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Others have hypothyroidism, polycystic ovary syndrome, or insulin resistance that creates metabolic resistance despite appetite suppression

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In addition, recently published reports have found that in some breeds, healthy dogs with normal-sized hearts may have left atrium-to-aortic root ratios (LA:Ao) significantly higher than 1.6.* There is evidence from prior veterinary research studies that premature treatment with pimobendan of dogs may accelerate the symptoms of MVD, including increased regurgitation of blood through the mitral valve, deterioration of the chordae tendineae, and enlargement of the left side of the heart

That is a maximum C-rating of 4