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In this Issue:

  • The CEO Corner
  • Grain-Free Dog Food Guidance - now on the CVCA website
  • 2018 KVMA Conference Recap
  • Article: Clinical Use of NT-proBNP in Cardiology, by Kristin Jacobs, DVM, Diplomate, ACVIM (Cardiology)
  • Supply Request Form
  • Annual Pet Calendar Contest - Favorite Pet Photo - October 9th-October 26th
  • Refer a Colleague to Sign-Up for the Murmur Newsletter by Nov. 1st - Receive a Gift of Appreciation
  • Payment Options and Flexibility
  • Follow us on Social Media

The CEO Corner

Katie Newbold_cropped-625358-edited

Our entire team loves hearing from our clients on how our care has impacted their lives. We so appreciate the time our clients take to fill out our surveys, communicate with us on social media, and share photos and videos of their pets at home. It means so much to know all the hard work has such a positive impact on so many families.
 
We would love to hear from you too! What is working well, what can we do better, how can we help provide the best service to you and care to your clients and patients? Please visit our survey here to give us feedback or reach out to us anytime!
 
We are truly thankful for our network of amazing veterinarians!

Best,
Katie Newbold, CVCA CEO
 
 

 

Grain-Free Dog Food Guidance - Visit the CVCA Website Dog with Food Bowl_ dreamstime-1-536257-edited
 
In July of 2018, the Food and Drug Administration announced an investigation of grain-free, dog food diets and a common type of canine heart disease  – dilated cardiomyopathy (D.C.M.).  One of CVCA’s board-certified veterinary cardiologists, Steven Rosenthal, DVM, Diplomate, ACVIM (Cardiology) was interviewed for The New York Times article: Popular Grain-Free Dog Foods May Be Linked to Heart Disease. CVCA's website now contains a nutrition resources page for Pet Owners and a page for Vets & Techs along with two paragraphs of 'guidance' to help address some of the questions and concerns on nutrition and DCM.
 
Nutrition Resources for Veterinarians/Technicians: https://www.cvcavets.com/for-veterinarians/nutrition-grain-free/

 


 

107th KVMA Meeting & 45th Mid-America Veterinary Conference

 

CVCA Cardiac Care for Pets, located inside of BluePearl Specialty & Emergency Hospital in Louisville, KY, was excited to take part in the 107th KVMA Conference @ The Galt House in Louisville, KY in September.  We hope you had a chance to stop by our exhibit table or sit in on a cardiology lecture from our board-certified cardiologist, Sarah Bell, DVM, MS, Diplomate, ACVIM (Cardiology). Visit our website at www.cvcavets.com to learn more about CVCA Cardiac Care for Pets.
KVMA - Full Room-447501-editedKVMA - CVCA BoothKVMA - SB Presenting-363151-edited

 

 


The Clinical Use of NT-proBNP

 By: Kristin Jacobs, DVM, Diplomate, ACVIM (Cardiology)

Kristin-Jacob

 The use of NT-proBNP has become an important part of veterinary cardiology.  NT-proBNP can be used as a screening test for cardiac disease in asymptomatic patients and in dyspneic patients to help determine if the cause of the symptoms are cardiac or respiratory.  Using these tests varies in different scenarios and varies among the different tests available.  While in human medicine, NT-proBNP can be used to guide treatment in patients with congestive heart failure, that information is not available in veterinary medicine at this time.

 

What is BNP/NT-proBNP?

  • A biomarker measured in blood
  • Produced by the ventricle in response to tension (either increased pressure or volume)
  • Released as proBNP and then cleaved to active C-terminal BNP and inactive metabolite NT-proBNP
  • NT-proBNP is more stable and more accurately measured than BNP and the most recent generation of the NTproBNP test measure metabolites of NTproBNP that are more stable in serum than the previously measured hormones  - no longer need special tubes!
  • Diuretic, natriuretic, vasodilator, inhibits the Renin Angiotensin Aldosterone System
  • Released early in course of heart disease
  • Levels in blood correlate to severity of heart disease
  • Test is species specific

Uses of NT-proBNP in Cats

Heart disease in cats is often silent.  In multiple studies, ~ 30% of cats with arterial thromboembolism (ATE) have no previous evidence of heart disease and no auscultable abnormalities at time of the ATE. Fifteen percent of apparently healthy cats have echocardiographic left ventricular hypertrophy.  It has become clear that auscultation alone is not enough to screen for heart disease in cats. Also, using NT-proBNP in addition to history and physical examination, improves practitioner confidence in radiograph interpretation.

When to use NT-proBNP in cats?

  • Screening for HCM
    • < 8 years of age, consider NT-proBNP every 2-3 years
    • > 8 years of age, consider NT-proBNP as part of senior wellness profile
  • Prior to anesthesia
    • Consider in all cats 2 years of age or older, especially with abnormal auscultation
    • NT-proBNP is preferred
    • Truly normal cats have an NT-proBNP < 60 pmol/L (higher than this, should cause some concern with regards to anesthesia)
  • Prefer NT-proBNP when possible, especially in asymptomatic cats. SNAP BNP may be used - interpretation is different.
 
Screening Asymptomatic Cats 

Cardiopet BNP

SNAP BNP

Interpretation

<100 pmol/L

Negative

Clinically significant heart disease unlikely.
Echo could be recommended.

>100 pmol/L

Abnormal

Increased risk of heart disease.
Echo strongly recommended.

 

Cats with Respiratory Signs or Pleural Effusion

Cardiopet BNP

SNAP BNP

Interpretation

<100 pmol/L

Negative

Not supportive of CHF

100-270 pmol/L

Abnormal

CHF possible but patient may have occult CM with respiratory disease. 

>270 pmol/L

Abnormal

CHF likely but still possibility of occult C with respiratory disease. 


Take Home Points

SNAP BNP testing

  • Abnormal test result - will see color change at ~ 150 pmol/L
  • Screening - Strongest value is if test is Abnormal
    • Some occult CM will be negative on SNAP BNP (see differences in cut-off values of Cardiopet BNP vs. SNAP BNP)
  • Respiratory Signs - Strongest value is if test is Normal/Negative - where you have likely ruled out possibility of CHF
  • Some cats with respiratory signs will be abnormal on SNAP BNP but have occult CM not CHF due to the difference in the cut-off

Remember: NT-proBNP can be increased by other diseases - most commonly in the cat: hyperthyroidism, severe renal disease and hypertension.

Uses of NT-proBNP in Dogs 

Dilated Cardiomyopathy (DCM) is often silent/occult and radiographic cardiac enlargement is difficult to detect, especially with early disease.  NT-proBNP can be used for screening for DCM in Doberman pinschers. The accuracy of using NT-proBNP as a screening test is improved to 91% when combined with Holter monitoring. It is important to note that levels of NT-proBNP in Dobermans with occult DCM are lower than the normal range for other breeds of dogs.


In contrast, degenerative mitral valve disease (DMVD) is the most common heart disease in dogs and is easily detected by a mitral murmur on physical examination.  Also, radiographic heart enlargement is relatively easy to detect.  There is evidence that NT-proBNP can be used in conjunction with echocardiography to predict the first onset of CHF


Screening for Heart Disease

 

NTproBNP Level

Interpretation

Recommendation

Dogs with murmur and
breeds at risk for DCM

 NTproBNP < 900  Clinically significant heart disease likely.  Echo could be recommended. 
   NTproBNP > 900  Clinically significant heart disease likely.  Recommend CVCA consult, consider thoracic radiographs if fluids or surgery indicated.
Doberman  NTproBNP > 735  Increased risk for
occult DCM.
 Recommend CVCA consult.
Recommend thoracic radiographs if fluids
or surgery indicated.
Dogs < 20 kg with murmur
consistent with MVD
 NTproBNP > 1,500  Increased risk for patient to present in CHF within
next 12 months.
 Strongly encourage CVCA consult. Recommend thoracic radiographs in the event fluids or surgery indicated. 

 

In contrast, As in cats, NT-proBNP can be used to help evaluate if respiratory signs are due to CHF vs. other (ie: respiratory disease, neoplasia, etc.). There is no SNAP BNP test available for dogs.  


Dogs with Respiratory Signs

NTproBNP Level

Interpretation

Recommendation

 NTproBNP < 900

Unlikely that clinical signs are
secondary to CHF.

Consider further respiratory diagnostics. 

 NTproBNP 900-1,800

Indicates presence of significant heart
disease, but equivocal for CHF.

Further diagnostics recommended to
determine heart failure vs. other disease.

Recommend CVCA consult.

 NTproBNP >1,800

Indicates presence of significant heart disease with likelihood that signs are secondary to CHF. 

Severe pulmonary hypertension (PHT)
also a strong differential. 

Recommend thoracic radiographs and treat supportively. If not responding appropriately, reevaluate for possible PHT.

Recommend CVCA consult. 


 

**** Some of the highest NT-proBNP values can be seen in patients with Pulmonary Hypertension - an elevated NT-proBNP means an echocardiogram is recommended, especially if not responding to CHF management ****

Remember - NT-proBNP can be increased by other diseases - most commonly in the dog: severe renal disease, pulmonary hypertension, Cushing’s disease, systemic hypertension.

See last page for Works Cited Sections for “Clinical Uses of NT-proBNP” 

 


 

 

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CVCA's Annual Pet Calendar Contest - October 9th to October 26th

This Year's Theme: Favorite Pet Photo2019 CVCA Calendar Ad
When:
 Starts October 9th @ 12 noon & Ends October 26th @ 12 noon

Who's Eligible: Former and/or Current CVCA Clients (Employees of CVCA and their immediate families are not eligible and winners from previous Pet Calendar Contests are not eligible.)
How to Enter & How to Vote:  https://www.cvcavets.com/pet-calendar-contest/

 

 

 

 

 

 

 

 

 

Refer a Colleague Murmur

 
Refer a Colleague to Sign-Up for the CVCA Quarterly Cardiology 
Murmur Newsletter and Receive an Appreciation Gift!
 
**Please ask your colleague for permission before referring them. 
 
 
3 Quick Steps
 
Step 1:  Refer a Colleague to sign-up, at no cost, for CVCA's Quarterly Cardiology Murmur Newsletter by completing the form below.  
Step 2:  Once CVCA receives the completed form, we will reach out to your colleague to verify the following information: 
    • Name of referring colleague.
    • Request approval to sign-up them up to receive the CVCA Murmur Newsletter 
    • Once CVCA receives approval, the person that referred a colleague will receive a gift of appreciation!  
Step 3:  Refer today!  Offer ends on Thursday, November 1st.  


Questions? Ask Denise Kessler at denise.kessler@cvcavets.com

 


 

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Works Cited Sections for “Clinical Uses of NT-proBNP”

1.  Reynolds, CA, Brown DC, Rush JE, et al. Prediction of first onset of congestive heart failure in dogs with degenerative mitral valve disease: The PREDICT cohort study. J Vet Cardiol 2012; 14 (1); 193-202.
2.  Singletary GE, Morris NA, O’Sullivan ML, et al.  Prospective Evaluation of NT-proBNP Assay to Detect Occult Dilated Cardiomyopathy and Predict Survival in Doberman Pinschers. J Vet Int Med 2012;26 (6):1330–1336 

3.  Singletary GE, Rush JE, Fox PR, et al.  Effect of NT-pro-BNP Assay on Accuracy and Confidence of General Practitioners in Diagnosing Heart Failure or Respiratory Disease in Cats with Respiratory Signs. J Vet Intern Med 2012; 26 (3):542–546

4.  Paige CF, Abbott JA, Elvinger F, et al. Prevalence of cardiomyopathy in apparently healthy cats. J Am Vet Med Assoc. 2009 Jun 1;234(11):1398-403.

5.  Hsu A, Kittleson MD, Palling A. Investigation into the use of plasma NT-proBNP concentration to screen for feline hypertrophic cardiomyopathy. J Vet Cardiol. 2009 May;11 Suppl 1:S63-70

6.  Oyama MA, Rush JE, Rozanski EA, et al. Assessment of serum N-terminal pro-B-type natriuretic peptide concentration for differentiation of congestive heart failure from primary respiratory tract disease as the cause of respiratory signs in dogs. J Am Vet Med Assoc. 2009 Dec 1;235(11):1319-25

7.  Fox PR, Oyama MA, Reynolds C, et al.  Utility of plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) to distinguish between congestive heart failure and non-cardiac causes of acute dyspnea in cats. J Vet Cardiol. 2009 May;11 Suppl 1:S51-61.

8.  Connolly DJ, Soares Magalhaes RJ, Fuentes VL, et al. Assessment of the diagnostic accuracy of circulating natriuretic peptide concentrations to distinguish between cats with cardiac and non-cardiac causes of respiratory distress. J Vet Cardiol. 2009 May;11 Suppl 1:S41-50.

9.  Fox PR, Rush JE, Reynolds CE, et al.  Multicenter evaluation of plasma N-terminal probrain natriuretic peptide (NT-pro BNP) as a biochemical screening test for asymptomatic (occult) cardiomyopathy in cats. J Vet Intern Med. 2011 Sep-Oct;25(5):1010-6

10.  Fine DM, DeClue AE, Reinero CR. Evaluation of circulating amino terminal-pro-B-type natriuretic peptide concentration in dogs with respiratory distress attributable to congestive heart failure or primary pulmonary disease. J Am Vet Med Assoc. 2008 Jun 1;232(11):1674-9

11.  Oyama MA, Fox PR, Rush JE, et al.  Clinical utility of serum N-terminal pro-B-type natriuretic peptide concentration for identifying cardiac disease in dogs and assessing disease severity. J Am Vet Med Assoc. 2008 May 15;232(10):1496-503.