Cardiology News
As many
of you already know, cardiology has always been my favorite
internal medicine discipline, and I have been blessed to train
with some of the best cardiologists in the country. I attended
two very interesting sessions at this year's ACVIM conference.
The first involves the heated debate regarding use of
angiotensin-coverting enzyme inhibitors (ACE-I) in the
prevention of congestive heart failure. Two recent studies
(Europe, USA) have both failed to document any significant
benefit when initiating enalapril in asymptomatic dogs with
mitral valvular insufficiency. However, many cardiologists
argue that the theoretical benefit of these drugs and the
evidence in humans suggests that we should use ACE-I in
asymptomatic dogs to delay the progression of heart failure.
Look for more interesting debate and study regarding this
issue in the next 2-3 years. As for now, you must make up your
own mind when to begin enalapril in each individual patient.
In my experience, there is no debate that all CHF patients
should be on an ACE-I medication; but in regard to
asymptomatic patients I recommend initiation of ACE-I whenever
there is documented cardiomegaly on radiographs (especially
left atrial enlargement) or volume enlargement of the
ventricle or atrium on echocardiography. Hopefully, by
initiating ACE-I at this time we may truly and significantly
retard the progression to CHF in these patients.
The
other interesting study is in regard to the treatment of
congestive heart failure due to diastolic myocardial disease
in cats (HCM, RCM). A well-designed multicenter study
demonstrates that only furosemide is significantly associated
with survival time. In comparison, beta-blockers and
calcium-channel blockers and ACE-I vasodilators used to
improve diastolic function and reduce heart rate appeared to
be associated with increased mortality rates in these CHF
patients. To me the biggest lesson in this study is the poor
prognosis anticipated with many patients once they are in
established CHF. This fact must be communicated to the owner
so that they can hope for the best but also can prepare for
the worst. Unfortunately, this study does not address the use
of beta-blockers, calcium channel blockers and ACE-I
vasodilators in asymptomatic pre-CHF patients. I think these
drugs may be beneficial in this setting in delaying or
preventing CHF development.
Oncology News
Dr. Clooten and I, both,
provide medical oncology as part of our internal medicine
service. As in all of your own practices, cancer is all too
often the underlying definitive diagnosis that we uncover
while working up many of our internal medicine referral
patients. This presents a difficult and emotional medical
situation for all involved - the patients, owners, and
clinicians. Our goal is to be aggressive whenever possible if
a realistic chance for cure may be achieved. In the many
situations when a cure is not possible our goal shifts to
palliative treatment options that will achieve the best
quality of life for as long as the patient and owners are
comfortable. Therefore, it is imperative that a rational
dialogue begin between the owners and clinicians so that it
can be determined what is in the best interest of each
individual cancer patient. There have been some great strides
made in certain cancer treatments over the past 20 years, but
at the same time I am often frustrated that the expected
response rates and survival times for many patients with
aggressive malignancies has not really changed. When dealing
with the owners of cancer-afflicted pets at TBVS, I prefer to
schedule a 1 hour appointment to thoroughly discuss the
diagnosis, medical-surgical or radiation treatment options
available, the anticipated response to treatment (cure vs.
palliative), expected average remission and survival times and
associated treatment and follow up medical costs. After this
discussion we want the owners to decide whether treatment is
the right thing to do in their individual circumstance. If
treatment is desired we will provide the necessary medical
(chemotherapy) and surgical therapies. If radiation is
recommended then we can refer the patient to one of several
radiation centers to complete this portion of their
therapy.
Cancer has become all too common in our lives.
We are committed to providing as much comfort to both patient
and owner during this unfortunate time. Your clients may
desire a complete discussion of cancer management for their
pet before deciding on whether to pursue treatment. Please
feel free to have them schedule and discuss the options with
us.
