MMVD stage C: treatment per the ACVIM consensus
9-year-old Cavalier King Charles with stage B2 MMVD, treated with pimobendan. It now has 52 breaths/min at rest and a cough, and radiographs confirm pulmonary oedema. The image is its colour Doppler echocardiogram.
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According to the 2019 ACVIM consensus, what is the recommended chronic home treatment for this stage?
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A. Only increase the pimobendan dose
With pulmonary oedema the dog is in stage C: it needs a diuretic. Pimobendan alone does not control congestion.
B. Antitussives (butorphanol) to control the cough
The cough is due to oedema and bronchial compression by the enlarged left atrium. Antitussives only mask the problem.
C. Furosemide + pimobendan + ACE inhibitor (enalapril or benazepril) + spironolactone
Correct. This is the chronic treatment for stage C. The image shows the mitral regurgitation (a turbulent jet into the left atrium) responsible for the volume overload.
D. Stop pimobendan and leave only an ACE inhibitor
Pimobendan improves survival in stage C (QUEST study) and should be continued; an ACE inhibitor alone does not control oedema.
lightbulb Key takeaway
Teach the owner to count the resting or sleeping respiratory rate: if it stays above 30 breaths/min, they should call. Check renal function and electrolytes 3–7 days after starting or adjusting the diuretic. In refractory stage D, switching to torasemide is an option.
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Updated: October 31, 2026 · Educational content for veterinary professionals. It does not replace current clinical guidelines or the judgement of the attending veterinarian.