Approach to the cardiac patient Flashcards
heart disease / stages?
do we need to intervene in any of them?
- A: Risk of heart disease
- B: Heart disease, no clinical signs
- B1: No chamber enlargement
- B2: Enlargement left atrium/ventricle
- C: Past or current signs of heart failure
- D: End-stage disease, refractory to standard therapy
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C/D: Either pulmonary edema or on furosemide to be stable
> C/D are considered to be in heart failure
physical exam / history clues for heart failure
- Weakness, exercise intolerance, syncope
- Respiration, cough (left sided CHF)
- Weight gain (ascites – right sided CHF)
- usually a short history (not chronic)
- history may be unremarkable
Heart failure:
- what does this mean for cardiac output?
- compensation?
- associated signs/pathology?
Reduced cardiac output
- Tachycardia
- Weak peripheral pulses
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Compensation mechanisms:
Sympathetic nervous system
* Beta-stimulation
* Vasoconstriction
RAAS
* Na, water retention
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Left sided – lungs
* Pulmonary edema
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Right sided - systemic
* Distended peripheral
veins
* Ascites, pleural effusion
Normal respiration rates (RR) in dogs, and RR in congestive HF?
- other resp signs?
- Sleeping RR: < 30/min
- Most between 7-20/min
- Congestive heart failure RR: > 40/min
- Tachypnea, dyspnea, cough
(resp signs more for left sided)
Physical examination HF findings for MMs, jugular?
- Mucous membranes:
- Color - pale
- Capillary refill time prolonged
<><> - Jugular vein pulsation in right sided CHF
Auscultation - heart
- what should we check?
- normal dog values for HR? what does this tell us?
- Heart rate: 80-160/min
- Rhythm: regular – irregular
> Auscultation - palpation peripheral pulse - Pulse quality: strong, adequate, weak, deficits
- Lung field: respiratory sounds
<><><><> - helps us figure out if the cardiac output is impaired
> more progressed disease > faster HR
what are normal heart sounds that we hear on auscultation?
what are abnormal heart sounds we can hear?
Normal heart sounds:
* S1: closure mitral, tricuspid valve
* S2: closure aortic, pulmonic valve
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Abnormal heart sounds: gallop (uncommon in small animals, different in LA)
* S3: During early ventricular filling
* S4: Atrial contraction
Heart murmurs
- timings? point of intensity? grades?
- Timing: Systolic (most are systolic), diastolic, continuous
- Punctum maximum: Apex, base, left, right
- Grading (1-6): The louder, the more severe disease
systolic vs diastolic vs continuous murmur causes
- systolic is narrowing of aorta/pulmonary vessels, or leakage of AV valves > ie. mitral or tricuspid regurgitation, pulmonic or aortic stenosis
- diastolic is leakage of pulmonary artery or aorta, or stenosis of mitral or tricuspid valve
- continuous if ongoing pressure difference eg. congenital connection between aorta and pulmonary artery (PDA)
what does the punctum maximum tell us about the nature of our heart murmur?
- loudest in apex = mitral regurgitation
- loudest in armpit (heart base), left side, and systolic = and pulmonic or aortic stenosis
> if continuous, PDA
<><> - mitral valve we hear at the left apex
- tricuspid on the right
Heart murmur grades?
which should make us worry?
- 1/6: Very quiet murmur, takes time to localize
- 2/6: Quiet murmur, quieter than the heart sounds
- 3/6: Obvious murmur, as loud as the heart sounds
- 4/6: Obvious murmur, louder than the heart sounds
- 5/6: Very loud murmur, with precordial thrill
- 6/6: Very loud, precordial thrill, detected with stethoscope lifted from chest wall
<><><><> - investigate loud and palpable murmurs (> or = 4/6)
Indications of cardiac disease - dog
- Cardiac disease: Heart murmur
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Heart failure: - Tachypnea, dyspnea (left sided)
- Tachycardia
- Weak peripheral pulses, pale mucous membranes
- Ascites (right sided)
Diagnostic tests for the cardiac patient? what they show us?
- Thoracic radiographs: Heart size, L - heart failure
- Echocardiography: Diagnosis, severity
- ECG: Arrhythmia
- Blood: Electrolytes, kidney, cardiac biomarkers
Thoracic radiographs for heart disease
- what is this good for?
- how to use it?
- Diagnostic of choice for left sided congestive heart failure
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Size of the heart: - Vertebra heart sum (dogs < 10.5)
- Left atrial size (VLAS < 2.4)
- Trachea, sternal contact
<><><><> - Pulmonary vessels/veins
- Lung fields
how to measure the heart to see if it is large
- one line from corina to apex
- perpendicular line where heart is widest
- then overlay these lines on spine, from fourth thoracic vertebra backwards > see how many vertebrae they cover, add numbers together to get VHS (vertebral heart size)
- VHS < 10.5 is normal
