Cardiology Flashcards
Which has the highest sensitivity for ventricular arrhythmias? Which one can’t be evaluated in real time?
A) ECG strip
B) Continuous ECG with q1min technician assessment
C) Recorded continuous telemetry
D) Holter
D Holter – most sensitive but can’t be eval in real time, if that’s important (ex: post splenectomy) then use recorded continuous telemetry
JVECC 2021 Teslenko
Which two breeds can have a left shift of the QRS mean electrical axis on ECG, even when healthy?
Pugs, Eng bulldogs
JAVMA 2023 Cipone
An elevation in which biomarker(s) is/are associated with worse prognosis in dogs with SIRS?
A) NT-proBNP
B) Cardiac troponin T (CTnT)
C) Both
D) Neither
B
May be due to “cardiac hibernation” (maladaptive systolic and diastolic ventricular dysfunction in septic patients)
JVECC 2019 Gommeren
Which are good point of care tests to discriminate R CHF vs other cause of nonhemorrhagic abdominal effusion?
NT-proBNP
Cardiac troponin I (CtnI)
GB wall edema
Distension of hepatic veins, CVC
NT-proBNP
Distension of hepatic veins, CVC
JVIM 2023 Morey
12yr FS DLH with noninvasive workup consistent with IBD vs LSA. She has a heart murmur grade 2/6 parasternal systolic. The owner declines any additional big workup (echo, scope) in favor of empiric steroids.
What would be a good practical test to monitor cardiac tolerance of steroids?
Baseline and follow up NT-proBNP
JVIM 2020 Block
What is the relative sens/spec (low, mod, high) of NT-proBNP to detect heart disease in clinically healthy cats?
How does the presence of a heart murmur affect these?
In general, low sens, high spec
With HM, moderate sens, high spec
So, not a good screening test (false negs) BUT positives can be trusted
JVIM 2021 Lu
12yr MI Yorkie with a new heart murmur grade 3/6 LAS. Which is a good screening test for subclinical MVD (ACVIM Stage B1, B2)?
Which one(s) scale with disease severity?
Which one(s) would be helpful if the dog were in respiratory distress and you wanted to rule out CHF (Stage C)?
ANP
cTnI
ACE2
Subclinical MVD - ANP only
Scale with MVD severity - ANP, cTnI, ACE2
Screen for CHF - ANP and cTnI
JAVMA 2020
JVIM 2023 Hammond
A) Dogs
B) Cats
C) Both
D) Neither
CTnI is a good screening test for subclinical heart disease (MVD or HCM, respectively) in _____
CTnI in critically ill patients is associated with nonsurvival in ____
Subclinical heart disease: Cats only
**Exception: new high sensitivity assay has moderate sense/spec for preclinical DCM dobies
Prognostic in critical illness: Dogs only (high CTnI is common in cats, but not prognostically informative)
JVIM 2019 Hertzsch
JVIM 2019 Kluser
15yr FS DSH that you manage for CKD IRIS Stage 3. She has a new heart murmur grade 3/6 LAS. Her CTnI was elevated, but her echo was normal. Explain.
Can see high CTnI due to renal dysfunction (not sure if maybe it’s GFR dependent?)
JFMS 2019 Langhorn
Name at least 3 non-cardiac diseases that can increase CTnI.
GDV
Babesia
Kidney disease
PHT
SIRS
JVIM 2019 Kluser
11yr FI chihuahua with fever of unknown origin and HM 3/6 LAS. CTnI was severely elevated. What does this suggest?
A) Physiologic murmur
B) MVD Stage C
C) Endocarditis
D) Correlates only with severity of heart disease, not etiology
E) Can be elevated due to inflammation
C – cTnI >0.6 is sens 52/spec 100 for endocarditis (compared to MVD Stage B and immune mediated disease)
JVIM 2021 Kilkenny
Which breed tends to have larger LV volumes +/- wall thickness?
A) Barrel chested breeds
B) Giant breeds
C) Toy breeds
D) Sighthounds
D
JVIM 2020 Esser
JVIM 2021 Wess
JVIM 2023 Stepien
POCUS is helpful to dx CHF in _______ presented in respiratory distress.
A) Dogs
B) Cats
C) Both
D) Neither
Cats only, esp if also high NT-proBNP.
In dogs, did not provide more for ddx list than hx and PE.
JVECC 2020 Hezzell
JVIM 2019 Ward
True or False: Gabapentin is an acceptable sedative for echocardiogram, as it will not alter any of the variables/measurements.
True
JFMS 2022 Veronezi
JFMS 2022
What is the significance of:
–High effective arterial elastance (Ea)
–High Ea/Ees
What is the gold standard way to measure? What is more practical?
High Ea: incr total arterial load of the LV, potentially due to high BP (afterload), HR, or both
High Ea/Ees: worse px in MVD dogs
Gold standard = cardiac catheter, pressure volume loops
But, can use echo to estimate
JVIM 2021 Osuga
What is the indication for transesophageal echo?
Procedure monitoring:
PDA ligation or coil
PV stenosis and balloon valvulopasty
JVIM 2022 Stoner
How do you calculate:
MHS (manubrium heart score)
Long MHS
Short MHS
Cardiac sphericity index
What would you expect with R and L sided heart disease?
MHS = heart length + (heart width/manubrium length)
Long MHS = heart length/ML
Short MHS = heart width/ML
CSI = heart width/heart length
R heart disease: high CSI, high short MHS with normal long and overall MHS
L heart disease: high short, long, and overall MHS
JAVMA 2020 Mostafa
What is subclavian steal syndrome?
Occlusion or stenosis of subclavian aa –> retrograde bloodflow in downstream ipsilateral vertebral artery –> vessel dilation, can potentially compress spinal cord and cause neck pain
JAVMA 2021 Shimbo
Doppler BP in cats:
–Which tends to read higher, forelimb or tail?
–Is it a big enough difference to affect clinical decisions?
Tail, medial 15-20mmHg higher than forelimb but too variable really to apply a correction factor.
Can affect which category they go in, usually normo vs HYPERtensive…not HYPOtensive (incl in sick cats).
JFMS 2019 Zeugswetter
JVECC 2021 De Rosa
Which setting offers the most consistent BP reading in cats?
A) Owner present
B) Owner absent
C) In carrier
D) On exam table
C
JVIM Hanas 2021
One study found that Birman cats have (higher) (lower) (no difference in) BP compared with other cat breeds.
That same study found that cats with outdoor access have (higher) (lower) (no difference in) HR compared with indoor only cats.
Birman - lower BP
Outdoor access - lower HR
JVIM Hanas 2021
Which predispose to HIGHER BP in cats? Select all that apply.
A) Weight
B) BCS
C) Age
D) Stress
E) Sitting
F) Laying down
Age, stress, sitting
JFMS 2021 Knies
How could you potentially use AUS to differentiate situational vs persistent hypertension?
Measure aortic strain (AoSt) which is based on aortic diameters, can look at level of the iliac arteries and at kidneys
AoSt = [(systole-diastole)/diastole]x100
Lower AoSt = less elasticity, r/o secondary to chronic SHT and smooth muscle hypertrophy
JVIM 2020 Corda
How might the following affect retinal vessel diameter?
Age
SHT
Older –> SMALLER retinal vessels (but does not correlate with BP)
Some SHT cats controlled on amlodipine will have shrinking (normalizing?) retinal vessels
JFMS 2021 Enache
Which is true?
A) BP should be monitored in all older cats, since early detection of SHT improves long term outcome.
B) BP should be monitored only in cats with risk factors for SHT
C) BP should only be monitored in cats with CS or biochemical abnormalties due to SHT
D) Early symptomatic treatment of SHT (ex: amlodipine) does not affect outcome
A
JVIM 2019 Conroy
Which is true about telmisartan to treat SHT in cats?
A) It is safe, relatively effective, and durable
B) It is effective but there is significant risk for hypotension
C) It is effective but there is significant risk for AKI
D) It is effective but GI side effects are common
E) It is initially effective but aldosterone escape occurs at median 1mo
A) Well tolerated, relatively effective (half of cats BP <150 at 1mo), durable
JVIM 2019 Coleman
JFMS 2019 Coleman
2019 Glaus
What is the most common underlying cause for hypertensive emergencies in dogs and cats?
Two most common CS?
Overall survival rate? How did species affect this?
AKI
Seizures > blindness
Half; we need a better way to recognize and treat
JSAP 2022 Beeston
Which ACE enzyme is involved in the alternate (protective) RAAS pathway? Which organs in the body is it primarily found (2)?
ACE2
Renal tubular epith»_space;> left ventricle
JVIM 2019 Larouche-Lebel
List at least 3 causes of diuretic resistance.
Poor GI absorption
Decr renal tubular transpofrt
Loop of Henle atrophy
RAAS activation
JVIM 2020 Adin
Which electrolyte can help differentiate MVD stage C vs D?
Low Cl –> more common in stage D
Possibly d/t higher diuretic dose (1:2 Na:Cl loss), diuretic resistance, RAAS, ADH, water retention
Note:
Corrected Cl = (mid ref range Na/measured Na) x measured Cl
Only stage D dogs (not B1, B2, compensated CHF dogs) have corr Cl > measured Cl, indicating water excess
JVIM 2020 Adin
JVIM 2020 Adin
Which is true about dogs with ACE polymorphism?
A) Tend to have higher baseline RAAS activity
B) Tend to have more aldosterone breakthrough
C) Tend to be resistant to ACEi
D) Tend to be resistant to spironolactone
E) Does not appear to affect RAAS
B – these dogs may particularly benefit from spironolactone
JVIM 2020
Which results in more alternative (protective) angiotensin peptides in dogs and cats, and one potential mechanism why?
ACEi
ARB
ARB
ACE2 shunts BOTH AT1 and AT2 to the alternative pathway. But, with ACEi, ACE doesn’t work –> no AT2 –> less substrate for ACE2.
JVIM 2020 Laroughe-Lebel
JVIM 2020 Huh
True or False: Estrogen upregulates ACE activity.
True – highest ACE in FI > FS > MI
JVIM 2023 Adin
True or False: Serum Cys-C and urinary NGAL are higher in MVD vs healthy dogs.
True
NGAL scales with MVD severity
Cys-C is associated w/ worse MVD prognosis even without azotemia
Altogether could imply MVD mediated renal damage
JVIM 2023 Iwasa
JVIM 2022 Triola
True or False: Cardiopulmonary bypass surgery causes AKI.
True – high Iosin and urinary CysB post op, some also incr creat
JVECC 2022 Starybrat
In dogs with PHT, which echo findings predict R CHF?
Which affect px?
Which is going to be more significantly affected in precapillary (vs postcapillary) PHT?
A) RA size
B) RV size
C) RA systolic dysfunction
D) RV systolic dysfunction
R CHF: RA size
Worse Px: RA size, RV dysfunction (quantified by TAPSE – tricuspid annular plane systolic excursion)
Precapillary PHT: RV systolic dysfunction
JVIM 2018 Vezzosi
JVIM 2022 Feldhutter
JVIM 2020
11yr MN mixed breed with acute onset of respiratory distress over the past 3 days. CXR showed R cardiomegaly and a patchy interstitial pattern. Echo is consistent with PHT. There is no L sided heart disease.
What group of PHT are you most concerned about? Why should you NOT try sildenafil?
Px?
Group 1: pulmonary arterial hypertension (r/o pulmonary venoocclusive disease, pulmonary capillary hemangiomatosis)
Sildenafil –> vasodilation –> pulmonary edema. Don’t do it!
Px is grave (true even in people) – MST 3d
JVIM 2019 Reinero
Which is true about treatment of pulmonary hypertension due to lung disease?
A) Tricuspid regurge pressure gradient is strongly predictive of survival.
B) Symptomatic tx (ex: sildenafil) may eventually be d/c’d if the underlying cause for PHT is treated and resolved.
C) Severely affected PHT dogs (ex: syncope) are less likely to benefit from sildenafil.
B
TRPG only weakly assoc with survival and dogs with severe CS can still respond to sildenafil
JVIM 2020 Johnson
True or False: In a study looking at respiratory dogs with and without bronchomalacia, PHT was equally distributed across both groups.
False – Over half of bronchomalacia dogs (and tended to be more severe) vs a quarter of non-BM
JVIM 2020 Gamracy
Which is true regarding ACEi dosing and survival in dogs with heart disease? Cats?
A) Better to start at a higher dose, split BID
B) Better to start at a higher dose given SID
C) Better to start at a lower dose BID to avoid adverse effects
D) Better to start at a lower dose SID to avoid adverse effects
E) ACEi do not impact survival
Dogs - A) higher dose BID
Cats - E) ACEi do not impact survival
JVIM 0221 Ward
JVIM 2019 King
How do kittens compare to adult cats regarding normal ranges for the following?
VHS
NT-proBNP
R heart measurements
LA diameter
Kittens – higher VHS, smaller LA diameter
No difference – NTproBNP, R heart
Helpful to establish RIs to help rule out pathologic vs innocent murmurs
JFMS 2021 Gunther-Harrington
How can you cause an “iatrogenic murmur” in cats during an exam?
Pressure on R thorax –> R heart wall –> DRVOTO
Esp in older, lean cats
JVIM 2020 Ferasin
JSAP 2022 Howell
True or False: In dogs with pulmonary stenosis, structural and functional echo findings correlate with clinical severity.
True
JVIM 2023 Patata
5yr FI Yorkie with intermittent PL collapse. She has never been to a vet before. You auscult a continuous murmur. Her anus is cyanotic but her gums are pink.
What is your top ddx?
What medication should you give to improve survival time?
R to L or bidirectional PDA
With sildenafil at initial presentation, MST 5yrs (without - 10mo)
If develops R CHF, survival 2mo
JVIM 2021 Greet
What is the success rate for Amplatzer self expanding vascular plugs in treatment of PDA? How does dog size affect this?
95+% regardless of dog size since they made smaller plugs that can be used with smaller catheters
JVIM 2021 Hildebrandt
JVIM 2020 Hulsman
Which routine echo measurement has highest operator dependent variability?
LA:Ao
JVIM 2020 Hsue
Which breed is prone to sick sinus syndrome? What clinical sign does this cause?
A) Yorkie
B) Mini poodle
C) CKCS
D) Mini Schnauzer
E) Mini dachshund
D) Mini schnauzer - esp prone to MV prolapse
Syncope
JAVMA 2021 DeProspero
In healthy CKCS, how does their mitral valve morphology differ from that of other healthy dogs?
What proportion of older CKCS have MVD?
Healthy dogs: elliptical, saddle-shaped MV
Healthy CKCS: flatter, reduced leaflet tenting
**Probably plays a role in them developing MVD
Almost 100% by 11yrs
JVIM 2019 Menciotti
What radiographic measurement predicts LA enlargement?
How to you obtain this measurement?
Vertebral LA size (VLAS) >2.5 vertebrae (90+% specificity if >3.5)
How: measure ventral carina to dorsal border of CVC. Take that lenght from cranial T4 and count vertebrae.
Better than VHS
JAVMA 2019 Malcolm
JVIM 2021 Lam
JAVMA 2020 Stepien
Just FYI. Advanced MVD/worse px/shorter survival
–Inappropriate LV arterial coupling (VAC) based on Ea/Eas
–High trimethylamine N-oxidase (TMAO)
–High carnitine and esters
–High NTproBNP
–High MINE score >8 (LA:Ao, LVEDD, FS, transmitral peak velocity)
JVIM 2021 Osuga
JVIM 2019 Karlin
JVIM 2021 Wilshaw
JVIM 2021 Vezzosi
What is sacubitril/valsartan (Entresto)?
Combo ARB and neprilysin (NEP) inhibitor (prevents ANP breakdown –> allowed to persist and oppose aldosterone)
JVIM 2018 Newhard
MVD dogs with mitral valve repair:
–How long to see improvement in QoL post op?
–When does this plateau?
–How long does it last?
1 mo, 3mo, at least a year
JAVMA 2022 Pennington
Infective endocarditis:
–Signalment (size, sex)
–Frequency of fever, vegetative lesions, positive blood culture?
–Top three isolates?
–MST? What one medication drastically extends this? How does affected valve affect MST?
–Male, large breed
–Half, almost all, 60%
–S. pseud, Bartonella, E. coli
–2.5mo – worse if develop CHF. Etiology and valve did not affect outcome. Antithrombotics –> MST not reached.
JVIM 2022 Reagan
True or False: Cats with HCM have markers of inflammation and glucose dysregulation.
True – high SAA, insulin, Glu, IGF-1
**Note – the glucose stuff was associated with high BCS too…correlation? Causation? But, one study fed a low glycemic, fish oil supplemented diet and found echo, cTnI and IGF-1 improved…
JVIM 2020
JVIM 2020 van Hoek
Which are true about pimo in HCM cats with CHF? Select all that apply.
A) It is safe for most HCM cats
B) It is only safe for HCM cats without LVOT obstruction
C) It may be effective for most HCM cats
D) It may be effective for HCM cats without LVOT obstruction
A, D
JVIM 2020 Ward
JVIM 2021 Schober
Are the following higher, lower, or no different in HCM cats with and without systolic anterior motion?
Both are higher
JVIM 2020 Seo
RCM is associated with (systolic) (diastolic) dysfunction.
What are the two subtypes of RCM?
How common is CHF at the time of diagnosis?
Prognostic factors?
Poor compliance –> diastolic dysfunction
Myocardial (90% of cats): interstitial myocardial fibrosis
Endomyocardial: thick hyperechoic tissue bridging LV lumen
~90% CHF
Highly variable depending on the study
–MST 2mo vs 1.2yrs
–Possible px factors: resp distress, LA:Ao
JFMS 2018 Locatelli
JVIM 2019 Chetboul
True or False: Cats in CHF tend to have high SDMA and creat.
True
JVIM 0220 Liu
NTproBNP is cheaper than recheck CXR. Can you use NTproBNP to monitor for resolution of CHF?
No
JVIM 2021 Murphy
True or False: Torsemide should only be used as a rescue diuretic, not first line.
False
–SID rather than BID/TID dosing
–Less than half the risk of cardiac death or euth in one study
JVIM 2020 Besche
Which is true about treating MVD Stage C with benazepril +/- spironolactone?
A) Benaz alone is equally effective
B) Combo is more effective and just as safe
C) Combo is more effective but greater risk of adverse effects
D) No additional benefit from spirono and there is incr risk of adverse effects
B
JVIM 2021 Coffman
Cardiac cachexia is a poor prognostic indicator for:
A) Dogs
B) Cats
C) Both
D) Neither
C Both
JVIM 2020 Santiago
For CHF vs non-CHF indications for positive pressure ventilation:
–Which is more likely to survive to discharge?
–Which is more likely to have longer survival post discharge?
CHF
Non-CHF
JVECC 2022 Oppenheimer
A-fib:
–Goal HR <____
–Factors at admit associated with failure to achieve HR goal (3)
–Worse prognosis (2)
HR <125 – MUCH longer MST (1.6yrs vs HR >125 1mo)
Hard to do if at admit:
–Big LA
–Incr CRP
–Low BP
Worse px
–Congenital heart disease
–Higher NTproBNP
JVIM 2023 Pedro
A-fib is an uncommon complication of MVD. What factors is it associated with? (1 signalment, 1 disease stage, 2 echo findings)
Large breed
Advanced disease
Big LA, decr FS
JVIM 2020 Guglielmini
JVIM 2020 Toaldo
Sotalol:
–Class of antiarrhythmic?
–2 MoAs?
–Dangerous or generally well tolerated?
Class III
K+ channel blocker
Nonselective beta blocker (BUT only modest neg inotropy; mitigated by prolonged AP –> incr time for Ca entry)
Generally well tolerated, even if preexisting systolic dysfunction or atrial enlargement
JVIM 2018 Visser
Atrioventricular accessory pathways (aka orthodromic atrioventricular reciprocating tachycardia)
–Signalment (Breed, sex)
–CS
–ECG
–High, moderate, low success rate with lidocaine? Radiofrequency catheter ablation?
Male labs
Nonspecific
Regular, narrow QRS complex tachycardia that terminates into second degree AV block
High, high
JVIM 2019 Wright
JVIM 2019 Wright
True or False: Lidocaine is arrhythmogenic when used to treat supraventricular arrhythmias.
True
JVECC 2022 Seo
Which is true about pericardial catheters?
A) Placement requires anesthesia
B) Placement is technically challenging
C) Arrhythmogenic
D) Increase risk of infection vs needle pericardiocentesis
E) Useful to facilitate repeat pericardiocentesis
E
Easy to place, sedation, no incr adverse effects vs needle
25% of dogs need repeat pericardiocentesis
JVECC 2019 Cook
JVECC 2021 Cook
ATE in dogs:
–Proportion with risk factors? (Most, some, few)
–Most common comorbidity?
–PE finding assoc with survival to discharge?
–Overall px?
Most, most commonly PLN
Ambulation status
Poor – <20% alive at 3mo
JVIM 2020 Ruehl
Which has the highest and lowest risk of ATE in cats?
CHF with pleural effusion
CHF with pulmonary edema
High LA:Ao
Highest risk: high LA:Ao
Lowest risk: CHF with pleural effusion
JFMS 2022 Busato
True or False: tPA, when given promptly after admit, significantly improves px in cats with ATE. But, they are at higher risk for reperfusion injury and AKI compared with supportive care.
False
Px no better and similar complication rate
JFMS 2019 Guillaumin
“Alabama Rot”
–Actual medical name for it?
–Breed(s) in US vs UK?
–Etiology?
–Typical presentations and associated prognosis?
Cutaneous and renal glomerular vasculopathy
US - greyhounds only. UK - many breeds.
Etiology unknown
Presentations:
–Skin only - excellent px
–Skin then AKI - 100% mortality if AKI came </= 10d after skin stuff
–AKI then skin – fair with intensive management
VCNA 2019 Jepson
Cutaneous and renal glomerular vasculopathy:
–CBC/Chem/UA and AUS
–Gold standard dfdx. What can this be confused with?
CBC: high neuts, non- or preregen anemia, thrombocytopenia
Blood smear: acanthocytes, echino, schisto (all support microangiopathic hemolysis)
Chem: renal, LEs, Tbili, CK
UA: almost all have hematuria/Hb; 70% olig/anuria; glu, casts
AUS: +/- hyperechoic renal cortices
Dfdx:
Gold standard = renal histopath, fairly contraindicated premortem. Fibrinoid necrosis, thrombosis, esp glomeruli. Can look like hemolytic uremic syndrome (but HU doesn’t have skin stuff).
Skin bx can be supportive but not definitive
VCNA 2019 Jepson
Tx for utaneous and renal glomerular vasculopathy?
Who knows – try clopidogrel and immunosupp
Rarely need significant wound care, abx
Consider dialysis, TPE
VCNA 2019 Jepson
True or False: Alveolar edema causes cough.
False – lower airways don’t have cough receptors. That’s why NCPE dogs present with incr RR/RE but NOT cough.
JSAP 2019 Ferasin
Which two breeds are prone to arteriosclerosis? What does this cause?
Shelties, greyhounds
ATE
VCNA 2019 Dunn
ATE in DOGS:
–How does onset of signs impact px?
–Tx besides medical management? How does this differ in cats?
–Acute –> much shorter survival (9d vs 10mo if chronic)
–Get rid of or squish the clot using IR, sx, local tPa, balloon, stent. Don’t do that in cats – one study showed similar outcome to med mgmt alone.
VCNA 2019 Dunn
Which is the most common?
Which should be treated with balloon valvuloplasty? What medication should be given preprocedure?
Pulmonic stenosis
Aortic/subaortic stenosis
Pulmonic stenosis - most common congenital heart defect
Tx with balloon. Atenolol (beta blocker) 2-4 weeks prior.
Aortic/subaortic stenosis – can try balloon but nothing (incl sx, med mgmt) worse great (risk of sudden death)
VCNA 2019 Scansen
What minimally invasive procedure can be performed for L CHF due to MVD?
MST post procedure?
Make an atrial septal defect –> immediate reduction in LA pressure
6mo
JAVMA 2021 Allen
True or False: High dose pimo is beneficial in dogs with advanced MVD and/or concurrent renal disease.
False
No difference in NTproBNP, echo, or GFR in high dose vs standard dose pimo
JVIM 2022 Kaplan
Neutrophil extracellular traps are high in cats with:
HCM
ATE
Both
Neither
Both – possible novel biomarker and therapeutic target
JVIM 2023 Li
