Therapie der Mitralklappenendokardiose beim Hund – ein Update

Zusammenfassung

Anhand von Anamnese, Signalement, Auskultations- und Röntgenbefund lässt sich bei Hunden die Verdachtsdiagnose der Mitralklappenendokardiose stellen. Die definitive Diagnosestellung und die genaue Bestimmung des Schweregrades erfordern jedoch eine radiologische Größenbeurteilung des Herzens und eine echokardiographische Evaluierung. Mithilfe der Anzeichen der Volumenbelastung kann so zwischen den Stadien B1 und B2 unterschieden werden. Im Stadium A und B1 bedarf es keiner Therapie, eine halbjährliche bis jährliche kardiologische Kontrolle sollte vorgenommen werden, um die Progression der Erkrankung zu beurteilen. Hinsichtlich der Behandlung im Stadium B2 bestand 2009 noch kein Konsens, doch ist heutzutage aufgrund der EPIC-Studie bei diesen Patienten die lebensverlängernde Wirkung von Pimobendan bewiesen. Nach den Resultaten überwiegend experimenteller Studien, in denen sich bei Gabe eines Hemmers des Angiotensin-konvertierenden Enzyms (ACE-H) ein Aldosteron-Escape-Mechanismus ergab, könnte die Hemmung des Renin-Angiotensin-Aldosteron-Systems durch Kombination von ACE-H und Spironolacton ebenfalls schon im Stadium B2 ein vielversprechender Therapieansatz sein. Für eine endgültige Entscheidung bleibt jedoch die DELAY-Stu die abzuwarten. Bei Hunden im akut lebensbedrohlichen dekompensierten Stadium C3 muss zunächst eine Stabilisierung mittels Steigerung der Diurese, positiv inotropen Medikamenten (Pimobendan) und Sauerstoffsubstitution erfolgen. Eine kontinuierliche Kontrolle der wichtigsten Vitalparameter ist durchzuführen. Anhand dieser Befunde wird die Therapie, insbesondere die Dosierung des Diuretikums, angepasst. Daher ist diese Behandlung nur unter intensivme dizinischer Betreuung möglich. Zur Therapie im chronischen Stadium C 1/2 wird das Vierfach-Therapieprotokoll bestehend aus Furosemid, Pimobendan, ACE-H und Spironolacton angeraten. Das Schleifendiuretikum Torasemid stellt dabei eine Alternative zu Furosemid dar. Hunde im Stadium D (trotz medikamentöser Therapie weiterhin refraktäres Herzversagen) sind schwierig zu stabilisieren und haben eine schlechte Prognose. Zur Stabilisierung finden üblicherweise Methoden Anwendung, die bislang nicht evidenzbasiert untersucht wurden.

Summary

Based on history, signalment, auscultation and radiographic examination, the suspected diagnosis of mitral valve endocardiosis can be made in dogs. However, radiological and echocardiographic examinations are necessary for the final diagnosis and can be used to differentiate between stages B1 and B2 through the signs of volume loading. In stages A and B1, no further treatment is required, a 6-month to annual cardiac check should be performed to assess the disease progression. For treatment in the B2 stage, there was no consensus in 2009. However, because of the EPIC study, the life-prolonging effect of pimobendan in dogs in stage B2 has now been demonstrated. According to multiple studies describing an aldosterone escape mechanism when using an angiotensin-converting-enzyme inhibitor (ACE inhibitor), the inhibition of the renin-angiotensin-aldosterone system by a combination of ACE inhibitor and spironolactone appears to be a promising therapeutic strategy in the B2 stage. However, for a final decision, the results of the DELAY Study should be awaited. In dogs with acute decompensation (stage C3), stabilization is required by increasing diuresis, positive inotropic drugs (pimobendan) and oxygen substitution. Continuous monitoring of the most important vital parameters, including capillary refill time, heart rate and rhythm, pulse rate and intensity, respiratory rate and type and neurological status, should be performed. Based on these results, the therapy should be adapted, above all the dosage of the diuretic drug. Therefore, this treatment strategy is only possible under intensive medical care. The quadruple therapeutic protocol consisting of furosemide, pimobendan, ACE inhibitor and spironolactone is recommended for therapy in the chronic stage C 1/2. The diuretic torasemide is a promising alternative to furosemide. Dogs in stage D (refractory cardiac failure despite treatment) are difficult to stabilize and have a poor prognosis. Methods, which have to date not undergone evidence-based evaluation, are normally used for stabilization.

Schlüsselwörter

Herzinsuffizienz - Behandlung - Graduierung - Therapie

Keywords

Heart failure - treatment - grading - therapy

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