Module 6: Cardiac Diagnosis 2 - Radiography, Biomarkers, and Echocardiography - Rhinehart & Schober (Weeks 9-10) Flashcards by Kianelys Heredia

C21: Thoracic Radiography & Biomarkers of CV Disease

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List the questions you should answer with radiographs:

What is the global size of the heart (normal, small, large)?
Is there a specific cardiac chamber enlargement?
Pulmonary arteries distended
Pulmonary veins distended
Pulmonary infiltrates?
Pleural effusion
Congestive heart failure?

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List the correct “technique” placement of the animal:

Lateral & ventrodorsal
Dorsoventral projections

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Technique:
Correct “PEP”: Positioning, Exposure, Phase of respiration: ____________

Inspiration

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Quantification - Cardiac Mensuration:
What is the correct Method of measuring the heart?

Method of Vertebral Heart Scale, Score, Sum (VHS)

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Quantification - Cardiac Mensuration
Term:
A linear relationship between cardiac dimensions and vertebral length (don’t change in length)

Isometric scaling

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Quantification - Cardiac Mensuration
What is a normal Right lat film in dogs?

< 10.5

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Quantification - Cardiac Mensuration
What is a normal Right lat film in cats?

< 8.1

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(T/F) Obesity and breed may influence the VHS score

True
- Obesity: the fat can get around the heart

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Radiographic Cardiovascular Anatomy:
Heart on Radiographs = ‘opaque silhouette’
Fill in the blanks thinking of what you would you find in that location (Clock) …
11-1:________
1:________
2-3:________
3-6:________
6-9:________
9-12:________

Aorta
MPA (Main pulmonary artery)
LAA (Left auricle appendage)
LV
RV
RA (enlargement: everything is pushed cranially)

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Radiographic Cardiovascular Anatomy:
(T/F) Only their borders can be identified - deviations of the borders suggest the enlargement of a particular structure

True

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Location for Lateral Position:
12-3:________
3-6:________
6-9:________
9-12:________

LA (Left Atrium)
LV (Left Ventricle)
RV
RAA (can budge with RA enlargement, one of the most cranial structures)

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What can the following cause …
- Bineventricular cardiomyopathy
- Severe mitral and tricuspid regurgitation
- Severe pericardial effusion
- Peritoneo-pericardial diaphragmatic hernia (PPDH)

Generalized (global) Cardiomegaly
- Very very large heart

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What can occur from the following …
- Severe mitral regurgitation
- Advanced feline cardiomyopathy
- Congenital heart disease (mitral stenosis, PDA, VSD)
- Dilated cardiomyopathy

LA enlargement

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What can occur from the following …
- Moderate to severe mitral regurgitation
- Canine and feline cardiomyopathy
- Congenital heart disease (SAS, PDA, VSD)
- Others

LV enlargement
- “longer than usual”

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What can occur from the following …
- Aortic stenosis
- Systemic hypertension
- Idiopathic
- Old age (cats)

Aortic root enlargement

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What can occur from the following …
- Moderate to severe tricuspid regurgitation
- Right ventricular cardiomyopathy
- Congenital heart disease (ASD, PS, Tetralogy of Fallot)
- Heartworm disease

RV enlargement

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What can occur from the following …
- Moderate to severe tricuspid regurgitation
- Congenital heart disease (tricuspid dysplasia)
- Severe RAAS activation or iatrogenic volume overload

RA enlargement

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What can occur from the following …
- Visible in v/d and d/v views (not later; projections)
- Pulmonic stenosis (“post-stenotic dilation”), ASD, VSD, PDA
- Pulmonary hypertension
- Heartworm disease

PA enlargement

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Start from the bottom and up
- Left heart enlargement (LV and LA)
- Pulmonary vein enlargement (Congestion)
- Interstitial opacities in lungs (perihilar or diffuse, unstructured)
- Alveolar infiltrates with air bronchograms (often “white” lung)
- Pleural effusion and pericardial effusion can be signs of both l-CHF and r-CHF (in particular in cats)

Left-sided Congestive Heart Failure

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Pulmonary vein enlargement (venous congestion) VENTRAL:
dorsal:
middle:
ventral:

artery
bronchus
vein (veins should be wider)

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Pulmonary Artery Enlargement (dilation) CENTRAL:
lateral:
middle:
medial:

artery
bronchus
vein

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(T/F) Arterial enlargement is often seen in cats with l-CHF

True

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Circulating Marker Proteins of Cardiovascular Function:
Cardiac Troponin I (Thin filament bound) ->
- Cardiac specificity
- 3 myocardial sources
- Biphasic release after injury
- membrane integrity

Leakage markers
- Primary myocardial disease
- Toxins/metabolites
- neurohormones
- Trauma
- Cytokines
- Hypoxia/Ischemia-Reperfusion
- Wall Stress
- Infections
- Neoplasms
- Drugs

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Circulating Marker Proteins of Cardiovascular Function: Brain natriuretic peptide (BNP) -> - Produced in the Atrial (healthy animals) - Subacute or chronic changes due to volume loading and hypertrophy - Species-specific assays!

Functional Markers - Confirmatory test: The cat with a heart murmur

List Specific Clinical Indications to Analyse Circulating Cardiac *Troponin I*:

- Suspect: Myocardial infarction - Suspect: **Myocarditis** - Arrhythmia of unknown origin - Chemotherapy with doxorubicin - Suspect: Ionophore toxicity **CANNOT be used as a screening test for canine DCM and Feline HCM**

What is a key-diagnostic method in veterinary cardiology?

Thoracic radiography

(T/F) Orthogonal films of sufficient quality are required for proper interpretation

True

How are the cardiac size and silhouette evaluated and quantified?

Using VHS

What is a clinical syndrome radiographically characterized by *LV and LA enlargement*, *venous engorgement* (congestion), and *fluid accumulation in the lungs and/or pleural space*?

l-CHF

(T/F) Only cTnI (structure) is 100% myocardium-specific

False, Both cTnI and NT-proBNP are 100% myocardium-specific. - Elevations of cTnI indicate ongoing *myocardial injury*

What would be an indication of myocardial hypertrophy and wall stress?

Elevations of NTpro-BNP

What is the major clinical indication for the use of NTpro-BNP?

The cat with soft heart murmur - risk stratification

(T/F) Cardiac biomarkers have incremental diagnostic value but *CANNOT* replace other, more conventional, diagnostic methods

True

C22: Echo Normal

Echocardiography

- almost 100% diagnostic - Uses ultra-high frequency sound waves (> 20,000 Hz) - *Piezo-electrical crystals* (in probe) - Electrical energy -> mechanical (vibration) -> *emission* -> travel in tissue 1,540 m/s -> *reflection* at cells | tissue surfaces -> *reception* (probe) -> *generation* of image - Frame rate = number of updated images (the higher it is the better) - High frequency: high resolution, low penetration - Low frequency: Lower resolution, higher penetration

(T/F) Transesophageal can be done *BOTH* in the ER and in general practice

False, Only for ER/Extreme situations

Handling of the transducer: Where is the "Echo windows" located?

- Right parasternal - Subcostal - Left parasternal

Red is towards the trasfuser and _________ is away from

blue

Term: Allows the two-dimensional assessment of single parts of the heart in their anatomically correct position during multiple cardiac cycles

2D (two-dimensional) Echocardiography

Term: Allows the one-dimensional assessmentof the motion of certain parts of the heart recorded *along a single ultrasound line* during multiple cardiac cycles with very high temporal resolution (Time-Motion-Graph)

M-mode Echocerdiagraphy

Term: When ultrasound waves hit *moving objects* they change their reflected frequency, which is proportional to the velocity of the object

The Doppler Principle of Echocardiography

Flow Qualities: Laminar

Normal

Flow Qualities: Turbulent

Abnormal - Valve stenosis - Valve insufficiency - Shunt flow

Assessment of LV diastolic Function & Valve competence: - Pulsed wave (PW) inflow signals recorded at the level of the opened valve leaflets

Diatolic Function

Assessment of LV diastolic Function & Valve competence: - Color flow Doppler to detect valve incompetency or stenosis

Valve Function

Dijo que hay cositas que vienen de aqui pero no en mucho detalle

C23: Echo diseased animals

Normal *systolic LV pressure* in a resting dog is:

120 mmHg

(T/F) LV pressure is *at all times* higher that RV pressure during the cardiac cycle

True

What information should be obtained from an Echocardiographic Study?

- Underlying *Disease* | lesion - Current *Functional Status* - Estimation of *Hemodynamics* - Disease *progression* - *Response to Therapy*

Term: is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle and the outer covering sac (pericardium) of the heart.

Cardiac Tamponade

E: A < 1.0

Flow pattern of LV *relaxation* abnormality

E: A = 1.0 to 2.0

*Normal (or pseudonormal)* transmitral flow pattern

E: A >> 2.0

The flow pattern of *restrictive* LV filling (relaxation abnormality + high LV filling pressure) - almost always associated with congestive heart failure

Term: Is used to assess *valve* function, *systolic* and *diastolic* function, the severity of valve lesions, and *intra and extracardiac pressures*

Doppler Echocardiography

Pressure gradients ( change P) across stenotic or restrictive lesions may be calculated by using the modified:

Bernoulli equation - changeP = 4 x Vmax^2 Clinical applications: - Severity of aortic stenosis, pulmonary stenosis, and pulmonary hypertension can be estimated

change P (normal) = 0-10 mmHg

Moderate aortic stenosis

(T/F) *Eccentric* hypertrophy is a response to pressure load

False, *Concentric* hypertrophy in a response to *pressure load*

(T/F) *Eccentric* hypertophy (dilatation) is a response to *volume load*

True

Thickened cardiac valves are due to:

- Malformation (dysplasia) - Degeneration (endocardi*osis*) - Inflammation (endocarditits)

How is systolic heart function assessed?

Subjectively by *wall motion amplitude* or Objectively by *M-mode (shortening fraction)*

How is *diastolic function* assessed?

Pulsed-wave Doppler

(T/F) Severity of *valve stenosis* is assessed by Doppler (Vmax, change P)

True

What does the *intracardiac "smoke" in cats* indicate?

Low flow state (blood stasis) and thus increased risk of thromboembolic disease

(T/F) Intracardiac smoke in *horses* is normal

True

(T/F) Heartworm and cardiac masses *can't* be seen on echo

False, they can be seen on echo but the *sensitivity* of echo is below 100% (leading to false negative results)

Which of the following statements regarding *central hemodynamics* is NOT CORRECT? a. Normal mean right atrial pressure is between 20 and 30 mmHg. b. Normal mean left atrial pressure is between 1 and 10 mmHg. c. Normal LV pressure (systolic/diastolic) is around 130/8 mmHg. d. Normal right ventricular pressure (systolic/diastolic) is around 22/5 mmHg. e. Normal mean pressure in the venae cavae is around 0-8 mmHg.

a. Normal mean right atrial pressure is between 20 and 30 mmHg.

List the differentials for *Left atrial enlargement*:

- Idiopathic left atrial dilation - Severe mitral regurgitatiion - Severe LV diastolic dysfunction - Large left-to-right shunt

Which statement regarding echocardiography in animals with cardiovascular disease is NOT CORRECT? a. Severe LV pressure overload will lead to concentric chamber hypertrophy. b. Severe tricuspid regurgitation will lead to right atrial enlargement. c. Low left ventricular shortening fraction indicates the presence of severe ventricular diastolic dysfunction. d. Severe dehydration can lead to LV and RV wall thickening. e. Two-dimensional echocardiography cannot unambiguously distinguish between mitral valve thickening from degeneration (endocardiosis) and mitral valve thickening from inflammation (endocarditis).

c. Low left ventricular shortening fraction indicates the presence of severe ventricular diastolic dysfunction.

(T/F) A large left-to-right shunting ventricular septal defect will cause severe left atrial and left ventricular volume overload

True - *Volume overload of*: - RV - LA - LV

In a dog with a VSD, systolic blood pressure is 120 mmHg and VSD flow is left-to-right at 5 m/s. Which statement explaining the central hemodynamic situation is CORRECT? a. The dog has a large nonrestrictive VSD. Pulmonary hypertension is clearly present. b. The VSD is likely small (restrictive). The estimated RV systolic pressure (which equals systolic pressure in the pulmonary artery) is around 20 mmHg, which rules out pulmonary hypertension. c. The estimated RV systolic pressure is around 100 mmHg. As RV systolic pressure equals pulmonary artery systolic pressure it can be concluded that the dog has severe pulmonary hypertension. d. RV pressure overload and thus pulmonary hypertension is clearly present based on the high velocity of VSD flow. e. Based on the pressure estimate, LV systolic pressure equals RV systolic pressure. Therefore, there should not be any flow across the VSD. Something with the echocardiographic estimations must be wrong – re-image the dog to come up with more realistic numbers.

b. The VSD is likely small (restrictive). The estimated RV systolic pressure (which equals systolic pressure in the pulmonary artery) is around 20 mmHg, which rules out pulmonary hypertension.

C24: Clinical Examination I

A comprehensive medical history & a through physical examination lead to _________% of your final diagnosis

> 80%

Epidemiology Risk: *Congenital heart disease* mostly seen in:

Young dogs

Epidemiology Risk: *Acquired heart disease* mostly seen in:

Old dogs

Epidemiology Risk: *Cardiomyopathy* mostly seen in:

Large breed dogs

Epidemiology Risk: *Degenerative mitral valve disease* is mostly seen in:

Small breed dogs - tracheal collapse is very commonly seen

(T/F) *Tachypnea* is a classical sign of CHF

True

If a *cat* is coughing, it is more than ___% bronchial

90%

Sudden loss of consciousness & postural tone with fast and complete recovery (< 1min)

Syncope ("fainting") *Causes:* - Vaso-vagal (reflex) - Arrhythmia - Decreased CO

(T/F) Cat with syncope due to an *arrhythmia*

True

Tachypnea: The rate of *respiration* is a very *sensitive* variable in the diagnosis of what?

Left-sided CHF

- Pale mucus membranes - Anemia - Vasoconstriction: due to high sympathetic toe (SNS)

Pallor

"Injected" - brick red - Sign of *systemic vasodilatation* or periodontal inflammation

Hyperemia

- Increased jugular venous pressure - *Sign of R-CHF* - Others: Large pleural effusion, Mediastinal mass, Thrombosis cran VC

Enlargement (congestion)

Pulsation: This is due to forceful atrial contraction against stiff RV

Increased *a-wave* - Pulmonary stenosis - Pulmonary hypertension

Pulsation: This is due to severe *tricuspid regurgitation* backflow of blood into the veins

Increased *v-wave*

Aortic thromboembolism (cat) from ...

Left-heart disease

Subcutaneous (pitting) edema in a dog with chronic severe ...

*Right-sided CHF*

List the differentials for *Subcutaneous edema*:

- Decreased Albumin - Thrombosis of *femoral vein* - Congenital lymphedema

Term: Palpable vibrations from the loud heart murmurs

Thrill (fremitus)

Apex beat is on the ...

Left *Increased* - Sympathetic stimulation - Increased Preload -> Increased systolic Fx *Reduced* - Systolic dysfunction - Effusion (Pleura| Pericard | PPDH) - Obesity

What can be seen with wide pulse pressure & "waterhammer" pulse?

- PDA - Bradycardia - Aortic insufficiency

List the causes of Hypokinetic pulses (Pulsus parvus, Pulsus filiformis (if in shock):

- Decreased volume (dilated cardiomyopathy) - Obstruction of the LV outflow tract

- Pulse rate < Heart rate Eg. Auscultation HR 160 bpm Pulse Palpation HR 128 bpm *Pulse Deficit 32 bpm* -> Due to *arrhytmias* = very short diastolic filling intervals lead to *decreased* filling, poor SV, and no pulse wave in the femoral artery

Pulse Deficit

Hyperthyroidism =>

- LV- hypertrophy - Tachycardia - Loss of body weight - Heart murmur - Gallop sound - Systemic hypertension

Term: Procedure to unmask *right-heart failure* - Used only in dogs

Hepato-jugular Reflex - Lift up abdomen (liver) for 20-30 sec - Acute increase of venous return to right heart - Congestion of external jugular vein - *Congestion disappears with a few heartbeats* - If not: right heart failure!

Which statement about cough in cats is Correct? a. Cough is a common clinical sign of advanced left heart disease. b. Severe cough is a reliable sign of tracheal collapse. c. Cough receptors have a particularly high concentration in the peripheral lung fields (around the alveoli). d. Cough in cats is rare, with inflammatory bronchial disease being the most common cause. e. Cough in cats is most commonly secondary to right-sided CHF with pleural effusion.

d. Cough in cats is rare, with inflammatory bronchial disease being the most common cause.

(T/F) High sympathetic tone as seen with severe heart failure often leads to systemic (arterial) vasoconstriction and pale mm.

True

(T/F) Pale mm *reliably indicate* presence of anemia

False

Distended (enlarged) external jugular veins most likely indicate the presence of:

Right-sided CHF

Which of the following matches is Correct? a. Strong arterial pulse – Pulsus paradoxus b. Weak arterial pulse – Pulsus parvus c. Delayed arterial pulse – Pulsus alternans d. ‘Waterhammer’ pulse – Pulsus filiformis e. Heart rate < pulse rate – Pulse deficit

b. Weak arterial pulse – Pulsus parvus

Which statement concerning the hepatojugular reflux (HJR) most often used in dogs is Correct?? a. Initiating the HJR is a non-invasive test for left heart failure. b. It tests the response of the body to sympathetic stimulation. c. It is a reliable test for the detection of volume overload of the body. d. The HJR is initiated to identify the presence of right heart failure. e. The dog’s chest is manually compressed, and the femoral artery is simultaneously palpated. A positive test (= stronger femoral pulse) indicates normal LV systolic function

d. The HJR is initiated to identify the presence of right heart failure.

C25: Clinical examination II: Auscultation

Can there be a definitive diagnosis with just auscultation?

Yes - Examples: Patent ductus arteriosus, Mitral regurgitation - Helps identify diastolic heart disease (gallops)

Chest Piece: - Going to use the most - Good for hearing *S1, S2, and murmurs*

Diaphragm

Chest Piece: - Good for hearing *gallops* (diastolic sounds) (low frequency sounds)

Bell

List the Valve areas:

- Mitral => Left apex - Aortic => *Left base* - Pulmonic => *Left base*, cranioventral to aortic - Tricuspid => Right apex

*Left apical* murmur is found on the ...

left apex (S1 - mitral & tricuspid close)

*Left basilar* murmur is found on the ...

Left base - Aortic (S2 - aortic & pulmonary close) - Pulmonic

*Right apical* murmur is found on the ...

Right apex - Tricuspid

Diastole (filling):

S3 => Early/rapid *ventricular* filling - High left atrial pressure and *CHF* (small animals) - Normal in large animals S4 => *atrial* contraction ("atrial kick") - Stiff non-compliant ventricle *(HCM in cats)* - Normal in large animals

(T/F) Very difficult to differentiate between S3 and S4 in small animals

True

Influenced by respiration - increases speed when inspiration - decrease speed when expiration

Sinus arrhythmia

"Tennis shoes in the dryer"

Atrial fibrillation

Bradycardia

Third degree AV block

Definition: Prolonged audible vibrations heard during a normally quite period of the cardiac cycle

Murmur - Increased velocity flow - Increased stroke volume - Decreased viscosity *Disease: Flow from HIGH pressure -> low pressure

Murmurs: - Functional/physiologic (Anemia, fever, fear, etc.) - Innocent

Non-pathologic

Murmurs: - Acquired vs. Congenital - Primary vs. Secondary

Pathologic - Structurally abnormal going on with the heart

List the common murmurs:

- *Functional*: Physiologic or innocent - *Subaortic/pulmonic stenosis:* left bas, systolic - most commonly in dogs - usually harsh - *Mitral regurgitation:* Left apical, systolic - common murmur in many species - Tricuspid regurgitation: Right apex, systolic - *Aortic regurgitation:* left base, diastolic - most common in horses > 10 years of age - "dive bomber" - Patent ductus arterious: Left base (craniodorsal), continuous (throughout systole and diastole) "machinery" or "washing machine"

You are examining a 10-year-old miniature poodle and hear a grade 3/6 left apical systolic murmur. What is this murmur most likely associated with?

Mitral Regurgitation

You are examining a cat and on auscultation, you hear a grade 2/6 left basilar systolic murmur. This murmur could be associated with all of the following EXCEPT: a. aortic stenosis b. pulmonic stenosis c. functional murmur d. patent ductus arteriosus

d. Patent Ductus Arteriosus -> Left base (craniodorsal), continuous (throughout systole and diastole) "machinery" or "washing machine"

**** You are doing a routine examination on an asymptomatic 10-year-old cat and identifying a gallop sound. What is this gallop sound most likely associated with?

a stiff non-compliant ventricle

***** You are examining a 7-year-old Quarter horse and hear the following murmur: a quiet murmur, softer than the S1/S2 sound but readily heard, localized over the mitral valve. The precordial impulse is normal and you do not feel a thrill. How would you grade the intensity of this murmur?

Module 6: Cardiac Diagnosis 2 - Radiography, Biomarkers, and Echocardiography - Rhinehart & Schober (Weeks 9-10) Flashcards

(125 cards)