Case Studies In Small Animal

Cardiovascular Medicine

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Recheck Exams

Case 5

Follow-Up

Clinical Diagnoses

bulletSevere hypertrophic cardiomyopathy (HCM) with left heart failure (pulmonary edema)
bullet Systolic anterior motion (SAM) of the mitral valve secondary to the HCM - seen on the two-dimensional echocardiogram and color flow Doppler pictures on the previous page.

Plans and Progress Notes

bullet6/11/98 11:00 AM S/O:  Thoracic radiographs revealed an enlarged cardiac silhouette with marked ventral alveolar and interstitial pulmonary infiltrates. The pulmonary arteries are enlarged. Lasix 8 mg (2mg/kg) was given IV at 9:15 AM and repeated IM at 10:30 AM. She was placed in an oxygen cage at 9AM at 40-50% O2. She urinated at 10AM. Her respiratory rate at 10 AM had decreased to 80 breaths/minute. Cardiology consult confirmed hypertrophic cardiomyopathy via ultrasound. She was placed on 1/4 inch nitroglycerin applied to inguinal skin q 6 hours, diltiazem 7.5mg TID, Lasix 1-2mg/kg PRN to attain a RR of 40 breaths/minute, also enalapril and aspirin to be commenced tomorrow.
bulletA: Hypertrophic cardiomyopathy with secondary pulmonary edema is confirmed. The Lasix will help to ease her breathing through vasodilatory, bronchodilatory, and more importantly, diuretic effects. The diltiazem will help to relax the myocardium, slow the heart rate, and allow better filling.
bulletP: Transfer to Cardiology Service this afternoon. Keep on O2 and continue medications.

Comments (Cardiology Service)

bulletECHO:  Severe HCM, with marked concentric LV hypertrophy, and severe left atrial dilatation.  Systolic anterior motion of the mitral valve is present at all times, but the LVOT velocity is only 3 meters/second. Mild pleural effusion is also present.  Radiographs: severe pulmonary edema, diffuse lobar involvement. The RR was only coming down slowly, so a 4 mg/kg dose was given s/c at 1 PM. This resulted in a decrease in RR to 30 breaths/minute. Minimal Lasix was required after this dose. Follow-up radiographs 24 hours later showed no remaining pulmonary edema (see below). Respiratory rate was 36 at discharge. Following diuresis, the BUN was 40, and creatinine 2.7, so we will attempt to control the pulmonary edema with low-moderate dose maintenance Lasix therapy.

Discharge Instructions

bulletThank you for bringing Alice to the UC Davis Veterinary Teaching Hospital.
bullet Alice has a progressive heart disease called hypertrophic cardiomyopathy (HCM). Her respiratory difficulty was due to left heart failure causing fluid accumulation in the lungs. The following medications will help reduce the clinical signs.
bulletMedications: Enalapril: Please give one tablet (1mg) orally once a day. Lasix: Please give one half tablet (6.25mg) orally twice a day. Diltiazem: Please give one fourth of a tablet (7.5mg) orally three times a day. Aspirin: Please give one baby aspirin tablet (80mg) orally once every three days. Note: The aspirin is not included in the pharmaceuticals provided today. A script was written and you may pick this drug up at any human pharmacy.
bulletMonitoring: If Alice shows any signs of respiratory difficulty, increased respiratory effort, or an increased sustained respiratory rate (greater than 35 breaths per minute at rest) please contact us or your regular veterinarian.
bulletRecheck: Please make an appointment for a one week recheck to evaluate her response to her medications.

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Right lateral radiograph taken 24 hours after medical therapy for pulmonary edema was instituted. The alveolar infiltrates seen at admission are gone. The lung fields are normal.

Recheck Examination on 6/17/98

Radiographic Report:

bulletToday's study is compared with radiographs dated 6/12/98 representing a 5 day recheck. There has been a progression of the amount of pulmonary interstitial infiltrates since the previous study. Severity of the infiltrates is now similar to that noted on the initial study dated 6/11/98. Persistent and static cardiomegaly is noted.

Discharge Instructions:

bulletThank you for bringing Alice to the UC Davis Veterinary Teaching Hospital.
bulletAlice looks clinically normal today with a normal respiratory rate but the thoracic radiographs revealed moderate pulmonary edema. For this reason the daily dosage of Lasix will be increased. Blood was taken to evaluate the kidney function. They showed that the BUN was normal (26) as was the creatinine (1.4). All electrolytes were also within normal limits.
bulletMedications: Lasix: Please give one tablet (12.5mg) twice a day. Maintain all other
medications as previously instructed.
bulletMonitor: Please continue to monitor Alice for any respiratory difficulty.
bulletRecheck: Due to the findings on today's radiographs and the increase in her Lasix dosage we would like to see Alice back here in one week.

Mark D. Kittleson, D.V.M., Ph.D. All rights reserved.