vtx logo

request clinical advice

vtx logo sticky

Liz Bode

Forum Replies Created

Viewing 15 posts - 1 through 15 (of 201 total)
  • Author
    Posts
  • Liz Bode
    Keymaster

    Replying to [email protected] 23/01/2024 - 12:48

    Hi everyone,

    Welcome to this course. Andy, in particular, has put a lot of effort into curating a course that he thinks will benefit you all in your day to day practice so we really hope you enjoy it 🙂

    Looking forward to seeing what questions get asked on here and if there is anything from a cardiology perspective then I am always happy to help 🙂

    Liz

    Liz Bode
    Keymaster

    Hi all

    Welcome to this course, I’m really looking forward to working with you and answering any cardiology-related questions. Feel free to ask whatever you like!

    I’m one of the Directors of vtx and a cardiology specialist working out of Chestergates Veterinary Specialists in the NW of England. I did my residency with Jenny and Scott and I’m delighted to be working with them both again!

    Liz x

    Liz Bode
    Keymaster

    Funnily enough we were talking about this today. I’m on call and had to place an NG tube in a patient that has been anorexic since Thursday and has acute hepatitis with hepatic encephalopathy! We discussed NG tubes vs O tube but didn’t feel a GA was the best route in this case so she has an NG tube in, I’d be happy sending her home with it in, but would think it might come out easily and also it’s hard to get the same quantities of food down them compared to an O-tube!
    Liz

    Liz Bode
    Keymaster

    Replying to [email protected] 19/11/2023 - 11:48

    Hi Amanda,

    I hope your dad is doing better now?

    This is a great question and one that I am not sure I can answer easily. We often see AKIs following initiation of diuretics in our feline and canine populations. However, we know much less in these patients with respect the cardiorenal axis and how we should be managing them.

    Ultimately, it is a fine balance between managing the heart failure and the AKI and, for me, it depends on the scale of the AKI. If it is mild I will usually withhold diuretics for a time, whilst monitoring the respiratory rate closely, or I will at least reduce the dose of diuretics the patient is receiving. Often this is enough to bring the creatinine down to more acceptable levels. However, when the AKI is more severe (and in my head I guess I have values of >300 even though I know this isn’t necessarily how an AKI is classified) I might start cautious IVFT. I say cautious because a patient in CHF doesn’t need a significant amount of volume, so usually I am looking at around. 2-4ml/kg/hr depending on the case. Again monitoring respiratory rate and ins and outs closely.

    I will be very interested to know what Kerry thinks about managing AKIs in the context of CHF but also when CHF is not a concern.

    Liz

    Liz Bode
    Keymaster

    Hi Sarah

    Great question and really that’s incredibly difficult. The only way is to treat the hyperthyroidism etc and see if the HCM regresses. If it’s secondary then the heart will normalise over time. Anecdotally, I think most cats have a mixture of both so never fully reverse remodel.

    Liz

    Liz Bode
    Keymaster

    Replying to Liz Bode 17/09/2023 - 15:49

    As this course is drawing to an end I thought I would close this case 🙂

    the image shows a large (1cm) VSD in the perimembranous region. It is classified as an inlet VSD as it occurs where blood moves from the RA to the RV (inlet septum) rather than the outlet septum where blood is moving from the RV to PA. The Doppler shows a L-R shunt and the shunt was significant enough to be causing volume overload of the left side. This, in turn, has resulted in the AF.

    We don’t see many cases such as this and I am currently waiting to see if the RVC could fix the defect under bypass..

    Liz Bode
    Keymaster

    Replying to Sarah Keir 24/09/2023 - 12:34

    Hi Sarah,

    Unfortunately, rivaroxaban is also bitter to taste! So some cats may not tolerate either.

    I generally will give both to cats that have a thrombus or very poor LA function that have already suffered an ATE episode. Otherwise I tend to just use clopidogrel. There is no evidence for the use of clopidogrel prior to ATE so we don’t really know how much, if any, difference it makes but it makes us feel like we are doing something at least.

    Liz

    Liz Bode
    Keymaster

    Hi everyone,

    I’d also like to welcome you all to this brand new course, it will be fantastic! I’m Liz, one of the other Director’s of vtx and a cardiologist. I’m available to answer any questions that you might have with regards cardiology!

    Enjoy the course, and as always, we welcome feedback about other content you might want to see on here.

    Liz

    Liz Bode
    Keymaster

    Replying to Sarah Keir 17/09/2023 - 19:02

    Hi Sarah

    Yes, it will be years (if at all) before this drug hits the veterinary market. So many more stages to pass through and the data wasn’t overwhelming for me. Still interesting though! Let’s hope larger studies show similar (or better) findings.

    Are you doing the Improve course with Cambridge? They’re a lovely group 🙂

    Liz

    Liz Bode
    Keymaster

    Replying to [email protected] 17/09/2023 - 19:15

    Hi Scott

    It’s available in the human medicine world but as far as I’m aware we don’t use it in veterinary yet. As I said, it’s a pilot study so much more data is needed before it becomes mainstream 😉

    Liz

    Liz Bode
    Keymaster

    I agree! The systolic function looks OK and so excludes DCM. A congenital condition is very likely here. SAS usually causes concentric hypertrophy, which isn’t present, but at end-stage SAS you get what we call ‘myocardial mismatch’ or ‘afterload mismatch’ where the walls actually become thinner due to replacement fibrosis. So, you could see normal/ thin walls with even severe SAS. In my mind though this left side looks volume loaded, so we are thinking about a disease process that is congenital and causes volume loading of the left side…it will become clear (hopefully) with these videos…what do you think now?

    https://drive.google.com/file/d/1UJWZeF3nPodqAGy01Bh4YdXkG2NyaZi7/view?usp=drive_link
    https://drive.google.com/file/d/1G1Kvx4VC2ehmTTHMkcXNVe_vd1sYk5K9/view?usp=drive_link

    In terms of the interatrial septum, you often get echo dropout around the middle of the septum. If you think there is an ASD you need to identify it on 2 views to make sure it isn’t an artefact 🙂

    Liz Bode
    Keymaster

    Hi Natalie,

    Some great questions, treating cats is confusing with little or no evidence for very much!! I will answer each question in turn:

    My understanding from the lectures is that all cats in congestive heart failure get frusemide at lowest effective dose.
    Yes, that’s correct. We will cover this later in the CHF section. However, as a rule of thumb I use 2mg/kg PO BID (TID if they were difficult to control) and then once I am happy the cat is stable I will try and reduce the dose to lowest effective, although not really below 1mg/kg BID.

    Those with evidence of smoke / spontaneous contrast on echo get clopidogrel to reduce risk of thrombus.
    Yes, clopidogrel is the one we choose as we have evidence for its use from the FATCAT study (2015) in recurrent ATE events. So, I prescribe it to cats with moderate dilation of the LA, smoke, or poor LA systolic function.

    Do you ever use aspirin in these cases?
    Not really, no. the therapeutic index isn’t very high (its not COX selective) and I would prefer to use clopidogrel with rivaroxaban (a factor Xa inhibitor) or one or the other. I might use aspirin if the cat is very difficult to tablet though, as better than nothing probably (although we don’t know this either!).

    I know a lot of clinicians use every third day (think it’s a quarter tablet?). Can this be given in combination with clopidogrel?
    Yes, you can use it in combination with clopidogrel as they work in different ways.

    You said there’s no good evidence that ACE inhibitors such as benazepril improve survival so we should not give these unless hypertensive?
    I will use an ACE inhibitor if the cat isn’t doing very well, but the King paper suggests that including an ACE inhibitor has no benefit either before CHF develops or during CHF. I will use spironolactone though as there is a (poor) study that suggests some benefit, but what I really use it for is boosting the potassium levels.

    And pimobendan is contraindicated unless it is DCM which is much rarer.
    It’s not contraindicated per se, it is just that there is no evidence that it works. This makes sense as pimobendan increases contractility but HCM is a diastolic disease. a recent paper showed no benefit in using it in cats with HCM to 180 days, so it is going out of fashion. I would definitely use it in a cat with DCM though, or possibly end-stage HCM where you see poor systolic function secondary to myocardial ischaemia.

    Then where I’m a little confused is – do you use beta blockers such as atenolol only in obstructive hypertrophic cases where there is systolic anterior motion, and then diltiazem in HCM cases without obstruction to improve diastolic filling? Or am I mixed up?
    Yes, atenolol only in severe HOCM. Again, no benefit here but physiologically it makes sense to use a beta blocker. You need to demonstrate the severity of the obstruction via Doppler though before prescribing it. We don’t use diltiazem in cats, unless they have an arrhythmia. It used to be prescribed for HCM as the thought was that slowing the HR down would improve myocardial perfusion, but it is TID dosing and there is no evidence that it works.

    Hope that clears things up for you 🙂

    Liz

    Liz Bode
    Keymaster

    Hi Natalie,

    So there is one loop only (I’m on holiday this week but will add more next week once I’ve got my laptop). In this loop you can see left atrial and ventricular dilation with normal systolic function. There is also AF on the ECG. The MV is slightly thickened but isn’t the concern in this dog. Any other thoughts as to processes that could cause these findings in a dog with a loud murmur?

    Liz

    Liz Bode
    Keymaster

    Replying to Natalie Niven 07/09/2023 - 17:01

    Hi Natalie,

    I’ve not seen one performed in dogs, only people, but the procedure is the same for both. They use cardioplegia and then place catheters within various vessels and circulate the blood through the bypass machine. The heart is approached via the left atrium and as this is a low pressure chamber with thin walls you can suture it up with little risk, but yes that will always be a risk. The main risk though is thrombosis following recovery and these dogs are given clopidogrel to prevent it. They then repair the valve by placing new chordae to tether the valve again.

    Yes, with decompression that is what you do. 30% have R CHF afterwards, but this is easier to manage than L. 30% close up. We don’t have any evidence as to whether they do better than meds alone but this technique is used in people too.

    Scott – that’s a great episode of Grey’s!

    Liz

    Liz Bode
    Keymaster

    Hi everyone

    Great to have you all join us on this course. I’m Liz, one of the directors of vtx but also a specialist in cardiologist working in private practice in the NW of England. Please feel free to ask me anything cardio related.

    Liz 🙂

Viewing 15 posts - 1 through 15 (of 201 total)