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Some dogs diagnosed with heart failure for the first time may have severe clinical signs requiring aggressive therapy (e.g,, with additional afterload reducers or temporary ventilatory assistance) that more typically would be reserved for those with refractory disease (see Stage D)." (So, Stage C means the dog is or has been in heart failure but drugs are enabling the heart to compensate for that failure.) " Stage D refers to patients with end-stage disease with clinical signs of heart failure caused by CVHD [MVD]that are refractory to 'standard therapy' (defined later in this document)