Company Logo
 
 

 

In this Issue:

  • The CEO Corner
  • Returning in March!  Sarah Bell, DVM, MS, Diplomate, ACVIM (Cardiology)
  • Article: Update on Hypertension Treatment in the Dog and Cat, by Bill Tyrrell, DVM, Diplomate, ACVIM (Cardiology)
  • February - American Heart Month Activities heart image
  • Client Video: What to Expect at CVCA
  • Save the Date - Upcoming CE Events
  • NEW Client Handout:  When Your Pet Needs a Cardiologist 
  • Subscribe to CVCA's Monthly Blog
  • Payment Options and Flexibility
  • Follow us on Social Media - @cvcavets

The CEO Corner

Katie Newbold_cropped-625358-edited

As we recognize American Heart Month and Valentine's Day in February, we are truly grateful for the support and ability to collaborate with our referral community.  CVCA saw nearly 21,000 cases last year and we love working with you, your patients, and your clients every day!  We are excited to continue growing our amazing team at CVCA and bringing our services to new areas and markets.  Please reach out to us anytime with questions, concerns or ideas on how we might be better able to support you in offering the best possible care to your clients. Please visit our survey here to give us feedback. We are truly thankful for our network of amazing veterinarians!

Best, 
Katie Newbold, CVCA CEO
 
 
 
 
 

Returning in March! - Sarah Bell, DVM, MS, Diplomate, ACVIM (Cardiology)  

Sarah-Bell

Dr. Bell welcomed her baby boy George in November and has been enjoying time at home with him!  Though we know she will miss spending  all day with George, we know our clients are excited to have her back in the office!  Join us in welcoming Sarah Bell back in March 2019! 
 
 
 
 
 
 
 
 
 
 

 
Update on Hypertension Treatment in the Dog and Cat
 By: Bill Tyrrell, DVM, Diplomate, ACVIM (Cardiology)
Dr. Tyrrell sees patients inside of The LifeCentre in Leesburg, Virginia and CARE Veterinary Center in Frederick, MD.

William-TyrrellSystemic hypertension in the canine and feline is a common disorder. It can be a difficult disease to diagnose as it tends to be silent until significant secondary organ damage occurs.  A recent update to the ACVIM consensus statement: “Guidelines for the identification, evaluation and management of systemic hypertension in dogs and cats” as well as the release of a new FDA approved medication, Semintra™ (Telmisartan), to treat hypertension in the feline has generated many questions to our cardiology team.  This issue of “The Murmur” is meant to summarize the updated ACVIM consensus statement, briefly discuss the use of Semintra™, and provide an update on how CVCA approaches and treats the hypertensive patient.

BLOOD PRESSURE MEASUREMENT METHODOLOGY

The procedure must be standardized in each hospital.Lauren and Blood Pressure

    • The same individual(s) should be responsible for all blood pressure (BP) measurements in the hospital. Training and experience are paramount.

    • CVCA solely recommends the use of Doppler blood pressure measurement equipment.  We feel this older technology represents the closest approximation to the gold standard of blood pressure measurement, direct arterial monitoring.  Oscillometric methodologies (although fancy with digital readouts) have been shown to be less reliable/accurate especially in cats and small breed dogs.

    • The environment should be isolated, quiet, and away from other animals.  Generally, the owner should be present. The patient should not be sedated and should be allowed to acclimate to the environment for 5-10 minutes prior to the BP being taken

    • The animal should be gently restrained in a comfortable position, ideally in ventral or lateral recumbency to limit the vertical distance from the heart base to the cuff.

    • The cuff width should be approximately 30-40% of the circumference of the cuff site, e.g. limb or tail depending on animal conformation, tolerance and/or user preference.

    • Only take measurements when the patient is calm and motionless.

    • The first measurement should be discarded and then an average of 5-7 measurements should be recorded.  Please note that some patients have BP readings that trend downward. In this case, once the measurements have plateaued, then take your 5-7 measurements and obtain a meaningful measurement.

    • If in doubt, e.g. very unlikely for a 2-year-old healthy cat to be hypertensive, repeat measurements with different cuff size or alternate limb/tail.

    • Record cuff size and site, patient’s demeanor, the rationale for values included/excluded, etc.

 

TYPES OF HYPERTENSION:

  1. Situational hypertension—It is very common for our patients to suffer from anxiety from the car ride, waiting room, exam room, odors, pheromones, etc.  This alone can temporarily increase blood pressure into hypertensive ranges. There is no justification to treat situational hypertension.  
  2. Secondary hypertension—This is the most common form of hypertension in veterinary medicine.  There are several disease states that commonly result in secondary high blood pressure in the veterinary patient.  Unfortunately, treatment of the underlying condition does not often result in normalization of blood pressure and treatment of the secondary hypertension is still necessary.

    • Canine

      • Kidney disease (acute and chronic with or without proteinuria)

      • Hyperadrenocorticism

      • Diabetes mellitus

      • Primary hyperaldosteronism

      • Pheochromocytoma

    • Feline

      • Kidney disease (chronic with or without proteinuria)

      • Hyperthyroidism

      • Primary hyperaldosteronism

      • Pheochromocytoma

      • Hyperadrenocorticism

  3. Idiopathic/Essential hypertension—This is not commonly seen in veterinary medicine as most hypertension is secondary to some other underlying disease process.  However, some case reports state that from 13-20% of hypertensive cats may be classified as idiopathic and may be much more prevalent than previously thought.2

 

TARGET ORGAN DAMAGE: The rationale for treatment of hypertension in our dogs and cats is to prevent other organ damage or worsened systemic disease secondary to the chronic effects of hypertension.  Hypertension has been associated with worsening of proteinuria and renal disease, ocular changes/retinal detachment, neurologic issues, and secondary cardiac changes. The following chart excerpted from the ACVIM consensus guidelines provides an excellent summary of target organ damage from systemic hypertension.1

ocular changes - feb murmurcat- feb murmur

 

feb murmur - hypertension chart

 

DIAGNOSIS: The diagnosis of systemic hypertension is based on reliable blood pressure measurements on multiple occasions or repeatable hypertensive readings from multiple sites in a patient that is deemed at risk for hypertension based on the presence of an underlying etiology. If target organ damage is noted, then treatment should be initiated. However, if hypertension is suspected, but no target organ damage is noted, then medication may only be indicated after validation of two or more hypertensive readings on separate occasions.  Hypertension in both dogs and cats is based on the risk for target organ damage (TOD).1

  • Normotensive (minimal TOD risk) = systolic BP < 140mmHg

  • Prehypertensive (low TOD risk) = systolic BP 140-159mmHg

  • Hypertensive (moderate TOD risk) = systolic BP 160-179mmHg)

  • Severely hypertensive (High TOD risk) = systolic BP > 180mmHg

Amlodipine Besylate - murmurTREATMENT/MANAGEMENT: Since hypertension is almost always (>80%) secondary to some other underlying metabolic abnormality, treatment for hypertension and additional diagnostics for a primary cause should be initiated simultaneously.  Depending on the patient, these diagnostics may include CBC, serum chemistry, UA, SDMA, quantitative assessment of proteinuria (urine protein: creatinine ratio (UPC)), serum T4 (cat), and cortisols (dog). Additional diagnostics may include an abdominal ultrasound and urine aldosterone and catecholamine levels.

Canine: The ACVIM consensus guidelines first recommends the use of a renin-angiotensin aldosterone system (RAAS) inhibitor like an ACE inhibitor (ACEi) or angiotensin receptor blocker (ARB).  The rationale to first use a RAAS inhibitor is most dogs with hypertension have some degree of renal disease and proteinuria. Calcium channel blockers (Amlodipine) preferentially dilate the renal afferent arteriole which could lead to further glomerular damage in the renally compromised patient.  However, the use of both a RAAS inhibitor that dilates the renal efferent arteriole combined with amlodipine that dilates the afferent arteriole should have a limited effect on glomerular function.1

CVCA’s treatment approach in the canine is usually as follows:

  • Idiopathic hypertension (confident no other metabolic issues/renal disease)—Amlodipine 0.1-0.5 mg/kg q 12-24 hours

  • Secondary renal hypertension/proteinuria—ACEi (Enalapril, Benazepril) 0.5 mg/kg q 12 hours usually combined with amlodipine 0.1-0.5 mg/kg q 12-24 hours. Some internists will use higher dosages of ACEi or an ARB to decrease proteinuria.  CVCA’s experience with monotherapy ACEi is that an ACEi usually does not adequately control hypertension and amlodipine is required as a secondary agent.


Feline: Despite renal disease often being implicated as a primary cause of hypertension in the cat, amlodipine is always the first line of therapy for hypertension.  A mean decrease in systolic BP of 28-55 mmHg in cats treated with amlodipine is often observed.3, 4, 5

CVCA’s treatment approach in the feline is usually as follows:

  • Recheck blood pressure in 1-2 weeks with goal of systolic BP < 160 mmHg

  • Recheck renal values and electrolytes in 1-2 weeks after starting therapy in particular if using ACEi or ARB therapy or if renal disease is preexisting.  If proteinuria was diagnosed, a repeat UPC will be indicated as well.

  • Adjust dosages of primary blood pressure agent or add in secondary medication if BP cannot be decreased to < 160mmHg


Further recommendations for follow up include:
  • Recheck blood pressure in 1-2 weeks with goal of systolic BP < 160 mmHg

  • Recheck renal values and electrolytes in 1-2 weeks after starting therapy in particular if using ACEi or ARB therapy or if renal disease is preexisting.  If proteinuria was diagnosed, a repeat UPC will be indicated as well.

  • Adjust dosages of primary blood pressure agent or add in secondary medication if BP cannot be decreased to < 160mmHg


Update on the new FDA approved drug for treatment of hypertension in the cat Semintra™/telmisartan)Semintra - murmur

Semintra/telmisartan 10 mg/ml oral solution was launched by Boehringer Ingelheim this past fall. It is the only FDA approved medication to treat hypertension the feline.  It has been licensed in Europe and Canada for the past several years. The initial dosage of Semintra is 1.5 mg/kg q 12 hours for 14 days followed by 2 mg/kg q 24 hours thereafter.  If hypotension occurs at this dosage, it can be decreased by increments of 0.5 mg/kg.

The following adverse reaction tables from both the 28-day field effectiveness study and the 5-month field effectiveness and safety study: (information excerpted from Semintra package insert)

Semintra - 1 - murmurSemintra - 2 - murmur

As one can see from the above adverse reactions, vomiting and non-regenerative anemia were common side effects of Semintra.  However, upon closer examination of the study population and the study itself, these cats were a median age of 14 years and all had IRIS stage 3 or greater chronic renal failure.  Thus, many of these “adverse effects” might be expected in this study population. There was also no control group in the 5-month study.

Semintra™/telmisartan is classified as an angiotensin receptor blocker with effects on the efferent renal arteriole.  Thus, monitoring of renal panels after initiation of Semintra™ is recommended just like the use of an ACEi. With the possible concern over non-regenerative anemia, it is also CVCA’s recommendation to recheck a CBC at the same time.

CVCA’s current recommendation for the use of Semintra™/telmisartan in the cat is as follows:

  • CVCA still recommends amlodipine as a first line agent in the treatment of systemic hypertension (0.625 – 1.25 mg per cat q 24 hours)

  • In cats with proteinuria and hypertension, Semintra™ is recommended as the first line therapeutic (1.5 mg/kg q 12 hours for 14 days followed by 2 mg/kg q 24 hours thereafter).

  • In cats with inadequately controlled hypertension on a maximum dosage of Amlodipine (1.25 mg q 12-24 hours), the addition of Semintra™ is recommended as a secondary agent (same dosage as above).


SUMMARY:
 
Hypertension can be both a frustrating condition to diagnose and treat in the dog and cat with it often being associated as a secondary disease process.  However, the therapeutics currently available to us have great efficacy and we are often quite successful in treating hypertension to either prevent and/or reverse target organ damage.  

The cardiologists and cardiology residents at CVCA are happy to assist in any manner with your patients.  Please don’t hesitate to phone/email us to discuss or refer a challenging case. Together we can achieve the best outcomes for our patients and clients.  


See last page for Works Cited Sections for “Update on Hypertension Treatment in the Dog and Cat” 

 

 

February is American Heart Month - CVCA is Raising Awareness and Giving Back!
 
February is American Heart Month which means it's time to raise awareness for heart disease in dogs and cats with CVCA Cardiac Care for Pets! Visit our website at www.cvcavets.com/americanheartmonth for more information. 


CVCA's Weekly QuizzesImage - Paper  Heart
What’s better than winning fun prizes while learning?! For the entire month of February, we will be posting weekly quizzes on our
 Facebook page. Each quiz is just ONE question, and the answer can be found somewhere within our website. Easy, right? Complete the quiz and one lucky entrant will win a prize EACH WEEK! That’s 4 chances at winning!
 
CVCA's Paper Heart Contest - Help Us Reach our Goal!
NEW this year… CVCA Cardiac Care for Pets is donating proceeds to the American Heart Association by way of our paper heart contest. Our goal is to reach 250+ photo submissions, tagged appropriately following the rules below, and CVCA will donate! The pet MUST be a current or past patient of CVCA – no exceptions. Want to help increase our donation amount? Here’s what you need to do:
Step 1: Use an official paper heart from one of our 13 locations or download one by clicking here.
Step 2: Snap a photo of your furry friend with the paper heart
  • Be as creative as you’d like!
Step 3: Post your photo to the CVCA Facebook or Instagram page. Last day to post is February 28th, 2019. 
  • Tag Both:
    • CVCA Cardiac Care for Pets – @CVCAVets
    • The American Heart Association – @AmericanHeart
  • Use both  hashtags:
    • #CVCAHeartStrong
    • #AmericanHeartMonth
Step 4: One lucky entrant will win a CVCA Swag Box and $50 Amazon Gift Card. Winner will be selected at random at the end of the contest.
 Click here to see the official rules of CVCA Cardiac Care for Pet’s paper heart contest and be sure to download the paper heart here!

 


 What Clients Can Expect at CVCA Cardiac Care for Pets

 
Many times clients do not know what to expect when they are referred to a specialty practice.  In an effort to help with this process, we developed the video below to provide a glimpse into what happens during a cardiac appointment with CVCA.  This video is available on the CVCA website for clients to view at: https://www.cvcavets.com/for-pet-owners/initial-consultation-appointment-benefits/
 
 
Video Capture

 


NEW Client Handout - When Your Pet Needs a Cardiologist

 

We continue to receive requests for a client handout veterinarians, technicians and practice managers
can use when discussing with clients on why their pet should see aWhen Your Pet Needs a Cardiologist board-certified cardiologist for a cardiac exam.
 
In addition, the handout discusses:   
  • Symptoms 
  • Diagnosis
  • Consultation
  • Cost and Payment Options  
CVCA will continue to collaborate with primary care veterinarians on the care of the patient by sending a full report on the diagnosis of the pet and the established treatment plan on the best possible care of the client. 
 
To view all of the client handouts available, at No Cost, or if you are in need of brochures, business cards, and more for your office we ask you fill out a Supply Request Form and we will get the items shipped out to you immediately. 
 
Questions, please contact Michael Brasz at michael.brasz@cvcavets.com
 
 
 



 

Save The Date - Upcoming CE Events, Conferences & Exhibits

 

Keep up-to-date with the latest CE events and conferences CVCA will be participating in by frequently visiting our website at https://www.cvcavets.com/conferences-events/ 

Kentuckiana Cluster of Dog Events 
Audience: Pet Owners Kentuckiana Cluster - Image
When: March 14th - March 17th 
Where: KY Fair & Exposition Center 
Stop by and visit our booth!
To learn more, click here.





Fetch DVM 360 Conference
fetch-logo-370x300
Audience: 
Veterinarians, Technicians, Practice Mangers and Students 

When: May 3rd- May 5th
Where: Baltimore, MD
CVCA will be exhibiting and 4 CVCA doctors will
be lecturing (photos below)!


          Pictured from left to right below:

          Neal Peckens, DVM Diplomate, ACVIM (Cardiology)Julia Shih, VMD, Diplomate, ACVIM (Cardiology),
          Michael Hickey, DVM, Diplomate (ACVIM) Cardiology) and Steven Rosenthal, DVM, Diplomate, ACVIM (Cardiology)

          To learn more about this event, click here.

Neal-Peckens Julia-Shih Michael-Hickey Rosenthal

 

 

  Subscribe to CVCA's Monthly Blog!


BLOGOur goal is to write and publish a blog once every month. As you might notice, the blog contains articles not solely heart focused, as we are hoping to educate the community and connect with people along the way! If you're interested in learning more about CVCA and staying up-to-date on industry-related topics and trends, subscribe to our monthly blog by clicking here!




Below is a snapshot of some of our most recent posts.  Feel free to visit our blog at:  
http://blog.cvcavets.com/blog

  • 2019 Pet Calendar Contest Winners
  • Holiday Dangers:  Poisonous Plants & Toxic Foods That Can Endanger Your Pet
  • What is a Board-Certified Veterinary Cardiologist and Why Does It Matter?
  • Tips & Tricks for Traveling with Your Pet 
 

 

We Offer Payment Options and Flexibility

 

 Care Credit1CC - payment optionspaymentbanc


For more information, visit https://www.cvcavets.com/for-pet-owners/payment-options/

 
Questions, email us at info@cvcavets.com

 
Follow us on Social Media:     fbart.png     newtwitterlogovectorepsfreegraphicsdownloadC44755clipart.png    Instagram_App_Large_May2016_200.png
 

Works Cited Sections for “Hypertension Treatment in the Dog and Cat”

1 Acierno M, Brown S, Coleman A, Jepson R, Papich M, Stepien R, Syme H. ACVIM consensus statement: Guidelines for the identification, evaluation and management of systemic hypertension in dogs and cats. J Vet Intern Med. 2018; 32:1803-1822.

2 Jepson RE, Elliott J, Brodbelt D, Syme HM. Effect of control of systolic blood pressure on survival in cats with systemic hypertension. J Vet Intern Med. 2007;21:402-409.

3 Elliott J, Barber PJ, Syme HM, Rawlings JM, Markwell PJ. Feline hypertension: clinical findings and response to antihypertensive treatment in 30 cases. J Small Anim Pract 2001;42:122-129.

4 Henik RA, Snyder PS, Volk LM. Treatment of systemic hypertension in cats with amlodipine besylate. J  Am  Anim  Hosp  Assoc. 1997;33: 226-234.

5 Snyder PS. Amlodipine: a randomized, blinded clinical trial in 9 cats with systemic hypertension.
J Vet Intern Med. 1998;12:157-162.