chasing fluid away… case report

Chasing fluid away… case report. Mr Jordi López-Alvarez LltVet MRCVS Resident in Internal Medicine ( Cardiology ) Small Animal Teaching Hospital, University of Liverpool Leahurst , Chester High Road, Neston Cheshire CH64 7TE, United Kingdom. FLOYD 4 yo GSD NM

cale
Télécharger la présentation

Chasing fluid away… case report

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Chasing fluid away…case report Mr Jordi López-Alvarez LltVet MRCVS Resident in Internal Medicine (Cardiology) Small Animal Teaching Hospital, University of Liverpool Leahurst, Chester High Road, Neston Cheshire CH64 7TE, United Kingdom

  2. FLOYD 4 yo GSD NM Referred for tachycardia (non-responsive to lidocaine) Presentation: June 2009

  3. Presentation: June 2009 Anamnesis: • Progressive (over 1 month): • exercise intolerance • tachypnoea • No history of previous illnesses was reported • Up-to-date with worming and vaccinations

  4. Presentation: June 2009 Physical examination: • 36.4 kg • Tachypnoea (44 rpm) • Mild abdominal distension with fluid thrill • Positive hepatojugular reflux • Chaotic rhythm and rate at 240 bpm • Marked pulse deficits at 100/min • Variable 2-3/6 left apical systolic murmur

  5. Diagnostic work-up • Haematology and biochemistry: NAD • Cardiac troponin I: 1.18 ng/mL (ref. value <0.15) • Blood pressure:150 mmHg

  6. Electrocardiography 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

  7. Thoracic X-rays

  8. Doppler echocardiography

  9. Doppler echocardiography

  10. Diagnosis Myxomatous degenerative valvular disease1 • secondary myocardial failure • atrial fibrillation • congestive heart failure 1 Borgarelli M, Zini E, D'Agnolo G, et al. Comparison of primary mitral valve disease in German Shepherd dogs and in small breeds. J Vet Cardiol 2004;6:27-34.

  11. CHF Treatment • Diuresis: sequential nephron blockade • ACEi • Pimobendan • Spironolactone • Others: antiarrhythmics, afterload reduction...

  12. Treatment • Hospitalisation over the week-end: • IV furosemide q 2-4h (until RR<40bpm) • Rate control: digoxin and diltiazem • At discharge • CHF: • Furosemide 1.5 mg/kg TID • Pimobendan 0.3 mg/kg BID • Benazepril 0.5 mg/kg SID • Spironolactone 1 mg/kg SID • Rate control: • Digoxin 0.125 mg/dog BID (0.003 mg/kg BID!!) • Diltiazem 2 mg/kg TID

  13. Sequential nephron blockade • Sodium transport: • Proximal tubule: 60% (cotransported with glucose, amino acids or phosphate) • Loop of Henle: 30% (Na+-K+-2Cl- carrier) • Distal convoluted tubule: 7% (Na+-Cl-cotransporter) • Collecting duct: 3% (aldosterone) NaCl Thiazides Na Na 2Cl Na K Aldosterone inhibitors Loop diuretics

  14. Spironolactone • Weak diuretic effect • Anti-aldosterone: • Potassium sparing effect • Anti-remodelling • Reduces cardiac morbidity and mortality2 2 Bernay F, Bland JM, Häggström J, et al. Efficacy of spironolactone on survival in dogs with naturally occurring mitral regurgitation caused by myxomatous mitral valve disease. J Vet Intern Med 2010;24:331-341.

  15. Torasemide vs. Furosemide • Longer half life (6h vs 4h) • More potent diuretic effect • Anti-aldosterone: • Potassium sparing effect • Anti-remodelling • Better oral absorption (absorption of furosemide but not torasemide is delayed in CHF) • No Clinical trials in Veterinary medicine

  16. CHF Treatment • Furosemide 2 mg/kg QID • Spironolactone 1 mg/kg SID • Hydrochlorthiazide + Amiloride 0.5 mg/kg BID • Torasemide 0.25 mg/kg BID

  17. RATE vs RYTHM Control • DIGOXIN • +/- DILTIAZEM • Recommendation: • 0.003 mg/kg BID and check the trough levels 1 week after • Lab ref: 1.0 - 2.4 • Aimed levels 0.5 – 1.2

  18. AMLODIPINE Dihydropyridine class calcium channel blocker Peripheral vasodilation  antihypertensive Ao = 80% Ao = 50% • Risk If hypotension: • Tachycardia • RAAS activation MR = 50% MR = 20%

  19. Palliative abdominocentesis

  20. Monitoring • Respiration rate at home • Body weight!! • Biochemistry: renal function? • Holter monitor: rate control? • Radiographs: Left Side-CHF? • Echo: Pulmonary hypertension

  21. Monitoring cTroponin I Abdominocentesis Digoxin Holter

  22. Conclusions • Owner commitment • Quality vs. Quantity of Life • Adequate monitoring • Pathophysiology and therapeutics knowledge

  23. Thank you!

More Related