Clinical Outcomes

Welcome to CareVet Clinical Outcomes

This is a network committed to advancing clinical understanding through real-world outcomes. We believe veterinarians hold unparalleled insight into what truly works in practice. Each week, we pose one focused clinical question to the veterinary community. On Mondays, we present the question. On Fridays, we share your responses—highlighting the treatments and protocols delivering the best outcomes. Together, we’re building a living library of frontline veterinary wisdom.

CLINICAL PERSPECTIVE

This Week’s Sticky Case

Patient

7-year-old Female Spayed Golden Retriever

Presenting Complaint

Progressive weight loss and intermittent diarrhea

History

Owner reports:

Soft stools for approximately 4 months
Episodes of diarrhea occurring every 1–2 weeks
Appetite remains excellent
Approximately 8-pound weight loss over the past 3 months
No vomiting
No travel history
Monthly heartworm/flea prevention current
Previously completed:
- Metronidazole trial
- Probiotic supplementation
- OTC sensitive stomach diet

Minimal improvement reported.

Physical Examination

Bright and alert
BCS 4/9
Mild muscle loss over epaxial muscles
Mildly thickened intestinal loops on abdominal palpation
No peripheral lymphadenopathy
Temperature: 101.8°F
HR: 90 bpm

Diagnostics

CBC

Mild mature lymphocytosis
Mild eosinophilia

Chemistry

Albumin: 2.2 g/dL (Low)
Globulin: Normal
Cholesterol: Low
ALT: Normal

Urinalysis

USG 1.032
No proteinuria

GI Panel

TLI: Normal
Folate: Low
Cobalamin: Low

Fecal

Negative

Provide Your Clinical Insight

Last Week’s Results

Responding DVMs overwhelmingly selected echocardiography as their next step in this case, highlighting the profession’s continued emphasis on definitive cardiac staging before initiating therapy. While specialists agree that echocardiography remains the gold standard for evaluating myxomatous mitral valve disease, many cardiologists would approach this case differently. Given the breed predisposition, characteristic murmur, and evidence of cardiac enlargement on thoracic radiographs, many specialists would feel there is sufficient evidence to begin pimobendan therapy while pursuing additional diagnostics as needed.

Responding DVMs were asked to identify their next step in the presented case. Over 57% of the responding DVMs selected treating the case by hospitalizing for IV fluids, analgesia, and supportive care. The specialists agree. Read more to learn why.

CLINICAL PERSPECTIVE

How would you handle the case?

A Murmur, Mild Cardiomegaly, and a Clinical Decision

Most cardiologists would agree that this dog almost certainly has myxomatous mitral valve disease (MMVD). The real question is not whether disease is present—but whether sufficient evidence exists to support intervention.

Historically, echocardiography was viewed as the definitive method for distinguishing Stage B1 from Stage B2 disease. However, over the last decade, veterinary cardiologists have invested significant effort in helping general practitioners identify clinically important cardiac enlargement using tools readily available in practice.

Specifically, radiographic measurements such as:

Vertebral Heart Size (VHS)
Vertebral Left Atrial Size (VLAS)

have become increasingly valuable in helping clinicians determine whether a patient has progressed beyond early-stage disease.

In a breed such as the Cavalier King Charles Spaniel—where MMVD prevalence is exceptionally high—a left apical systolic murmur combined with evidence of cardiac enlargement on thoracic radiographs substantially increases the likelihood that clinically relevant remodeling is already occurring.

For many specialists, this becomes less of a diagnostic question and more of a treatment-timing question.

Why Many Cardiologists Would Start Pimobendan

The EPIC trial fundamentally changed how veterinarians think about preclinical mitral valve disease.

The study demonstrated that dogs with evidence of cardiac enlargement secondary to MMVD experienced a significant delay in the onset of congestive heart failure when treated with pimobendan.

As a result, modern cardiology focuses heavily on identifying dogs that have entered Stage B2 disease before heart failure develops.

In referral settings, echocardiography remains the ideal method for confirming staging. However, in everyday clinical practice, many cardiologists acknowledge that high-quality thoracic radiographs and breed-specific measurements can provide enough information to make informed treatment decisions.

This is particularly true when:

The breed is predisposed to MMVD
A characteristic murmur is present
Radiographic enlargement is already documented
Clinical signs of heart failure remain absent

In these cases, delaying treatment solely to obtain an echocardiogram may not always be necessary.

Where Echocardiography Still Fits

From an internal medicine perspective, the most appropriate next recommendation is:

Hospitalize for IV fluids, analgesia, and supportive care

The reason is simple: this dog is already demonstrating evidence of clinically significant disease.

While the laboratory abnormalities are relatively mild, the patient has multiple indicators suggesting systemic involvement:

Persistent vomiting
Decreased appetite
Mild dehydration
Cranial abdominal pain
Inflammatory leukogram
Positive pancreatic lipase screening test
Breed-associated hyperlipidemia

The combination of these findings suggests a patient that is unlikely to benefit from dietary management alone during the acute phase.

Why Not Simply Monitor?

Monitoring alone may be appropriate for dogs with murmurs but no evidence of cardiac remodeling.

This patient is different.

The combination of:

Breed predisposition
Characteristic murmur
Mild radiographic enlargement

suggests progression beyond the earliest stages of disease.

The concern is not that the dog is currently in heart failure.

The concern is missing the window where intervention has been shown to improve long-term outcomes.

Specialist Takeaway

While echocardiography remains the gold standard for cardiac staging, many contemporary cardiologists would view this case as having sufficient evidence of preclinical MMVD with cardiac remodeling to justify treatment.

For that reason, many specialists would recommend: Start Pimobendan

The broader lesson is that advances in radiographic measurements such as VHS and VLAS have empowered general practitioners to make more informed cardiac treatment decisions without always requiring referral-level imaging.

In this case, the goal is not simply to diagnose heart disease—it is to intervene during the period where therapy has the greatest opportunity to alter the course of disease and improve outcomes.