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| AN EVERYDAY APPROACH TO CANINE DEGENERATIVE MITRAL VALVE DISEASE suffer from primary airway or respiratory disease as opposed to heart failure. Etiology of the cough can be differentiated by paying close attention to: UÊ,>`io}À>«hiVÊhi>ÀÌÊ>n`Ê«Õlmon>ÀÞÊÛiinÊÃiâi UÊ/Þ«iÊ>n`Ê`iÃÌÀiLÕÌionÊovÊ«Õlmon>ÀÞÊ«>ÌÌiÀn UÊ Ûi`inViÊovÊÕ««iÀÊ>iÀÜ>ÞÊVoll>«Ãi° Medical Therapy Once a diagnosis of heart failure is made, 4 medica- tions comprise the cornerstones of treatment for heart failure secondary to DMVD. 1. Diuretics: /hiÊmoÃÌÊVommonlÞÊ«ÀiÃVÀiLi`Ê`iÕÀiÌ- ic is furosemide, which is typically administered at 2 to 3 mg/kg/day PO in dogs with mild heart failure and up to 4 to 6 mg/kg/day PO in dogs ÜiÌhÊmoÀiÊ ÃiÛiÀiÊ Ãi}nÃ°Ê olÕÃiÃÊ ovÊ inÌÀ>ÛinoÕÃÊ furosemide, 2 to 4 mg/kg IV Q 2 to 4 H, are used for rapid diuresis in dogs with life-threatening failure. 2. ACE Inhibitors: ACE inhibitors directly address >VÌiÛiÌÞÊovÊÌhiÊÀininq>n}ioÌinÃinq>l`oÃÌiÀoniÊÃÞÃ- tem and work in tandem with diuretics to control congestion. Enalapril, 0.5 mg/kg PO Q 12 H, is the most commonly prescribed ACE inhibitor and iÃÊ }iniÀ>llÞÊ Üill-ÌoliÀ>Ìi`°Ê ,in>lÊ LioVhimiÃÌÀÞÊ Û>lÕiÃÊ>n`ÊiliVÌÀolÞÌiÃÊ>ÀiÊÕÃÕ>llÞÊVhiVki`ÊLivoÀiÊ and 3 to 5 days after starting diuretics and ACE inhibitors or changing doses. 3. Inodilators: /hiÊ ino`il>ÌoÀÊ >}inÌÊ «imoLin`>nÊ VoÕnÌiÀ>VÌÃÊ 6 Ê >n`Ê ,Ê ÌhÀoÕ}hÊ ÓÊ `ivviÀinÌÊ mechanisms: the first through calcium sensiti- â>ÌionÊ >n`Ê inVÀi>Ãi`Ê mÞoV>À`i>lÊ VonÌÀ>VÌiliÌÞÆÊ ÌhiÊ ÃiVon`Ê ÌhÀoÕ}hÊ Û>Ão`il>Ìion°Ê *imoLin`>nÊ im«ÀoÛiÃÊÃÕÀÛiÛ>lÊ inÊ`o}ÃÊÜiÌhÊhi>ÀÌÊ v>ilÕÀiÊÃiV- ondary to DMVD and when compared directly >}>inÃÌÊ Lin>âi«Àil]Ê iÝÌin`ÃÊ lon}iÛiÌÞÊ LÞÊ >lmoÃÌÊ Ó-vol`Êmi`i>nÊÃÕÀÛiÛ>l]Ê{ÊmonÌhÃÊlon}iÀÊinÊ«imo- Lin`>nÊ}ÀoÕ«®ÊoÛiÀÊ ÊinhiLiÌoÀð8 /hiÃiÊ ÎÊ mi`iV>ÌionÃpvÕÀoÃimi`i]Ê «imoLin- `>n]Ê>n`Êin>l>«ÀilpVom«ÀiÃiÊÜh>ÌÊV>À`iolo}iÃÌÃÊ refer to as triple therapy and are considered standard of care for heart failure secondary to DMVD. In my practice, if owners are constrained to administering less than 3 medications, such as instances in which the dog is difficult to pill, the priority of administration is furosemide, pimo- bendan, and then enalapril. 4. Aldosterone Antagonists:Ê/hiÊ>l`oÃÌiÀoniÊ>nÌ>}- onist, spironolactone, is the fourth agent common- lÞÊÕÃi`Ê voÀÊ ÌÀi>ÌminÌÊovÊhi>ÀÌÊ v>ilÕÀi°Ê ÌÊ«ÀoÛi`iÃÊ >``iÌion>lÊLloVk>`iÊovÊÌhiÊÀininq>n}ioÌinÃinq aldosterone system and produces modest diuresis. In a European study, spironolactone, 2 mg/kg PO Q 24 H, was shown to significantly increase sur- ÛiÛ>lÊinÊ`o}ÃÊÜiÌhÊhi>ÀÌÊv>ilÕÀiÊ`ÕiÊÌoÊ 6 9 ÆÊiÌÊiÃÊ VÕÀÀinÌlÞÊ>««ÀoÛi`ÊvoÀÊÕÃiÊinÊ`o}ÃÊinÊÌhiÊ ÕÀo«i>nÊ 1nion°Ê spironolactone as standard therapy, primarily due 24 Today's Veterinary Practice July/August 2012 >À`iolo}iÃÌÃÊ h>ÛiÊ LiinÊ ÃloÜiÀÊ ÌoÊ >`o«ÌÊ Mark Oyama, DVM, Diplomate ACVIM (Cardiology), is a professor in the Department of Clinical Studies at University of Pennsylvania School of Veterinary Medicine. His interests lie in the pathophysiology of mitral valve disease and cardiomyopathy and in new blood-based tests for detection of heart disease. He is a past president of the ACVIM Specialty of Cardiology and an Editorial Peer Review Board member for Today's Veterinary Practice. Dr. Oyama received his DVM degree from University of Illinois and completed an internship at The Animal Medical Center in New York City and residency at University of California–Davis. to the somewhat atypical nature of the study cohort. Additional studies to better clarify the util- ity of spironolactone are currently ongoing. IN SUMMARY UÊ/hiÊ`i>}noÃiÃÊovÊ 6 Ê iÃÊ Àil>ÌiÛilÞÊ Ãim«liÊ >n`Ê based on auscultation and signalment. UÊ/hoÀ>ViVÊ À>`io}À>«hÞÊ iÃÊ >nÊ iÝVillinÌÊ mo`>liÌÞÊ ÌoÊ>ÃViÀÌ>inÊL>ÃiliniÊ>n`Ê«Ào}ÀiÃÃiÛiÊhi>ÀÌÊ Ãiâi]Ê ÜhiVhÊ`iÀiVÌlÞÊVoÀÀil>ÌiÃÊÌoÊÃiÛiÀiÌÞÊovÊ`iÃi>Ãi°Ê nÊ addition, in dogs with clinical signs, radiographs help distinguish cardiac from respiratory causes. UÊ o}ÃÊ ÜiÌhÊ l>À}iÊ hi>ÀÌÃÊ >n`Ê À>«i`lÞÊ inVÀi>Ãin}Ê hi>ÀÌÊ ÃiâiÊ >ÀiÊ >ÌÊ hi}hÊ ÀiÃkÊ voÀÊ hi>ÀÌÊ v>ilÕÀiÆÊ inVÀi>Ãi`Ê oÜniÀÊ >n`Ê ÛiÌiÀin>ÀÞÊ moniÌoÀin}Ê iÃÊ warranted. UÊ/hiÀiÊ>ÀiÊnoÊ`ÀÕ}ÃÊÌh>ÌÊh>ÛiÊLiinÊÕniµÕiÛoV>llÞÊ «ÀoÛinÊÌoÊÃloÜÊ«Ào}ÀiÃÃionÊovÊ`iÃi>ÃiÊinÊÌhiÊ«Ài- clinical stage. UÊ vÊ>n`ÊÜhinÊhi>ÀÌÊ v>ilÕÀiÊ`iÛilo«Ã]ÊÌhiÀ>«ÞÊÜiÌhÊ furosemide, pimobendan, and an ACE-inhibitor ³É-ëiÀonol>VÌoni®Ê ÃhoÕl`Ê LiÊ inÃÌiÌÕÌi`Ê ÜiÌhÊ attention paid to renal blood analysis, patient ÀiëiÀ>ÌoÀÞÊivvoÀÌÊ>n`ÊÀ>Ìi]Ê>n`Ê>VÌiÛiÌÞÊliÛil°Ê■ Disclosure Statement Dr. Oyama has received funding for clinical studies and speaking honoraria from Boehringer Ingelheim Vetmed- ica (makers of pimobendan) and consults for and has received speaking honoraria from CEVA Pharmaceuti- cals (makers of spironolactone). ACE = angiotensin-converting enzyme; DMVD = degenerative mitral valve disease; ECG = electrocardiography; echo = echocardiography; MR = mitral regurgitation; VHS = vertebral heart size (References continued on page 67)