I recently posted a question on VIN about a case I had regarding pulmonary hypertension. I have used the cut-off’s in June Boon’s book as well as published in other places that state PAH is diagnosed when systolic pulmonary arterial pressures are over 30mmHg.
Mild PAH 30-50
Moderate 50-80
Severe >80
I recently posted a question on VIN about a case I had regarding pulmonary hypertension. I have used the cut-off’s in June Boon’s book as well as published in other places that state PAH is diagnosed when systolic pulmonary arterial pressures are over 30mmHg.
Mild PAH 30-50
Moderate 50-80
Severe >80
My case had a TR max velocity of 2.88 m/s which translated into a pulmonary pressure of about 33mmHg. So I would call this mild PAH. The cardiologists on VIN said that this is normal in a dog being examined in a clinical situation and that they do not consider PAH to be present until at least 40mmHg is present.
I am curious to see what others are using as their cut off as I would hate to diagnose a pet with PAH that doesn’t actually have it.
Comments
Gotta love this can of worms
Gotta love this can of worms Jacquie:)
As with any pathology that is getting discovered on “what to do with it”… like the USA and Pimobendan a few years ago after europe had used it for some time before it cgot ont he boat across the water….and one could make the ace inhibitor issue stick here too, you will have a widee array of opinions….the proactives; treat before it fails and if they dont fall over form hypotension and spike renal values and anorexia then great… and the retroactives; wait til it fails then tx.
Technically yes 2.8 m/sec is PHT but june boon la/ao>1.35 (1.15 is normal) is LAE but asymptomatic, for example, and we dont treat yet. Sit and wait and see if it gets worse…reason for a recheck in a few months…
We have made a policy amongst our 6 Drs in NJ mobile (3 of us boarded 1 abvp and 2 acvim) that we don’t tx asymptomatic pht until well into the 3.5+ m/sec range. My experience i have not seen exercise intolerance until they are close or above 3.5 m/sec TR so that’s our magic number. If someone on my team treats an asymptomatic PHT above 3.5 Tr jet then i wont argue with them. Don’t know if i would do it myself but thats our policy to reflect the group experience. 3.3 with typical clinical signs then yes but most have traditional left sided disease first and secondary pht so treat the primary first and the pht drops usually anyway without going to sildenafil.
Along these lines I have never seen a TR <3.0 be only symptomatic for PHT. Maybe someone has and they will post but not in my norms and I do a ton of echo.
Interestingly enough I have see that some of these pht dogs are also systemic hypertension dogs and by treating the systemic HT with norvasc or similar I have seen the TR jet drop 20-40 cm/sec. Never written up but I have seen it over an over again. No, norvasc is not a PHT drug but again tx the primary issue first and see what the "PHT" does. Same issue using an ACEi for systemic HT and the LA is larger than normal but not big enough to get a main stem bronchus cough or left CHF so not big enough to tx. But tx the hypertension wiht an acei and he may be ahead of the game and be the proactive cardio folks best buddy. Just another reason to use an acei.
If the clinical PHT is from primary thoracic/pulmonary disease or acute PTE then that's a different story. Viagra all the way and some aspirin and maybe plavix for PTE suspect.
Of course there will be a cool variety on this post for sure which is the fun of it but this is what we do in NJ right or wrong but not seeing bad effects anywhere medically or businesswise:)
Gotta love this can of worms
Gotta love this can of worms Jacquie:)
As with any pathology that is getting discovered on “what to do with it”… like the USA and Pimobendan a few years ago after europe had used it for some time before it cgot ont he boat across the water….and one could make the ace inhibitor issue stick here too, you will have a widee array of opinions….the proactives; treat before it fails and if they dont fall over form hypotension and spike renal values and anorexia then great… and the retroactives; wait til it fails then tx.
Technically yes 2.8 m/sec is PHT but june boon la/ao>1.35 (1.15 is normal) is LAE but asymptomatic, for example, and we dont treat yet. Sit and wait and see if it gets worse…reason for a recheck in a few months…
We have made a policy amongst our 6 Drs in NJ mobile (3 of us boarded 1 abvp and 2 acvim) that we don’t tx asymptomatic pht until well into the 3.5+ m/sec range. My experience i have not seen exercise intolerance until they are close or above 3.5 m/sec TR so that’s our magic number. If someone on my team treats an asymptomatic PHT above 3.5 Tr jet then i wont argue with them. Don’t know if i would do it myself but thats our policy to reflect the group experience. 3.3 with typical clinical signs then yes but most have traditional left sided disease first and secondary pht so treat the primary first and the pht drops usually anyway without going to sildenafil.
Along these lines I have never seen a TR <3.0 be only symptomatic for PHT. Maybe someone has and they will post but not in my norms and I do a ton of echo.
Interestingly enough I have see that some of these pht dogs are also systemic hypertension dogs and by treating the systemic HT with norvasc or similar I have seen the TR jet drop 20-40 cm/sec. Never written up but I have seen it over an over again. No, norvasc is not a PHT drug but again tx the primary issue first and see what the "PHT" does. Same issue using an ACEi for systemic HT and the LA is larger than normal but not big enough to get a main stem bronchus cough or left CHF so not big enough to tx. But tx the hypertension wiht an acei and he may be ahead of the game and be the proactive cardio folks best buddy. Just another reason to use an acei.
If the clinical PHT is from primary thoracic/pulmonary disease or acute PTE then that's a different story. Viagra all the way and some aspirin and maybe plavix for PTE suspect.
Of course there will be a cool variety on this post for sure which is the fun of it but this is what we do in NJ right or wrong but not seeing bad effects anywhere medically or businesswise:)
Thanks Eric
Interestingly
Thanks Eric
Interestingly enough this was a syncope case so this is why I was interested if PAH was present in the first place. I know that PAH has to be severe for syncope to occur – a pulmonry pressure of 33 would not cause this. He did have a mild peribronchial pattern and was a brachycephalic so I guess there could be mild PAH due to bronchial airway disease. He was not coughing.
This dog did have MVD but no LAE or right heart changes. We did not have a chance to try a Holter monitor so could not rule out a heart arrythmia problem causing syncope. This could also be an excitement syncope case as fainting occurs when the dogsgets excited.
I agree that I would not treat for PAH in this dog.
Thanks Eric
Interestingly
Thanks Eric
Interestingly enough this was a syncope case so this is why I was interested if PAH was present in the first place. I know that PAH has to be severe for syncope to occur – a pulmonry pressure of 33 would not cause this. He did have a mild peribronchial pattern and was a brachycephalic so I guess there could be mild PAH due to bronchial airway disease. He was not coughing.
This dog did have MVD but no LAE or right heart changes. We did not have a chance to try a Holter monitor so could not rule out a heart arrythmia problem causing syncope. This could also be an excitement syncope case as fainting occurs when the dogsgets excited.
I agree that I would not treat for PAH in this dog.
FROM PETER MODLER
Hi!
FROM PETER MODLER
Hi!
I totally agree with the people on VIN. 33 mm Hg can be normel in a more or less sressed dog. 40 mm Hg is more reliable. Think of systemic hypertension: A normal dog has a syst BP of about 130 mm Hg. But under clinical circumstances it can raise to 150 mm Hg or even more without being pathologic.
Best Regards!
peter
FROM PETER MODLER
Hi!
FROM PETER MODLER
Hi!
I totally agree with the people on VIN. 33 mm Hg can be normel in a more or less sressed dog. 40 mm Hg is more reliable. Think of systemic hypertension: A normal dog has a syst BP of about 130 mm Hg. But under clinical circumstances it can raise to 150 mm Hg or even more without being pathologic.
Best Regards!
peter
i would consider an event
i would consider an event monitor or rule out hypertension. SHT dogs can have syncope.
any coughing or vomiting before the event?.. vagal tone issue… “Cough drop syndrome?”
Eric
i would consider an event
i would consider an event monitor or rule out hypertension. SHT dogs can have syncope.
any coughing or vomiting before the event?.. vagal tone issue… “Cough drop syndrome?”
Eric
I totally agree with Eric.
I totally agree with Eric. PHT is less likely the cause if PGs are that low. Most patients with symtomatic PHT have RV Hypertrophy with the exception of sudden onset PHT (e.g. sudden thrombembolic event) where the RV has not enough time for hypertrophy. But these dogs mostly have a dilated RV and obvious TI which then reveal high PGs.
I would start with a Holter-ECG.
BR
Peter
I totally agree with Eric.
I totally agree with Eric. PHT is less likely the cause if PGs are that low. Most patients with symtomatic PHT have RV Hypertrophy with the exception of sudden onset PHT (e.g. sudden thrombembolic event) where the RV has not enough time for hypertrophy. But these dogs mostly have a dilated RV and obvious TI which then reveal high PGs.
I would start with a Holter-ECG.
BR
Peter
just go to the clincal search
just go to the clincal search page and put in “pulmonary hypertension” for the pathology search and lots of those cases come up of every type of PHT:)
http://www.sonopath.com/case-studies/search
man I love what we built!:)
just go to the clincal search
just go to the clincal search page and put in “pulmonary hypertension” for the pathology search and lots of those cases come up of every type of PHT:)
http://www.sonopath.com/case-studies/search
man I love what we built!:)
I am creating a new thread
I am creating a new thread Clinical PHT from A PTE so we can see an example of what Peter is talking about in a case where a patient is throwing clots to lungs
I am creating a new thread
I am creating a new thread Clinical PHT from A PTE so we can see an example of what Peter is talking about in a case where a patient is throwing clots to lungs
Excellent – very
Excellent – very helpful!
Jacquie
Excellent – very
Excellent – very helpful!
Jacquie