– 10 yr old FS Wheaten Terrior with a history is suspected pancreatitis in July (v/d, poor appetite, +cPLI) 4DX negtative
– u/s performed at the time was unremarkable with no evidence of pancreatits; treated for pancreatitis and responded well however energy levels never returned and appetite remained decreased
– presented today for severe tachycardia with ECG sent IDEXX: sustained atrial tachycardia 380-400 bpm ddx: primary cardiac vs systemic disease; rDVM started patient on sotalol 20mg then called me in for an echo
– 10 yr old FS Wheaten Terrior with a history is suspected pancreatitis in July (v/d, poor appetite, +cPLI) 4DX negtative
– u/s performed at the time was unremarkable with no evidence of pancreatits; treated for pancreatitis and responded well however energy levels never returned and appetite remained decreased
– presented today for severe tachycardia with ECG sent IDEXX: sustained atrial tachycardia 380-400 bpm ddx: primary cardiac vs systemic disease; rDVM started patient on sotalol 20mg then called me in for an echo
– heart rate came down with sotalol but still tachycardiac for the exam
– there is LAE, moderate MR and mild TR (no evidence of PAH with TR jet recorded although RVW appears a little thickened, aortic and pulmonic velocities normal)-this was a tough echo due to tachycardia where Doppler was not performing great 🙁
– 3-view chest rads clear for pulmonary edema or masses; LAE noted PetMap BP taken after echo 159/50
– I did not rescan the entire abdomen but took a second look at the adrenals in case I missed a pheo
The adrenals look normal to me although the right adrenal may be a bit bumpy. The only pheo I have seen was quite obvious with large adrenal tunour present. Could I be missing a subtle pheo in this patient that is beyond the resolution of my probe?
Could CVD be causing the atrial tachycardia? I have seen atrial fib caused by LAE but not this before. The patient does not have a history of a heart murmur and one could not be heard today with the tachycardia
(the 3rd clip is the right adrenal which is not labelled)
Comments
Hi Jacquie!
LAE can cause
Hi Jacquie!
LAE can cause afib as well as atral tachycardia. When the HR is very high, the heart murmur is often more difficult to hear.
I usually use digoxin (+ diltiazem, if the digoxine does not help sufficiently). But the electrolytes have to be checkes first!!
Normally, I do a Holter before to assess the heart rates at home.
Sotalol can also help and can be combined with Digoxin.
However, the intestinal resorption of digoxin can be reduced if it is combined with PPIs, Cimetidine or Metroclopramide. And I would rather not combine it with Spironolactone.
Re Pheo: To me it doesn’t look like one even though not all are quite obvious. If the tachycardia is intermittent (Holter!), you can measure the Normetanephrine: Crea-Ration in the urine to r/o a pheo. If the blood pressure was normal in a tachycardia-period, a pheo is unlikely.
Peter
Hi Jacquie!
LAE can cause
Hi Jacquie!
LAE can cause afib as well as atral tachycardia. When the HR is very high, the heart murmur is often more difficult to hear.
I usually use digoxin (+ diltiazem, if the digoxine does not help sufficiently). But the electrolytes have to be checkes first!!
Normally, I do a Holter before to assess the heart rates at home.
Sotalol can also help and can be combined with Digoxin.
However, the intestinal resorption of digoxin can be reduced if it is combined with PPIs, Cimetidine or Metroclopramide. And I would rather not combine it with Spironolactone.
Re Pheo: To me it doesn’t look like one even though not all are quite obvious. If the tachycardia is intermittent (Holter!), you can measure the Normetanephrine: Crea-Ration in the urine to r/o a pheo. If the blood pressure was normal in a tachycardia-period, a pheo is unlikely.
Peter
Hi Jacquie!
LAE can cause
Hi Jacquie!
LAE can cause afib as well as atral tachycardia. When the HR is very high, the heart murmur is often more difficult to hear.
I usually use digoxin (+ diltiazem, if the digoxine does not help sufficiently). But the electrolytes have to be checkes first!!
Normally, I do a Holter before to assess the heart rates at home.
Sotalol can also help and can be combined with Digoxin.
However, the intestinal resorption of digoxin can be reduced if it is combined with PPIs, Cimetidine or Metroclopramide. And I would rather not combine it with Spironolactone.
Re Pheo: To me it doesn’t look like one even though not all are quite obvious. If the tachycardia is intermittent (Holter!), you can measure the Normetanephrine: Crea-Ration in the urine to r/o a pheo. If the blood pressure was normal in a tachycardia-period, a pheo is unlikely.
Peter
Thanks Peter – nice to get
Thanks Peter – nice to get your opinion on this! Would you also add in an ace-inbitor at this stage?
Jacquie
Adreals look normal to me you
Adreals look normal to me you have some poor signal strength at the cranial aspect of the right adrenal but it has the normal wide base
Since the dog is currently
Since the dog is currently not in left sided CHF, I would check first, if the reduction in heart rate decreases in left atrial size. A heart rate of 350 can lead to CHF even if the heart is structurally normal.
If the left atrium remains large, I would likely give Pimobendan.
Peter
Peter – Pimo over an ACEi –
Peter – Pimo over an ACEi – why? I thought Pimo was only indicated if left-sided CHF is present but maybe this is a different case due to the arrhythmia or maybe Pimo is better since this pet has not been feeling well and the reason for the arrhythmia is not clear cut? Makes sense to treat the arrhythmia first.
Yes the old adage is make the
Yes the old adage is make the heart happier first ad then see what the arrythmia does. Of course this is the case ifn volume overload cases as opposed to structurally nsf boxer cmy. But if volume overload is present making Starling happier is always th ebest bet and often arrythmias become more manageable or even not frequent enough to have to treat when in an early phase.
General ?
Are cardiologists
General ?
Are cardiologists using Pimobendan and Digoxin at the same time?
I’ve seen it used but Dig for
I’ve seen it used but Dig for rate control primarily because it pales in comparison to the inotrope effect of pimobendan.
Hi Jacquie!
ACEI have very
Hi Jacquie!
ACEI have very likely no effect on the progression of compensated DMVD/Mitral insufficiency.
The combination of ACEI/Spironolactone could possibly have and effect but this has – in my opinion – not been sufficienty proven.
Pimobendan can be combined with Digoxin and has, as Eric wrote, a much better effect on cardiac function, preload and afterload. Digoxin is primarily used to reduce ventricular response rate with supraventricular tachycardia.
I use Pimobendan more and more in dogs with DMVD and enlarged left atrium, even if they are not congested. Pimo has been shown to decrease left atrial pressures significantly. And I think that this will likely be the future of medical treatment, even though it is currently still off-lable.
Peter
Thanks for this Peter – it is
Thanks for this Peter – it is sometimes hard to keep up with what drugs to use when in veterinary cardiology!
Sure, hope well meet in NYC
Sure, hope well meet in NYC in Oct(IVUSS)
Peter
I will be there! Looks like a
I will be there! Looks like a great meeting
An update on this case for
An update on this case for interest sake. This pet’s arrhythmia could not be controlled despite medical therapy so was referred to a cardiologist at OVC in Guelph. The pet is now being referred to a cardiologist in the U.S. ( didn’t get the name of the institution) where an ablation procedure will be performed on the heart in effort to control the arrhythmia. very interesting case!