ACVIM CONSENSUS GUIDELINES

FOR THE DIAGNOSIS AND TREATMENT

OF MYXOMATOUS MITRAL VALVE
DISEASE IN DOGS
 Background
This report, issued by the ACVIM
Specialty of Cardiology consensus panel,
revises guidelines for the diagnosis and
treatment of myxomatous mitral valve
disease (MMVD), also known as
endocardiosis and degenerative or
chronic valvular heart disease, in dogs.
In 2009, the consensus panel
adapted a staging system for According to this approach,
heart disease and heart failure, patients are expected to
MMVD is the most common heart and sought to link clinical signs advance from one stage to
the next stage.
disease of dogs in many parts of the to appropriate treatments at
world, accounting for approximately each stage.2
75% of heart disease cases seen in
dogs by veterinary practices in North
America. It is estimated that
approximately 10% of dogs This new staging system for MMVD, updated in 2019,
presented to primary care veterinary describes 4 basic stages of heart disease and heart failure
practices have heart disease.

Identifies dogs at high risk for developing heart disease

The panel adopted the following scheme,
adapted from the American Heart
Association, to rate the strength of the
recommendations in these guidelines.
STAGE A (predisposed breeds)
The panel chose to use a hybrid of the
American Heart Association and Veterinary
Emergency Critical Care RECOVER
evidence grading criteria, as outlined below: STAGE B Identifies dogs with structural heart disease

Classes of Recommendations Levels of Evidence (LOE)

Describes asymptomatic dogs that have no radiographic
B1 or echocardiographic evidence of cardiac remodeling in
The highest level of evidence
Class I BENEFIT>>>RISK based on high quality studies
response to their MMVD
STRONG generating a clear and
statistically valid result.
Refers to asymptomatic dogs that have more advanced mitral
Class IIA BENEFIT>>RISK This level of evidence is valve regurgitation that meet clinical trial criteria used to
MODERATE based on well-designed, B2
controlled studies for identify dogs that clearly should benefit from initiating
interpretation by the reader. treatment to delay the onset of heart failure
Class IIB BENEFIT>RISK
Based on quality studies
WEAK which leave room for
observation and discussion. STAGE C Denotes dogs with either current or past clinical signs
Class III BENEFIT=RISK of heart failure caused by MMVD
Considered the weakest
EXPERT OPINION LOE based on experience
Class IV RISK>>BENEFIT of the panel.
Refers to dogs with end-stage MMVD, in which clinical
STAGE D signs of heart failure are refractory to standard treatment
In 2009, the consensus panel adapted a staging system for heart disease and heart failure.
Then, in 2019, the consensus guidelines were updated to reflect an expanded staging scheme,
linking clinical signs to appropriate treatments based on risk and level of evidence.
 GUIDELINES FOR DIAGNOSIS AND TREATMENT OF MMVD
Describes asymptomatic dogs that have no radiographic or echocardiographic
STAGE A Identifies dogs at high risk for developing heart disease (predisposed breeds) STAGE B1 evidence of cardiac remodeling in response to their MMVD

Small breed dogs, including breeds with known predisposition LOE: EXPERT Treatment is not recommended in these dogs because at this early LOE: EXPERT
CLASS 1 RECOMMENDATIONS stage of disease, progression to heart failure is uncertain. CLASS 1
RECOMMENDATIONS to develop MMVD should undergo regular evaluations. OPINION OPINION
FOR DIAGNOSES No drug or dietary treatment.
FOR DIAGNOSES
AND MONITORING
Owners of breeding dogs or those at high risk may choose to LOE: EXPERT Reevaluation by echocardiography is suggested (or radiography if LOE: EXPERT
participate in approved screening events. CLASS 1 echocardiography is unavailable) in 6-12 months. CLASS 1
OPINION OPINION

If evidence of a murmur or mitral regurgitation (MR) is identified, LOE: EXPERT Asymptomatic MMVD causing MR severe enough to result in cardiac
RECOMMENDATIONS dogs should no longer be bred. CLASS 1
OPINION
STAGE B2 remodeling, dogs in this category should meet the following criteria:
FOR TREATMENT

+
• Murmur intensity >3/6
No drug treatment. LOE: EXPERT • Echocardiographic LA : Ao ratio in the right-sided short axis view
CLASS 1 RECOMMENDATIONS
No dietary treatment. OPINION in early diastole >1.6
FOR DIAGNOSES
• Left ventricular internal diameter in diastole, normalized for body
weight (LVIDDN) >1.7
LOE:
STAGE B Identifies dogs with structural heart disease • Breed-adjusted radiographic vertebral heart score (VHS) >10.5 CLASS 1 STRONG
If only radiographic examination is possible, cardiomegaly may be
Short axis basilar views and recently described 2-dimensional, diagnosed in cases where the VHS ≥11.5 and the vertebral left atrial
long-axis echocardiographic ratios have proven to be effective LOE: size (VLAS) ≥3.01,2. If radiographic cardiomegaly does not meet
RECOMMENDATIONS for identifying left atrial and ventricular enlargement in dogs CLASS 1 STRONG both of these criteria, an echocardiogram should be performed
FOR DIAGNOSES with MMVD. prior to the initiation of therapy.

Echocardiography is to identify the cause of the murmur, answer

specific questions regarding the severity of cardiac chamber CLASS 1 LOE: LOE:
MODERATE VLAS values of >3 likely identify Stage B2 MMVD. CLASS 1
enlargement, and identify comorbidities. MODERATE

Because of marked variation in thoracic conformation, in addition

LOE: LOE:
to using a vertebral heartscore, the use of the vertebral left atrial CLASS 1 Pimobendan at a dosage of 0.25-0.3 mg/kg PO q12h. CLASS 1
size (VLAS) may be beneficial. MODERATE RECOMMENDATIONS STRONG
FOR TREATMENT

+
Having baseline radiographs at a time when the dog is
asymptomatic can enhance the ability to differentiate cardiac LOE: EXPERT Surgical intervention in advanced Stage B2 is possible and LOE:
CLASS 1 CLASS IIA
from noncardiac causes of cough. OPINION recommended by some panelists. MODERATE

Thoracic radiography in all patients at a time when the patient LOE: EXPERT
is asymptomatic for MMVD. CLASS 1 LOE:
OPINION Dietary treatment. CLASS IIA
WEAK

LOE: EXPERT
Blood pressure measurement. CLASS 1
OPINION
For patients in stage B2 on either initial examination, 5 (of 10) LOE:
panelists recommend treatment with ACEI. CLASS IIA
WEAK
 Denotes dogs with either current or past clinical signs Refers to dogs with end-stage MMVD, in which clinical signs
STAGE C of heart failure caused by MMVD. STAGE D of heart failure are refractory to standard treatment

LOE:
Analyze serum NT-proBNP concentration. CLASS 1 CHF involves the same diagnostic steps outlined for Stage C plus the finding of failure to respond to
RECOMMENDATIONS MODERATE RECOMMENDATIONS treatments outlined in the Stage C guidelines.
FOR DIAGNOSES FOR DIAGNOSES Chronic PO furosemide dosages > -8 mg/kg q24h in any dosing regimen to maintain patient comfort
Most symptomatic dogs with MMVD are middle-aged or older, LOE: EXPERT in the face of appropriate dosages of pimobendan, an ACEI, and spironolactone indicate disease
and it is prudent to complete the clinical database. CLASS 1 progression to Stage D.
OPINION

Complete clinical database (including thoracic radiographs LOE: EXPERT RECOMMENDATIONS HOSPITAL-
and ideally echocardiogram). CLASS 1
OPINION Pimobendan dosage may be increased
FOR TREATMENT BASED LOE: EXPERT
(off-label use) to include a third 0.3 mg/kg CLASS IIA

+
daily PO dose. OPINION
Pimobendan, 0.25-0.3 mg/kg administered LOE:
CLASS 1
PO q12h. WEAK
RECOMMENDATIONS HOSPITAL-
FOR TREATMENT BASED LOE: Torsemide, a potent and longer-acting loop
ACEI (0.5 mg/kg PO q12h). CLASS IIB LOE:

+
WEAK diuretic, may be used to treat dogs no longer CLASS 1
CHRONIC adequately responsive to furosemide. MODERATE
Furosemide 2 mg/kg IV (or IM) followed by 2 (HOME-BASED)
mg/kg IV (or IM) hourly until patient’s
LOE: EXPERT
CLASS I
respiratory signs are substantially improved. OPINION Furosemide (or torsemide) dosage should
be increased as needed to decrease the LOE: EXPERT
CLASS IIA
accumulation of pulmonary edema or body OPINION
Oxygen supplementation, if needed, LOE: EXPERT cavity effusions.
can be administered.
CLASS I
OPINION

Furosemide CRI (0.66-1 mg/kg/hour) for LOE: Pimobendan dosage is increased by some LOE: EXPERT
CLASS IIA CLASS IIA
life-threatening pulmonary edema. WEAK panelists to include a third 0.3 mg/kg daily dose. OPINION

Torasemide at approximately 5% to 10% of the LOE:

furosemide dosage (0.1-0.3 mg/kg q24h7). CLASS 1 Beta blockers generally should not be initiated LOE: EXPERT
MODERATE CLASS IV
at this stage. OPINION
Continue pimobendan, LOE:
0.25-0.3 mg/kg PO q12h.
CLASS I
STRONG Dietary requirements:
CHRONIC
(HOME-BASED) All of the dietary considerations for Stage C (above) apply.
LOE:
Continue PO furosemide (2mg/kg q12h). CLASS I
MODERATE

Spironolactone (2.0 mg/kg PO q12 - 24 h). LOE:

CLASS I
MODERATE

Diltiazem (often combined with digoxin) in LOE:

CLASS I
cases of complicated atrial fibrillation. MODERATE

Dietary recommendations:
- Ensure adequate protein intake LOE:
CLASS I
- Modestly restrict sodium intake MODERATE
- Omega-3-fatty acids

In centers with low complication rates, patients LOE:

benefit from surgical intervention to repair their CLASS I
MODERATE
mitral valve apparatus.

LOE:
Continue or start ACEI (0.5 mg/kg PO q12h). CLASS IIB WEAK

None of the panelists routinely use LOE: EXPERT

nitroglycerin. CLASS III
OPINION
1
Keene BW, et al. ACVIM consensus guidelines for the diagnosis and treatment of myxomatous
mitral valve disease in dogs. J Vet Intern Med. 2019 May;33(3):1127-1140.
2
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(6):1142–1150.

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