HCM treatment modalities

RE: HCM treatment modalities

Martin Atkinson — Mon, 14 May 2018 18:48:35 GMT

[quote user="GrooveJet"]2) ACE-I once left atrium enlarging or ProBNP ^^^[/quote]

[quote user="Russell leadsom"]I now include pimobendan following this, even with HOCM.[/quote]Yes its amazing how what some of us have been doing for ages on clinical experience and has been poo-pooed by 'experts' has suddenly become acceptable.

RE: HCM treatment modalities

Russell leadsom — Mon, 14 May 2018 15:56:24 GMT

https://avmajournals.avma.org/doi/abs/10.2460/javma.245.5.534

I now include pimobendan following this, even with HOCM.

maybe we don’t know as much as we like to think!?

RE: HCM treatment modalities

Elisabeth Knappett — Mon, 14 May 2018 15:43:29 GMT

That's really useful - thanks very much for posting the advice. With respect to ACEi, what is everyone using? I have a cat who will not take any form of tablet ACEi (tried them all!) and was managing very well on prilium - but this is now withdrawn! The only other liquid ACEi I can find is ramipril (human formulation) - anybody else used this before?

RE: HCM treatment modalities

Miriam Lodewyks — Mon, 14 May 2018 11:57:58 GMT

Thanks y'all,

Had a chat with a cardiologist about this and his advice was as follows:

1) Clopidogrel! they hate it, but he has not yet seen a cat throw an embolism whilst being on it, so reckons it must be working. Not convinced about Aspirin.

2) ACE-I once left atrium enlarging or ProBNP ^^^.

3) Frusemide as above, even if symptoms not obvious (cats good at hiding them).

4) Atenolol appears to be useful at stabilising and maintaining cardiac output in early stages of HCM, but is counter-productive once LA begins to enlarge, so wean off at this stage.

Hope I understood that correctly, and that it perhaps helps some of you also.

RE: HCM treatment modalities

nikki — Sun, 13 May 2018 23:20:17 GMT

I usually recommend clopidogrel if LA enlargement. And I will use b blockers if there is evidence of lvoto and tachycardia. I don't tend to reach for acei or pimobendan until they show signs of chf. This is basically what I've been taught on multiple cardiology cpds so just adopted same tx.

RE: HCM treatment modalities

Kate Richardson — Sun, 13 May 2018 14:53:25 GMT

[quote user="Liz Barton"]I usually send the owners home with some furosemide to keep 'on the shelf' in case the cat has a respiratory distress episode, but advise them to phone the vet prior to administering. I have found it helps immensely when they go into CHF and have difficulty breathing at home... the owners call us, we tell them to give the furosemide and bring the cat down 1hr later, and breathing has often improved to make transport safer.[/quote]

That;s a great idea and one I shall pinch.

I would use a beta blocker if significant tachycardia. But if we are talking about a cat with no symptoms, no LA enlargement, no smoke, and no tachycardia, I would probably tend not to give anything, but recheck echo in 6months.

RE: HCM treatment modalities

Liz Barton — Sun, 13 May 2018 00:50:01 GMT

YES to clopidogrel, but warn the owners they hate the tablets (though I think the newer ones are more palatable). If it becomes a huge stress giving the tablets you might be doing more harm than good! I would put them on this before ACE inhibitors, but they would be my second add-on. Pimobendan is contraindicated if there's dynamic LV outflow tract obstruction, so unless you've ruled this out by echo don't start them on it as you could do more harm than good.

What's resting HR like? Do you need to consider rate control with antiarrhythmics? I'm always very hesitant with these, and if they're >240 at the vets I put them on it, 200-240 with no signs of low output I'd hold off, but with clinical signs I'm not sure - what would others do? I'd probably hold fire and see what effect the other drugs (e.g. pimobendan) first.

I usually send the owners home with some furosemide to keep 'on the shelf' in case the cat has a respiratory distress episode, but advise them to phone the vet prior to administering. I have found it helps immensely when they go into CHF and have difficulty breathing at home... the owners call us, we tell them to give the furosemide and bring the cat down 1hr later, and breathing has often improved to make transport safer.

RE: HCM treatment modalities

Martin Atkinson — Sat, 12 May 2018 11:05:20 GMT

[quote user="Kate Richardson"]Clopidogrel definitely does what it says on the tin- I did a dental on an elderly cat that needed multiple extractions a while ago that is on it and didn't think about how it might affect things- bleeding was much more profuse than usual [/quote]It is a chastening experience and one I may not have thought about previously - thanks for the alert.

That said I'm on Dabigitran as an anti-coagulant for my AF and the cardiologist suggested that I stop taking it for a while if I'm going to be doing something involving a high risk of injury like 'skiing off piste'. Rather prophetic, as 48 hrs after I stopped taking it I had my crash into a fence and fractured both my scapulae. Also although I didn't realise at the time until I had coincidental cardiac MRI 2 weeks later I had a pericardial effusion which had cleared another 2 weeks later on a subsequent echocardiography. Cardiologist thought the most likely explanation for the effusion was a bleed from the trauma associated with the crash. Sobering thoughts.

Given I'm at risk of crashing on my bike virtually every day perhaps I ought to stop it altogether!!

RE: HCM treatment modalities

Rob Loxley — Fri, 11 May 2018 19:14:57 GMT

[quote user="Martin Atkinson"]I don't know why I'm bothering with this because DM will be along soon to shoot me down in flames[/quote]

Maybe I believe in homeopathy for these cases (I don't!), there's no evidence but my anecdote is that they live longer, it does 'no harm', maybe sometime in the future someone will prove it works

RE: HCM treatment modalities

Miriam Lodewyks — Fri, 11 May 2018 14:46:26 GMT

Thanks for pointing that out Kate. Easy mistake to make!

Will make sure it doesn't happen to me.

RE: HCM treatment modalities

Kate Richardson — Fri, 11 May 2018 14:42:29 GMT

[quote user="Martin Atkinson"] I would put them on Clopidegrel, aspirin has been shown to be useless in humans so why assume it is any better in cats, 18.75 mg tabs sid from Summit.[/quote]

Clopidogrel definitely does what it says on the tin- I did a dental on an elderly cat that needed multiple extractions a while ago that is on it and didn't think about how it might affect things- bleeding was much more profuse than usual and I did think to myself while doing the procedure has this cat got a clotting disorder (but still didn't put 2 and 2 together at that stage), the blood did clot and once sutured, all looked fine. Cat recovered well, ate, no signs of problems, then 4-5 hours later when we put the cat in it's carrier for the owners to collect later, we noticed a massive amount of blood in its mouth! Hospitalised overnight for obs, no additional treatment needed, and went home the next day, no further haemorrhage, back onto its clopidogrel a couple of days later! Lesson learnt!

RE: HCM treatment modalities

Martin Atkinson — Fri, 11 May 2018 13:50:59 GMT

I don't know why I'm bothering with this because DM will be along soon to shoot me down in flames.

1) I would put them on Clopidegrel, aspirin has been shown to be useless in humans so why assume it is any better in cats, 18.75 mg tabs sid from Summit.

2) The EPIC trial in dogs has shown that pre-emptive treatment delays onset of cardiac failure and the specialists said before there is no evidence that this helped even though I had found it did for years before. Can we assume that the same rule applies to cats and in 5-10 years time or whatever a cat EPIC trial will show the same.

Given cats very often drop dead with no warning or develop ATE - are we going to wait for this to happen because we have no research available to show pre-emptive treatment works.

Personally I have been putting cats on ACEi (Benazepril) for years and yes its all anecdotal but IME the cats which are on this have lived longer than those that weren't. I would probably now put them on Pimobendan.

RE: HCM treatment modalities

Camilla Edwards — Fri, 11 May 2018 13:48:02 GMT

Sort of relevant - just listened to this podcast on HCM - very interesting! https://www.rvc.ac.uk/small-animal-referrals/news-events/clinical-podcasts/72-hcm-in-cats

RE: HCM treatment modalities

Rob Loxley — Fri, 11 May 2018 13:23:19 GMT

B-blocker if DLVOTO?

RE: HCM treatment modalities

Emily Rainbow — Fri, 11 May 2018 09:50:38 GMT

Its really not palatable when split so use the smaller tablets from Summit.

RE: HCM treatment modalities

Miriam Lodewyks — Fri, 11 May 2018 09:02:34 GMT

As the dose of Clopidogrel appears to be in the region of 1/8 of a tablet, do you have that specially compounded, or do you "crush n divide"?

RE: HCM treatment modalities

Kate Richardson — Tue, 08 May 2018 21:51:21 GMT

Assuming cats are essentially normal otherwise ie you don’t suspect hyperthyroidism for example?

I would check for a cause such as hypertension

heart rates?

As LA is enlarged, I would start clopridogel or aspirin if they had smoke in the left atrium, if no smoke I would still consider it.

Not saying I’m right though