Submitted:
27 January 2026
Posted:
28 January 2026
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Abstract
Myxomatous mitral valve disease (MMVD) is the most common acquired cardiac disease and a leading cause of congestive heart failure in dogs. Over the past three decades, experimental studies and clinical trials have established an expanding evidence base supporting pharmacologic interventions, particularly drugs that modulate hemodynamics or target the renin-angiotensin-aldosterone system (RAAS). At the same time, gaps remain in our knowledge, and several areas of clinical practice are guided more by expert consensus or extrapolation from human cardiology than by robust veterinary data. This review summarizes current evidence for pharmacologic interventions in MMVD, including established therapies such as ACE inhibitors, mineralocorticoid receptor antagonists, diuretics, and inodilators, as well as emerging drug classes such as angiotensin receptor-neprilysin inhibitors and SGLT-2 inhibitors. For each therapeutic class, we assess the strength of the available evidence, discuss methodological limitations of existing studies, and identify key gaps where additional research is needed to inform optimal clinical use.
Keywords:
canine MMVD
; heart failure
; therapy
Introduction
Mitral regurgitation (MR) is a defining hemodynamic lesion of canine myxomatous mitral valve disease (MMVD), resulting from progressive valvular degeneration and incomplete leaflet coaptation. Persistent MR causes chronic volume overload in the left atrium and left ventricle, leading to compensatory cardiac remodeling. MMVD is the most common acquired cardiac disease in dogs and a leading cause of congestive heart failure (CHF) in small-animal practice. The goal of this review is to provide an evidence-based overview of medical therapy for canine MMVD. Specifically, we summarize the mechanistic pathways that drive disease progression, with an emphasis on neurohormonal activation as a rationale for multimodal renin-angiotensin-aldosterone system (RAAS) blockade, discussing relevant mechanistic insights from the human literature on vascular inflammation and remodeling. We then review the clinical trial evidence supporting established therapies for canine MMVD, and conclude by discussing emerging and adjunct drug classes with early translational or pilot canine data.
Renin-Angiotensin Aldosterone System Modulation
Biology of the Renin-Angiotensin Aldosterone System in Mitral Regurgitation
Canine MMVD causes MR, leading to chronic volume overload and neurohormonal activation. Among the neurohormonal pathways involved in MMVD pathophysiology, the RAAS plays a critical role in maladaptive remodeling and fluid retention. While there is limited information on treatment-independent RAAS activation in dogs with congestive heart failure (CHF), several trials have demonstrated clinical benefits of RAAS modulation with angiotensin converting enzyme inhibitors (ACEIs) and mineralocorticoid receptor antagonists (MRAs) in dogs with CHF [1,2,3,4,5,6]. In addition, findings from a recent retrospective study suggest that higher doses of ACEIs are associated with improved survival in dogs at the initial onset of CHF [7].
Chronic activation of the classical arm of the RAAS (Ang II/aldosterone) results in vasoconstriction, sodium and water retention, sympathetic activation, endothelial dysfunction, and fibrotic remodeling, among others. These effects provide the rationale for introducing RAAS-modulating therapies, including ACEIs and MRAs, in the management of canine CHF [3,8,9,10]. Beyond attenuating the Ang II/aldosterone axis, RAAS-modulating therapy may also shift signaling toward the counter-regulatory (alternative) arm of the RAAS. This axis centers on the angiotensin-converting enzyme 2 (ACE2), which converts angiotensin II (Ang II) to angiotensin (1-7) (Ang(1-7)). Via the Mas receptor, Ang(1-7) counterbalances angiotensin II type 1 receptor (AT1R) signaling, promoting vasodilation and natriuresis while limiting inflammation, oxidative stress, and fibrosis [11,12,13]. Accumulating evidence suggests that RAAS modulators do not only suppress the classical Ang II/aldosterone axis but also activate the counter-regulatory ACE2-Ang(1-7)-Mas pathway [14,15,16,17,18].
The RAAS is a highly complex machinery that comprises circulating and tissue compartments. In the myocardium, kidney, vasculature, and adrenal glands, ACE-independent pathways (e.g., chymase, cathepsins) generate Ang II, contributing to a mechanism known as ACE-inhibitor escape [19,20]. In this context, aldosterone breakthrough, defined as a rebound or increase in aldosterone concentrations despite ACEI or angiotensin II receptor blockade (ARB) therapy, has been shown in experimental models and in cases of naturally occurring MMVD [17,21,22,23,24,25]. Proposed drivers of aldosterone breakthrough include incomplete ACE suppression, activation of non-ACE pathways, hyperkalemia-mediated aldosterone stimulation, and increased adrenal sensitivity to Ang II. This feature supports the rationale for combination RAAS therapy rather than monotherapy in the treatment of canine MMVD [6].
Diurnal oscillations in renin-angiotensin-aldosterone biomarkers add a time dimension to RAAS regulation, complicating, but also informing, the optimal treatment time with RAAS modulators. RAAS peptides, blood pressure, and urinary electrolytes fluctuate with a circadian periodicity and are strongly influenced by food intake in dogs [26,27,28]. The timing of drug dosing and biomarker sampling, therefore, can meaningfully impact the measured magnitude of drug effects, representing an often-overlooked source of between-subject variability in veterinary clinical trials. This time dependence implies that pharmacodynamic (PD) effects vary across the 24-hour cycle and that suboptimal scheduling can leave “troughs” of incomplete RAAS suppression, particularly in the early morning when renin activity tends to rise [28]. Incorporating principles of chronobiology into therapeutic planning may therefore offer an opportunity to improve drug efficacy, consistent with the basic tenets of chronotherapy [29,30,31].
Renin-Angiotensin Aldosterone System Activation, Vascular Inflammation and Remodeling: Lessons from Experimental Models and Human Studies
In human cardiovascular disease, chronic excessive activation of the RAAS plays a pivotal role in vascular inflammation and remodeling. The role of chronic inflammation in cardiac diseases was recently emphasized by the American Heart Association (AHA) Presidential Advisory, highlighting the interconnected nature of cardiovascular diseases, chronic kidney disease (CKD), type 2 diabetes (T2DM), and obesity [32]. In this framework, the Advisory introduced the concept of Cardiovascular-Kidney-Metabolic (CKM) health, underscoring the mutually reinforcing risks of these chronic diseases. Mechanistically, this clustering reflects shared common pathophysiological pathways, such as chronic inflammation, oxidative stress, and metabolic dysregulation, that accelerate disease progression and complicate therapeutic management overall [33]. Against this pathophysiological background, key findings from the literature highlight the contribution of RAAS activation to cardiovascular remodeling:
- Pro-inflammatory effects of angiotensin II. Ang II regulates cytokine and chemokine expression in the kidneys, vasculature, and heart, thereby promoting vascular inflammation and remodeling [34,35,36]. In experimental models, chronic infusion with Ang II increases blood pressure, induces myocardial infiltration of inflammatory cells, and promotes cardiac fibrosis [37].
RAAS modulators, including ACEIs and ARBs, have been shown to reduce circulating levels of pro-inflammatory markers, such as C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), and interleukins such as IL-6 and IL-1β [40,41,42]. They also attenuate oxidative stress by reducing reactive oxygen species (ROS) generation, thereby preserving endothelial function and limiting vascular damage [43]. These anti-inflammatory effects are primarily mediated by blocking Ang II-driven activation of key signaling pathways, notably nuclear factor kappa B (NF-κB) [44]. Clinically, these actions have been associated with reduced cardiovascular morbidity and mortality, especially in patients with chronic inflammatory conditions such as heart failure, hypertension, and kidney disease. Importantly, reduction in inflammatory markers has also been linked to improved outcomes in patients with metabolic syndrome and diabetes [45,46]. To date, there is no direct evidence that these anti-inflammatory and vasculoprotective effects of RAAS modulators translate to canine MMVD.
A systematic review and meta-analysis of 32 randomized controlled trials in human patients further supports these findings [47]. Across 3,489 human patients with cardiovascular, metabolic or inflammatory diseases, ACEIs significantly reduced inflammatory markers including CRP, IL-6, and TNF-α. Perindopril and ramipril showed marked reductions in IL-6, while enalapril decreased both TNF-α and CRP. Treatment with an ARB also reduced IL-6, but showed less consistent effects on other inflammatory markers, suggesting that ACEIs may confer more robust anti-inflammatory effects in this context.
Beyond ACEIs and ARBs, MRAs such as spironolactone also exhibit anti-inflammatory and anti-fibrotic effects. Mechanistically, the aldosterone-MR axis intersects with canonical inflammatory pathways. TNF-α is a proximal driver of inflammatory cascades via TNF receptor 1 (TNFR1) (cell death/inflammation) and TNF receptor 2 (TNFR2) (immune modulation/tissue repair), with downstream activation of NF-κB-dependent transcription of inflammatory genes (e.g., cytokines and adhesion molecules) [48]. Lipopolysaccharide (LPS) engagement of Toll-like receptor 4 (TLR4) likewise triggers NF-κB-mediated production of proinflammatory, antiviral, and antibacterial cytokines [49]. In human subjects at elevated risk of heart failure, spironolactone has been associated with greater reductions in biomarkers of collagen turnover, such as PICP (Pro-Collagen 1 C-Terminal Pro-Peptide). Across heart-failure syndromes, MRAs improve cardiac structure and function and are associated with better clinical outcomes, with the strongest evidence in heart failure (HF) with reduced ejection fraction, and emerging evidence in HF with preserved ejection fraction [50,51]. Reductions in circulating markers of collagen synthesis have been reported across multiple cardiovascular populations treated with MRA, consistent with their antifibrotic activity [52,53]. Mechanistically, in ex vivo human blood leukocytes, spironolactone suppresses transcription and secretion of proinflammatory cytokines, including TNF-α, lymphotoxin, interferon gamma (IFN-γ), granulocyte-macrophage colony-stimulating factor (GM-CSF), and IL-6. In macrophage models (RAW 264.7 cells and mouse peritoneal macrophages), it inhibits LPS-induced TNF-α and prostaglandin E2 (PGE2), consistent with attenuation of the IκB kinase (IKK)/NF-κB pathway [54,55]. Collectively, these findings support the view that MR antagonism complements broader RAAS modulation by engaging immunoinflammatory circuits relevant to myocardial and vascular remodeling. Our consortium is actively investigating the immunomodulatory effects of spironolactone and its active metabolites (canrenone, 7-α-thiomethyl-spironolactone) in canine peripheral immune cells and in adult stem cell-derived canine organoid models [56].
Taken together, these reports on ACEI, ARB and MRA underscore the broad anti-inflammatory and anti-fibrotic effects of RAAS modulation and its potential protective role across cardiovascular, renal and metabolic diseases. While these findings provide important mechanistic insights, there is currently no evidence that comparable effects exist in dogs with MMVD.
Angiotensin Converting Enzyme Inhibitors: Clinical Efficacy, Pharmacokinetics and Pharmacodynamics
Clinical Efficacy in Congestive Heart Failure (Stage C). Angiotensin converting enzyme inhibitors have been a mainstay of RAAS modulation in MMVD for decades. A series of trials published in the 1990s studied the effects of enalapril vs. placebo added to background management (furosemide +/- digoxin) in dogs with CHF secondary to MMVD or dilated cardiomyopathy (DCM); this review will focus on outcomes from the MMVD cohorts in these studies.
The first trial, COVE, followed 141 dogs with MMVD and CHF for 28 days and reported outcomes related to clinical signs and quality of life [1]. Enalapril was initially dosed at 0.5 mg/kg PO q24h, with option to increase dose to q12h based on clinician discretion; approximately 45% of dogs ultimately received twice-daily dosing of enalapril. Dogs with MMVD receiving enalapril demonstrated improvement in activity, mobility, total cough score, and overall clinician evaluation compared with placebo at Day 28. Adverse events were equivalent across enalapril and treatment group. The second trial, IMPROVE, included a separate group of 22 dogs with MMVD and CHF, and reported echocardiographic and invasive hemodynamic measurements after the first dose and after 21 days of dosing of either enalapril or placebo [2]. In this cohort, enalapril was dose consistently at 0.5 mg/kg PO q12h. Results of hemodynamic testing were combined between MMVD and DCM dogs in this study and showed that enalapril-treated dogs had greater decreases in pulmonary capillary wedge pressures, heart rate, and blood pressure compared to placebo in the first 24 hours after dosing. The final trial in this series, LIVE, followed long-term survival outcomes of 67 dogs with MMVD from either the COVE or IMPROVE cohorts [10]. Although the actual median dosage of enalapril was not reported in LIVE, based on dosing regimens for COVE and IMPROVE, dogs received enalapril 0.5 mg/kg PO with approximately half of dogs receiving twice-daily dosing. The primary outcome measure in LIVE was treatment failure, defined as death or euthanasia from CHF or worsening clinical signs. Time to treatment failure was significantly longer for the enalapril group (median of 160 days) compared to placebo (87 days).
In a separate trial involving benazepril instead of enalapril, BENCH enrolled 61 dogs with CHF secondary to MMVD [3]. Dogs received benazepril at a median dose of 0.33 mg/kg PO q24h or placebo, with a 34-week follow-up period. Benazepril was associated with longer time to the primary endpoint of death or withdrawal due to CHF (436 days in benazepril group vs. 151 days in placebo group), and also with higher scores for quality-of-life variables. Together, these studies establish benefits of ACEIs in terms of survival, hemodynamics, and quality of life when added to standard therapy for CHF secondary to MMVD.
A critique of these early clinical trials of ACEIs in CHF is the absence of pimobendan as part of background therapy, since the drug was not yet available at the time. Some investigators argue that the hemodynamic and survival benefits of pimobendan are sufficiently robust to render RAAS inhibition unnecessary. The VALVE study sought to address this question by comparing “dual therapy” (furosemide and pimobendan) with “triple therapy” (furosemide, pimobendan, and the ACEI ramipril) in dogs with MMVD and CHF [57]. The trial did not demonstrate a difference in outcomes between groups. However, several features of the study design limit interpretation [58]. Ramipril was administered at a low dose (0.21 mg/kg PO q24h) – the lowest ACEI dose evaluated in a veterinary clinical trial – whereas more recent pharmacokinetic and pharmacodynamic data suggest that an optimal dose is considerably higher (approximately 0.5 mg/kg PO q12h). The average furosemide dose was also unusually high (8 mg/kg/day), making it unsurprising that RAAS suppression with low-dose ramipril alone was inadequate and positive outcomes were not achieved. The high furosemide dose likely also increased the likelihood of aldosterone breakthrough, but spironolactone use was left to clinician discretion and prescribed in fewer than 10% of cases. Finally, over 25% of dogs in the “dual therapy” group had previously received ACEIs for an average of 9 months before enrollment, potentially conferring cardioprotective effects prior to randomization.
A recent retrospective study sought to extend the findings of VALVE by comparing outcomes of dogs receiving dual therapy (furosemide and pimobendan), triple therapy (furosemide, pimobendan and benazepril), or quadruple therapy (furosemide, pimobendan, benazepril and spironolactone) [59]. No differences in time to cardiac death were noted between treatment groups in this study. However, several aspects of study design limit applicability of this study, primarily the fact that drug selection was based on cardiologist preference and not randomized. Several variables differed between treatment groups at baseline, including echocardiographic LV size (higher in triple and quadruple therapy groups) and furosemide dose (higher in dual therapy group). Furthermore, the benazepril dose in the dual and triple therapy groups was low (0.3-0.36 mg/kg/day), limiting the potential benefit of ACEIs in these study groups.
Taken together, these limitations suggest that the neutral results of VALVE and this recent retrospective study are reflective of study design and dose selection rather than of true absence of benefit from ACEIs in CHF. In contrast, the weight of prior evidence supports favorable effects of ACEIs on survival, hemodynamics, and quality of life when appropriately dosed. Potential adverse effects of ACEIs include hypotension, azotemia, and electrolyte derangements, but these are rare even at the higher doses now recommended [7]. For this reason, ACEIs at a dose of 0.5 mg/kg PO q12h remain a recommended component of treatment for stage C MMVD in the ACVIM Consensus Guidelines [60].
Clinical Efficacy in Advanced Preclinical Myxomatous Mitral Valve Disease (Stage B2). Two prospective, placebo-controlled clinical trials have evaluated enalapril in dogs with advanced preclinical MMVD, with discordant results. The VETPROOF study enrolled 124 dogs of multiple breeds with MMVD and cardiomegaly, treated with enalapril at a mean dose of 0.46 mg/kg PO q24h [61]. The primary endpoint, delay in time to CHF, showed a modest prolongation of approximately 4 months compared to placebo, with a borderline P-value (895 vs. 778 days, P = 0.06). Secondary analyses, however, demonstrated significant benefits of enalapril, including a higher proportion of CHF-free dogs at 500 and 1500 days, and improved all-cause survival in a sub-study of 96 participants followed to death (unpublished data). Notably, the survival advantage in this sub-study (approximately 9 months) did not extend specifically to CHF-related mortality, perhaps reflecting ancillary benefits of ACE inhibition such as renal protection.
By contrast, the SVEP trial enrolled 229 Cavalier King Charles Spaniels, including both dogs with and without radiographic cardiomegaly, treated with once-daily enalapril at a lower mean dose (0.37 mg/kg PO q24h) [62]. In this population, enalapril had no effect on time to CHF (1150 vs. 1130 days for enalapril vs. placebo), regardless of baseline cardiac size. Given the longer median time to CHF in SVEP, this population overall appears to have had less advanced disease than in VETPROOF, and the single-breed design introduces unique considerations.
Several factors may explain the disparate outcomes of these two studies. VETPROOF enrolled a heterogeneous breed population, whereas SVEP was restricted to Cavalier King Charles Spaniels, a breed with a high prevalence of an ACE gene polymorphism associated with reduced ACE activity [63]. This genetic background may blunt the therapeutic effect of ACE inhibition, particularly in the absence of MRAs to block aldosterone escape. Differences in disease severity are also notable: SVEP included both B1 and B2 dogs, while VETPROOF enrolled only dogs with cardiomegaly, more closely reflecting the population at higher risk of progression to CHF. Finally, the lower enalapril dose in SVEP, along with the relatively conservative dosing in both studies, may have limited treatment efficacy. As discussed below, the early ACEI trials in veterinary medicine used doses that are now recognized as suboptimal based on pharmacokinetic, pharmacodynamic, and modeling studies.
A third large-scale study, the DELAY trial, also investigated ACEI in preclinical MMVD, but in combination with spironolactone rather than as a monotherapy [64]. DELAY was a randomized, placebo-controlled trial of benazepril (median dose 0.3 mg/kg PO q24h) plus spironolactone (median dose 2.8 mg/kg PO q24h) in 184 dogs with stage B2 MMVD. DELAY did not demonstrate benefit in its primary endpoint (onset of CHF or cardiac death), but several secondary endpoints favored active treatment, including reductions in echocardiographic measures of heart size and decreases in N-terminal pro–B-type natriuretic peptide (NT-proBNP). Because these measures are strongly associated with outcomes in MMVD, the discordance between neutral survival results and positive structural and biomarker changes is difficult to reconcile. Interpretation is also complicated by the low benazepril dose employed (median 0.3 mg/kg PO q24h, lower even than SVEP), raising concern that the ACEI component was subtherapeutic.
A shared limitation of all three trials is the absence of pimobendan, which was not available at the time and has since been shown to provide robust benefit in stage B2 MMVD. Debate therefore continues regarding the role of ACEIs in asymptomatic disease. The 2019 ACVIM Consensus Panel could not reach agreement, with 5 of 10 panelists recommending ACEIs in stage B2 [60]. Real-world prescribing data from the LOOK-Mitral study, which aggregates records from 13 North American cardiology specialty centers, similarly suggest that approximately 60% of clinicians routinely prescribe ACEIs for stage B2 MMVD [65].
Pharmacokinetics and Pharmacodynamics. In dogs, benazepril, enalapril, and ramipril are ester prodrugs rapidly hydrolyzed in the liver to their active diacid metabolites (benazeprilat, enalaprilat, ramiprilat) [66]. After oral dosing in healthy dogs, absorption is generally linear with dose-proportional pharmacokinetics. ACEI active metabolites are highly protein-bound (>90%) and distribute widely to vascular and tissue ACE sites, resulting in prolonged ACE inhibition despite an apparently short elimination half-life. Their high affinity for vascular and tissue ACE creates a large extravascular target compartment. When distribution and clearance are faster than the dissociation rate constant (that is, the rate at which the inhibitor unbinds from ACE), the terminal decline in plasma concentration is governed by unbinding and back-redistribution rather than classical clearance. As such, for the active diacids of ACEI, the apparent terminal half-life in plasma reflects slow dissociation from the tissue and endothelial ACE pool rather than elimination from the central compartment [67].
Benazeprilat exhibits mixed biliary and renal excretion in dogs (~54% biliary and 46% urinary) (Fortekor®: Summary of Product Characteristics. European Medicines Agency. Retrieved September 22, 2025: https://www.ema.europa.eu/en/medicines/veterinary/referrals/fortekor.), a profile that is considered advantageous when renal function is impaired. In contrast, enalaprilat is primarily excreted by the kidneys (>90% recovered in urine within 24 h in humans), making it more susceptible to accumulation with renal impairment. Ramiprilat is excreted via both bile and urine in dogs [68,69,70]. Captopril is an active, sulfhydryl-containing ACEI with rapid systemic clearance in dogs (~600 mL/kg/h) and a short effective half-life (~2-3h), typically necessitating twice- to thrice-daily dosing. It also has a comparatively higher propensity for gastrointestinal adverse effects [71,72]. Food has minimal effect on benazepril pharmacokinetics in dogs Fortekor®: Summary of Product Characteristics. European Medicines Agency. Retrieved September 22, 2025: https://www.ema.europa.eu/en/medicines/veterinary/referrals/fortekor.), while it reduces captopril bioavailability by ~30-40%. Accordingly, captopril is best given on an empty stomach [73].
Quantification of circulating RAAS activity in dogs historically relied on plasma ACE activity (ACEA) as a surrogate. However, measures of ACEA are heavily method-dependent (e.g., use of exogenous substrate, non-physiologic pH/temperature) and reflect catalytic activity rather than in vivo peptide concentrations. Importantly, as shown in multiple reports, plasma ACEA correlates poorly with Ang II and aldosterone, and may suggest “adequate” inhibition of the RAAS even when angiotensins profiling demonstrates residual RAAS activity [74,75,76]. The field of RAAS bioanalysis therefore shifted to immunoassays, most commonly plasma renin activity (PRA) and Ang II measured by radioimmunoassay (RIA) or enzyme-linked immunosorbent assay (ELISA), which brought analyses closer to biology but remained limited by technical issues such as cross-reactivity, matrix effects, and peptide lability [77]. The current bioanalytical standard relies on equilibrium liquid chromatography-tandem mass spectrometry (LC-MS/MS) to quantify a peptide panel consisting of Ang I, Ang II, Ang(1-7), Ang(1-5), and aldosterone, thereby generating a systems-level fingerprint that captures ACE-independent Ang II generation and feedback within the cascade [78]. In turn, these richer datasets support mechanism-informed models that better reflect the nonlinearity of the RAAS and the overall pharmacodynamic effects of ACEIs and other RAAS modulators [16].
The dose-exposure-response relationship of benazeprilat was recently investigated in healthy dogs using intensive pharmacokinetic sampling, RAAS fingerprinting, and model-based simulations [15,16]. In a 35-day, randomized, partial-crossover study, nine purpose-bred Beagles underwent RAAS activation induced by a low-sodium diet and received three benazepril dosing regimens: 0.125 mg/kg every 12 hours (q12h), 0.25 mg/kg q12h, and 0.5 mg/kg every 24 hours (q24h) [15]. Serial plasma samples collected over 24 hours enabled quantification of benazeprilat concentrations alongside a comprehensive RAAS peptide panel, measured via LC-MS/MS. The panel included Ang I, Ang II, Ang III/IV, Ang(1-7), and Ang(1-5), with secondary indices such as ACE suppression (ACE-S = Ang II/Ang I), plasma renin activity surrogate (PRA-S), aldosterone suppression (ALT-S), and the aldosterone-to-Ang II ratio (AA2). Benazeprilat exposure increased in a dose-dependent manner across the tested range. Overall, more frequent dosing (q12h) produced greater suppression of Ang II and ACE-S, with reciprocal increases in Ang I and PRA-S. At the highest dose, Ang(1-7) trended upward while Ang(1-5) declined, a pattern consistent with ACE inhibition and compensatory activation of the alternative RAAS arm. Hemodynamic variables, including arterial blood pressure, did not differ significantly between groups over the acute 12-hour observation windows. To our knowledge, no comprehensive peptide-based dose-response analyses analogous to the work of Sotillo and colleagues in 2023 have been published for enalapril, ramipril, or captopril in dogs [15]. Existing reports primarily rely on ACE activity and/or PRA, with limited measurements of angiotensins.
Building on these experimental findings, a nonlinear mixed-effects systems pharmacology model was developed to link benazeprilat exposure with dynamic changes in RAAS peptide over time, while accounting for diurnal oscillations of these biomarkers [16]. The model jointly fit benazeprilat PK with RAAS PD data to reproduce the temporal profiles of Ang I, Ang II, Ang III/IV, Ang(1-7), and Ang(1-5) across doses and dosing frequencies. In silico simulations were performed to compare dosing schedules at equivalent daily doses, confirming that twice-daily administration of benazepril (e.g., 0.25 mg/kg q12h) achieved more sustained Ang II suppression compared to once-daily dosing (e.g., 0.5 mg/kg q24h). Among the tested dosing scenarios, 0.5 mg/kg q12h provided the most robust inhibition of the classical RAAS pathway (Ang II and ACE-S), alongside favorable shifts in alternative-pathway markers (increased Ang(1-7) and decreased Ang(1-5)). This systems pharmacology framework has now been deployed as a user-facing virtual trial engine, enabling prospective exploration of dosing regimens, schedule optimization, population variability, and selection of PD readouts (https://benjaminpkpd.shinyapps.io/benazepril-dosage-calculator/). Moving forward, biomarker data collected from canine patients with MMVD are needed to refine this mathematical modeling platform and validate these preliminary findings in the context of clinical cardiac disease.
Mineralocorticoid Receptor Antagonists: Spironolactone and Aldosterone Breakthrough
Aldosterone Breakthrough. Aldosterone promotes myocardial and vascular fibrosis, impairs endothelial function, exacerbates electrolyte retention, and potentiates sympathetic and inflammatory signaling. MRAs counteract these effects at the receptor level through genomic and non-genomic mechanisms, providing therapeutic benefits that are complementary to ACEI. Because Ang II is a major contributor to aldosterone release, ACE inhibition alone would be expected to reduce aldosterone concentrations and mitigate its long-term deleterious effects. However, aldosterone levels may remain chronically elevated in some patients receiving ACEI or ARB therapy (alone or in combination). This phenomenon, known as “aldosterone breakthrough,” is well-characterized in humans and has also been reported in ACEI-treated dogs with experimental RAAS activation [21,79,80,81]. In a clinical study of 39 dogs with MMVD, approximately one third developed aldosterone breakthrough during ACEI therapy. The incidence was similar in dogs with advanced preclinical disease (stage B2) and those with stage C CHF [23]. Although the underlying mechanisms of aldosterone breakthrough remain poorly understood, it shows that single-agent RAAS blockade with an ACEI does not invariably suppress the negative effects of aldosterone.
Clinical Efficacy in Congestive Heart failure (Stage C).As an MRA, spironolactone mitigates the effects of aldosterone, thereby promoting natriuresis and reducing cardiac fibrosis. In humans, the RALES trial demonstrated a 31% reduction in risk of cardiac mortality for humans with late severe heart failure when spironolactone was added to a loop diuretic, ACEI, and digoxin [82]. Additional studies in humans including EPHESUS and EMPHASIS have shown similar benefits with addition of the MRA eplerenone to background treatment in CHF secondary to myocardial infarction [83,84]. In veterinary medicine, several studies have evaluated use of spironolactone in addition to conventional therapy in management of CHF secondary to MMVD in dogs.
The first study of spironolactone in clinical MMVD was a prospective randomized trial following dogs with MMVD that initially participated in one of two short-term studies: (1) a 2-month study with furosemide mandatory at inclusion, and (2) a 3-month study with furosemide not allowed at inclusion [5]. These study groups were then combined for a 12-month follow-up period, in which 123 dogs were initially enrolled and 79 completed the study. Dogs received either spironolactone 2 mg/kg PO q24h or placebo in addition to background therapy of ACEI, +/- furosemide, and +/- digoxin. The primary endpoint, (a composite of cardiac death, euthanasia, or severe worsening of MR requiring furosemide >10 mg/kg/day or other unauthorized treatment) was reached 11/102 dogs receiving spironolactone and 28/110 dogs receiving placebo (risk reduction of 55%, HR 0.45 [0.22-0.90]). For the endpoint of cardiac mortality, risk reduction was even higher at 69% (HR 0.31 [0.13-0.76]). Overall, 15-month survival was significantly higher in the spironolactone group compared to the placebo group (84% vs. 66%). Limitations of this study included the relatively high rate of withdrawal from the study, as well as relatively low event rate, with less than 50% of dogs reaching study endpoints. The relatively long survival time – longer than typically reported for dogs with CHF secondary to MMVD – underscores that fewer than half of the dogs were in CHF at the time of study inclusion. While this study supports the potential benefit of spironolactone in MMVD, the study design – which involved combining groups with different disease stages and variable concomitant treatments – complicates interpretation of this study’s findings and limits its generalizability.
The BESST trial randomized dogs with CHF secondary to MMVD to receive either benazepril alone (median dose 0.36 mg/kg PO q24) or a combination of benazepril and spironolactone (benazepril median dose 0.37 mg/kg PO q24, spironolactone median dose 2.97 mg/kg PO q24), in addition to a background of furosemide [6]. The primary outcome variable (cardiac death or euthanasia, worsening pulmonary edema, or worsening of CHF requiring furosemide dose > 8 mg/kg/day) was reached in 168/216 dogs in the benazepril + spironolactone group, and 171/198 dogs in the benazepril group (risk reduction 44%; OR: 0.56 [0.32-0.98]). Median time to reach this cardiac endpoint was 105 days in the combined group vs. 69 days in the benazepril group. Differences in group outcomes were apparent relatively early in the treatment period, with twice as many dogs in the benazepril group reaching the cardiac endpoint by Day 7 compared to the benazepril + spironolactone group (12.6% vs. 6.7%, respectively). Incidence of adverse effects was similar between groups. These results are similar to the outcomes seen in MRA trials in people, demonstrating significant reduction in cardiac morbidity and mortality with the addition of spironolactone to an ACEI in dogs with CHF. The major limitation of this study in terms of clinical generalizability is the absence of pimobendan in the background standard therapy.
Two studies of spironolactone in canine CHF have reported neutral outcomes. In the first small prospective study [85], eleven dogs with MMVD were randomized to receive low-dose spironolactone (median dose of 0.52 mg/kg PO q24) or placebo, in addition to a background of furosemide, ACEI, +/- pimobendan, and +/- digoxin. No differences in survival, clinical, or echocardiographic variables between groups were noted at 3 or 6 months. Limitations of this study include very small sample size, short follow-up time, and some clinical differences between the groups at baseline. Perhaps most importantly, the dose of spironolactone used was quite low, and below the dose considered optimal by pharmacokinetic and pharmacodynamic studies (see below). A major goal of the study was to assess potential adverse outcomes of adding spironolactone in conjunction with other CHF drugs. Similar to the other veterinary trials that showed positive outcomes with spironolactone at higher doses, low-dose spironolactone was also well-tolerated in this context. Two other clinical studies in dog with MMVD have more specifically reported renal function test results and electrolytes before and after addition of spironolactone to background therapy [86,87]. Both studies found that spironolactone was well-tolerated with no clinically relevant changes in renal values or electrolytes compared to either baseline levels or a placebo group.
The second study reporting neutral outcomes with the addition of spironolactone was the previously mentioned retrospective comparison of dual, triple, and quadruple therapy [59]. Limitations associated with the retrospective nature of this study have been previously mentioned, including treatment group based on attending cardiologist preference (not randomized), differences between groups in echocardiographic LV size at baseline, differences in furosemide and pimobendan doses between treatment groups, and overall low dose of ACEI utilized in both triple and quadruple therapy groups.
Overall, the highest quality of evidence investigating spironolactone in CHF secondary to MMVD suggest benefit in cardiac morbidity and mortality when added to standard therapy, particularly when combined with an ACEI. Spironolactone is generally well-tolerated, even in conjunction with other CHF therapies. This is consistent with literature in human CHF and supports the synergistic RAAS-suppressing benefit of addressing aldosterone breakthrough. For these reasons, spironolactone is part of current ACVIM consensus guideline recommendations for treatment of CHF secondary to MMVD [60].
Clinical Efficacy in Advanced Preclinical Myxomatous Mitral Valve Disease (Stage B2). Only one study, the DELAY trial, has investigated spironolactone in the preclinical phase of MMVD, and it did so in the context of combined therapy with ACEIs [64]. As previously discussed, DELAY showed no benefit of benazepril + spironolactone in its primary endpoint (onset of CHF or cardiac death), but the treatment group did show reductions in echocardiographic measures of heart size and decreases in NT-proBNP. As in earlier ACEI studies, the benazepril dose used was relatively low and may have limited therapeutic impact. If so, the DELAY trial may have functioned more as an evaluation of spironolactone in the absence of robust ACE inhibition, raising the possibility that spironolactone alone is insufficient to meaningfully alter disease course. This interpretation would align with the concept that the principal benefit of MRAs lies in preventing aldosterone breakthrough in patients already receiving effective RAAS blockade, rather than as standalone therapy. In the absence of strong evidence to suggest benefit, spironolactone is not currently recommended by ACVIM consensus guidelines for treatment of stage B2 MMVD, and prescriber data suggests that only approximately 10% of cardiologists routinely prescribe spironolactone to B2 dogs [60,65].
Pharmacokinetics and Pharmacodynamics. Regulatory pharmacokinetic studies report rapid biotransformation of spironolactone to canrenone and 7-α-thiomethyl-spironolactone (7α-TMS) in dogs; food increases oral bioavailability (to 80-90%); absorption is approximately linear across 2-4 mg/kg; and steady state conditions are achieved by Day 2-3 (Cardalis®: Summary of Product Characteristics. European Medicines Agency. Retrieved September 22, 2025: https://www.ema.europa.eu/en/medicines/veterinary/EPAR/cardalis.). Reported PK parameters for the active metabolites of spironolactone include large apparent volumes of distribution (153-177 L) (Prilactone®: Summary of Product Characteristics. European Medicines Agency. Retrieved September 22, 2025: https://www.ema.europa.eu/en/documents/scientific-discussion/prilactone-epar-scientific-discussion_en.pdf.), extensive protein binding (90%) (Cepeloron®: Summary of Product Characteristics. European Medicines Agency. Retrieved September 22, 2025: https://www.ema.europa.eu/en/medicines/veterinary/EPAR/cepeloron.), and plasma clearance of 0.9-1.5 L/h/kg, with predominantly fecal excretion (70%) (Prilactone®: Summary of Product Characteristics. European Medicines Agency. Retrieved September 22, 2025: https://www.ema.europa.eu/en/documents/scientific-discussion/prilactone-epar-scientific-discussion_en.pdf.). With the fixed benazepril/spironolactone combination at labeled doses, terminal elimination half-lives of 6-7 h are reported for canrenone and 7α-TMS (Cardalis®: Summary of Product Characteristics. European Medicines Agency. Retrieved September 22, 2025: https://www.ema.europa.eu/en/medicines/veterinary/EPAR/cardalis.).
In a randomized AB/BA crossover study in healthy Beagles, spironolactone (2 or 4 mg/kg PO q24h for 7 days) increased circulating aldosterone, Ang I, Ang II, and Ang(1-5) concentrations, as measured by equilibrium LC-MS/MS. However, separation between the 2 and 4 mg/kg doses was minimal despite higher exposure to canrenone and 7α-TMS at 4 mg/kg. This finding is consistent with earlier renal Na+/K+ antagonism data demonstrating a pharmacodynamic plateau near 2 mg/kg in an experimental hyperaldosteronism model [17]. It also aligns with data from a furosemide continuous-rate infusion model, in which plasma Ang II and aldosterone increased at 5 hours despite background ACE inhibition (± spironolactone), indicating robust upstream RAAS activation during forced diuresis [88].
Combination Therapy: ACEI and MRA
Clinical Efficacy. Given the synergistic benefits of ACEI and MRA, a combined product has been developed to provide both drugs in a single pill. The fixed combined dose selected during product development was designed to target a dosage of benazepril 0.25 mg/kg PO q24h and spironolactone 2 mg/kg PO q24h. As discussed, this represents an optimized dose of spironolactone, but potentially a suboptimal dose of benazepril based on retrospective analyses, experimental studies of RAAS endpoints in healthy dogs, and mathematical modeling. The two drugs can also be given separately, allowing for flexibility in dosing between ACEI and MRA.
As discussed previously in the context of spironolactone, two studies have evaluated the efficacy of the combination of ACEI and MRA in dogs with MMVD. One of these trials (BESST) focused on dogs with newly diagnosed CHF (stage C) and demonstrated significantly reduced risk of CHF relapse or cardiac death with the combination product compared to benazepril alone. The other trial (DELAY) addressed advanced preclinical disease (stage B2) and showed no difference in time to CHF or cardiac death with combination product compared to benazepril alone but did report favorable changes in cardiac size and NT-proBNP. As discussed previously for both trials, the spironolactone dose was consistent with current practice, but the low ACEI dose complicates interpretation and makes it difficult to assess the true value of combined therapy in this context.
Pharmacokinetics and Pharmacodynamics. In a prospective, parallel-group study of 18 healthy Beagles with RAAS activation induced by a low-sodium diet, three 14-day dosing regimens with a benazepril/spironolactone combination were compared: (i) labeled dose of Cardalis® once-daily (LD24) (benazepril 0.25 mg/kg + spironolactone 2 mg/kg), labeled dose of Cardalis® twice-daily (LD12), and double-labeled dose twice-daily (2LD12) (benazepril 0.5 mg/kg + spironolactone 4 mg/kg) [18]. Compared with LD24, 2LD12 produced the greatest suppression of the classical RAAS and shifted signaling toward the ACE2/Ang(1-7) pathway: Ang II and ACE-S decreased, Ang(1-7) increased, and aldosterone increased relative to Ang II (AA2). The LD12 group showed intermediate changes. Collectively, these findings suggest that, within the fixed dose combination, ACEI drives circulating Ang II/ACE-S suppression, while MRA contributes receptor-level blockade with expected aldosterone feedback, yielding the strongest overall RAAS modulation when the drug combination is given twice a day. Across dosing regimens, there were no clinically relevant changes in creatinine, blood urea nitrogen, sodium, or potassium; while isolated self-limiting gastrointestinal signs (vomiting/soft stool) occurred in a minority of dogs. These observations are consistent with prior reports that ACEI/MRA combinations are generally well tolerated in dogs. Building on previous in silico work with ACEI alone, a quantitative systems pharmacology (QSP) model is being developed for the benazepril-spironolactone combination, linking active-metabolite exposure (benazeprilat, canrenone, 7-α-thiomethyl-spironolactone) to a multi-analyte RAAS fingerprint (Ang I, Ang II, Ang(1-7), Ang(1-5), aldosterone; indices ACE-S, PRA-S, AA2). The model is designed to deconvolve the net contribution of each agent and support in silico optimization of dose/schedule synchronization and biomarker targets for prospective clinical studies in dogs with MMVD.
The observations from the combination study largely mirrors those from benazepril monotherapy using the same experimental model: greater ACEI yields stronger Ang II and ACE-S suppression with parallel activation of the alternative arm of the RAAS [15]. They are also consistent with systems-pharmacology predictions that q12h ACEI provides more sustained classical-pathway control than q24h at the same daily dose. Taken together, these results provide a rationale for twice-daily dosing of the ACEI/MRA combination to minimize between-dose gaps, particularly under conditions of increased RAAS activation (e.g., during loop-diuretic use).
Inodilators
Inodilators combine the drug effects of positive inotropy and vasodilation. In veterinary medicine, the most used drug in this class is pimobendan where most of the evidence for companion animals exists. Other drugs in this category have minimal evidence for use in dogs including levosimendan and milrinone. The inodilator effects of pimobendan and levosimendan are owed to their ability to sensitize the cardiac sarcomere to calcium and inhibit phosphodiesterase-III [89]. With pimobendan and levosimendan intracellular calcium is not increased [89]. Milrinone also functions as a phosphodiesterase-III inhibitor and exerts inotropic and vasodilatory effects but does so in part via increased intracellular calcium, distinguishing it from pimobendan [90]. The increased cellular calcium adds additional risk, resulting in its extremely limited use in settings where pimobendan or levosimendan are available.
Clinical Efficacy in Congestive Heart Failure (Stage C). The QUEST study established that the addition of oral pimobendan to standard CHF therapy was superior to benazepril for treating CHF in canine MMVD [91]. Dogs with MMVD and CHF were randomized to receive either pimobendan at a dose of 0.4-0.6 mg/kg/day or benazepril at a dose of 0.25-0.5 mg/kg/day [91]. The study concluded that pimobendan significantly prolonged time to composite endpoint when compared to benazepril (267 vs 140 median days, respectively) [91]. When all primary endpoints were considered, median survival time was also significantly longer in the pimobendan group compared to the control group [91]. In a later manuscript, subsequent investigation of the data obtained from the QUEST trial found no differences in quality of life between treatment groups but identified a longer time period for dogs treated with pimobendan prior to the first dose escalation of diuretics [92]. Heart size was also reduced in dogs after institution of pimobendan when compared to benazepril [92]. These results, although compelling, are limited due to the exclusive enrollment of dogs weighing between 5 and 20kg [91,92]. Additionally, they do not address the impact on the common, current practice of combined furosemide, pimobendan, and ace-inhibitor therapy for chronic management of canine CHF secondary to MMVD. Several studies have attempted to investigate the role of furosemide and pimobendan with or without an ace-inhibitor and or spironolactone [57,93]. Limitations such as inappropriately low ACEI dosing and/or retrospective nature of these studies are substantial and significantly limit the ability to interpret the clinical impact of triple or quadruple therapy [57,93].
Levosimendan use is limited to preclinical studies in canine cardiomyocytes and some studies of animal models [94]. While results are favorable and mimic those of pimobendan, the driving force for preference of levosimendan in human CHF is secondary to adverse arrhythmia events in humans receiving pimobendan that have not been recapitulated in canine patients receiving pimobendan. Levosimendan is well tolerated and improves a variety of clinical outcomes across a wide number of human CHF etiologies [95]. These findings taken in combination reinforce the value of inodilators in the management of congestive heart failure across species.
Clinical Efficacy in Advanced Preclinical Myxomatous Mitral Valve Disease (Stage B2). Dogs with advanced preclinical MMVD are typically hyperdynamic via echocardiographic assessment of systolic function, making the use of inodilators less intuitive. This may in part explain the delay between the QUEST and EPIC trials. The EPIC trial was published in 2016 which evaluated the use of pimobendan (0.4-0.6 mg/kg/day) vs. placebo in what is now known as stage B2 MMVD [96]. The primary variable of interest was heart failure free survival days, which were significantly extended by approximately 15 months in dogs receiving pimobendan compared to placebo. Like the QUEST study, a second look at additional data and variable was performed on the EPIC data and identified that pimobendan significantly reduced heart size at Day 35 [97]. Like the QUEST trial, the study was limited to small dogs with MMVD, which limits the application of this data to large-breed dogs with the disease [96,97]. Additionally, the average dog enrolled in the EPIC trial exceeded the required entrance criteria for left atrial size and left ventricular diastolic dimension. This suggests that later intervention with pimobendan than what was proposed by the EPIC trial may result in similar clinical benefits and warrants further investigation, particularly for clients with financial constraints. The role of pimobendan in patients with cardiorenal syndrome has been investigated in preclinical studies and clinical trials. In experimentally induced MR of healthy laboratory dogs, the administration of pimobendan increased renal blood flow [98]. In a clinical trial of dogs with stage B2 MMVD, estimates of GFR via iohexol clearance did not show evidence of improved GFR at standard (0.2-0.3 mg/kg q12h) or high (0.5-0.6 mg/kg q12h) of pimobendan [99]. Additional investigation into the effect of pimobendan in dogs with concomitant MMVD and renal disease are warranted.
Pharmacokinetics and Pharmacodynamics. Recent pharmacokinetic and pharmacodynamic investigations of pimobendan have focused on multiple routes of administrations and multiple formulations, making generalization of dosing recommendations challenging [100,101,102,103]. Pimobendan is metabolized to its active metabolite O-demethylated metabolite (ODMP) evidenced by only a small delay in peak pimobendan vs. ODMP plasma levels across multiple studies.
In a clinical trial of 34 dogs with stage B2, 14 dogs with stage C, and 8 dogs with stage D MMVD, oral pimobendan pharmacokinetics were investigated using the FDA-approved chewable tablet form of pimobendan, Vetmedin® [103]. A sparse sampling and population pharmacokinetic design was performed. Concomitant medications and pimobendan dosage were as prescribed by the attending clinician and not controlled for in this clinical trial, emphasizing the value of this dataset for extrapolation to clinical patients. All dogs were receiving pimobendan at a stable dose (average: 0.36 mg/kg) for at least five consecutive days. In this study, the elimination half-life of the population was approximately 1 and 1.3 hours for pimobendan and ODMP respectively [103].This aligns with the manufacturer-stated elimination half-lives of approximately 0.5 and 2 hours, respectively. The study consistently found a high degree of inter-individual pharmacokinetic variability (>40%) across parameters. In this cohort, that variability could not be explained by disease stage, concomitant therapies, or pimobendan dose differences.
In one single dosing study of eight healthy laboratory dogs receiving a standard dose of 0.25 mg/kg of a non-aqueous pimobendan solution, peak pimobendan and ODMP plasma concentration similarly occurred at 1 and 1.3 hours respectively and remained detectable for 8-12 hours with peak inotropic response by echocardiogram around 3-4 hours post dose [100]. A pharmacodynamic study of 30 dogs with stage B2 MMVD showed that compared to placebo, 7 days of twice-daily standard (0.25mg/kg) or high-dose (0.5mg/kg) oral pimobendan (Vetmedin®) resulted in echocardiographically determined reductions in heart size and increased systolic function at 3-4 hours post-pill [99]. No pharmacodynamic differences were identified between the standard- and high-dose pimobendan groups; however, the study was small and did not assess outcomes beyond seven days of therapy [99]. Dose escalation of pimobendan is relatively common in clinical practice and is without clear evidence currently [103].
Loop Diuretics
Clinical Efficacy. Loop diuretics, such as furosemide and torasemide are cornerstone therapies for managing CHF in MMVD. They primarily act by alleviating fluid overload through natriuresis and diuresis. In dogs with MMVD, furosemide is widely prescribed to reduce pulmonary edema and clinical signs of congestion, with evidence from ACVIM consensus guidelines supporting its use in stages C and D [60]. However, repeated administration of loop diuretics activates the RAAS, contributing to aldosterone breakthrough, diuretic resistance, and potentially progressive cardiac remodeling [21,22,23,88]. Given its longer half-life and greater diuretic potency, torasemide may be a useful option in dogs with advanced CHF and apparent furosemide resistance; in a small case series with three dogs, its use was associated with improved management of recurrent congestive signs [104].
Due to the critical need for diuresis in the management of acute and chronic CHF, placebo-controlled clinical trials supporting its use does not exist in the modern literature. The TORIC study in human patients with CHF established the safety, efficacy and superiority of torasemide when compared to furosemide for management of CHF [105]. The TORIC study established reduced mortality, greater reduction in function heart failure class, and improved electrolyte safety when compared to the furosemide group in more than 1,300 total patients. For veterinary medicine, a parallel pair of randomized, prospective, single-blind, 3-month, positive-controlled studies make up the foundation of the TEST study and provide the best level of evidence and insight to the efficacy of furosemide and torasemide in dogs with MMVD [106]. The study also provides comparative data between the parallel studies which generated valuable insight into drug efficacy and potential superiority of torasemide. The TEST study used a median once-daily dose of torasemide at 0.24 mg/kg or a median twice-daily dose of furosemide at approximately 1.4 mg/kg. The TEST study aimed to see if the study drugs could impact one of two strata: (1) dogs with ongoing CHF as either a first event or recurrence of uncontrolled congestion requiring a dose adjustment of diuresis, and (2) dogs with controlled CHF. The outcomes of interest in the first uncontrolled CHF stratum were improvement in clinical and radiographic signs of CHF while the outcomes of interest in stratum 2 were maintenance or improvement in clinical status. Importantly, dogs in the TEST study were permitted to receive ACEI, pimobendan and digoxin, provided it was already in place and the dose was not adjusted at enrollment or throughout the 3-month study. However, other medications such as spironolactone or ARBs were excluded. The study concluded that torasemide was non-inferior to furosemide at the doses studied and without greater risk of adverse events. A composite endpoint of spontaneous cardiac death, euthanasia due to CHF or worsening of NYHA CHF classification was utilized. Compared to furosemide, torasemide at the dose studied conferred a 2-fold reduction in risk of reaching this composite endpoint. While the TEST study aimed to compare torasemide and furosemide, it represents evidence of efficacy for both compounds which are otherwise challenging to identify within the primary literature, particularly with good sample size [106].
Pharmacokinetics and Pharmacodynamics. In dogs, oral furosemide has moderate-to-high bioavailability (70-80%) with significant between-subject variability (EMEA/MRL/644/99. (1999). Furosemide: Summary Report - Committee for Veterinary Medicinal Products. European Medicines Agency. EMEA/MRL/644/99-FINAL. https://www.ema.europa.eu/en/documents/mrl-report/furosemide-summary-report-committee-veterinary-medicinal-products_en.pdf.). Systemic availability is nearly complete after intramuscular administration. Following oral dosing with furosemide, peak plasma concentrations are reached within 1-2 hours, and the elimination half-life is short (1-3.5 hours), consistent with a rapid onset but a relatively brief diuretic effect (3-6 hours) [107,108]. Furosemide is highly bound to plasma proteins (>90%), has a relatively small volume of distribution (0.2-0.7 L/kg), and is primarily eliminated by the kidneys (about 60%) [107,109]. Torasemide has higher oral bioavailability (typically 90%), a longer half-life (6-7 h), and mixed hepatic/renal clearance, supporting once-daily dosing (commonly 0.1-0.5 mg/kg, in some cases q12-24h) with sustained natriuresis for approximately 12 hours (Upcard®: Summary of Product Characteristics. European Medicines Agency. Retrieved September 22, 2025: https://ec.europa.eu/health/documents/community-register/2015/20150731132335/anx_132335_en.pdf, Isemid®: European Public Assessment Report. European Medicines Agency. Retrieved September 22, 2025: https://www.ema.europa.eu/en/medicines/veterinary/EPAR/isemid.) [110,111]. In CHF, the diuretic response to both agents may be attenuated by renal impairment and RAAS activation, often necessitating dose escalation. For furosemide, doses may increase up to 4-6 mg/kg q8h, and ACVIM defines refractory (Stage D) cases as requiring >8 mg/kg/day or the torasemide equivalent [60].
The dose-response relationship of furosemide was investigated in healthy dogs using intensive sampling and a combined multiple comparison procedures and modeling (MCP-Mod) approach, [112]. In a 5-day parallel-group study, 24 Beagles were randomized to saline control or furosemide at 1, 2, or 4 mg/kg IM q12h. Blood and urine were collected at steady-state (24 hours after the last dose), with PRA measured via enzyme immunoassays and aldosterone via LC-MS/MS. Twenty-four-hour diuresis was quantified from metabolism cage collections. Furosemide induced dose-dependent increases in diuresis, PRA, and aldosterone, with submaximal diuretic effects observed at doses lower than those identified to activate the circulating RAAS. Practically, projections from the statistical model suggest that doses lower than 1 mg/kg q12 would produce a significant effect on diuresis, with only mild activation of the systemic RAAS in healthy dogs with preserved hemodynamics. However, these dose-response estimates were derived in hemodynamically stable dogs and should be interpreted cautiously when extrapolated to dogs with MMVD, in which altered renal perfusion, neurohormonal activation, and disease-related pharmacodynamic shifts may substantially modify diuretic responsiveness.
These preliminary findings align with broader PK/PD population modeling in healthy dogs, showing dose-dependent diuresis and natriuresis for both furosemide and torasemide, alongside RAAS activation (marked by increased aldosterone levels). Diuretic resistance was reported at high doses; however, a ceiling effect was not reported for either loop diuretic at the maximum tested doses of 8 mg/kg/day for furosemide and 0.4 mg/kg/day for torasemide [111].
In experimental models of RAAS activation and in clinical studies, furosemide elicits dose-related RAAS activation, with increases in renin activity, Ang II, and aldosterone, despite effective diuresis. Accordingly, close monitoring for hypokalemia and pre-renal azotemia is warranted. Transient rises in serum creatinine and urea nitrogen have been reported during aggressive IV regimens, though the magnitude varies by study [21,88].
Adjunctive Therapy
Adjunctive Treatments for Management of Acute Decompensated Congestive Heart Failure
A number of treatments are used by clinicians in the management of acute decompensated CHF secondary to MMVD despite lack of clinical trials demonstrating benefit, in many cases because a placebo-controlled trial would prove unethical. These include oxygen support and advanced applications of oxygen therapy (e.g., high-velocity nasal insufflation of oxygen, mechanical ventilation), paracentesis for treatment of cavitary effusions, and narcotic sedation to reduce anxiety and dyspnea-related distress. Other adjunctive treatments are indicated for patients with specific cardiac complications or comorbidities, such as anti-arrhythmic drugs for patients with hemodynamically significant arrhythmias.
Some pharmacologic therapies for acute CHF have been studied experimentally or in small uncontrolled trials:
- Nitroglycerin is a venodilator that can reduce preload and thereby potentially treat pulmonary congestion. An experimental trial in healthy dogs demonstrated splenic dilation in response to nitroglycerine ointment but in an experimental model of mitral regurgitation, nitroglycerine ointment did not decrease LV end-diastolic pressure [113,114]. Two small studies have described use of intravenous nitroglycerine as a continuous rate infusion, one of which noted local tissue reaction (phlebitis and necrosis) in 3 of 29 dogs receiving the drug (Climent-Pastor A, Dominguez LL, De Blas I et al. Use of intravenous nitroglycerin in the treatment of acute left-sided congestive heart failure in dogs and cats. 33rd Congress of the European College of Veterinary Internal Medicine - Companion Animals, Barcelona, 2023.) [115]. No clinical trials of nitroglycerine have been performed in dogs with naturally-occurring heart disease.
- Sodium nitroprusside is a potent balanced vasodilator that reduces both preload and afterload. It can be titrated as an intravenous infusion with the goal of decreasing severity of mitral regurgitation and improving forward stroke volume. In a canine coronary microembolization model of CHF, nitroprusside decreased pulmonary artery wedge pressure but did not alter cardiac output [116]. Nitroprusside has not been studied in dogs with clinical CHF.
- Hydralazine is an arteriolar vasodilator that reduces afterload, again with the goal of decreasing mitral regurgitation and improving forward cardiac output. In a small case series of seven dogs with refractory CHF secondary to MMVD, hydralazine reduced systolic blood pressure and decreased radiographic pulmonary edema [117]. Although no dogs became hypotensive, 6 of 7 dogs developed sinus tachycardia. In another small study, 22 dogs with MMVD and early CHF were assigned to either enalapril or hydralazine monotherapy, followed by the addition of furosemide 3 weeks later [118]. Dogs receiving hydralazine, but not enalapril, had increased heart rate and decreased heart size compared to baseline; although blood pressure was not measured in this study, hypotension was cited as a potential mechanism to explain these findings.
- Clevidipine is a novel intravenous dihydropyridine calcium channel blocker that can acutely reduce afterload with the goal of reducing mitral regurgitation and improve cardiac output. Like sodium nitroprusside, clevidipine can be administered as a constant-rate infusion to titrate systemic blood pressure and reduce afterload on a minute-to-minute basis. In a prospective, randomized, open-label clinical trial, partially published in abstract form and with the full report in preparation, clevidipine was well tolerated in dogs with MMVD and CHF. Clevidipine at a median dose of 5.25 μg/kg/min achieved a target reduction of mean arterial pressure by 20% in a predictable and dose-dependent fashion without major adverse events or impact on measures of renal function (Sharpe AN, Li RHL, Burkitt-Creedon JM, Gunther-Harrington CT, Stern JA. Evaluation of the Safety and Efficacy of Clevidipine in Dogs with Congestive Heart Failure Secondary to Myxomatous Mitral Valve Disease. Proceedings of the ACVIM Forum 2022, 36(6): 2300-2301.).
- Dobutamine is a β1 agonist and positive inotrope that improves cardiac contractility and cardiac output, and in the setting of MMVD might function as a pharmacologic annuloplasty to decrease mitral regurgitation. Like nitroprusside, it is short-acting and can be titrated as an infusion; disadvantages include the risk of tachyarrhythmias and relatively short period of effectiveness due to downregulation of β1 receptors. In a coronary microembolization model of canine CHF, dobutamine increased cardiac output and left ventricular ejection fraction, and decreased systemic vascular resistance [114]. Dobutamine has not been evaluated in naturally-occurring canine heart disease.
Adjunctive Treatments for Management of Chronic Refractory Congestive Heart Failure (Stage D)
Many pharmacologic therapies are used for adjunctive treatment in late disease stages despite lack of evidence-based recommendations. Clinical trials are challenging in populations with such late-stage disease due to low patient numbers, lack of homogeneity of the population, comorbidities, and ethical concerns in medically fragile patients. The following outlines existing evidence for some of these adjunctive therapies. As noted above, additional treatments may be indicated in patients with specific cardiac complications, particularly anti-arrhythmic drugs for ventricular rate control in atrial fibrillation (e.g., diltiazem, digoxin) or for control of frequent or complex ventricular ectopy (e.g., sotalol, mexiletine, amiodarone):
- Amlodipine is a dihydropyridine calcium-channel blocker and arterial vasodilator. It is clearly indicated in dogs with MMVD and concurrent systemic hypertension, but it may also have adjunctive benefits in normotensive dogs by reducing afterload and thereby decreasing the severity of mitral regurgitation. In an experimental model of MR, amlodipine significantly decreased left atrial pressure, and in a small, short-term, non-blinded echocardiographic study of naturally occurring MMVD, treatment was associated with reduced left atrial and left ventricular dimensions [119,120]. No blinded or placebo-controlled trials have been performed. A retrospective study of 21 dogs with CHF due to MMVD described amlodipine administered alongside furosemide, pimobendan, ACEI, and spironolactone, suggesting that long-term combination therapy is well tolerated [121].
- Sildenafil is a phosphodiesterase V inhibitor that serves as a selective pulmonary vasodilator. Pulmonary arterial hypertension is common in advanced MMVD, arising either from passive postcapillary overload from elevated left atrial pressure, or from a combination of postcapillary and reactive precapillary mechanisms. Sildenafil is often recommended in cases of MMVD complicated by clinically significant pulmonary hypertension, particularly when echocardiographic evidence is strong and compatible clinical signs are present (e.g., syncope and dyspnea despite adequate control of left-sided CHF, or presence right-sided CHF) [122]. In a small double-blinded placebo-controlled crossover study in 13 dogs with pulmonary hypertension secondary to MMVD, sildenafil improved exercise capacity and quality of life scores compared to placebo, with no adverse effects [123]. Echocardiographically-estimated pulmonary artery pressure decreased in both groups, and while the change was numerically larger in the sildenafil group, the difference was not statistically significant. Several retrospective studies have also reported positive outcomes of sildenafil in larger cohorts of dogs with pulmonary hypertension that include subsets with MMVD [124,125]. A commonly cited concern is that pulmonary vasodilation might worsen pulmonary edema. A small, randomized placebo-controlled trial of 14 dogs with MMVD, CHF, and postcapillary pulmonary hypertension (defined as tricuspid regurgitation gradient >2.7 m/s) included 7 dogs treated with sildenafil in addition to triple therapy (furosemide, pimobendan, and ACEI). In this small sample, sildenafil was well tolerated without exacerbation of pulmonary edema [126]. Two small trials have evaluated sildenafil in preclinical MMVD (>75% stage B1) dogs: one suggested improved heart rate variability, while the other reported modest reductions in some echocardiographic variables and NT-proBNP [127,128]. However, these differences were small, often remained within normal ranges, and were inconsistent across timepoints, underscoring the difficulty of assessing pharmacologic interventions in early preclinical MMVD.
- Hydrochlorothiazide is a thiazide diuretic that blocks the sodium-chloride cotransporter in the distal convoluted tubule and may be added for sequential nephron blockade when loop diuretics are insufficient. Evidence is limited to experimental studies in healthy dogs [129]. It has not been evaluated in naturally occurring MMVD or CHF.
- Cough suppressants (e.g., hydrocodone) are often prescribed for symptomatic relief of cough, especially in dogs with concurrent dynamic airway disease. In patients with advanced MMVD, cough may be exacerbated by compression of the left mainstem bronchus secondary to left atrial enlargement. There are no specific studies of cough suppressants in dogs with MMVD or CHF.
- Bronchodilators (e.g., theophylline, aminophylline, and terbutaline) are sometimes prescribed to relieve bronchoconstriction and reduce cough. As weak sympathomimetics, they may also modestly increase cardiac contractility and heart rate. No studies have specifically assessed bronchodilators in dogs with MMVD or CHF.
Emerging Therapies
Angiotensin Receptor-Neprilysin Inhibitors (ARNI). Neprilysin is a broad-spectrum endopeptidase that degrades vasoactive peptides, including natriuretic peptides (atrial and brain natriuretic peptides (ANP/BNP)), bradykinin, and substance P. As a neprilysin inhibitor, sacubitril therefore increases natriuretic peptide concentrations. The fixed-dose combination of sacubitril with valsartan (an ARB) is designed to shift the neurohormonal status toward vasodilation, natriuresis, and antifibrosis without the adverse safety profile historically associated with ACE-NEP dual inhibition [130,131]. In dogs, preclinical evidence from the low-sodium model of RAAS activation shows that sacubitril/valsartan increases circulating cyclic guanosine monophosphate (cGMP) and reduces aldosterone levels compared to ACEI or ARB monotherapy [25,132]. These experimental observations were later supported by pilot clinical data. In a double-blind, placebo-controlled pilot trial involving thirteen dogs with Stage B2 MMVD, 30 days of sacubitril/valsartan therapy (20 mg/kg PO q12h) attenuated the increase in the urinary aldosterone-to-creatinine ratio compared with placebo, without significant effects on NT-proBNP concentrations, echocardiographic parameters, or thoracic radiographic findings [133]. In Stage C MMVD, a 4-week randomized study comparing sacubitril/valsartan (20 mg/kg PO q12h) with ramipril (0.125 mg/kg PO q12h) (both added to standard care including furosemide and pimobendan) demonstrated greater potential for reverse remodeling, reflected by reductions in the left atrial-to-aortic root ratio (LA/Ao), left ventricular internal diameter in diastole (normalized; LVIDDN), end-diastolic volume index (EDVI), and end-systolic volume index (ESVI), while NT-proBNP and urinary aldosterone levels were comparable between groups [134]. Together, the available evidence, although sparse, suggests that ARNIs can effectively modulate RAAS and natriuretic pathways in dogs, potentially mitigating aldosterone breakthrough and cardiac remodeling. However, the lack of large-scale, long-term outcome trials in naturally occurring canine MMVD underscores the need for further research to establish their role relative to ACEI/MRA standards of care.
Sodium Glucose Cotransporter-2 Inhibitors (SGLT-2I). Multiple large, placebo-controlled trials have established SGLT-2Is as disease-modifying therapies across heart failure phenotypes in humans, with benefits extending well beyond glycemic control [135,136,137,138,139,140,141,142,143]. Mechanistically, these small molecules reduce oxidative stress and chronic inflammation, promote autophagy, attenuate advanced glycation end-product signaling, and shift myocardial and whole-body substrate use toward ketone bodies [144]. SGLT-2 inhibition also modulates innate immunity: in endothelial cells and macrophages, dapagliflozin suppresses TLR4 expression and downstream NF-κB activation and promotes polarization toward anti-inflammatory M2 macrophages [145]. This property complements RAAS inhibition (which primarily attenuates neurohormonal and hemodynamic stress) by providing direct immunometabolic benefits that could mitigate cardiac and renal injury.
Although peer-reviewed outcome data in dogs remain limited, early translational studies support the tolerability and potential use of SGLT-2Is as adjunctive therapy in CHF. In a rapid atrial pacing model of canine atrial fibrillation, canagliflozin limited atrial electrical/structural remodeling and fibrosis [146]. The pharmacokinetics and nonclinical safety of empagliflozin in dogs are also well characterized. In Beagles, empagliflozin exhibits low clearance, high oral bioavailability and high selectivity [147,148]. In 52-week dog studies, toxicological findings included dose-related vacuolation of the adrenal zona glomerulosa and renal changes observed at exposures far exceeding clinical levels; the adrenal effect was considered secondary to glucosuria-related osmotic/diuretic stress [149]. Overall, these nonclinical data suggest a favorable safety margin relative to projected therapeutic exposures, with renal toxicity anticipated at supratherapeutic empagliflozin doses.
Pilot clinical studies further support feasibility and short-term safety in client-owned dogs. In naturally obese dogs, DWP16001 (another SGLT-2I drug candidate) (0.2 mg/kg PO q24h) reduced body weight, body condition score, and anthropometric measures over 8 weeks relative to controls [150]. As adjunctive therapy to insulin in diabetic dogs, DWP16001 has been shown to improve glycemic control [151]. In a multicenter randomized controlled trial evaluating DWP16001 at 0.025 mg/kg PO q24h, reductions in glycemic markers were significantly greater in dogs with poor baseline control (fructosamine ≥ 500 µmol/L, HbA1c ≥ 6%), with a trend toward decreased insulin requirement and no clinically relevant adverse effects [152]. In insulin-treated diabetic dogs, short-term add-on canagliflozin (2-4 mg/kg q24h for 7 days) significantly lowered interstitial glucose compared with insulin alone, but it also increased the incidence of hypoglycemia, warranting a reduction in the insulin dose [153].
A recent prospective, randomized pilot study in a small cohort of dogs with symptomatic stage C MMVD found that short-term dapagliflozin (0.25-0.45 mg/kg q24h) improved cardiac geometry and function vs. conventional therapy, with reductions in left-atrial and left-ventricular dimensions over the treatment period, consistent with a favorable hemodynamic effect [154]. Additionally, two preliminary studies, not yet published in peer-review form, have evaluated SGLT-2Is in dogs with heart disease. The first was a small double-blind, placebo-controlled 30-day pilot study in dogs with DCM, in which empagliflozin (0.3 mg/kg PO q24h) was well tolerated, increased β-hydroxybutyrate levels and induced glycosuria, but did not produce meaningful changes in echocardiographic indices [155]. The second was an open-label pilot study involving 10 dogs with stage B2 or C MMVD or DCM. Dapagliflozin (0.5-0.8 mg/kg PO q24h for 5-7 days), added to stable background therapy, induced significant glycosuria and decreased urine potassium and creatinine (manuscript under review).
Collectively, these preliminary data suggest that SGLT-2Is may serve as a promising adjunct to existing therapies for MMVD, with the potential to reduce diuretic requirements (albeit likely transiently) and improve metabolic efficiency [156,157]. However, their clinical utility remains to be validated in large, well-controlled cohorts of dogs with CHF to establish efficacy, safety, and optimal dosing strategies.
Glucagon-Like Peptide-1 Receptor (GLP-1R) Agonists. GLP-1R agonists exert anti-inflammatory and antioxidant effects that extend beyond their established roles in obesity and T2DM. GLP-1 receptor agonist peptide analogs modulate endothelial and immune-cell signaling, attenuate NF-κB-associated pathways and reduce pro-inflammatory mediators; in human studies they have been associated with improved vascular function and lower circulating markers of endothelial activation (e.g., soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular cell adhesion molecule-1 (sVCAM-1)) [158,159,160]. In human cardiac tissue, higher GLP-1R expression correlates with low-grade inflammation and endothelial dysfunction. Increased GLP-1R expression is associated with higher oxidative stress that is attenuated by GLP-1R agonists via the canonical GLP-1R-adenosine monophosphate-activated protein kinase (AMPK) pathway [161]. Among patients with T2DM and CKD, semaglutide lowers the risk of major kidney events as well as cardiovascular and all-cause mortality [162]. GLP-1R is expressed in renal and immune compartments, and GLP-1R agonists attenuate pro-inflammatory and pro-fibrotic signaling in both clinical populations and experimental models of diabetic kidney disease or hypertension [163,164,165,166].
In dogs, GLP-1-related cardiac research has largely focused on pacing-induced DCM and ischemia-reperfusion models aimed at human translation, whereas much of the broader canine literature centers on metabolic rather than cardiac endpoints. In pacing-induced DCM and coronary occlusion/reperfusion models, short-term GLP-1 (GLP-1(7-36) and its metabolite GLP-1(9-36)) infusions increased myocardial glucose uptake, improved left-ventricular performance, and limited post-ischemic stunning, with proposed mechanistic links to p38α mitogen-activated protein kinase-nitric oxide (MAPK-NO) signaling and enhanced L-type Ca2+ current at the myocyte level [167,168,169,170]. In metabolic studies, liraglutide stabilized post-prandial glycemia in healthy and type 1 diabetic dogs without increasing insulin, consistent with prandial glucagon suppression. Repeated dosing with exenatide over 12 weeks (10 μg SC q12h on weekdays and q24h on weekends) reduced body weight and improved β-cell function indices in prediabetic dogs but did not improve whole-body insulin sensitivity or glucose tolerance [171]. Intraportal exenatide failed to show insulin-independent hepatic effects in conscious dogs [172]. Finally, prolonged, physiologic GLP-1 exposure can indirectly increase hepatic glucose uptake in canine models [173], and preliminary data suggest that liraglutide facilitates weight loss and appetite control in obese senior dogs [174].
Conclusion
Evidence-based therapy for MMVD in dogs has advanced considerably, particularly with respect to RAAS-modulating drugs and loop diuretics, where multiple clinical trials demonstrate improved survival, quality of life, or both. Nonetheless, questions persist regarding the role of RAAS inhibition in preclinical disease, the optimal dosing strategies for RAAS modulators, and the integration of newer therapies into standard practice. While emerging data from pharmacokinetic/pharmacodynamic studies and translational models are beginning to refine dosing regimens and support precision approaches, large-scale clinical outcome studies remain limited. For the practicing clinician, current recommendations in advanced preclinical MMVD (ACVIM stage B2) emphasize the use of pimobendan and critical weighing of potential pros and cons of RAAS inhibition. In symptomatic disease, the evidence-based standard of care is a synergistic combination of loop diuretics, pimobendan, and multimodal RAAS blockade. Looking forward, the incorporation of novel drug classes and individualized medicine may provide further gains in survival and quality of life. Continued clinical research will be essential to fill existing gaps and to ensure that therapy for canine MMVD is both evidence-based and optimized for individual patients.
Author Contributions
All authors contributed equally to this manuscript.
Conflicts of Interest
JPM has received consulting fees from Ceva Santé Animale, Dechra Ltd., and Boehringer Ingelheim. JLW has received consulting fees from Ceva Sante Animale. JAS operates a cardiac genetics testing service at North Carolina State University that offers pharmacogenetic profiling relative to some drugs discussed.
Declaration of Generative AI in Scientific Writing
ChatGPT-5.2 (OpenAI, 2025) was used to assist in drafting and improving the grammar of this manuscript. Its use was limited to enhancing readability and supporting the writing process, without generating new data, analyses or conclusions. Use of AI assistance is disclosed in line with prevailing authorship and publication-ethics guidance from the Committee on Publication Ethics (COPE (Committee on Publication Ethics. COPE Core Practices. COPE; 2017. Updated regularly. Available from: https://publicationethics.org.)) and the International Committee of Medical Journal Editors (ICMJE (International Committee of Medical Journal Editors. Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals. ICMJE; updated 2024. Available from: https://www.icmje.org.)). All AI-generated text was reviewed and edited by the authors, who take full responsibility for the final content of the publication.
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