Peer Reviewed Heart Failure in Dogs: 6 Practical Tips from Cardiologists

6 Practical Tips from Cardiologists

Heart Failure in Dogs

Ashley B. Saunders, DVM, Diplomate ACVIM (Cardiology), and
Sonya G. Gordon, DVM, DVSc, Diplomate ACVIM (Cardiology)
Texas A&M University

Heart failure is a complex condition. Despite DEGENERATIVE MITRAL VALVE DISEASE

multiple underlying causes and clinical DMVD is the most common acquired heart
manifestations, successful management is possible. disease in dogs. Common clinical signs and
This article describes canine heart failure, provides pathophysiology include:
in-depth information about the most common • Heart murmur due to mitral valve (and,
diseases that lead to heart failure, and offers practical sometimes, tricuspid valve) regurgitation, leading
tips for diagnosis and management. to left atrial and left ventricular dilatation
• Progressive dilatation of the left ventricle,
DEFINITION ultimately leading to systolic dysfunction
Heart failure is a complex condition that can develop • Significant left atrial enlargement, leading to
from congenital or acquired heart disease in dogs. atrial (supraventricular) arrhythmias
Depending on the specific disease process, it can • Development of pulmonary hypertension,
affect the left and right sides of the heart, manifesting which can contribute to clinical signs, such as
in respiratory signs and weakness due to: respiratory distress and syncope.
• Fluid retention: Congestion; sometimes called Not all dogs with DMVD will develop heart
backward failure failure, characterized by pulmonary edema (see
• Pump failure: Low cardiac output; sometimes Progression to Congestive Heart Failure). In
called forward failure. general, dogs with heart enlargement are at greater
While the underlying heart disease can vary risk for heart failure, but only 30% of dogs with
depending on age and breed, chronic heart failure asymptomatic DMVD develop clinical signs and
management for degenerative mitral valve disease require heart failure therapy.
(DMVD) and dilated cardiomyopathy (DCM) initially
relies on a combination of a diuretic, angiotensin- DILATED CARDIOMYOPATHY
converting enzyme (ACE) inhibitor, and pimobendan, DCM is a primary disease of the heart muscle,
with additional medications added as necessary. characterized by a relatively long asymptomatic
stage (1–2 years) followed by sudden death (due to
Progression As heart function deteriorates, fluid volume within arrhythmias) or heart failure. Changes associated
the heart and vasculature increases as a consequence with DCM, starting with the earliest, include:
to Congestive of activation and upregulation of neurohormonal
• Reduced systolic function of predominantly the
Heart Failure
systems, such as the renin-angiotensin-aldosterone
system. This complex pathophysiology leads to
left ventricle
increased: • Dilatation of the left ventricle and, to a lesser
`` Preload degree, the left atrium due to systolic dysfunction
`` Stretch of heart chambers and high preload
`` Hydrostatic pressure in vessels that supply the left • In some dogs, mitral regurgitation, once the heart
(pulmonary veins) and right (vena cavae) atria.
is sufficiently dilated, because the mitral annulus
The result is either: is stretched to a degree that prevents the mitral
`` Congestion and pulmonary edema (left-sided valves from closing effectively.
heart failure)
Arrhythmias are common in this disease, both
`` Ascites with or without pleural effusion (right-sided
heart failure). in the asymptomatic and symptomatic stages,
and often require treatment. The most common

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 Heart Failure in Dogs: 6 Practical Tips from Cardiologists Peer Reviewed

Cough is a common complaint that does not often persists after active pulmonary edema has been Cough:
necessarily indicate heart failure. Instead, it may be resolved with diuretic therapy (Figure 1).
related to an enlarged heart compressing the airway
It is useful to ask the following questions about a
Caused by
Heart Failure
(ie, mainstem bronchial compression) or primary
cough:
airway/lung disease.
`` How long has the cough or respiratory signs been
In a dog with a good appetite and normal activity present? or Respiratory
`` Is the cough harsh (often described as “ending
Disease?
level, a chronic, harsh cough that ends with a gag is
less likely to be associated with heart failure. Cough with a gag” or a sound similar to “a cat with a
from mainstem bronchial compression can occur hairball”)?
before onset of congestive heart failure (CHF) and `` How are the dog’s appetite and activity level?

FIGURE 1. Right lateral thoracic

radiographs in 2 dogs with
DMVD and radiographic
cardiomegaly, including
left atrial enlargement (LA):
A 14-year-old shih tzu (A)
was receiving heart failure
medications (enalapril,
furosemide, pimobendan),
but still had a chronic, harsh
cough that had been present
for several months despite
administration of cardiac drugs.
The dog had a good appetite
and activity level, with an at-
home resting breathing rate
of 24 breaths/min. Mainstem
bronchial compression (arrow)
was documented. Following
progressive enlargement
of the left atrium, a cough
from mainstem bronchial
compression can develop
before heart failure, and persist
after initiation of heart failure
therapy. Although this type
of cough does not typically
resolve, it is often managed
with a cough suppressant once
the dog is not in active CHF. A
9-year-old Cavalier King Charles
spaniel (B) presented for acute
onset cough and breathing
difficulty over 24 hours.
There is pulmonary venous
enlargement (arrow) and an
interstitial pattern consistent
with pulmonary edema as
evidence of CHF.

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Peer Reviewed Heart Failure in Dogs: 6 Practical Tips from Cardiologists

arrhythmias are atrial fibrillation, ventricular despite early age of onset, rate of progression is
premature complexes, and ventricular tachycardia. reportedly no different than progression rate in
other breeds.
A CASE TO CONSIDER • Lifetime risk for DCM in Doberman pinschers
Consider the following scenario: An 8-year-old castrated is approximately 60%; thus, about half of all
male bichon frise has a 6-month history of exercise- Doberman pinschers develop this disease. The risk
induced cough and a grade 3/6 systolic left-sided for asymptomatic DCM in Doberman pinschers
heart murmur. The owner is concerned that the dog is increases with age and likely peaks around 7 years;
coughing during the night and has labored breathing. however, the condition is sometimes seen in dogs
During auscultation, the murmur is classified as grade as young as 3 years of age.
4/6 systolic, heard loudest at the left apex. Identifying an individual dog’s type of heart
disease helps guide assessment and treatment
Consider These Questions recommendations.
Is this dog experiencing heart failure? Can you
answer this question based on the available 2. Be a Detective: Ask Detailed Questions
information, or do you need further details? What Take time to gather information from the patient’s
additional information is needed? history and physical examination, including details
that may help determine whether the dog has heart
Consider These Answers failure and why it may have occurred.
The signalment, combined with a heart murmur
and cough, suggests that heart failure is possible; Does the history support heart disease and heart
however, additional information from the history, failure?
physical examination, and diagnostic tests is needed • Is there a history of heart disease in a relative or
littermate?
to confirm whether the diagnosis is CHF.
• Is congenital or acquired heart disease more
likely? For instance, in a middle-aged to older
PRACTICAL TIPS FOR DIAGNOSIS &
dog, is the murmur a relatively new finding,
MANAGEMENT
suggesting an acquired disease, or has it been
Following are 6 practical tips for optimizing heart
present since the dog was a puppy, suggesting
failure diagnosis and management in dogs. These tips
undiagnosed congenital heart disease? See
also provide the additional information needed for
Consider These Cases (#1).
diagnosis of CHF as discussed in Consider These
• Does the history of clinical sign progression
Answers.
support heart failure? Findings from the history
that support heart failure are listed in Table
1. Consider Patient Signalment
1. These findings, while not specific for heart
Age and breed are useful when considering
failure, suggest that pulmonary edema may
reasonable differential diagnoses for the type of
be present, especially when combined with
disease responsible for heart failure.
signalment and abnormal findings on physical
Dogs younger than 2 years of age are more likely
examination.
to have congenital heart disease, while middle-aged
to older dogs are more likely to have an acquired,
Does the physical examination support heart disease
adult-onset disease. Certain breeds are predisposed and heart failure?
to specific disease processes. Classic examples include • A left apical systolic murmur is a characteristic
DMVD incidence in small breeds, such as miniature finding in dogs with mitral regurgitation from
poodles and Cavalier King Charles spaniels, and
DCM incidence in large breeds, such as Doberman
Table 1.
pinschers and Great Danes.
Clinical Signs Supportive of Heart Failure
Specific examples include:
• Incidence of DMVD in Cavalier King Charles • Difficulty breathing
• Worsening chronic cough that is associated with
spaniels increases with age but, in general, increased respiratory rate
DMVD occurs at a younger age in this breed • Decreased appetite
compared with other breeds. A mitral murmur • Recent onset of coughing
can become evident at or after 4 years of age, but • Reduced activity or exercise ability

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 Heart Failure in Dogs: 6 Practical Tips from Cardiologists Peer Reviewed

FIGURE 2. Lead II electrocardiogram demonstrating sinus tachycardia with a regular rhythm and heart rate of 175
beats/min in a dog with CHF (25 mm/s; 10 mm/mV).

FIGURE 3. Lead II electrocardiogram demonstrating sinus arrhythmia with an irregular rhythm and heart rate of 80
beats/min in a dog with a murmur, chronic cough, and tracheal collapse (25 mm/s; 10 mm/mV).

DMVD, and a loud murmur is more likely with

advanced disease. See Consider These Cases (#2). Case #1: A 9-year-old castrated male golden
retriever was presented for increased respiratory rate
Consider
• A rapid heart rate, most often a sinus tachycardia
(Figure 2), is associated with epinephrine and
and restlessness. Initially, on the basis of signalment, These Cases
the clinician considered pericardial effusion and a
increased sympathetic drive in heart failure. A heart base tumor as possible differential diagnoses.
normal heart rate or respiratory sinus arrhythmia However, the owner remembered that the dog had a
(Figure 3) suggests an absence of sympathetic murmur as a puppy. During the physical examination, a
drive and indicates that heart failure is not the most grade 4/6 systolic left basilar murmur was auscultated
and heart sounds were not muffled. Congenital
likely cause of respiratory signs.
subaortic stenosis resulting in left-sided CHF (ie,
• Are there other signs of potential heart disease, pulmonary edema) was subsequently diagnosed.
including a gallop or arrhythmia?
»» As the atria increase in size, dogs may develop Case #2: Consider the case presented on page
supraventricular arrhythmias, such as premature 26—the 8-year-old castrated male bichon frise with
beats, bursts of supraventricular tachycardia, and 6-month history of exercise-induced cough and a
atrial fibrillation. An arrhythmia may be heard grade 3/6 systolic left-sided heart murmur, whose
owner reported coughing during the night and
during auscultation of the thorax or appreciated
labored breathing. When you auscultate the dog,
upon palpation of pulses. the murmur has increased to a grade 4/6 systolic left
»» Pulses may be irregular, weak, or occasionally apical murmur. Based on clinical presentation, which
absent. An S3 gallop can be heard in dogs with scenario outlined in Table 2 is more consistent with
DCM associated with rapid ventricular filling heart failure in this patient?
into an enlarged, poorly contracting and relaxing
ventricle. Table 2.
Physical Examination Scenarios:
3. Know When to Test Coughing Dog with Heart Murmur
Thoracic radiographs and serum biochemistries are PARAMETERS SCENARIO 1 SCENARIO 2
complementary: Heart rate 110 beats/min 170 beats/min
Radiographs are critical for assessing cough or Respiratory
35 breaths/min 80 breaths/min
respiratory signs and monitoring heart failure rate
therapy. Thoracic radiographs provide information
Scenario 2—demonstrating increased heart and
on measures of heart size (ie, number of rib spaces, respiratory rates compared with Scenario 1—is consistent
vertebral heart size), specific chamber enlargement, with CHF in this coughing dog with a heart murmur.
pulmonary vessel size, and pulmonary patterns.

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Peer Reviewed Heart Failure in Dogs: 6 Practical Tips from Cardiologists

Abnormalities that support CHF include: are important to consider when making treatment
• Left atrial enlargement recommendations. It is also essential to consider
• Pulmonary venous enlargement the patient’s medical history, current drug therapy,
• Perihilar interstitial-to-alveolar pattern from potential adverse effects of cardiac medications, and
pulmonary edema. drug interactions.
During initial presentation for coughing or • Decreased glomerular filtration rate in a dog
decreased exercise tolerance, radiographs are the with kidney disease may be a concern when ACE
best way to confirm presence of venous congestion inhibitors, diuretic therapy, and nonsteroidal anti-
and pulmonary edema. Radiographs can also inflammatory drugs are being administered.
indicate bronchial compression due to an enlarged • Electrolyte concentrations are affected by ACE
left atrium and rule out alternate diagnoses, such as inhibitors and diuretics.
pneumonia or pulmonary neoplasia. When CHF is • Pulmonary hypertension can develop in dogs
suspected, diuretic therapy can be initiated before with DMVD, protein-losing diseases, and
thoracic radiography if the patient is dyspneic. hyperadrenocorticism.
Periodic biochemistry monitoring is important
in dogs receiving diuretics and ACE inhibitors or 5. Make Recommendations for Home Care That
those with comorbid conditions, such as kidney Considers the Pet’s and Care Taker’s Quality
disease. Adjustments in diuretic dosing can be based of Life
on clinical signs, radiographic findings, and kidney Involve owners in monitoring their dogs’ heart
values to achieve the lowest effective dose. disease:
Set up a recheck schedule to monitor disease
Echocardiography is a powerful tool; know when to progression, potential adverse effects of medications,
perform it: patient quality of life, and any challenges faced by
Echocardiography can establish the type of heart the owner. Recheck evaluations for a dog in heart
disease and identify complicating factors, such failure are often recommended every 2 to 4 months,
as pulmonary hypertension, systolic ventricular or sooner, if medications are adjusted or clinical
dysfunction, high left-sided filling pressures, decompensation occurs.
intracardiac shunts, atrial tears, and pericardial Educate owners about clinical signs that
effusion. Echocardiography can also identify indicate their dogs need medical attention, including
anatomic abnormalities and assess function, but it cough (new or worsening), breathing difficulty,
cannot specifically diagnose the presence of CHF. anorexia or vomiting, and lethargy or collapse.
Echocardiography is not typically necessary until Encourage owners to record resting or sleeping
a dog is clinically stable; however, it can provide breathing rates at home. Many dogs have a resting
useful information to guide treatment protocols and breathing rate of less than 35 breaths/minute, often
is especially helpful when response to heart failure in the mid-teens to mid-twenties. An elevated
therapy does not meet expectations and additional breathing rate that is repeatable within the hour,
treatment may be indicated. A more detailed study especially if the dog has breathing difficulty or a
requires an experienced sonographer to identify decrease in appetite or activity level, should prompt
complex issues and characterize congenital defects medical attention.
(see Tip 6). Additional points to consider:
• Ensure the dog is eating and taking its
4. When Recommending Therapy, Consider medications. Make recommendations for a
Comorbidities and Drug Interactions and palatable diet and advise the owner to avoid high-
Adverse Effects salt foods and treats when possible.
For the 2 most common acquired heart diseases • Set activity level expectations, which varies
in the dog—DMVD and DCM—recommended for each dog. Light activity is acceptable and
heart failure therapy includes multiple medications, encouraged, especially if it enhances quality of
typically furosemide, pimobendan, and an ACE life, but strenuous activity needs to be avoided.
inhibitor. • Consider the owner’s lifestyle when making
Adult dogs are more likely to have concurrent treatment recommendations. For instance, therapy
systemic diseases—kidney disease, protein-losing given more than twice daily may be difficult for
diseases, hyperadrenocorticism, and arthritis—that some owners.

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 HEART FAILURE IN DOGS: 6 PRACTICAL TIPS FROM CARDIOLOGISTS Peer Reviewed

ASHLEY B. SAUNDERS SONYA G. GORDON

Ashley B. Saunders, DVM, Diplomate ACVIM Sonya G. Gordon, DVM, DVSc, Diplomate
(Cardiology), is an associate professor of ACVIM (Cardiology), is an associate pro-
cardiology in the Department of Small fessor of cardiology in the Department of
Animal Clinical Sciences at Texas A&M Uni- Small Animal Clinical Sciences at Texas
versity College of Veterinary Medicine and A&M University College of Veterinary
Biomedical Sciences. Her interests include Medicine and Biomedical Sciences. She is
interventional cardiology and advanced routinely invited to speak at local, national,
imaging, heart failure management, and and international veterinary meetings. She
educational technology. She is the recip- has published numerous manuscripts and
ient of multiple teaching awards and is a book chapters, and recently coauthored
Montague Center for Teaching Excellence a practical small animal clinical cardiol-
Scholar. ogy book, The ABCDs of Small Animal
Cardiology.

Success is often measured by quality of life as and prognostic variables of dogs with clinical chronic
degenerative mitral valve disease attributable to myxomatous
well as duration of survival after diagnosis. With
degeneration. J Vet Intern Med 2012; 26:69-75.
good management, many dogs with progressive Borgarelli M, Haggstrom J. Canine degenerative myxomatous
heart failure can have a good quality of life as well as mitral valve disease: Natural history, clinical presentation and
therapy. Vet Clin North Am Small Anim Pract 2010; 40:651-
improved survival times.
663.
Chiavegato D, Borgarelli M, D’Agnolo G, Santilli RA. Pulmonary
6. Establish a Relationship with a Local hypertension in dogs with mitral regurgitation attributable to
myxomatous valve disease. Vet Radiol Ultra 2009; 50:253-
Cardiologist
258.
Consider referral to a cardiologist, when available. Wess G, Schulze A, Butz V, et al. Prevalence of dilated
Clinical evaluation by a cardiologist can be beneficial cardiomyopathy in Doberman Pinschers in various age
groups. J Vet Intern Med 2010; 24:533-538.
to establish the diagnosis, develop a comprehensive
treatment and re-evaluation plan, fine-tune therapy, and
keep up with current guidelines, especially when the
diagnosis is difficult or therapy ineffective.
Guidelines for the staging, diagnosis, and
management of degenerative valve disease were
established by a committee of cardiologists and
published by the American College of Veterinary
Internal Medicine in 2009 (see Suggested
Reading). Additional information from clinical trials
continues to become available.

ACE = angiotensin-converting enzyme; CHF

= congestive heart failure; DCM = dilated
cardiomyopathy; DMVD = degenerative mitral
valve disease

Disclosure Statement
Drs. Saunders and Gordon have received research
funding and programmatic support from Boehringer
Ingelheim Vetmedica (makers of pimobendan) and
IDEXX Laboratories.

Suggested Reading
Atkins C, Bonagura J, Ettinger S, et al. Guidelines for the
diagnosis and treatment of canine chronic valvular heart
disease. J Vet Intern Med 2009; 23:1142-1150.
Borgarelli M, Buchanan JW. Historical review, epidemiology and
natural history of degenerative mitral valve disease. J Vet
Cardiol 2012; 14:93-101.
Borgarelli M, Crosara S, Lamb K, et al. Survival characteristics

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