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Cardio objectives
CAEM
| Question | Answer |
|---|---|
| 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 |
| RBBB | P and PR normal, QRS WIDE and NEGATIVE |
| 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
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