Exam 4 Flashcards
1
Q
Heart Sounds
A
o S1 – mitral & tricuspid – longer lower pitch
o S2 – aortic & pulmonic – higher shorter pitch
o Gallop – S3 & 4 – abnormal in SA
2
Q
Describe Murmurs
A
o Point of max intensity (loudest or easiest to feel)
o Systolic, diastolic, continuous
o Radiation
o Pitch: harsh vs musical
o Grade
3
Q
Grading Murmurs
A
o 1/6 – intermittent in one valve area
o 2/6 - consistent in one valve area
o 3/6 – multiple vLVE AREAS
o 4/6 – multiple valve ares & louder than 3
o 5/6 – palpable thrill
o 6/6 – can hear w/o stethoscope
4
Q
Puppy Murmur
A
o Normal puppies can have 1-2/6
o 1-2/6 should go away
o If becomes 3/6 or greater -> send for echo
5
Q
Causes For Physiologic Murmurs
A
o Anemia
o Hyperthyroidism
o Fever
o Breed (boxers)
6
Q
Gallop Vs Click
A
Ventricular gallop
* S3 Diastole
* Due to high atrial P + poorly compliant ventricle
* Normal in horses & cattle
Atrial gallop
* S4 Diastole
* Due to increased atrial contraction P
Clicks
* Systole
* Due to mitral and tricuspid prolapse
7
Q
Pulsus Paradoxus
A
o Pericardial dz w/ tamponde
o Decrease in strength of pulse during inspiration
8
Q
Bounding Pulses
A
o Exercise, excitement, stress
o Early shock
o Aortic insufficiency
o L to R patent ductus arterisosus
o Hyperthyroidism
9
Q
Weak Arterial Pulse
A
o Poor perfusion
o Shock
o Heart failure
o Aortic stenosis
10
Q
Affects of Heart Failure on Heart Rate
A
o HR is Constant battle between sympathetic and parasympathetic tone
o Heart failure increases sympathetic tone
->
o Increased vagal tone
11
Q
Systolic Vs Diastolic Failure
A
Systolic
* Impaired contractility
* Valve leakage caused by degeneration (endocardiosis), valve infection (endocarditis), or congenital malformations
* Dilated cardiomyopathy (primary or genetic)
* Myocardial damage
* Volume recirculation caused by congenital defects (patent ductus arteriosus and ventricular septal defects)
* Primary tachyarrhythmias (supraventricular or ventricular)
Diastolic
* Impaired relaxation
* Chronic afterload elevation (systemic or pulmonary hypertension)
* Hypertrophic cardiomyopathy (primary or genetic)
* Pericardial disease (fluid accumulation or
constriction)
* pulmonic and aortic valve stenosis
(semilunar)
12
Q
Signs of Congestive Heart Failure in Dogs
A
- General weight gain
- SQ edema - rare
L sided
* Pulmonary edema
R sided
* Ascites
* Pleural effusion
* Pericardial effusion
13
Q
Signs of Low Output Failure
A
- Hypotension
- Hypothermia
- Bradycardia
- Cold extremities
- Pale mucous membranes
14
Q
Consequences of Decreased Stroke Volume
A
Remodeling
* eccentric hypertrophy (dilation) or concentric hypertrophy (thickening)
Elevated catecholamines
* increased HR, O2 consumption, & decreased time in diastole
Renal effects
* decreased perfusion -> upregulate RAAS -> increased afterload, renal fibrosis, fluid retention
15
Q
3 Results & Causes of Heart Remodeling
A
Eccentric (dilation)
* Valve regurgitation
* DCM
* Volume recirculation due to congenital defects
* Myocardial damage
Concentric (thickening)
* Valve narrowing
* Chronic increased afterload
* HCM
Cell death & fibrosis
16
Q
Mechanisms Behind Arrhythmias
A
Increased Automaticity
* Higher rate of firing of nodes
Re-entry
* Abnormal tissue allows conduction do go into circuit rather than through AV node
Abnormal Ca cycling
* Weird spike of Ca
* Early or delayed repolarizations
17
Q
Frequency of Echo Probe
A
o High frequency – better resolution
o Low frequency – better penetration
18
Q
Color Doppler
A
o BART Map
o Blue away
o Red toward
o Green turbulence
o Nyquist level high -> less turbulence shown
19
Q
Continuous Vs Pulse Wave Doppler
A
Continuous Wave Doppler
o Sends continuous Doppler signal
o quantify maximum velocity along one line.
o needed for congenital lesions and to determine velocity of valve regurgitation
Pulse Wave Doppler
o assess or pulse a single area and determine velocity and time of waves in a defined area
o Only able to determine low velocity (usually <1.5 m/s)
o Used to assess diastolic function and others
20
Q
Assessment of Systolic Vs Diastolic Function w/ Echocardiography
A
Systolic Function
o Fraction shortening %
o Ejection fraction %
Diatsolic Function
o Mitral inflow E & A waves
o Isovolumetric relaxation time
21
Q
Measuring Chamber Dimensions on Echo
A
o L atrium to aorta ratio
o R atrium & ventricle subjectively compared to L
22
Q
What should be on an echo report
A
o chamber size and if enlarged the severity
o Left ventricular systolic function & maybe diastolic
o valve anatomy and any regurgitation or stenosis.
23
Q
Natriuretic Peptide; What is it, Use, Tests, Physiological Contraindications
A
o B-Type natriuretic peptide (BNP)
o Originally found in the pig brain
Use
* Atrial and ventricular (more ventricular) myocytes in response to increase volume or stretch
* Used to diagnose cardiomyopathies
Tests
* IDEXX has Snap for CATS
* send out test for dogs asymptomatic
* Bionate in house machine
Physiological Contrainidications
* Decreased by increased thyroid
* renal issues cause odd values
24
Q
Marker for Myocyte Injury; What is it, Use, Why use, Physiological Contraindications
A
o Troponin = “ALT” of the heart
Use
* Myocardial injury from myocarditis, ischemia, cardiomyopathy
* Release into blood
Why to Use
* Unexplained arrhythmias -> myocarditis
* Abnormal appearing myocardium on echocardiogram -> myocarditis or neoplasia
Physiological Contrainidications
* Other dz can elevate Triponin
25
Why test Taurine Levels
o Taurine deficiency can lead to DCM
o Especially think of cockerspaniels
26
Why Test Carnitine Levels
o Decreased blood levels associated w/ DCM in boxers
o Can treat w/ L-carnitine
27
Genetic Testing for HCM
o Ragdolls and Maine Coons
o Phenotype does not equal genotype
o Helpful in breeding animals
o Current test are available at NC state and UC Davis.
o Blood or mucosal swab
28
Genetic Testing for Boxer ARVC & Doberman DCM
o Helpful in breeding animals.
o Current test are available at NC state
o Blood or mucosal swab.
o Striatin (Boxer)
o PDK 4 (Dobermans)
29
Things to Pay Attention to When Looking at Thoracic Rads
o Cardiac size and if chambers are enlarged
o Pulmonary vessels size
o Pulmonary pattern (interstitial, bronchial, alveolar)
o Great vessels and mediastinal structures
30
Views Needed for Thoracic Radiographs
o Need 2 views
o VD for lungs
o DV for cardiac structures
31
L Atrial & Ventricular Enlargement on Rads
Lateral
* “tall” heart – L ventricle enlargement
* Loss of caudal waist – L atrium enlargement
DV
* Widening of the left and right bronchus (bow legged cowboy) – L atrial enlargement
* “3 O clock” enlargement – L auricle (cats & heart dz)
* “4-6 O clock” enlargement – L ventricle
32
R Atrial & Ventricular Enlargement on Rads
DV
* “reverse D” on R side – RV enlargement or PA enlargement
* buldge at “9 O clock” – R atrial enlargement
33
Aortic Buldge
o Small buldge at “1-3 O clock”
34
Vertebral Heart Score & Pulmonary Vessel Size
o Draw line from carina to base of heart – length
o Draw Line horizontally - width
o # of vertebral bodies width + length = VHS (should be less than 10.5)
o Vessels should not be wider than 9th rib
35
Alveolar Vs Interstitial Vs Bronchial Pattern
Alveolar Pattern
o completely whited out
o Silhouette sign - can’t see border of heart
Interstitial Pattern
o More white than should be
o Still see cardiac silhouette
Bronchial Pattern
o Round structures all throughout lungs
36
Diagnosing L sided CHF in Dogs Vs Cats
Dogs
o L atrial enlargement +
o Pulmonary venous congestion +
o Pulmonary infiltrates consistent w/ CHF (perihilar region)
Cats
o Pulmonary edema (not always perihilar)
o Pleural effusion
o Or both
37
Waves on an ECG
P wave
* Atrial depolarization
QRS
* Depolarization of ventricles
T
* Ventricular recovery
38
Info on an ECG
o Heart rate
o Amplitude and duration changes of P wave
and QRS deflection
o T wave changes
o Mean Electrical Axis (MEA)
o Detection and classification of ectopic beats**
o Detection and classify the etiology of
brady/tachyarrhythmias
39
Telemetry ECG
o ECG info sent to central computer
o 24-48hrs of data
Used for monitoring
* post-surgery
* response to anti-arrhythmics
* metabolic or endocrine dz
40
Things to Remember when Recording ECG
o Best position is R lateral recumbancy
o Use highest voltage
Difficulty seeing P waves?
* Increase amplitude
* Turn off filter
41
Sinus bradycardia; Causes, Treatment
Due to
* GI dz
* Resp dz
* Ocular dz
* Neuro dz
Fix
* Atropine or glycopyrrolate if occurring under anesthesia
42
Sinus tachycardia; Ventricular or supra? Causes
o Supraventricular arrhythmia
Due to
* Pain
* Anemia
* Dehydration
43
1st Degree AV Block
o increased length between P and QRS
o normal or high vagal tone
o can be secondary to digoxin, diltiazem, beta blockers
44
2nd Degree AV Block
o more P waves than QRS
o high vagal tone
o treat w/ atropine
45
Atropine Response Test
o atropine SQ or IM
o wait 30 mins
Positive response =
o double original rate or >140 BPM
OR
o Blocked P waves go away
46
High Grade 2nd Degree AV Block
o MANY more P waves than QRS
o Try atropine
o Usually need pacemaker
47
3rd Degree AV Block
o more P waves than QRS
o Ps seem independent of QRS
o Try atropine
o need pacemaker urgently if syncope
o Junctional or ventricular escape rhythm
o Syncope can occur
48
Sick Sinus Syndrome
o Long pause w/ no beats
o And escape QRS beats
o Need pacemaker
o May be associated w/ tachycardia
o Sinus node problem w/ lack of escape beats
49
Atrial Standstill or Sinoventricular Rhythm
o No P waves
o Check K levels (often high)
o If K normal -> atrial cardiomyopathy
50
Atrial Standstill Hyperkalemia Treatment
Protect myocardium while fixing underlying cause
o Ca gluconate (protect myocardium)
Fix Hyperkalemia
o Dextrose
o Insulin
o Fluid for diuresis
51
Atrial Standstill Vs Sick Sinus Syndrome
Atrial Standstill
* Consistent lack of P
Sick Sinus
* Intermittent lack of P
52
Premature Ventricular Complexes; Treatment
o Treat depending on many factors
o Beat too soon near previous beat
Treatment
* SPAM
* Sotalol
* Procainamide
* Atenolol
* Amiodarone
* Mexiletine
53
When to Avoid Beta Blockers
o Decreased systolic function
o CHF
54
Ventricular Tachycardia; What does it look like, treatment
o P-QRS-T present but fast and irregularly placed
Treatment
* Lidocaine 2 mg/kg in dogs bolus -> then CRI
* Amidoarone
* Procainamide
* Esmolol
* Electrical cardioversion
55
Atrial or Supraventricular Complex; What does it look like, What does it mean, Control Rate, Suppress Ectopic Focus
o Looks normal but P-QRS-T comes to close to previous one
o Unlikely to treat single APCs
o treat high frequency
or complexity
o Look for structural heart disease
o Could be precursor to worsening arrhythmia ( A fib)
Control Rate
* DAD
* Digoxin
* Atenolol
* Diltiazem
Suppress Ectopic Focus
* Sotalol
* Procainamide
56
Atrial Fibrilation; What does it look like? Control Rate, Control Rythm
* No consistent P waves
* Irregular QRS-QRS intervals
* Often Tachycardia w/ structural heart dz
Control Rate
* DAD
* Digoxin
* Atenolol
* Diltiazem
Control Rhythm
* Quinidine (horses)
* Sotalol
* Amiodarone
* Electrical cardioversion
57
Atrial Flutter; What does it look like? Treatment
o Many P waves quickly in a row
o Type of supraventricular tachycardia
o Irregular or regular
Treatment
* DAD
* Digoxin
* Atenolol
* Diltiazem
58
Bundle Branch Block; What does it look like?
* L or R
* Look for structural dz
* Progression to complete block vs normal variant
* P & QRS waves present
* Happen one right after another w/ no space
59
Vetricular Fibrilation; What does it look like? Treatment.
o Crazy ECG
o Are leads attached?
o Need to defibrillate
60
Electrical Alterans; What does it look like? Why?
o QRS waves stair step in height
o Can be secondary to pericardial effusion
61
Idioventricular Rhythm; What does it look like? Cause, Treatment
o Normal P-QRS-T waves with occasional weird/wide QRS w/o P & T
o Rate 120-160
Cause
* GDV, splenic dz, septic conditions
Treatment
* Pain control
* Check K levels
62
ST Segment Depression or Elevation; What does it look like? Cause
o Large pause btwn QRS & T
o Myocardial ischemia
63
Valve Degeneration; Pathophysiology, Most common valves affected
Pathophysiology
o expansion of extracellular matrix with glycosaminoglycans and proteoglycans
o Valvular interstitial cell alteration
o Attenuation or loss of the collagen-laden fibrosa layer.
o Malformation of the mitral apparatus, biomechanical dysfunction, and mitral incompetence
o Leakage & regurgitation
Most Common valves
o Mitral > tricuspid > aortic
o Mitral & tricuspid often together
64
Valve Degeneration; Auscultation, Clinical Signs, Diagnosis
Auscultation
o mid systolic click
o systolic murmur
o maybe arrhythmia
Clinical Signs
o Asymptomatic
o Respiratory distress
o Cough
o Syncope
o Exercise intolerance
Diagnosis
o Rads look for bronchus compression, fluid in luns, L sided enlargement
o Echo to assess cause & severity
o Echo to determine concurrent pulmonary hypertension
65
Stage A Valve Degeneration
o High risk
o No structural abnormalities
o No treatment
66
Stage B1 Valve Degeneration
o Asymptomatic
o Mild/no cardiac enlargement
o No treatment
o Recheck in 6mo
67
Stage B2 Valve Degeneration
o Asymptomatic
o significant cardiac enlargement
Treatment
* Pimobendan
* ACE inhibitor IF systemic hypertension
68
Stage B3 Valve Degeneration
o Symptomatic due to bronchus compression (cough)
o No CHF
Treatment
* ACE inhibitor
* Pimobendan
* Amlodipine IF still have hypertension w/ ACE inhibitor
* Cough suppression (hydrocodone)
69
Stage C & D Valve Degeneration
Stage C
o Symptomatic
o Mild CHF
Stage D
o Symptomatic
o Severe CHF
Treatment
* Furosemide (most important)
* ACE inhibitor
* Pimobendan
* Spironolactone (avoid hypokalemia & cardioprotection)
70
Surgical Option for Valve Degeneration
o Vclamp
o Very few surgeons but have good success rate
o Very expensive
71
Other considerations for Valve Degeneration
o Low Na diet
o Torsemide – 8x stronger diuretic than furosemide
72
Valve Degeneration Complications other than CHF
o Atrial Arrhythmias
o Pulmonary hypertension
o Ruptured chordal structures
o L atrial tears
73
Atrial Arrhythmias; When to treat, Treatment
o Common w/ L atrial dilation
o Treat if Afib or significant runs of tachycardia
Treatment
* Digoxin if w/ CHF
* Diltiazem if not CHF
74
Treatment for Pulmonary Hypertension
o Treat underlying pulmonary or cardiac dz
o Vasodilation w/ Sildenafil
o Pimobendan for (+)ionotropy
75
L atrial tear; Pathophysiology, Treatment
Pathophysiology
* Jet lesions from regurgitation
* Weakening of wall & tear
Treatment
* Can do pericardiocentesis
* No surgery
* Poor prognosis
76
CHF; Causes, Hospital Treatment, AT-Home Treatment
Causes
o Vol overload
o P overload
o Decreased ventricular compliance
o Myocardial failure
Hospital Treatment
o Furosemide & Nitroglycerine ointment to reduce pre-load
o O2
o Pimobendan
o NO FLUIDS
o Butorphanol for sedation
o Avoid beta blockers
At-home Treatment
o furosemide - preload
o Ace Inhibitor - afterload*
o Pimobendan - Inodilator
o +/- Spironolactone –preload*
o Reduce dietary sodium– preload
o Fish oils
o Can add beta blockers after CHF resolved -> Antiarrhythmic
o ADD Clopidogrel for cats
77
Clinical Signs of Backward Failure
Left Failure
* Pulmonary edema
* Dyspnea
* Cough
* Pulmonary crackles/wheezes
Right Failure
* Abdominal distension from ascites and/or hepatomegaly
* Pleural effusion
* Muffled heart & lung sound
* Dyspnea
* SQ edema (rare)
78
Forward Failure; Clinical Signs, Diagnosis
Clinical Signs
* Hypotension
* Hypothermia
* Bradycardia
* Decreased perfusion
Diagnosis
* RADS***
* Echo
* BP
* BNP in cats**
79
What do you see on Rads in L Sided CHF
o Enlarged left atrium
o Pulmonary venous congestion (normal if on diuretics)
o Pulmonary infiltrates consistent with left sided CHF
o Pleural effusion in cats
80
What is cardiogenic shock; Treatment
o Hypotension +
o Hypothermia +
o Bradycardia
Treatment
* Dobutamine CRI
81
Acute CHF Treatment
o Nitroprusside CRI when normotensive
82
What to Monitor During Treatment for CHF
o Dehydration
o potassium
o Renal function (BUN/Creatinine)
o Arrhythmias (tachycardia)
o Signs of recurring CHF
o Chest rads
o Respiratory rate
o BP (drug induced hypotension)
83
Feline Cardiomyopathy; Clinical Signs, Diagnosis
Clinical Signs
o Asymptomatic
o Respiratory distress
o Hind limb paralysis
o Syncope/sudden death
Diagnosis
o Auscultation
o ECG (if arrhythmia)
o Chest rads
o BNP
o Blood pressure
o Thyroid testing
o Genetic testing
o Echo (definitive antemortem)
84
Feline Cardiomyopathy; Auscultation, ECG, Chest Rad Findings
Auscultation findings
o Murmur
o Gallop (hear S4)
o Arrhythmia
o Tachycardia (maybe)
o Crackles/wheezes
ECG Findings
o Ventricular arrhythmias
o Atrial Arrhythmias
o P wave amplitude and duration changes
o R wave amplitude changes
o Left anterior fasicular block
o No changes
Chest Rad Findings
o Left atrial enlargement (often not obvious)
o Left auricular enlargement
o Left ventricular enlargement
o Right sided enlargement for ARVC
o Pulmonary venous enlargement
o Interstitial to alveolar infiltrates without classic distribution like dogs
o Pleural effusion (maybe chylous)
85
Feline Cardiomyopathy & BNP
o Released from both ventricles and atrium during stretch (primarily ventricles).
o Elevation does not indicate the etiology of the cardiac disease.
o Levels affected by renal disease, hypertension, and thyroid level.
SNAP BNP
* 100 pmol/L
* use in symptomatic patients
* use in conjunction w/ rads
86
Feline Cardiomyopathy & Thyroid Testing
o Look for in older animals
o Hyper thyroid ->
o systolic hypertension ->
o tachycardia ->
o ventricular hypertrophy
87
Feline Cardiomyopathy & Blood Pressure
o Cardiac disease does not cause systemic hypertension.
o Hypertension can cause heart disease.
o Systemic hypertension needs to be ruled out as cause of ventricular hypertrophy.
o BP should be checked before starting medications (ACE inhibitors)
88
Feline Cardiomyopathy & Genetic Testing for HCM
o Ragdolls and Maine Coons
o Phenotype does not equal genotype
o Breeder send out.
o Blood or mucosal swab
89
HCM Vs DCM Vs RCM Vs UCM
HCM
o Thickened L ventricle free wall and/or IVS
o +/- L atrial dilation
o can be obstructive due to mitral valve being pulled toward septum
DCM
o L atrial & ventricular dilation
o Poor L ventricle systolic function
RCM
o Normal wall thickness
o Normal L ventricle systolic function
o Bi-atrial dilation
UCM (unspecified)
o Doe not fit into any 1 category
90
Clinical Signs of Canine ARVC & DCM
ARVC
* Asymptomatic
* Exercise intolerance
* Syncope/sudden death
DCM
* Asymptomatic
* Respiratory distress, coughing
* Exercise intolerance
* Syncope/sudden death
* Ascites
91
Auscultation of Canine ARVC & DCM
ARVC
* Soft S1 and S2 sounds
* Arrhythmia
* Tachycardia
DCM
* Murmur (often low grade)
* Soft S1 and S2 sounds
* Arrhythmia
* Tachycardia
* Crackles/wheezes
92
ECG Findings of Canine Cardiomyopathies
DCM
* Ventricular arrhythmias
* Atrial or supraventricular arrhythmias
* Afib (most common)
* P wave amplitude & duration changes
Atrial Cardiomyopathies
* No P waves (atrial stand-still)
Early Dz
* No changes
93
Chest Rad Findings of Canine ARVC & DCM
DCM
* Left atrial & ventricular enlargement
* Pulmonary venous enlargement
* Interstitial to alveolar infiltrates
ARVC
* Often normal
* May have R atrial & ventricular enlargement
94
Pro BNP, Triponin, & Taurine Diagnosis of Canine Cardiomyopathies
Pro BNP
o Inexpensive
o Not helpful in boxers
o Still need follow up echo
Triponin
o Not specific for primary heart dz
o May show for boxers & other dogs
Taurine
o Taurine deficiency may happen in cockerspaniels
95
Treatment for Feline HCM
Symptomatic
o ACE inhibitor
o Furosemide
o Anticoagulant
o No Diltiazem or Atenolol until out of CHF
Asymptomatic
o Atenolol
o Diltiazem (if lung issues)
o Anticoagulants (if atrial enlargement)
o Enalapril
o Nothing if everything is mild
96
Follow-up Care for Feline HCM
Asymptomatic
* Echo
CHF
* Rads
* Renal values
97
Anesthesia & Drug Use in Feline Cardiomyopathies
o Avoid Ketamine with HCM
o Judicious use of IV fluids
o Monitor BP, SPO2, and ECG
o Don’t use steroids
98
Subclinical DCM Treatment
o Enalapril or Benazapril
o Vetmedin
o Spironolactone
99
ARVC Treatment
o Base need for anti-arrhythmia therapy
o Sotalol, mexiletine or atenolol
o Fish oil
100
Atrial Cardiomyopathy Treatment
o Make sure no hyperkalemia
o Treat CHF if present
o Pacemaker implant
101
Pulmonic Stenosis; Types, Clinical Signs, Treatment
o Most common location in dogs is valvular.
o Valvular - fusion of the semilunar leaflets.
o Valve dysplasia – is common even with valve stenosis (hypoplastic annulus and valve thickening).
o Subvalvular and supravalvular less common.
Clinical Signs
* L basilar systolic murmur
* Severity of lesion correlates w/ murmur
* Normal pulse quality
Treatment
* Surgery - > open valve w/ balloon
* Atenolol before & after sx or instead of
102
R2A & Pulmonic Stenosis
o Not good surgical (balloon valvuloplasty) candidate
o Risk of rupture of coronary
o Seen in Boxers & bulldogs
103
PDA; Pathophysiology, Clinical Signs, Rads, Treatment
o Patent connection between main pulmonary artery and aorta
o Most common congenital heart defect in the dog
Pathophysiology
* Asymmetric muscle ->
* Incomplete closure of PDA
Clinical Signs
* Continuous murmur
* Hyperdynamic femoral pulses
Rads
* Tall & wide heart
* Larger -> higher urgency for sx
Treatment
* Surgical ligation or ductal occlusion
* W/o surgery left sided volume overload and heart failure
104
Ventricular Septal Defect; Who, Clinical Signs, Pathophysiology, Treatment
o Most common congenital lesion across species
Clinical Signs
* Systolic murmur right caudal sternal border
Pathophysiology
* Communication between R & L ventricle ->
* L sided volume overload due to majority of shunting in systole
* Paramembranous, muscular, or subpulmonic
Treatment
* Usually no surgery
* Bad shunts die early
* Consider pulmonic banding
105
Subaortic stenosis; Who, Clinical Signs, Pathophysiology, Treatment
o Common in dogs
Pathophysiology
* Valvular or supravalvular
Clinical Signs
* Often loud left basilar systolic murmur
* Severity correlates with intensity of murmur
* Weak pulses associated with rate of rise of systolic pressure
Treatment
* Not good candidate for balloon or open heart
* Beta blocker (atenolol) – moderate to severe
* Treat for CHF (ACE inhibitors, Furosemide, +/- pimo) when develops
* Pimobendan is contraindicated with obstructive lesions
106
Tricuspid Dysplasia; Who, Clinical Signs, Pathophysiology, Treatment
o Common in labs
Clinical Signs
* Right apical systolic murmur
* Supraventricular arrhythmias
Pathophysiology
* valve thickening
* shortened chordal structures
* abnormal valve opening (stenosis)
* tethering of leaflets
Treatment
* Furosemide
* Enalapril
* Pimobendan
107
Mitral Valve Dysplasia; Clinical Signs, Pathophysiology, Treatment
Pathophysiology
* Can be predominately regurgitation
* Can be predominately stenosis or both
* Valve thickening, shortened chordal structures, abnormal valve opening (stenosis), tethering of leaflets
Clinical Signs
* Systolic murmur can be vary in intensity - Left apex
Treatment
* Pimobendan and ACE inhibitor when volume overload (left atrium and ventricle)
* Treat CHF when develops
* Treat arrhythmias (supraventricular).
* Balloon valvuloplasty if stenosis
108
Atrial Septal Defects; Who, Clinical Signs, Pathophysiology, Treatment
o Common in poodles
Clinical Signs
* No to soft murmur
* Split S2
Pathophysiology
* R side volume overload
Treatment
* Closure w/ sandwich device
109
Reversed Congenital Defects; Clinical Signs, Pathophysiology, Treatment
Pathophysiology
* Increased pulmonary pressure can lead to R to L shunting
Clinical Signs
* Soft to no murmur
* Rear limb cyanosis & weakness (PDA)
* Dyspnea and exercise intolerance
Treatment
* Sx contraindicated in reverse (R to L) PDA
* Sildenafil, L-arginine & Pimobendan for pulmonary hypertension
110
Persistent R Aortic Arch; Clinical Signs, Diagnosis
Clinical Signs
* Polycythemia
* No patent blood flow
* GI regurgitation
Diagnosis
* Radiographs show aorta causing stenosis of esophagus
111
Factors in Tetralogy of Fallot
o Right ventricular hypertrophy
o Pulmonic stenosis
o VSD
o overriding aorta
112
Pericardial Dz; Clinical Signs, Physical Exam, ECG, Rads
Clinical Signs
o Collapse
o Weakness
o Dyspnea
o Cough in small dogs
o GI
Physical Exam
o Muffled heart sounds
o Muffled lung sounds (pleural effusion)
o Weak femoral pulses
o Pulsus paradoxus
o Tachypnea
o Ascites
ECG
o Ventricular ectopy
o Tall QRS – short QRS – tall QRS - etc
Rads
o Globoid heart
113
Pericardial Dz; Causes, Diagnosis, Treatment
Causes
o Idiopathic
o Hemangisarcoma
o Aortic body tumor
o CHF in cats
Diagnosis
o Pericardiocentesis on R side
o ECG to look for arrhythmias & make sure you’re not hitting heart
o Cytology
Treatment
o Laparoscopic of thoracotomy Pericardectomy (best for aortic body tumor)
o Chemo (best for hemangiosarcoma)
o Tranexamic acid – antifibronolytic
o Yunnan Baiyao – procoagulant (doesn’t work)
o Aminocaproic acid
114
Features of Aortic Body Tumor Vs Hemagiosarcoma Vs Mesothelioma Vs Idiopathic Pericardial Effusion
Aortic Body Tumors
o Characteristic on echo
o Brachicephalic breeds predisposed
Hemangiosarcoma
o Often R atrial/auricle
o May see in R ventricle & L heart
o Often diagnosed based on echo, location, breed, age
Mesothelioma
o Over diagnosed on cytology
Idiopathic Pericardial Effusion
o No underlying cause identified
o Hemorrhagic – just like neoplastic effusions
o Some require only single pericardiocentesis
o Some require multiple centesis or pericardectomy
115
Restrictive Pericardial Dz
o Caused by pericardial effusion
o Pericardectomy to avoid
116
Peritoneal Pericardial Diaphragmatic Hernia
o Not all need surgery**
o Not related to trauma**
o Signs related to organs herniated
o Abnormal fusion of the septum transversum
with the pleuroperitoneal folds
o ultrasound can be helpful to identify if organs herniated
117
Bacterial Endocarditis; Predisposing factors, Pathophysiology
Predisposing Factors
* Pre-existing valve damge
* Bacteremia
* Adherence
* Immunosuppression
* Subaortic stenosis
* Often L side & mitral > aortc
* Medium to large breed dogs
* Males > females
Pathophysiology
* Disruption of the valve lead to volume overload and even CHF
->
* Embolization of thrombi
->
* Deposition of immune complexes
->
* Aortic and mitral valves most common in small animals
118
Bacterial Endocarditis; Clinical Signs, Clin Path, ECG, Echo, Diagnosis
Clinical Signs
* Fever of unknown origin
* Chronic infections
* Recent corticosteroid administration
* Seizures
* Lameness
* Heart murmur
* CHF
* Hyperdynamic pulse
* thromboemboli
Clin Path
* Anemia
* Leukocytosis
* Thrombocytopenia
* Pyuria
* Proteinuria
* Hyperglobulinemia
* Azotemia
* Hypoalbuminemia
ECG
* Premature beats
* Complete AV block
Echo
* Vegetative growth
* Regurgitation
* L atrial or ventricular dilation
Diagnosis
* Blood culture (3 samples, 3 sites, 30 mins apart)
119
Bartonella Testing
o Likes to live on aortic valve (endocarditis)
o Culture enriched PCR
o Bartonella alpha-Proteobacteria growth medium (BAPGM)
120
Treatment of Bacterial Endocarditis
Resolve bacteremia and source of infection
* Long term antibiotics required (minimum6-8weeks).
* Ideally based on cultures
Treat cardiac complications
* Anti-arrhythmics
* Congestive heart failure (furosemide, ACE inhibitor, pimobendan, and spironolactone)
Treat embolization/immune complex complications
* Renal failure, seizures, immune mediate or septic arthritis
* Antithrombotics & anticoagulants not useful
121
Treatment of Bartonella
o Azithromycin - high intracellular concentrations
o Combo doxycycline, enrofloxacin, clavamox (clinical benefit seen)
o Gentamicin/aminoglycosides some consider ideal for initial therapy
o Relapses possible, it is questionable if ever cleared
122
Common Dz w/ Hypercoagulation & How to test for Hypercoagulation
Common Dzs w/ Hypercoagulation
o Heart Dz in cats
o Protein losing nephropathy
o Hyperadrenocorticism
o Immune mediated anemia
o Neoplasia
Testing Hypercoagulation
o Thromboelastography
o Sonoclot
o Antithrombin III levels
123
Symptoms of Thromboembolism
R heart
* Pulmonary thromboembolism -> respiratory issues
L heart
* Hind limb paralysis
* Forelimb paralysis
* Seizure
* Acute renal failure
124
Aortic Thromboembolism in Cats; Clinical Signs, Clin Path, Treatment
Clinical Signs
* Absent/reduced pulses
* Cold extremities
* Painful in first 24hrs
* Contracted gastrocnemius
* LMN deficits
Clin Path
* Elevated CK, ALT, AST
Treatment
* Opioids
* Maybe epidural
* External warming
* LMW Heparin & Clopidogrel prevent more clotting
* Treat CHF if present
* Low rate fluids if no CHF
* Echo
* Sx (unlikely due to anesthesia & reperfusion)
125
Reperfusion Injury
* Blood supply returns to tissue after period of ischemia ->
* Inflammation & oxidative damage to tissue ->
* Increased serum potassium levels
126
Target Organs & Conditions Related to Systemic Hypertension
Target Organs of Systemic Hypertension
o Brain/CNS
o Eyes
o Heart
o Kidneys
Conditions
o Blindness
o Hemorrhage (retinal)
o retinal detachment
o glaucoma
o seizures
o Accelerated renal deterioration
o Left ventricular hypertrophy - murmur
o Epistaxis
127
Values of Hypertension
o Dog > 180 mmHg, (systolic Doppler)
o Cat > 160 mmHg (systolic Doppler)
o MAP >145 mmHg (oscillometric)
128
Dzs Underlying Hypertension
o Cushing’s (dogs)
o Hyperthyroidism (cats)
o Pheochromocytoma
o Renal dz
129
How to take BP w/ Doppler
o Shave area of the leg where probe is to be placed, and use alcohol and ultrasound gel
->
o Cuff - 40% the circumference of leg ->
o Inflate cuff to 200 mmHg or until flow signal disappears, whichever is greater ->
o deflate at a rate of 2 mmHg/sec. until 1st audible flow signal is heard (Systolic BP)
o 5 measurements, in intervals of 30 seconds, then average
130
Acute Vs Chronic Treatment of Systemic Hypertension
Acute Treatment of Systemic Hypertension
o Na Nitroprusside CRI
o Hydralazine
o Amlodipine
Chronic Treatment of Systemic Hypertension
o Ace Inhibitors (especially with proteinuria)**
o Amlodipine**
o Maybe Angiotensin Receptor Blocker (Telmisartan is approved for cats)
o Maybe Beta blockers (not first line)
131
Acute and Chronic Causes of Pulmonary Hypertension
Acute
* Pulmonary embolism
* Hypoxia due to constriction
Chronic
* Chronic bronchitis
* Airway/tracheal collapse
* Chronic embolism
* Vascular injury
132
Pathophysiology of Pulmonary Hypertension
o Vasoconstriction
->
o Blood stasis
->
o Thrombosis ->
o Endothelial damage
->
o Inflammatory cells/ mediators
->
o Attenuation of peripheral vessels ->
o Dilation of proximal vessels ->
o Persistence of pulmonary pressures
133
Cor Pulmonale
o Elevation of pulmonary arterial P ->
o R ventricle P overload ->
o R ventricle concentric hypertrophy ->
o Systemic venous congestion ->
o R heart failure
134
Diagnosing Pulmonary Hypertension
o History of respiratory dz
o Abnormal lung sounds
o Jugular pulsations + hepatojugular reflux
o Loud, snappy S2 (or split S2)
o Tricuspid regurgitation
o Reverse D on rads
o Evidence on echo
135
Echo Signs of Pulmonary Hypertension
o Dilated +/- hypertrophied RV
o Poorly contracting RV
o Tricuspid regurgitation
o Pulmonary hypertension
o Leftward shift - IV septum
o Pulmonary artery dilation
o Thrombus in R atrium or R ventricle, or pulmonary artery
136
Treatment of Pulmonary Hypertension
o Find & treat underlying cause
o Reduce systemic oxygen consumption & improve O2 delivery
o Block alveolar hypoxic vasoconstriction
o Sildenafil! (Viagra)
137
Heartworm Dz; Where, Pathophysiology, Rad Findings, Diagnosis
o Mostly in SE
Pathophysiology
* Mosquito ->
* Adult worms live in the PAs
->
* Villous myointimal
proliferation ->
* typical lesion ->
* Resistance to pulmonary flow + vascular damage ->
* pulmonary hypertension
Rad Findings
* Enlarged pulmonary arteries (esp proximal)
* Enlarged R atrium, ventricle
* +/- interstitial opacitiy around pulmonary arteries
Diagnosis
* Antigen test (test of choice)
* Chest rads
* Echo
* ECG
138
Wolbachia
* Rickettsial intracellular, gram-negative
* Assists with D. immitis (heartworm) development
* Increases D. Immitis fecundity
* Pretreat with doxycycline to kill Wolbachia before heartworm tx
139
Complications Associated w/ Heartworm Dz
* Chronic hepatic congestion/ cirrhosis
* Glomerulonephritis (Ag-Ab complex)
* Renal amyloidosis
* Thromboembolic disease
* Anaphylaxis to dying worms
* Caval syndrome (very high worm burden)
140
Heartworm Pre-Treatment Staging
Stage 1
* No clinical signs
* Normal rads & clin path
Stage 2
* Occasional cough
* Mild fatigue
* Mild interstitial opacity
Stage 3
* Persistent respiratory symptoms
* Weight loss
* Diffuse perivascular & interstitial opacity
* Anemia
* Increased ALT/ALP
* Thrombocytopenia
* Proteinuria
Stage 4
* Acute collapse or critical condition +
* All signs of stage 3
* Vena caval syndrome
141
Vena Caval Syndrome
* Large heartworm burden
* Obstruction of right heart filling
* Acute Collapse
* Hemolytic Anemia
* DIC
142
Heartworm Treatment
“slow” kill method
* takes 2+ years
* monthly preventative dose of macrocyclic lactones
* Doxycycline 10mg/kg PO BID for 1 month every 3 months
“Fast” kill method
* adulticide therapy
* 1st dose melarsomine ->
* 2nd dose melarsomine 1month later ->
* 3rd dose melarsomine 24hrs after 2nd dose
143
Heartworm Prophylaxis
* Ivermectin PO
* Milbemycin PO
* Selamectin topical
* Moxidectin injectable
144
Feline Heartworm Dz; What makes it different than canine, Diagnosis, Clinical Signs
o Less common than dog
o Often no microfilaria present
o Small worm burdens
o Difficult to diagnose
Diagnosis
* Antigen + Antibody tests + Rads
Clinical Signs
* Often looks like feline asthma
* Eosinophilic pneumonitis
* Sudden death common
145
Define: Stertor/Stridor, Crackles, Wheezes
Stertor & stridor
* Discontinuous sounds & wheezes audible w/o stethoscope
* Dz above thoracic inlet
Crackles
* Crackling on auscultation
* Inspiratory = airway dz
* End of inspiration or Expiratory = parenchymal dz
Wheezes
* Musical continuous sounds on auscultation
* Airway or bronchial constriction
146
Canine Chronic Bronchitis (COPD); Symptoms, Clinical Findings, Findings on wash, Treatment
Symptoms
* Loud resonating cough
* Terminal gag
* May cough more at night
Clinical Findings
* Mixed inflammatory cell infiltrates,
* ciliary dysfunction,
* glandular and epithelial hyperplasia,
* excessive mucus production,
* bronchiectasis and airway thickening
Wash
* High neutrophils
* +/- high macrophages
Treatment
* Bronchodilators
* Corticosteroids
* Cough suppressants (butorphanol)
* Antibiotics if bacterial
147
Aspiration Pneumonia; Rads, Treatment
Rads
* Cranioventral opacity
Treatment
* O2
* Bronchodilators
* Antibiotics based on culture
* Shock therapy if septic (cautious w/ fluids)
* Prevent further aspiration
148
Non-cardiogenic Pulmonary Edema; Rads, Properties of Fluid, Treatment
Rads
* All lungs full of fluid
Fluid
* mild inflammation
* high protein fluid
* edema protein ratio ~80%
Treatment
* O2
* Cautious fluid therapy
* +/- steroids
* diuretics in beginning but no help later
* sildenafil for pulmonary hypertension
149
Pleural Effusion; Clinical Signs, Rads, Management
Clinical Signs
* Abnormal breathing
* Quiet lung sounds
Rads
* large volume of fluidpresent
* No detail of heart, vessels or other structures
* Lung lobes are retracted and individual lobes highlighted by the fluid opacity
Management
* Severe - O2 -> Thoracocentesis -> Additional diagnostics
* Mild - Rads to confirm effusion & look for reason
* Tap & Characterize
150
Principles pf Thoracocentesis
* Syringe for small volumes
* Butterfly for larger vol
* Sedate cats
* Can restrain sternal or recumbent
151
Pulmonary Thromboembolic Dz; Rads, Treatment
Rads
* Signs of obstruction
Treatment
* O2
* Sildenafil for pulmonary hyper
* Bronchodilators
* Anticoagulants
* Clopidogrel for anti-platelet
* Thrombolytics in early stages
152
Feline Allergic Bronchitis; Acute Vs Chronic Clinical Signs
Chronic
* Cough
* Inspiratory effort & noise
Acute
* Tachypnea/dyspnea
* Inspiratory & expiratory effort
153
Feline Allergic Bronchitis; Rads, Pathophysiology, Wash
Rads
* “fine honeycomb”
* parabronchial pattern on outskirts
Pathophysiology
* Sensitization to the Ag (IgE)
->
* Re‐exposure releases mediators (histamine, kinins, eosinophilic chemotactic factor) ->
* Bronchioconstriction occurs
Wash
* Eosinophils!
154
Feline Allergic Bronchitis; Treatment of Cough & Dyspnea
Coughing
* Theophylline (bronchodilator)
* Terbutaline
* Corticosteroids
* Maybe inhaled corticosteroids/bronchodilators
Acute Dyspnea
* O2
* Albuterol
* Injectable and/or inhaled corticosteroids
155
Tracheal & Bronchial Collapse; Clinical Signs, Rads, Treatment
Clinical Signs
* Flattening of tracheal rings +/‐ redundant dorsal trachealis mb
* Toy and small breed (paunchy?)
* ‘Goose honk’ = loud hacking
* +/- Concurrent chronic bronchitis‐ common!
* +/- Concurrent Mitral Regurgitation
Rads
* Bronchial cuffing (donuts)
Treatment
* Weight loss
* Avoid using collar
* Cough suppressants
* Treat concurrent dz
156
Nasopharyngeal Polypse; Signalment, Clinical Signs, Treatment
Signalment
* Young cats
Clinical Signs
* Loud breathing
* Mass effect in nasopharynx
Treatment
* Surgical removal
* Bulla osteotomy if invading inner ear
* Can recur
