EPIC criteria question

Sonopath Forum

EPIC criteria question

I had a good question sent to me by one of my scanning clients today regarding using the EPIC criteria for MMVD:

“Hi Jacquie, I’m just trying to apply the findings [of EPIC ]regarding the use of Pimobendan in small dogs with heart murmurs that are asymptomatic for CHF.    

I had a good question sent to me by one of my scanning clients today regarding using the EPIC criteria for MMVD:

“Hi Jacquie, I’m just trying to apply the findings [of EPIC ]regarding the use of Pimobendan in small dogs with heart murmurs that are asymptomatic for CHF.    

Is my understanding correct that they need to fulfill ALL of the criteria listed?   i.e. unless they have a grade 3/6 murmur and VHS > 10 .5 then it is not worth doing the ultrasound to determine if treatment is warranted.”
In my opinion, an echo should be still performed even if VHS is normal as VHS is not a perfect test. Any thoughts?



I’m not a VHS fan so I will

I’m not a VHS fan so I will be skewed on this because I see it misinterpreted erroneously all the time… not on the measurement but on the clinical significance of the measurement. I believe an echo is a good idea on all heart murmurs to at least create a baseline, see if there is prolapse (which I would monitor more closely on rechecks), look at function and morphology in order to adequately manage that patient. A moderate to severe HCM without volume overload I would recheck in 3 months as I would a MV prolapse in similar normal volume case. Whereas a benign cat murmur I may not recheck at all or if minor LV hypertrophy maybe I recheck in a year. All of these scenarios may have a practitioner saying there is cardiomegaly on rad interpretation..and often is just overlying chest fat for example… a more common north american disease in pets than actual heart disease:)

Regarding the Epic study i will leave that to Peter’s paper dissecting ability but the latest I hear is that Pimo can be used in B2 vd with solid repeatable LA enlargement without traditional failure (wet lung with left cardiomegaly) and this is the criteria I use but there are many other factiors here and each heart is different.


The curbside guide that Peter contirbuted to deals wiht this as well plug plug…


However, I really despise the cardiology in a box concept and categorizing everything because there is a lot of subjective experience based value to treat certain patients and not all B2s (pimo possible cases) are created equal.

regarding non violume overload murmur cases, I think its dangerous to use pimo on B1 with normal LA size and that’s where the French got into trouble when pimo first came out in the late 90s in France and why USA took so long to get it approved and was very cautious because the practitioners were giving pimo and gettign sudden death, thought to be based on the marketing campaign at that time and I’m paraphrazing an ECVIM talk by Lombard many years ago, at heart murmurs without further studies (echo for example) other than maybe radiographs and there was no true volume overload. We all know people calling cardiomegaly inappropriately on rads and many mistake right heart enlargement owing to conformational or respiratory pressure issues for left sided disease. I get this all the time in mobile practice and they have their hand on the pimo bottle and I have to talk them out of it all the time when the la size is normal and there hapens to be some MR.

Then there’s the non cardiogenic pulmonary edema (NCPE) that gets triple therapy when its not a heart problem and I see a volume contracted LA as a result…

So moral of the story: echo it to be safe and assess the parameters mentioned above amongst others befoire looking for the pimo bottle and B2 and beyond is fair game for pimo and I nearly always couple it with at least low dose lasix to drop volume and pressures a bit and because I’m american we like ace-inhibitors and think they work so i may add that too:) and we may think they work because they are cheaper for us and makes us think we are helping and we may be right… or we may just be subject to years of subliminal marketing who knows any more as cardiologists are all over the map on when to use an ace-i… just go to a talk on ace-i at acvim cardio pathway and be a fly on the wall. Its always a good time:)

Sorry for the rant but lots of layers on this discussion.

Peter Im sure will be more eloquent:)


thanks, Eric for



thanks, Eric for joining in!!!

Yes, a mildly increased VHS does not always mean that there is really an enlargement present.  – I totally agree. But at leaset, the VHS is very sensitive, this means, a VHS <10.5 rules out enlargement with a very high likelyhood.

Re DMVD and EPIC: Yes, all criteria must be fulfilled. So, if the VHS is <10.5, Pimo is not indicated. Still, if you have a dog with a murmur and a low VHS, I would still recommend an echo, not because of Pimo, but to confirm the diagnosis and to rule out other diseases. You are basically right with your statement that dogs with DMVD and with a VHS<10.5 and murmurm <3/6 do not require Pimo and therefore you could leave out an echo – but just under the assumption that you already know that it is DMVD!!

EPIC made one thing clear: You cannot give PImo to a dog with preclinical DMVD without doing an echo.


best regards!





Thank you Peter and Eric!

Thank you Peter and Eric!

I would hate for this client to stop recommending echos for her patients based on VHS which I think she was getting at in her question.

Good to be clear that all critieria of EPIC needs to be met when recommending Pimo.


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