Cardiology Objectives Flashcards
(35 cards)
Lecture 8
Formulate a differential diagnosis for syncope in dogs.
what about left basilar systolic heart murmurs?
Cardiac
* Tachyarrhythmia
* Bradyarrhythmia
* Low CO
Neurogenic
* Reflex-mediated or situational
Exertional syncope
Cyanotic heart disease
Drug-related
Hyperviscosity
- Aortic Stenosis
- (Subvalvular
- Valvular
- Mass obstruction)
- Functional
- (Elevated outflow velocity
- Anemia
- Thyrotoxicosis
- Pyrexia)
- Pulmonary valve stenosis
- (Congenital
- Secondary to increased flow (ASD))
Lecture 8
Characterize the diagnostic work-up for a dog with syncope. How would you prioritze testing?
- Blood Pressure
- Electrocardiogram
- Echocardiogram
- Bloodwork - CBC & Chemistry (+/- cardiac troponin I)
- Splenic ultrasound
- +/- Holter or Event Monitor
- +/- Thoracic radiographs
- (FNA of dermal masses)
Lecture 8
Describe the electrocardiographic features of ventricular
tachycardia. How do you determine from which ventricle a PVC is likely originating?
PVCs have a QRS that is wider and much different in appearance than the sinus complex
Starts in RV: depolarization along lead II; positive R
Starts in LV: depolarization direction oppositie lead II; negative S.
Lecture 8
Know the first line therapy for acute in-hospital treatment of ventricular tachycardia. At-home therapy options include…?
- Intravenous antiarrhythmics
– Lidocaine (sodium channel blocker), procainamide, amiodarone - Oral antiarrhythmics
– Sotalol
– Amiodarone
– Mexiletine
Lecture 8
List 5 categories/causes of ventricular arrhythmias in dogs.
- Heart disease
– Cardiomyopathy, myocarditis, etc. - Endocrine / Metabolic
– Thyroid excess, hypokalemia, etc. - Autonomic imbalance
– Elevated sympathetic tone - Drugs/Toxins
– Digoxin, cocaine, etc. - Systemic Issues
– Splenic disease, GDV, sepsis, DIC, etc.
Lecture 9
What is the most common form of congenital heart disease in the dog?
in the cat?
PDA
VSD
VSD was googled
lecture 9
List 5 differentials for a loud systolic heart murmur in a puppy. Where
would the heart murmur be loudest for each differential?
- Subaortic stenosis
– Left heart base, poor femoral pulse - Pulmonary valve stenosis
– Left heart base, normal pulse - Ventricular septal defect
– Right thorax - Tricuspid valve dysplasia – regurgitation
– Right apex - Mitral valve dysplasia – regurgitation
– Left apex
lecture 9
Characterize the auscultatory features of an innocent/functional heart murmur.
Decreased blood viscosity, increased velocity from stress or athleticism, or unknown causes can all
result in an innocent heart murmur. Innocent or physiologic heart murmur often have characteristics that differ
from pathologic murmurs – innocent murmurs may be sensitive (changes with position / respiration), of short
duration (early systolic), single (no associated clicks/gallops), small (limited to a small area, does not radiate), soft (low amplitude), and systolic in timing. These six ‘S’s can help to decide if a murmur is of pressing concern or can
be monitored less intensively.
from spring 24 cardio lectures
lecture 9
Discuss the diagnostic strategy for evaluating a young dog or cat with a
loud heart murmur
- Thoracic radiographs
- Echocardiogram
- Blood pressure
- +/- Bloodwork
lecture 10
List differential diagnoses for a dog that is coughing.
§ Laryngeal disease
§ Tracheal disease (tracheal or bronchial
collapse)
§ Hilar lymphadenopathy
§ Left atrial enlargement, bronchial compression
§ Heart base mass or parenchymal neoplasia
§ Airway disease/Chronic bronchitis
§ Pneumonia
§ Congestive heart failure
§ Heartworm disease
lecture 10
What diagnostics may be helpful to further investigate the
cause of the cough?
THORACIC
RADIOGRAPHS
THORACIC
POCUS
+/- BLOOD
GAS
+/- ECHO
additional diagnostics for PH:
§ CBC, Chemistry panel, UA
§ Coagulation profile
§ Heartworm test
§ (Full assessment for possibility of hypercoagulable state)
§ Thoracic CT
§ Bronchoscopy
lecture 10
What are causes of pulmonary hypertension?
increased pulmonary blood flow
increased pulmonary vascular resistance
increased pulmonary venous pressure
- Pulmonary arterial hypertension
a) Idiopathic, heritable, drugs/toxins
b) Congenital cardiac shunts - PH due to left heart disease
- PH due to respiratory disease, hypoxia, or both
- PH due to pulmonary thromboemboli (PTE)
- Parasitic disease (heartworm)
- Multifactorial causes or masses compressing PAs
More on PH due to respiratory disease
(Group 3)
§ Chronic obstructive airway disorders
§ Tracheal or mainstem bronchial collapse
§ Bronchomalacia
§ Primary pulmonary parenchymal disease
§ Interstitial lung disease
§ Infectious pneumonia
§ Diffuse pulmonary neoplasia
§ Obstructive sleep apnea
§ Chronic exposure to high altitude
lecture 10
Describe treatment strategies for a patient with pulmonary
hypertension.
§ Sildenafil or tadalafil
§ Phosphodiesterase 5 Inhibitor (PDE5 I)
§ Vasodilation of pulmonary arteries
§ 1-3 mg/kg PO q8hrs (sildenafil)
§ 1-2 mg/kg PO q24hrs (tadalafil)
§ Oxygen supplementation
§ Potent vasodilator
§ Sedation (butorphanol 0.2mg/kg IV or IM)
§ +/- Pimobendan (support right heart function)
§ Phosphodiesterase 3 Inhibitor (PDE3 I)
§ 0.25-0.3 mg/kg PO q12hrs
§ If group 2 – treat left heart disease
§ If group 3 - respiratory disease, hypoxia
§ Cough suppressants – hydrocodone
§ Treat secondary infection
§ Steroids
§ If group 4 – PTE
§ Tissue plasminogen activator (TPA)
§ Anticoagulants – heparin, apixaban,
rivaroxaban
§ Anti-platelet - clopidogrel
lecture 11
Describe abnormal physical exam findings that raise suspicion for
cardiomyopathy in the cat. What is a gallop sound and what is its
significance?
Pleural effusion
Gallop sound
Tachypnea
Weight loss
Gallop sound
◦ S3 or S4 heart sound audible
◦ S3 – vibration of ventricular walls during active
ventricular filling
◦ S4 – final ventricular filling by atrial contraction
in a poorly compliant ventricle
◦ Differentiate from systolic clicks and
split heart sounds
lecture 11
What diagnostics may you consider in a cat in respiratory distress in
which cardiac disease is suspected?
◦ Initial:
◦ Thoracic POCUS
◦ Consider point-of-care NTproBNP
◦ When stable:
◦ Thoracic radiographs
◦ Echocardiogram
◦ Bloodwork
◦ Blood pressure
consider a thoracocentesis if cat is in crisis
lecture 11
List three common causes of left ventricular concentric hypertrophy
in the cat.
HYPERTHYROIDISM
SYSTEMIC HYPERTENSION
PRIMARY HYPERTROPHIC
CARDIOMYOPATHY
lecture 11
What is NT-proBNP and how do you interpret an elevated value?
◦ N-terminal pro B-type natriuretic peptide
◦ BNP is a hormone secreted by cardiomyocytes
that causes renal and sodium loss, as well as
vasodilation
◦ Production and excretion is increased in response
to stretch of the heart
lecture 11
Be familiar with the staging of feline cardiomyopathy and treatment
for asymptomatic cats and cats in congestive heart failure (acute
and chronic therapy).
Stage A: no treatment, +/- monitor
Stage B1: no treatment, +/- atenolol
therapy if documented dynamic left ventricular outflow tract obstruction (DLVOTO)
Stage B2: * Consider clopidogrel
* +/- antiarrhythmics (atenolol or
sotalol) if concurrent ventricular arrhythmias
Stage C (CURRENT/PREVIOUS CHF OR ATE):
◦ Acute decompensated HF
◦ Furosemide
◦ 1-2mg/kg boluses IM or IV or
CRI
◦ Supplementary oxygen
◦ Sedation (butorphanol)
◦ +/- thoracocentesis
◦ Chronic heart failure
◦ Furosemide (1-2mg/kg PO
q12hrs)
◦ Titrated to maintain resting RR
<30 breaths per minute
◦ Clopidogrel (18.75mg/cat
PO q24hrs)
◦ Can be given in empty gelatin
capsule due to bitter taste
◦ +/- ACE inhibitor
◦ Diet low in sodium
Stage D: * If furosemide dose
> 6mg/kg/day PO, consider torsemide
(0.1-0.2 mg/kg PO
q24hrs)
* +/- spironolactone (1-2mg/kg PO q12-24hrs)
* Monitor for facial dermatitis
* +/- pimobendan if systolic dysfunction present
lecture 11
Discuss owner education and monitoring of cats with CHF.
Monitoring at home: Most important for owners to monitor RESTING or SLEEPING respiratory rate at
home (Ideally <30 breaths per min)
Also monitor for increased respiratory effort, syncope, inappetence, hiding, paresis or paralysis
Rechecks:
Stage B1
Monitored annually
Stage B2
* q6-12 months
*Consider effect of stress on patient
Stage C
CHF**
* 3-10 days after discharge from hospital
* q2-4 months, but consider effect of stress on
patient
** ATE
* 3-10 days after discharge from hospital
* 2 weeks after discharge to recheck for distal
limb necrosis
* q1-3 months but consider effect of stress on
patient
lecture 12
Describe the pathophysiology of feline aortic thromboembolism.
Thrombus originates in left heart and
dislodges to systemic arterial system
¬ Thromboembolism to ≥ 1 limb
¬ Most commonly associated with
cardiomyopathy, although cardiac disease
not present in all cats
¬ rarely associated with pulmonary
neoplasia
Poor prognostic indicators:
¬ Hypothermia
¬ ≥2 limbs affected
¬ Absence of motor function
¬ Bradycardia
¬ CHF
lecture 12
What are 5 physical examination findings for a patient with FATE?
5 P’s!!
¬Pulselessness
¬ Pallor
¬ Pain
¬Paresis
¬Polar or poikilothermia
(cold)
Other tools to diagnose?
¬ Lactate and glucose on affected limb
¬ Lack of Doppler BP
¬ Increased creatinine kinase (CK) (and AST/ALT)
¬ With ATE:
¬ Glucose decreases
¬ Lactate increases
lecture 12
What diagnostics may be helpful in diagnosing FATE?
¬ Lactate and glucose on affected limb
¬ Lack of Doppler BP
¬ Increased creatinine kinase (CK) (and AST/ALT)
¬ With ATE:
¬ Glucose decreases
¬ Lactate increases
lecture 12
What treatment strategies are used in the setting of FATE?
STAGE C (ATE)
¬ Analgesia is PRIORITY
¬ Fentanyl, hydromorphone, or methadone
Anti-thrombotic therapy
¬ Low-molecular weight heparin (enoxaparin SQ)
¬ Unfractionated heparin
¬ Oral factor Xa inhibitor (PO) – apixaban or rivaroxaban $$
Anti-platelet therapy
¬ Clopidogrel as soon as cat can tolerate oral meds
Other therapies
¬ Sedation or anxiolytics
¬ Rule out CHF
¬ Treat if in CHF
¬ Caution to mistake tachypnea due to pain for CHF
¬ Careful to not make azotemic
Thrombolytic drug therapy is controversial (TPA tissue plasminogen
activator)
¬ Not recommended by ACVIM consensus statement
¬ Some may advocate in acute setting (<6 hours since event)
Confirm ATE
¬ Diagnostics such as cardiac POCUS or echocardiogram
lecture 12
What is the prognosis for patients with FATE?
Poor
¬ Studies suggest ~1/3 of cats presenting to a University
hospital will be euthanized, 1/3 of cats will succumb to
disease, and 1/3 will live through event
If severe cardiac disease, overall prognosis post-ATE is
poor
Can consider 24-72 hours of hospitalization if owners are aware of risks
Patient will be at risk for future ATE
