The four chambers of the heart comprise the pumping organ of the
cardiovascular system. It is important in maintaining proper circulation of the
blood. However, there are times wherein alteration happens and thus failure of
the heart occurs. One cause of this is dilated cardiomyopathy wherein the volume
capacity of the heart is increased with a decrease in myocardium size. It can be
diagnosed by using physical examination, radiography, echocardiography and
electrocardiography. Treatment and management of the disease is divided into
three phases namely stabilizing of the patient, maintenance therapy and the
treatment of arrhythmias. The outcome of the disease is dependent on the
management and therapy, however, it should be noted that treatment must go on
for life or the clinical signs will soon reappear.
The Simplify® antigen kit is used in adjunct with the microfilaria test because
there is a high chance that even if dirofilariasis is present, microfilaria will not be
exhibited in the blood smear. The result is negative which supports the results of
the laboratory microfilaria test.
On the thoracic radiograph, the trachea is normal and is patent due to the
presence of radioluscent area which may signify air. On the examination of the
cardiac silhouette however, deviations from the normal were observed. The
normal range for the cardiac silhouette in vertebral heart scale is 9.7 ± 0.5
(Buchanan and Bucherler, 1995). However, upon measuring the size of the
silhouette, the long axis is 6 vertebrae whereas the short axis measures 5
vertebrae. Also a classical sign of cardiomyopathy is the resting of the ventricles
within the sternum. However, this method is not as accurate as the vertebral
heart scale method.
Differential diagnosis of the case includes infectious tracheobronchitis,
tracheal collapse, upper airway obstruction, dirofilariasis and cardiomyopathy.
Infectious tracheobronchitis was ruled out because there is no thickening of the
tracheal lumen seen in the radiograph, tracheal collapse and upper airway
obstruction were also ruled out due to the presence of radioluscent area on the
radiograph on the area of the trachea suggesting patency. Dirofilariasis was ruled
by laboratory methods, however it should be noted that a negative result on wet
mount examination of blood for dirofilaria yields high negative, an antigen kit was
used to ultimately rule out the infection.
Using the clinical signs and radiograph as diagnostic tools, Mocha was
tentatively diagnosed to have cardiomyopathy. Furosemide, enalapril and
cefalexin were prescribed together with a Prescription Diet® h/d Canine dog food.
The dose, preparation and the amount to be given is summarized in Table 2.
Prescription Diet® h/d Canine dog food is formulated to help manage dogs with
the symptoms of heart diseases and related fluid retention because sodium (0.03%)
is present at small amounts in the food with potassium at 0.23%.
The client was advised to restrict food intake with high sodium levels,
restriction of activity is not necessary and should allow the dog to choose its own
activity and giving adequate water because of the effects of furosemide and
enalapril which may in turn cause dehydration of the patient.
III. Follow-Up
On a follow-up call last August 7, 2008, the owner was enthusiastic to report
that coughing stopped even within 1 day of treatment and that diarrhea also
stopped. The dog was not also eating its prescribed food and “starving” itself at
day and scavenging the trashes at night. Since the client already went to another
clinica prior to admission at the hospital, the owner related that liver function
tests were high, however upon inquiry if the attending veterinarian gave a
prescription, he gave none. The client was asked to return on August 9, 2008.
On August 9, 2008, Mocha was apparently healthy, bright, alert and responsive.
Heart rate was 130 beats per minute and all other organ system seems to be
apparently normal. A series of laboratory examination were run to assess the
improvement of Mocha and to check for liver function and potassium levels due to
possible complications with diuretic treatment. Results of the laboratory
examination are summarized in Table 3.
Liv 52, a liver tonic, was prescribed (I tablet s.i.d as supplement) together with
a home made recipe consisting of 125 g ground or lean beef, 2 cups cooked white
rice, one tablespoon of vegetable oil and pet vitamins. Calcium supplement may
also be added but was not since calcium levels have not yet been assessed.
On August 23, 2008, the client was asked to bring Mocha back to reevaluate her
condition and the drugs being used. A laboratory examination including potassium
and alanine transferase serum levels were reevaluated. Results of the laboratory
examination are summarized in Table 4.
Drugs given were reevaluated and the prescription was modified. Enalapril,
which is usually the mainstay treatment for heart failure patients, was prescribed
using the same dose and preparation. Furosemide has been removed from the
prescription because of its hypokalemic effect. Jetepar replaced Liv 52 as liver
tonic because of its more potent effect. Taurine and L-carnitine may be prescribed
to make use of its cardioprotectant effects. However, since L-carnitine in its pure
form is not available in the market, only taurine was prescribed to the dog.
On September 13, 2008, Mocha went back to the hospital for her drug intake to
be revaluated. Upon seeing that her condition is improving, the attending
veterinarian decided to reduce the frequency of the enalapril intake from twice a
day to once a day only, using the same dose. Jetepar and Pet tabs are still being
given as supplements.
IV. Discussion
The disease has 3 clinical manifestations depending on the state of the animal.
Class I are animals that are asymptomatic but have arrhythmia detected on
physical examination, Class II have episodes of syncope weaknesses and Class III
may present congestive heart failure with arrhythmias (Meurs, 1998). Based on the
definition, Mocha may be classified as Class III patients because of the
enlargement of the heart on radiography and also typical signs which is suggestive
of congestive heart failure.
The hemogram, serum chemistry and urinalysis are usually normal unless
altered by severe heart failure (high alanine transferase), treatment for heart
failure and concurrent disease (Tilley and Smith, 1997). Anemia may have resulted
from the overhydrated status of the dog or due to the infection caused by the
underlying amoebiasis. Since the cause was possibly treated using a diuretic and
an anti-microbial, anemia have resolved. Leukocytosis and neutrophilia are
suggestive of infection and prompt therapy against the cause which is usually
bacteria is most significant. High alanine transferase levels have been correlated
with hypoxemia which causes increased hepatocyte destruction leading to seeping
out of the enzymes in the blood stream.
Other tests that should be checked routinely include creatinine, potassium and
calcium levels. A normally functioning kidney is a necessity in the treatment of
heart failure since diuresis is occurring in the kidney. Potassium levels need to be
constantly evaluated since it is excreted at high levels together with sodium and
water and hypokalemia should be prevented by giving supplements (Erling and
Mazzaferro, 2008). Pet-Tabs® with 5% potassium is used as the supplement for this
cause. Calcium levels need to be evaluated since it is a primary ion together with
ATP causing the contraction of the heart (Stephenson, 2007). Problems with
contraction of the heart may be a result with a decrease in calcium levels in the
extracellular fluid (ECF), normal levels of calcium but decreased in receptors or
normal calcium and receptors but the cascade in the contraction is disrupted.
Calcium:phosphorus ratio have to be evaluated to rule out possible
hypoparathyroidism. However, the exact cause of contractile problem will not
affect the treatment of the disease.
Outcome is based mainly on the class on which the animal belongs to: Class I
patients usually have a good prognosis and may be expected to live for more than
a year, Class II patients are at risk of sudden death and Class III patients with less
than 6 months (Meurs, 1997). However, the course of disease is always fatal and
that possible complications should always be noted (Tilley and Smith, 1997).
V. References
Allen DG, Dowling PM, Smith DA, Pasloske K and Woods JP. 2005. Handbook of
Veterinary Drugs. Baltimore: Lippincott Williams and Wilkins. pp. 156-157,
196-197, 209-210, 230-231.
Bulmer BJ and Sisson DD. 2005. Therapy of Heart Failure. In Ettinger SJ and
Feldman EC (eds.). Textbook of Veterinary Internal Medicine: Diseases of
the Dog and Cat Volume II. 6th ed. St. Louis: Elsevier Saunders. pp. 948-
972.
de Morais HA and Scwartz DS. 2005. Pathophysiology of Heart Failure. In Ettinger
SJ and Feldman EC (eds.). Textbook of Veterinary Internal Medicine:
Diseases of the Dog and Cat Volume II. 6th ed. St. Louis: Elsevier Saunders.
pp. 914-940.
Dove, RS. 2001. Nutritional therapy in the treatment of heart disease in dogs.
Alternative Medicine Review, 6(Suppl):S38-S45.
Erling P and Mazzaferro EM. 2008. Left-sided congestive heart failure in dogs:
pathophysiology and diagnosis. Compendium, 30(2): 79-91.
Erling P and Mazzaferro EM. 2008. Left-sided congestive heart failure in dogs:
treatment and monitoring of emergency patients. Compendium, 30(2): 94-
104.
Meurs KM. 2005. Primary Myocardial Disease in the Dog. In Ettinger SJ and Feldman
EC (eds.). Textbook of Veterinary Internal Medicine: Diseases of the Dog
and Cat Volume II. 6th ed. St. Louis: Elsevier Saunders. pp. 1077-1082.
Root CR and Bahr RJ. 1998. The Heart and Great Vessels. In Thrall DE (ed.).
Textbook of Veterinary Radiology. 3rd ed. Philadelphia: W.B. Saunders. pp.
335-353.
Tilley LP and Smith FWK Jr. 1997. The 5 Minute Veterinary Consult – Canine and
Feline. Media: Williams and Wilkins. pp. 418-419, 422-423, 470-471, 474-
475, 550-551, 850-851.