Medical Management of Congestive Heart Failure in General Practice

ArticleNovember 20234 min readSponsored
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Sponsored by Ceva Animal Health, LLC

Myxomatous mitral valve disease (MMVD) is the most commonly diagnosed cardiac condition in dogs.1 This chronic, progressive disease ultimately leads to congestive heart failure (CHF) in as many as 30% of cases,1 requiring proactive treatment approaches.

Although referral to a cardiologist can offer benefits in the management of MMVD that has progressed to CHF, referral is not always an option. Limited specialist availability and client financial constraints may require general practitioners to manage these cases without specialist assistance. Given the prevalence of MMVD and the frequency with which it progresses to CHF, all general practice veterinarians should have a working knowledge of how to manage this condition in practice.

Management of Congestive Heart Failure Caused by Myxomatous Mitral Valve Disease

In 2019, the American College of Veterinary Internal Medicine (ACVIM) released consensus guidelines for the diagnosis and treatment of MMVD.2 These guidelines recommend specific treatments for patients at each stage of MMVD, ranging from stage A (dogs that are predisposed to MMVD, with no identifiable signs of disease) to stage D (dogs with end-stage, refractory CHF associated with MMVD).

The ACVIM guidelines call for all dogs with stage C MMVD, which refers to dogs with any current or former indicators of CHF, to be treated with a combination of 4 medications: pimobendan, furosemide, an ACE inhibitor (enalapril or benazepril), and spironolactone.2 Pimobendan, furosemide, and an ACE inhibitor have long been mainstays of CHF management, and their benefits are well-outlined. However, the 2019 ACVIM guidelines recommend the addition of spironolactone at a dose of 2 mg/kg PO q12-24h.2

Although ACE inhibitors are intended to block aldosterone production, the reality is that some aldosterone is produced outside of the renin-angiotensin-aldosterone system (RAAS).3 Aldosterone can lead to both cardiac fibrosis and sympathetic nervous system activation.3 Spironolactone directly inhibits the effects of aldosterone; therefore, a combination of an ACE inhibitor and spironolactone is more effective than an ACE inhibitor alone in minimizing the effects of aldosterone.

CARDALIS™: A Unique Combination

CARDALIS™ (spironolactone and benazepril hydrochloride chewable tablets) is a once-daily chewable tablet that contains both spironolactone and benazepril hydrochloride. This tablet fulfills half the requirements of quadruple therapy, as recommended by the ACVIM, for the treatment of MMVD-associated CHF.

In a 2021 study of 569 dogs with CHF due to MMVD that compared CARDALIS™ plus furosemide against benazepril plus furosemide, CARDALIS™ demonstrated greater efficacy (fewer cardiac deaths, treatment failures, and signs of CHF) than benazepril alone.4

Combining 2 necessary medications into a single chewable tablet can aid in client compliance, which is a recognized problem in the management of cardiovascular disease.5 CARDALIS™ simplifies therapy, allowing patients to receive the recommended treatment with fewer daily medications. CARDALIS™ is also highly palatable; in a field study of 233 dogs dosed daily for 14 days, CARDALIS™ was accepted voluntarily (with or without food) in 87.6% of doses.6 The combination of 2 required medications in a highly palatable chewable tablet can help decrease stress associated with medication administration for both clients and patients.


Using CARDALIS™ in the treatment of CHF associated with MMVD is not only associated with improved patient outcomes, but it can also simplify treatment. Combining benazepril and spironolactone, 2 medications required for the treatment of MMVD-associated CHF, in a single, palatable chewable tablet can make treatment easier and less stressful for both clients and patients.


Do not administer in conjunction with non-steroidal anti-inflammatory drugs (NSAIDs) in dogs with renal insufficiency. Do not use in dogs with hypoadrenocorticism (Addison's disease), hyperkalemia or hyponatremia. Do not use in dogs with known hypersensitivity to ACE inhibitors or spironolactone. The safety and effectiveness of concurrent therapy of Cardalis™ with pimobendan has not been evaluated. The safety of Cardalis™ has not been evaluated in pregnant, lactating, breeding, or growing dogs. Cardalis™ administration should begin after pulmonary edema is stabilized. Regular monitoring of renal function and serum potassium levels is recommended. Common side effects from a field study include anorexia, vomiting, lethargy, diarrhea and renal insufficiency.

CARDALIS™ and the CARDALIS™ logo trademarks are the property of Ceva Santè Animale S.A.

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