CASE STUDY. Bayleigh s Heart Disease. Written by Mark Stephenson, DVM Case Managed & Co-Written by Sonya Gordon, DVM, DVSc, DACVIM-CA

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1 CASE STUDY Bayleigh s Heart Disease Written by Mark Stephenson, DVM Case Managed & Co-Written by Sonya Gordon, DVM, DVSc, DACVIM-CA

2 Patient Information PATIENT: Bayleigh PET OWNER: Ms. K. BREED: Irish Wolfhound (purebred) SEX: Female/Spayed DOB: July 17, 2012 (3 yo) PROBLEMS: Presumed Cardiomyopathy 1. Lone Atrial Fibrillation 2. Ventricular Tachycardia FIRST DAY USING VOYCE : May 30, 2015 VETERINARIAN: Sonya Gordon, DVM, DVSC, Diplomate ACVIM (Cardiology) History Bayleigh was referred to the Texas A&M cardiology service on Nov 4, 2014 for consultation because an irregular rhythm was detected while she was being evaluated prior to surgery (to remove a foreign body, a large rag, from her stomach). Diagnostic tests including an echocardiogram and electrocardiogram were performed, resulting in a diagnosis of atrial fibrillation with normal left ventricular and atrial size and normal left ventricular function (lone atrial fibrillation) and mild/ early chronic valvular heart disease. Bayleigh was cleared for surgery, but instructed to return to the cardiology service for a recheck of her heart rate and possible treatment of her atrial fibrillation after she had recovered from surgery. Bayleigh returned for a recheck on Nov 24, According to the owner, Ms. K., she was doing great. It was noted that she was nervous in the hospital, and thus to better determine what her heart rate was on average and to know if she required medication, a Holter (24 hour ECG) was ordered. The Holter demonstrated that her average heart rate was approximately 120 BPM (too high for her) and she also had unexpectedly significant (life threatening) ventricular arrhythmias. Additional diagnostic tests to try and identify a cause for the ventricular arrhythmias such as myocarditis did not identify any specific etiologies. Initial therapy to slow the relatively fast atrial fibrillation rate and reduce the frequency and severity of ventricular arrhythmias was sotalol at 1.6 mg/kg (120 mg BID, Bayleigh weighs 73 kg). A recheck Holter to assess the therapy was done Dec 30, 2014 and demonstrated adequate rate (mean HR 90 BPM) control but poor control of the ventricular arrhythmias. An additional medication (mexilitine) was recommended to add on to the sotalol but was declined for financial reasons, therefore the sotalol was increased to 2.2 mg/kg. At this time the owner was also reminded of the risks for Bayleigh (e.g. sudden death). Bayleigh was then invited to take part in a Texas A&M Voyce trial. Bayleigh was one of the first 5 clinical cases in which Dr. Gordon selected to utilize Voyce at Texas A&M. Dr. Gordon felt she was a good candidate because follow-up was becoming cost prohibitive and Voyce could help her remotely monitor Bayleigh. Bayleigh started wearing Voyce June 1,

3 Case Management with Voyce Head Cardiology Technician, Kathy, and Dr. Gordon began to monitor Bayleigh s weekly trending data. After monitoring her Voyce parameters, in particular resting heart rate, it was easy to see the trends in her weekly resting heart rate and resting respiratory rate and thus not become overly concerned with a single daily reading that might be abbarant. In the first few weeks while wearing the Voyce Health Monitor, Bayleigh s average weekly heart rate went from 73 to 77 then 79. This was a little higher than what Dr. Gordon wanted to see. During the week of June 28, 2015, Bayleigh s overall weekly heart rate average increased from her overall average of 78 BPM (during the previous month) to 91 BPM. Kathy took action and notified Dr. Gordon, who noted that this was not only a significant increase week over week (17%), but there was a large spike one day in particular of 160 BPM. This sudden increase in combination with the trending increase in heart rate over the first three weeks was a significant finding for both Kathy and Dr. Gordon. In addition, these resting heart rates were higher than expected when compared to a dog with a similar clinical condition. Weekly Heart Rate average increased to 91 BPM with a large spike of 160 BPM on 7/1. Historical Heart Rate average had been 78 BPM, indicating a 17% increase. Voyce data gives me a better sense of where my heart failure patients are and it can help show me when I should see them for a recheck. Remote monitoring helps to make the experience of living with a dog with heart failure as easy as possible for an owner. - Sonya Gordon, DVM, DVSc, DACVIM-CA 3

4 All of these findings combined were enough evidence to contact the owner with Dr. Gordon s concerns and ask her to return for another Holter monitor. The Holter average heart rate was about 100 BPM (increased relative to the last Holter) and there were still severe lifethreatening ventricular arrhythmias. These results prompted the owners in consultation with Dr. Gordon to gradually discontinue the sotalol and initiate amiodarone. Voyce data helped Dr. Gordon convince the owner to return for a recheck Holter, which resulted in a change in medications. Results of Holter monitor, and changes in medication, were noted by Dr. Gordon in Bayleigh s Voyce data. Voyce weekly average heart rate after three weeks on the new treatment regime showed that Bayleigh s resting heart rate average was reduced to 75 BPM. Dr. Gordon repeated the Holter to confirm the reduced heart rate as well as an improvement in ventricular arrhythmias, resulting in good clinical outcome for Bayleigh. Voyce data shows a lower and more stable resting heart rate reflecting positive clinical outcome. 4

5 Discussion Bayleigh s case represents a relatively common dilemma in dogs with atrial fibrillation. The hallmark of management for atrial fibrillation is chronic rate control; however, it is difficult if not impossible to know what a dog s average heart rate is by listening to them in hospital. This situation requires Holter recordings which are expensive (and often declined) and still only provide one day of data. Voyce data can help look at trends in establishing, then maintaining control of resting heart rate over time. In addition, dogs with atrial fibrillation are at risk for congestive heart failure and thus monitoring resting respiratory rate chronically is also indicated. The need for remote heart rate monitoring is even more important when dogs are obviously anxious in the hospital setting. As a result of the data that Voyce offered Dr. Gordon, she and her head cardiology technician were able to see trends that allowed the veterinary team to recommend that Bayleigh return for a recheck earlier than she would have normally. Dr. Gordon and Kathy were better able to objectively understand the effect of treatment, and how to adjust medications and know that Bayleigh s heart rate was controlled. Voyce also provided Dr. Gordon with objective data to support conversations with the pet owner, helping her to understand and agree to the change in treatment. She was impressed with the correlation to the Holter and the role it played in client communication. Dr. Gordon says, Voyce gives me a better sense of where my patients are and it shows me when I absolutely have to see them. It has triggered more communication. It allows me to continue to be involved in the care of their pet without bothering them. Client Reports on Experience with Voyce Ms. K reports that Bayleigh has a great deal of energy, and they often go out walking first thing in the morning. While she used to let Bayleigh off leash in the morning to run, she feels that it is not a good idea to put that added stress on her heart so she no longer does so. Ms. K. enjoys using Voyce to check on how Bayleigh is doing. She reports that she and her husband have tried to take respiratory rates at home to monitor Bayleigh (before Voyce) but that with the Voyce Health Monitor, she no longer has to monitor respiratory rate, which is a relief. There have been a few times that the veterinary technician has called because Bayleigh s heart rate is elevated above average. Ms K. reports I think that Voyce has made us more aware. When the doctor has called because her heart rate is elevated, I think about any issue that may have caused that. Then I look more closely to see what is going on. I am trying to find any triggers for elevated heart rate and manage those triggers. Of increased contact with her veterinary hospital, Ms. K says: I am very impressed with the fact that they are calling. It makes me feel good that they would be able to catch something before it is a very serious episode, and we could address it. 5

6 Outcomes Dr. Gordon plans to continue the current treatment of Bayleigh s heart disease, and continue to support her patient through Voyce Pro data, in order to alert her to trends in resting heart and respiratory rates. Dr. Gordon and Kathy s experience with Bayleigh has given them an understanding of the importance of non-invasive remote vital sign monitoring, and they are excited to use Voyce Pro data in future cases to enhance their ability to detect serious changes in their patients cardiac condition earlier, and manage potential life-saving treatment more effectively. Dr. Gordon comments, Voyce allows me to prescribe the best surveillance without forcing my clients to do it themselves. It is a way to enhance quality of life because you can actually remove that day-to-day or moment-to-moment worry and the responsibility/burden on the client. I think the clients know that we are looking at their pet s data and they feel protected in a way. They know that we have their back. Closing Notes from Dr. Gordon For Bayleigh, we prescribed the Voyce Health Monitor and were able to see how she was doing. Based on the health data we were seeing, specifically her resting heart rate, her [initial] clinical management was not ideal. My technician alerted me to her high average heart rate and we brought her in for a recheck. This is one example of what Voyce Pro is able to do for us remain involved and intervene before a patient is presented to us in a decompensated state. A Holter monitor gives me one day of data, but with Voyce, I may only get one heart rate for the day but I get to see long term trends that are probably more reflective of the true average heart rate, allowing me to detect important changes in my patients over time. Voyce data gives me a better sense of where my heart failure patients are and it helps show me when I should see them for a recheck. Remote monitoring helps to make the experience of living with a dog with heart failure as easy as possible for an owner. For Bayleigh, we prescribed the Voyce Health Monitor and were able to see how she was doing. Based on the health data we were seeing, specifically her resting heart rate, her clinical management was not ideal. My technician alerted me to her high average heart rate and we brought her in for a recheck. This is one example of what Voyce Pro is able to do for us remain involved and intervene before a patient is presented to us in a decompensated state. - Sonya Gordon, DVM, DVSc, DACVIM-CA 6