Sonopath Forum

Pulmonary Hypertension

I have a 12 year old Cavalier Cross with severe mitral insufficiency and pulmonary hypertension (Tricuspid Regurgitation 4.25 m/sec). He is not in CHF at this time

He meets all the criteria of the EPIC study.

I was planning on starting him on Pimobendan and Sildenafil.

Here are my 2 questions:

1. Can I start him on an Ace Inhibitor along with the Sildenafil?

2. Should I hold off on any diuretic at this point since he is not in CHF

I have a 12 year old Cavalier Cross with severe mitral insufficiency and pulmonary hypertension (Tricuspid Regurgitation 4.25 m/sec). He is not in CHF at this time

He meets all the criteria of the EPIC study.

I was planning on starting him on Pimobendan and Sildenafil.

Here are my 2 questions:

1. Can I start him on an Ace Inhibitor along with the Sildenafil?

2. Should I hold off on any diuretic at this point since he is not in CHF

Comments

Peter

July 18, 2019 at 6:16 am -

Hi!
Pimo and Sildenafil is a

Hi!

Pimo and Sildenafil is a good choice. I use ACEIs only in combination with Furosemide (as soon as diuretic tratment is needed)

Re Furosemide: Can you post the Cornell Index and the La:Ao ratio of this patient? Thanks!

peter

Peter

July 18, 2019 at 6:16 am -

Hi!
Pimo and Sildenafil is a

Hi!

Pimo and Sildenafil is a good choice. I use ACEIs only in combination with Furosemide (as soon as diuretic tratment is needed)

Re Furosemide: Can you post the Cornell Index and the La:Ao ratio of this patient? Thanks!

peter

randyhermandvm

July 18, 2019 at 11:14 am -

Thanks Peter.
LA/AO 2.1
LVIDd

Thanks Peter.

LA/AO 2.1

LVIDd (Cornell) 1.97

Can I use Tadalafil once daily instead of Sildenafil?

Peter

July 19, 2019 at 6:16 pm -

Hi!
Yes, Tadalafil at 2 mg/kg

Hi!

Yes, Tadalafil at 2 mg/kg sid is a good choice as well.

Given these dimensions I would likely start with some mild dose of Furosemide (e.g. 0.5-1 mg/kg bid), ACEI and Spironolactone as well. This is because the dog seems to be at risk for developing CHF and some mild congestion might contribute to PHT here.

Unfortunately, Cavaliers tend to have PHT secondary to airway disease or maybe due to some genetic predisposition which worsenes their prognosis…

Peter

randyhermandvm

July 20, 2019 at 2:30 am -

Thanks Peter.
Shall start him

Thanks Peter.

Shall start him on a low dose of Furosemide and Enalapril.

I will also talk to the owners about Spironolactone.

veteurope1

July 20, 2019 at 6:50 pm -

Interesting post.
I saw a

Interesting post.

I saw a CKCS recently who presented with inappetance, v+ and tachypnoea and ascites. He had pulmonary hypertension, hepatic venous congestion and ascites (modified transudate). He also had MMVD and LAE but I did not think this was severe enough to be causing such advanced R CHF/ secondary PH. He had severe cystic acute on chronic pancreatitis with steatitis.

He had been on pimobendan so I added spironolactone and sildenafil and symptomatic treatment for pancreatitis. No IVFT or furosemide given. I was going to wait until he started eating to add in low dose furosemide and aci-i.

Can you get right sided CHF (presumably secondary to PH/airway disease) in these MMVD cavies without being in left sided CHF? Can you manage these without furosemide?

Peter

July 24, 2019 at 6:12 pm -

Hi!
Basically, post-capillary

Hi!

Basically, post-capillary pulmonary hypertension secondary to left sided CHF cannot exceed 50-60 mm Hg without secondary causes. This is because LA pressures in CHF are around 40 mm Hg and the driving pressure through the lungs is about 7-10 mm Hg. So, if you are dealing with higher pressures there is always sth else going on. Particularly CKCS frequently have primary airway disease which might be the primary reason for PHT. I did quite a few mitral valve repairs in CKCS and saw them for follow up exams. They improved quickly and did very well, some for years. But then, most of them developed PHT without mitral regurgitation and had to be eventually euthanised. CKCS are not normal dogs…. Your approach was completely correct. I always add theophylline at 5-10 mg/kg bid, sometimes inhaled cortisone if they are symptomatic (cough).

So – yes, they can get PHT without left heart failure and – yes- I would manage them without furosemide.

Thanks for posting!

Peter

veteurope1

July 24, 2019 at 6:37 pm -

Thanks Peter, it’s great to

Thanks Peter, it’s great to clear things up and learn from you.

randyhermandvm

August 25, 2019 at 1:46 pm -

I recently did a seminar on

I recently did a seminar on Vet Girl On The Run on Pulmonary Hypertension.

This Cavalier recently passed away acutely. May have been due to his underlying heart disease and/or his PH.

I do have some concern that when I added Sildenafil it may have put him over the edge here.

I am posting a couple of slides with information.

I guess to use is all about the Trans Pulmonary Gradient which we cant really measure with Echo.

I guess what I am saying here is use of Sildenafil with Triple Therapy for heart disease is not without some risk.

randyhermandvm

August 25, 2019 at 1:50 pm -

If you must use Viagra or

If you must use Viagra or Cialis- you can get them from Canada for a much lower cost. Generics are available.