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SMALL ANIMAL > 2.2.4: Heart failure management > Flashcards

2.2.4: Heart failure management Flashcards

1
Q

True/false: whatever the cause, cardiac output falls and is detected via a drop in blood pressure.

A

True
* Degenerative valvular disease -> regurgitation means less forward flow into the aorta
* Dilated cardiomyopathy -> forward flow falls due to poor contractility
* Restrictive / hypertrophic cardiomyopathy -> forward flow falls because heart cannot fill
* Congenital disease - variable

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2
Q

Factors to consider in management of the patient with heart disease

A
  • Primary cause of heart disease and if this can be addressed
  • Treatment of heart failure
  • Identification of dysrhythmias and treatment if indicated
  • Identifying any complicating and co-existing factors
  • Regular assessment
  • What does the owner want?
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3
Q

Typical presentation of heart disease

A
  • Heart failure: cough/ dyspnoea
  • Exercise intolerance
  • Collapse
  • Non-specific malaise / weight loss
  • Occasionally heart disease is found by chance
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4
Q

Stage A heart disease

(ACVIM statement)

A

patients at high risk of heart disease but that have no identifiable structural disorder of the heart e.g. every CKCS

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5
Q

Stage B heart disease

A

patients with structural heart disease e.g. murmur but no clinical signs.

Stage B1: asymptomatic patients with no radiographic or echocardiographic evidence of cardiac remodelling.
Stage B2: asymptomatic patients with radiographic or echocardiographic evidence of left-sided cardiac enlargement.

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6
Q

Stage C heart disease

A

patients with past or current clinical signs of heart failure associated with structural disease.

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7
Q

Stage D heart disease

A

patients with end-stage disease with clinical signs of heart failure that are refractory to “standard therapy”

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8
Q

What treatment would you prescribe for a patient in Stage B1 heart disease?

A

Patient does not require specific treatment at this time, but consider:
* Weight control
* Regular reassessment
* Client education

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9
Q

What treatment would you prescribe for a patient in Stage B2 heart disease?

A
  • There is occult disease with cardiac remodelling especially left atrial enlargement
  • Prescribe pimobendan PO
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10
Q

What treatment would you prescribe for a patient in Stage C heart disease?

A
  • This patient has clinical signs of congestive heart failure
  • Time to institute double / triple / quad therapy
  • i.e. Pimobendan + diuretics/ ACE inhibitors/ aldosterone antagonists
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11
Q

What is right-sided heart failure typically secondary to?

A
  • Usually secondary to pericardial effusion or due to right-sided valvular disease
  • Often then leads to a degree of left-sided disease
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12
Q

What are the goals of heart disease treatment?

A
  • Control salt and water retention
  • Reduce workload for heart by decreasing afterload and decreasing physical activity and stress
    Improve the pump function (improve systolic function, diastolic function, and reverse/ modify myocardial remodelling
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13
Q

Indications for vasodilator use

A
  • When there are clinical signs of CHF
  • -> aiming to remove the fluid by vasodilation and by decreasing salt and water retention
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14
Q

What should you monitor when using vasodilators like ACE inhibitors?

A
  • Must monitor renal parameters!
  • We need to make sure there is not azotaemia/ hypotension
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15
Q

What is the mode of action of ACE inhibitors? How does this help the patient in heart failure?

A

ACE inhibitors = vasodilators
They dilate veins, arteries, or both.

Venous dilators
* Decrease preload
* Reduce fluid buildup

Arterial dilators
* Reduce afterload
* Increase output
* Reduce valve leakage

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16
Q

Examples of ACE inhibitors

A
  • Imadipril
  • Enalapril
  • Benazepril
  • Ramipril
17
Q

What drugs could we use to treat DCM?

A

DCM = contractility failure. Need drugs that improve contractility (positive ionotropes).
e.g. Digoxin, pimobendan

18
Q

Which patients should you avoid using digoxin in?

A

Patients with renal disease - digoxin is excreted renally

19
Q

Effects of pimobendan

A
  • Positive ionotrope: improves contractility; is a calcium-sensitising drug
  • Inodilator: leads to decreased systemic/ pulmonary vascular resistance
  • Causes vasodilation
  • Has anti-thrombotic activity
  • Used in Stage B2 and Stage C patients
20
Q

What drugs could we use to treat RCM/HCM?

A

RCM/HCM = the heart fills poorly. Need to help the heart relax -> Positive lusitropes
e.g. calcium channel blockers: diltiazem, verapamil
e.g. beta-blockers: propanolol, atenolol

In asymptomatic cats, there is no evidence that any drug alters the course of HCM until they are in heart failure.

21
Q

How should you treat the animal who presents as an emergency with congestive heart failure?

A
  • Oxygen
  • Cage rest
  • Avoid stress
  • Butorphanol (IM) to sedate as necessary
  • Furosemide IV until resp rate and resp effort reduce
  • Consider pimobendan IV
  • Monitor for dysrhythmias and consider anti-dysrhythmic medication if needed
  • Monitor renal values/ electrolytes
22
Q

A patient presented in acute CHF. You have now stabilised them. What is your plan going forward?

A
  • If BP allows, gradually start low dose ACE inhibitor and increase over 24-48hrs
  • Start spironolactone PO SID
  • Start pimobendan PO
  • Wean patient from IV furosemide to PO 3x daily
  • If HR has not started to reduce after a few hours, consider anti-dysrhythmic medication (might have atrial fibrillation)
23
Q

How would a patient in acute CHF present?

A
  • Dyspnoeic
  • Cyanotic
  • Coughing/ coughing up fluid
  • Keeping a raised chest
24
Q

How do diuretics work? How does this benefit the patient in heart failure?

A
  • Diuretics remove fluid - they act at the kidney to increase urine output
  • They control oedema formation in the patient in CHF
25
Q

What type of diuretics are there?

A
  • Loop diuretics e.g. furosemide
  • Potassium sparing diuretics e.g. spironolactone
  • Thiazide
26
Q

How does furosemide work?

A

Furosemide = loop diuretic
* Very potent
* Plasma half life = 15 mins
* Peak effect orally = 1-2 hrs
* Duration of action = 4-5 hrs
* Can be given SC, IM, IV, orally. Most potent given IV -> causes vasodilation with immediate effect
* Good for acute severe dyspnoea
* Tailor to severity of volume overload and oedema
* If high dose needed, reduce ASAP
* Take care in cats with restrictive/ hypertrophic disease (1mg/kg BID)

27
Q

What should you monitor for when using loop diuretics like furosemide?

A

Monitor for azotaemia and hypokalaemia

28
Q

How does spironolactone work?

A

Spironolactone
* Aldosterone antagonist (hence potassium sparing effect)
* Beneficial in CHF: improvements in cough, syncope, mobility

29
Q

Management of heart failure - non-medical options

A
  • Low salt diet: reducing salt intake could activate RAAS/ minimal benefit. Avoid salt load.
  • Exercise regime: consistency is key, do not push them to exhaustion.
  • Aspirate fluid
30
Q

Complications of heart failure treatment

A

Renal insufficiency (pre-renal)
* Likely due to overdoing it on the therapy side i.e. leading to decreased blood volume and poor renal perfusion

Electrolyte imbalance (esp K+)
* Furosemide leads to K+ loss
* ACE inhibitors lead to K+ retention
* Spironolactone leads to K+ retention
* Generally hyperkalaemia is rare; hypokalaemia is common!

31
Q

Uses of clinical pathology in heart disease

A
  • Often not useful in identifying primary disease; could potentially tell us about bacterial endocarditis
  • Useful for routine monitoring: clinical biochemistry and electrolytes
  • Useful for assessing the deteriorating patient: may be renal / K+
  • Useful for assessing therapy failure
  • Markers elevated in cardiac failure: natriuretic peptides e.g. BNP, ANP
  • Markers elevated in myocardial disease e.g. troponins
32
Q

What can you do if treatment is failing?

A
  • Change treatment: increase dose/ frequency of furosemide/ ACE inhibitor; increase dose of pimobendan
  • Consider adding other drugs: antidysrhythmic/ negative chronotropes (E.g. for atrial fibrillation), add sildenafil if pulmonary hypertension, add additional diuretic if needed, add codiene/ butorphanol
  • If the animal decompensates, go back to emergency treatment
33
Q

What should you make the owner aware of in terms of long-term management of heart disease?

A
  • Disease is lifelong and requires lifelong management
  • Emphasise need for regular daily routine
  • Administer prescribed medication consistently
  • Consistent exercise schedule needed
  • Must maintain appetite
  • Warn about possible side effects/ toxic effects of medications
  • Prognosis poorer in cardiomyopathy
34
Q

Co-existing diseases that may contribute to failure and how this occurs

A

Hypothyroidism
* Normally T3 and T4 increase bloodflow and cardiac output - n their absence we will see reduced cardiac output.
* Also see low voltage complexes in hypothyroid animals.

Cushing’s
* Many clinical signs common to heart failure
* e.g. protein/muscle catabolism
* Commonly same signalment: middle aged to older small breed dogs

SMALL ANIMAL (90 decks)

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