Management Of Heart Failure 2 Flashcards
What is the effect of hypothyroidism of heart failure?
Reduces the systolic fucntion
How does cushing’s disease afffect cardiac failure?
Fluid retention
What co -existign diseases affect cardiac failure therapy? (2)
Renal insufficiency – digoxin (not uncommon – but makes it difficult)
Hepatic insufficiency
Is hyper or hypo kalaemia more common in cardiac failure treatment? How can this be overcome?
Hypokalaemia is NOT RARE! Especially in cats! Watch out for a lethargic cat. May need supplement
In cats try to use SID drugs. You can always get a gelatine capsule and put all the drugs into one capsule.
What are the complications of HF therapy? (3)
- Renal insufficiency – pre-renal (urea often high and creatinine normal)
- Electrolyte imbalance – POTASSIUM
- Furosemide - K+ loss. Amount of loss out weighs the retention by ACEI
- ACEI - K+ retention
- Spironolactone - K+ retention
When would we use clinical pathology? (4)
–Identifying primary disease
- NOT often useful
- Bacterial endocarditis? May see on haematology
–Routine monitoring (this is for monitoring not diagnostics)
•Clinical biochemistry and electrolytes
–Assessing deteriorating patient
•Deterioration may be renal/K+ issue
–Therapy failure
What biomarkers can we use for cardiac failure? How do we use them?
•Markers elevated in cardiac failure
–Natriuretic peptides – BNP, ANP
–Pro BNP
–These go up in heart failure. Atria is stretched so they are released and they are the counterbalance to fluid retention.
–Assay for these
•Markers elevated in myocardial disease
–Troponins – damage to myocardium leaks tryponins into the blood. Via an assay.
–Important in human medicine. Not used as much in vets. Humans – acute myocardial infarction as you kill lots of myocardium at once.
•None well validated in veterinary practice
–Would/will be very useful?
•People try to use these markers to differentiate heart disease from resp disease – but you should do this by the clinical presentation. Do not replace your clinical judgement!!!!!! The lab test may say no – but f they present with HF they have it!!!
Why do we need regular reassessment? (2)
Assess efficacy of therapeutic regime
Ensure compliance with management regime
What is the frequency on reassessment determined by? (3)
Severity of failure – acute presentation see in a few days. Once stable – every few months
Patient stability
Economic guidelines
What can be involvement in regular reassessment? (6)
- Assess patient for side effects, toxicity etc
- Blood levels of drugs – digoxin?
- Drug doses may need to be adjusted
- Cut down diuretic based on resp rate
- There is rarely a standard dose
- Regular blood profiles are advisable
- Repeat investigations if indicated
- Once you have CHF no matter what the cause – you know what you are managing and don’t need to investigate. May need to repeat radiographs if an animal has worsening cough to understand if there is worsening HF or something else.
- May be justification for every few months of U/S in cats to monitor for clots – but Malcolm says other than this it is unnecessary
- Weigh
What could we base changes of treatment on? (2)
- Can we reduce diuresis?
- Owner monitoring
What is the frequency of re-examination?
– 1-3 monthly (NB cost)
– 2 days for acute changes, week long when less critical
– acute severe CHF is a critical care issue, re-evaluation ongoing
What can we change diuretic doses based on?
Resp rate
What can cause worsening of LCHF despitae therapy?(4)
–Worsening of disease
- Rupture of CT, atrial tear
- Rupture a chord – acutely sick and profound resp distress
–Furosemide resistance?
•On for months to years
–Compliance?
–R sided failure and poor GI drug absorption?
What can we do if CS of HF change? (2)
•changes to treatment (discuss off label)
– increase dose / frequency of frusemide
– increase dose / frequency of ACEi
– increase dose of pimobendan
• consider adding other drugs
– antidysrhythmic / negative chronotropes
– sildenafil if pulmonary hypertension
– hydrochlorothiazides
– omega 3 fatty acids - no evidence
I am getting desperate here –
does anything else help in treatment of CHF? (6)
- Cough suppressants
- codeine approx 1mg/kg q12 h
- steroids – inhaled or oral (not used so much – used if coexisting airway dx)
- Bronchodilators – theophylline and its derivatives
- Afterload reducer – hydralazine/amlodipine
- NB monitor BP
- Drain abdominal or pleural effusions
- Omega 3 fatty acids in cachexia
- Anabolic steroids in cachexia??
What is the Emergency CHF therapy for decompensation? (9)
Furosemide
- 2mg/kg IV initally then
- 1mg/kg hourly afterwards until respiratory rate and effort reduce (up to 4 doses in cats more as necessary in dogs)
Oxygen supplementation
Pimobendan if systolic dysfunction (all CDVD and DCM cases)
- Consider injection
Cage rest
Avoid stress
Sedation as necessary (Butorphanol 0.1 - 0.2mg/kg)
Glyceryl trinitrate ointment
Monitor renal values / electrolytes
Antidysrhythmic medication if necessary
Specialist therapies:
Acute class 3/D CHF (needs hospitalising)
– vasodilators eg amlodipine
– intravenous therapy
sodium nitroprusside
positive inotropes e.g. dobutamine for DCM
What can cause intractable cough? (4)
–Unstable LCHF
–Enlarged LA
–Bronchomalacia
–Chronic airway disease
How can you diagnose an intractable cough (3)
–Inflated chest radiographs
–Bronchoscopy
–BAL
How can we treat an intractable cough? (4)
–Unstable LCHF
•Further alterations to treatment regime
–Enlarged LA
•Reduce LA size with therapy
–Standard therapy
–Afterload reducers – amlodipine, hydralazine
•Bronchomalacia, airway collapse, concurrent bronchitis
–Bronchodilators
»Inhalers, theophylline
–If all else fails – codeine but beware LCHF
–Use codeine if it gets worse – does not make heart worse like steroids can. They are probably at EOL here and so at least they are happy
What do we need to discuss with the O when it comes to treatment? (4)
The natural history of the disease.
The prognosis.
The likely management regime.
Financial considerations.
What MUST we tell the owner about HF management? (5)
- A regular daily routine
- The administration of prescribed medication
- A consistent exercise schedule
- The possible side/toxic effects of medications
- Maintaining appetite
–Do not give them salt e.g. crisps!!!!!! Sudden salt – bad.
Prognosis of HF?
Life expectancy = several weeks to a few years, poorer in cardiomyopathy??
Not all dogs with murmurs develop heart failure
