refractory hypertension

Re: refractory hypertension

Virginia Campbell — Wed, 09 Jul 2014 00:28:07 GMT

Thanks for that. Reckon I should sit tight and not start any new anti-hypertensive drugs for now. Will see about booking for for cspec lipase etc

Re: refractory hypertension

Rory Bell — Tue, 08 Jul 2014 23:30:31 GMT

Hello again

the testicular mass might be a sertoli cell tumour, but most of those that are functional are intrabdominal, and are associated with signs of feminisation as well as PU/PD and dermatological changes. Assuming this dog does not have signs of feminisation then it's probably less likely that his testicular tumour is causing clinical signs. Ultimately, you won't know for sure unless you remove it and analyse both it and the dog's response.

That said, i do suspect that this dog is cushingoid. He was PU/PD before you documented evidence of renal failure, and you have some strongly supportive biochemical (LDDST and ACTH stim), and clinical (PU/PD, alopecia) signs of hyperadrenocorticism (HAC).

A lot of dogs and, according to some reports the majority, of dogs with HAC are hypoxemic. This is probably due to a combination of factors; pulmonary mineralisation and respiratory muscle weakness being but two of the possibilities. Glucocorticoid myopathy will affect appendicular skeletal muscles, so if a dog has subclinical osteoarthritis, this will be exacerbated by HAC. On the other hand, HAC dogs don't generally become cyanosed on exercise, so HAC, if it exists, it probably at most contributory.

Fractional shortening is a very imprecise indicator of cardiac function in your patient. In a dog with mitral endocardiosis, the majority of their stroke volume will be ejected into a relatively low pressure system; i.e. the left atrium and pulmonary vein rather then the aorta. This eases the aterload on the left ventricle which now has the opportunity to pump into a relatively low resistance / high capacitance circuit. Your patient will not be hypertensive if this mechanism has lead to congestive heart failure.

So...., I'd assess for pancreatitis (cPL) and particularly if that was negative I'd consider treating for HAC, and reassessing both renal parameters and BP in response to treatment.

Let me know if you have any more info, or questions.

Re: refractory hypertension

Virginia Campbell — Tue, 08 Jul 2014 14:10:13 GMT

Hi all,

Thanks for the thoughts so far. I have the case notes now. Will try to streamline this, but take a deep breath: also remember I didn't get to see the dog till April this year at vaccination. Dog is now rising 13 years old. Sorry no units for bloods, for speed.

May 2012. bit off form and U+ in house. free catch urine protein +++ and trace blood. treated for cystitis. also had grade 3 heart murmur. bloods ALT 269 ALKP 665 chol 8.89. All others inc bile acid stim wnl. Big liver on abdo ultrasound, kidneys looked OK.

July 2012 heart scan - mitral valve endocardiosis but good FS. atrium sl enlarged hence started 5mg fortkor sid. dental 2 weeks later

Aug 2012 urea 15 ALT 411 ALKP 1248 chol 13, all others wnl. cspec lipase 494 (bit increased) but wouldn't eat low fat food. bit arthritic.

Jan 2013 ALT 262 ALKP 549 urea 14 chol 9.3 ACTH stim basal cortisol 116 post 499 echo FS 35% bit dec but wnl

floated round 15-15.5 kg all of this time. stayed on ACE inhibitor all this time.

April 2014 - I saw the dog for vaccination and started putting my spoke in. looks a bit skinny and O thinks has lost weight, and is PUPD and bit more exercise intolerant than used to be. bilat flank alopecia - poss Sertoli cell tumour as one testicle big and firm, other small and soft.

14.5kg

ALT 193 ALKP 381 urea 37 crea 181 chol 11 all other things OK; phos wnl at 1.86 urine SG 1.016 ACTH stim basal 147 post stim 538

HR 150 grade 5 murmur but pulse qual surprisingly decent. echo - FS OK, left atria big big but generally not much change.

abdo ultrasound: big liver, sludgey gall bladder, ultrasonographer (who's pretty good) couldn't find adrenals. multiple fluid filled cysts in both kidneys

LDDS basal cortisol 215 4hr 53.5 8 hour 164....so this and ACTH stim would fit with Cushings, but I would expect that if he'd been Cushingoid this long his liver should be getting steadily worse, and I think there's enough concurrent disease to account for a raised cortisol, and he didn't have big shiny adrenals on scan, and anyway I'm scared of vetoryl in this dog!

June 2014 - 12.8kg so more weight loss; still not himself - first bp measurement. started famotidine (which he wouldn't tolerate - made him vomit!) and amlodipine, which he did, but no effect seen when bp measured again and ALKP bit more raised at 457; ALT 161. currently trying couple of renal diets to see if he will eat them.

So that's the story so far. Dunno if you would call him a heart failure dog or not. His pulses feel OK but his tongue goes a bit blue now and then and he is exercise intolerant (due to heart or concurrent disease, I don't know).

HE's not on pimobendan, as his FS has been OK.

I do believe the bp measurement as he's the most placid dog you could imagine...you can do the bp single handed on him with nobody holding him

I haven't looked at his retinas...oops...will do next time

Re: refractory hypertension

Virginia Campbell — Tue, 08 Jul 2014 14:10:07 GMT

Hi all,

July 2012 heart scan - mitral valve endocardiosis but good FS. atrium sl enlarged hence started 5mg fortkor sid. dental 2 weeks later

Aug 2012 urea 15 ALT 411 ALKP 1248 chol 13, all others wnl. cspec lipase 494 (bit increased) but wouldn't eat low fat food. bit arthritic.

Jan 2013 ALT 262 ALKP 549 urea 14 chol 9.3 ACTH stim basal cortisol 116 post 499 echo FS 35% bit dec but wnl

floated round 15-15.5 kg all of this time. stayed on ACE inhibitor all this time.

14.5kg

ALT 193 ALKP 381 urea 37 crea 181 chol 11 all other things OK; phos wnl at 1.86 urine SG 1.016 ACTH stim basal 147 post stim 538

HR 150 grade 5 murmur but pulse qual surprisingly decent. echo - FS OK, left atria big big but generally not much change.

abdo ultrasound: big liver, sludgey gall bladder, ultrasonographer (who's pretty good) couldn't find adrenals. multiple fluid filled cysts in both kidneys

HE's not on pimobendan, as his FS has been OK.

I do believe the bp measurement as he's the most placid dog you could imagine...you can do the bp single handed on him with nobody holding him

I haven't looked at his retinas...oops...will do next time

Re: refractory hypertension

Rory Bell — Mon, 07 Jul 2014 18:34:47 GMT

Hi Virginia,

Was this dog ever in overt (decompensated) heart failure? You need pretty good cardiac performance to maintain that degree of hypertension, so it's physiologically improbable that a dog with a failing heart could maintain a BP of 230mmHg (mean arterial pressure = cardiac output x systemic vascular resistance). I'd therefore consider repeating the BP assessment, perhaps, as Andy mentioned, in a home environment, perhaps, if possible using doppler and oscilometric techniques. Also a good idea to perform a fundoscopic exam to see if you have corroborating evidence of severe hypertension. I'd probably so this before upregulating his antihypertensive meds. Is there any evidence of disease states that could result in hypertension (e.g. renal disease)?

cheers

Rory

Re: refractory hypertension

Martin Atkinson — Mon, 07 Jul 2014 17:11:47 GMT

I agree with the other comments on investigating the cause of the hypertension but all things aside maybe you could try some Diltiazem. It has fallen out of favour as it is not as effective an anti-hypertensive as amlodypine and with the advent of pimbendan but maybe the two in tandem may help, but make sure there is not an AV block (shouldn't be with and HR of 140) or CHF first so ECG & X-ray

Re: refractory hypertension

Andrew Kent — Fri, 04 Jul 2014 19:02:12 GMT

Hi Virginia,

Have you looked in this dog for any underlying causes of hypertension (hyperadrenocorticism, pheo etc?) as these dogs can sometimes be hard to control.

Do you know anything more specific about the nature of its heart disease? If not it might be helpful to have an echo so that you can plan the medical management more closely, or even some thoracic radiographs to look for oedema.

Personally I would try to control the BP better as it is likely to be leading to a more rapid deterioration of all of his diseases, but it is true that there can be a balance with some dogs and not dropping it too much.

I would also make sure you are happy that his BP in genuinely this high - how are you measuring it and in what setting? If in the practice then a home visit may be a good idea. What do his retinas currently look like.

From a therapeutic point of view I would go for an increase in his benazepril dose, gradually titrating up to 0.5mg/kg every 12 hours. Check renal parameters 3-5 days after each dose increase and then reassess BP after 2 weeks.

If the dog has heart disease as well then other diuretics (frusemide/spironolactone) can help lower BP also so would be another option.

Just a few thoughts but hope it helps,

Andy

Re: refractory hypertension

Michael Woodhouse — Fri, 04 Jul 2014 18:00:34 GMT

I'd be very worried that the BP is compensatory and if you drop it you push him over the edge.

Is he getting any pimobendan? I'd be inclined to 'help' the heart and see what the BP does.