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Heart disease Something physically abnormal about heart.
What is heart failure Cardiac output is inadequate to meet organ demands despite adequate preload.
What is systolic failure Poor contraction
What is diastolic failure Poor relaxation
What are normal heart sounds in dogs and cats S1 and S2
What are abnormal heart sounds in dogs and cats S3 and S4
Detection of heart dz/heart failure depends on: History, physical exam, radiographs
Diagnostic testing for heart dz PE, rads, ECG, echocardiogram, lab testing (nutritional deficiencies, drug monitoring, disease)
key words in patient's history for heart failure Dogs: coughing, exercise intolerance, respiratory effort, syncope, weakness, abdominal swelling, fatigue. Cats: no coughing. Breathing too fast.
Pulse deficits Indicate pathologic arrhythmia
Auscult AV valves S1, ICS 3-5, left and right
Auscult aortic/pulmonic valves S2, ICS 2-4, left
Gallop rhythm Normal S1/S2 AND S3 or S4. STIFF Ventricle
Murmurs turbulent blood flow (pathologic OR physiologic
PMI Left base pulmonary valve/artery Aorta
PMI Left apex mitral valve
PMI right base radiation from left basilar murmurs
PMI right apex tricuspid valve
PMI right sternal border VSD L-to-R shunting
Systolic heart sound S1 .i1i. Filling
Diastolic heart sound S2 . 1i. Sys/Dias .i1i1i. Sudden end of ventricular filling
What information ECG gives? HR, rhythm, conduction pattern, chamber enlargement, myocardial ischemia, inflammation, necrosis, electrolyte abnormalities, effusions, drug toxicity, symp/parasympathetic tone
When is an ECG indicated? Evaluate heart dz, drugs/toxicity, arrhythmias/pulse deficits, syncope, weakness, anesthesia, electrolyte screening
Sequence of electrical activation in the heart? Atrial depolarization, AV node conduction, ventricular depolarization, repolarization.
P-wave Atrial depolarization
PQ interval Conduction through AV node
QRS complex Depolarization of ventricular myocardium
ST segment No electrical charge change, baseline recording
T wave ventricular repolarization
ECG interpretation consists of 5 parts: Paper speed, lead, calibration, artifact (ex. purring), normal species values
Sinus rhythm Upright P waves in lead II at a believable rate (<240)
MEA Mean Electrical Axis: usu I and aVF, subtract + from - boxes.
Right axis deviation on MEA RV enlargment or BBB (conduction disturbance) Same on L, L for LV
Right atrial enlargement gives this pattern: P-pulmonale, P wave taller than .4mV in dog, .2mV in cat.
Left atrial enlargement gives this pattern: P-mitrale. P wave wider than .04mV dogs and cats.
LV enlargement Widened QRS, enlargement or dilation
LV hypertrophy? Subaortic stenosis, hypertrophic cardiomyopathy, hypertension, hyperthyroid
LV dilation? Mitral insufficiency, L to R shunt, PDA
RV enlargement R axis deviation, from pulmonic stenosis, Tetr of Fallot, HW dz, lung dz with pulm hypertension.
Ddx for wide QRS BBB, VPC, vent escape, vent enlargement
LBBB characteristics P and PR normal, QRS WIDE and POSITIVE
Depressed ST segment ddx myocardial ischemia, acute infarction, hyper/hypokalemia, trauma
Elevated ST segment ddx myocardial hypoxia, pericarditis, transmural infarction, epicardial contusion
T wave ddx myocardial hypoxia, hypothermia, metabolic dz, cardiac drug toxicity
Long QT segment ddx hypocalcemia, magnesaemia, kalemia
Short QT interval hypercalcemia, kalemia
Low voltage QRS <1 mV lead II. Pericardial effusion, pleural eff, hypothyroid, obesity Cats can have whatever size they want.
6 ddx for arrhythmias primary cardiac dz, sepsis, drugs/toxins, metabolic/electrolyte/neoplasia, hypoxia, high vagal tone
Sinus arrhythmia ECG R to R variation, bradyarrhythmic
Wandering pacemaker ECG Stumpy P waves, variable
Sinus tachycardia ECG Upright P waves, HR >160
Sinus bradycardia ECG HR <60
Sinus arrest Long blank stretches
Junctional escape beat ECG No P waves, i.e. not sinus
Ventricular escape beat ECG Lots of P waves, wide and bizarre QRS
Atrial premature complex ECG Premature P wave (depolarizing in a different direction)
VPC ECG Early exaggerated QRS
Atrial tach ECG No P wave associated with it so not BBB, supraventricular, over 240 so not sinus tach
Atrial fib ECG No P waves. Random, fast, supraventricular QRS normal but irregular
Atrial flutter occasional QRS
VTach w+b but so fast it's hard to see
V fib Worms
1st degree AV block ECG Prolonged AV conduction, "lazy gatekeeper"
2nd degree AV block ECG Mobitz 1 Some P waves get through, consistent P-R
2nd degree AV block ECG Mobitz II 4:3 P:R ratio (always one more P wave than QRS)
3rd degree AV block ECG No P waves, w/b QRS, complete AV block.
RBBB w/b QRS, very irregular
LBBB w/b QRS, somewhat regular
Atrial standstill ECG No P waves, supraventricular (tall and upright)
Goals of acute CHF treatment Relieve congestion, oxygenate, improve CO
L CHF shows what signs pulmonary edema, respiratory distress, anxious and hypoxic
R CHF shows what signs ascites, jugular vein distension, pleural effusion
diuretics furosemide
vasodilators hydralazine, nitroprusside, nitroglycerin
sympathomimetics pimobendan, dobutamine,
sedation morphine sulfate, butorphanol, acepromazine
Treatment for dog with acute CHF furosemide, oxygen, vasodilators (hydralazine, nitroprusside for more aggressive treatment), sympathomimetic (pimobendan, dobutamine for more severe cases)
Treatment for cat with acute CHF furosemide, oxygen, nitroglycerin, thoracocentesis. Dobutamine.
Mild Chronic CHF, dog 1. Low dose furosemide 2. ACEi 3. pimobendan
Moderate chronic CHF, dog 1. Mid dose furosemide 2. ACEi 3. pimobendan 4. digoxin 5. spironolactone (ALDO antagonist)
Severe chronic CHF, dog 1. Max furosemide 2. ACEi, pimobendan, spironolactone, digoxin 3. hydralazine (vasodilation) 4. thoracocentesis
Refractory CHF, dog SQ furosemide, nitroprusside, dobutamine, oxygen
Mild Chronic CHF, cats Low dose furosemide ACEi (enalapril, benazepril)
Moderate chronic CHF, cats Furosemide, ACEi pimobendan spironolactone thoracocentesis
Severe CHF cats Max furosemide. ACEi, spironolactone, pimobendan, thoracocentesis.
Characteristics of supraventricular tachyarrhythmias Narrow QRS, P waves associated with VPCs, VPC looks like normal sinus complex
Characteristics of ventricular tachyarrhythmias Wide QRS, fusion beats present, not associated with P waves.
Treating supraventricular tach. Vagal maneuvers: sinus decreases gradually, atrial abruptly. Calcium channel blockers and beta-blockers
Calcium channel blockers Diltiazem. To lower HR acutely. Safe with CHF.
Beta-blockers Atenolol, sotalol, etc. Not safe with CHF. Antiarrhythmic, negative inotrope, chronotrope, lusitrope.
Side effects of beta-blockers: hyperkalemia, lethargy, anorexia, bradycardia
Chronic supravent therapy Diltiazem, atenolol, digoxin (takes 5 days)
Treating acute ventricular arrhythmia lidocaine, procainamide, esmolol
When to treat ventricular arrhythmia? clinical signs, hemodynamic compromise, risk of sudden death
Chronic maintenance for ventr arrhythmia Mexiletine, sotalol, atenolol
Treating bradyarrhythmia: when? If syncopal, clinical signs, hemodynamic compromise
How to treat bradyarrhythmia? Pacemaker!
Pulmonic stenosis: characteristics? Left base systolic, right tricuspid (insufficency). RV enlargment, edema, jug disten, weak pulses, hepatomegaly
aortic stenosis: characteristic murmur? left base systolic. LV enlargement, arrhythmias,
Pulmonic stenosis therapy? CHF, anti arrhythmics, beta blockers. Balloon valvuloplasty, surgery.
Aortic stenosis therapy? CHF, anti arrhythmics, beta blockers. Balloon valvuloplasty for aortic (not subaortic) stenosis. Cardiac bypass.
PDA PMI Continuous L base murmur
Mitral Insufficiency PMI L apex murmur
Congenital volume overload: shunts (PDA, VSD, ASD), AV valve dysplasia (mitral in cats, both in dogs), semilunar valves
VSD PMI R sternal border murmur
ASD PMI Systolic L base murmur
PDA rads LA, LV enlarged. General cardiomegaly, pulm overcirculation
VSD rads LA, LV enlarged. L CHF. Variable R side enlargement, pulm oc
ASD rads RA, RV enlarged. R CHF. pulm oc
PDA ECG Tall R, wide P, sinus tach
VSD ECG often normal
ASD ECG +/- R axis shift. Tall P, sinus tach
Tetralogy of Fallot VSD, overriding aorta, pulmonic stenosis, RV hypertrophy. Central cyanosis, polycythemia, lethargy.
Findings with endocardiosis Enlarged LA, rounded heart, venous enlargement, mainstem bronchial compression, elevated trachea. Mitral valve most commonly affected. Hypotension, L CHF. Supraventricular arrhythmia.
Findings with endocarditis Staph, strep, e. coli. Sepsis, stenoses, CHF, thromboembolism, DIC etc. New Murmur plus FEVER. Ventricular arrhythmia. Heart blocks (irreversible). Culture the URINE.
Created by: ceres