Cardiology Flashcards
Pressure overload definition
disease that requires the heart to generate greater than normal ventricular pressures to eject blood
Systolic dysfunction definition
disease that results in reduced pumping function of the heart (low stroke volume and cardiac output)
Volume overload definition
Disease that results in a higher than normal end diastolic volume in the ventricle
diastolic dysfunction definition
diseases that result in reduced relaxation function of the heart
what are the 6 rules of the heart
- Two circulations are arranged in series. Systemic and pulmonary circulation
- the heart is a muscle
- The heart’s response to disease is predictable -
- The heart has 3 functions: conduction, diastole, systole
- blood is lazy - flows in the direction of least resistance
- Blood pressure = cardiac output x vascular resistance
concentric hypertrophy definition
appears as an increased wall thickness and small chamber Pressure overload is the common cause
Eccentric hypertrophy definition
Appears as a normal wall thickness with a dilated chamber. Wall thickness remains normal. Volume overload is the common cause
What items in an animals history are helpful?
- onset, duration, progression of presenting complaint - changes in weight, appetite, thirst, urination/defecation, vomiting - coughing/sneezing/respiratory effort/ gagging (frequency, character) - activity level and any recent changes in activity or endurance, fainting spells, weakness, or collapse - Travel and vaccination history and any concurrent medical conditions -diet and medications and supplements
Define cachexia
A disproprotionate loss in muscle mass that is commonly seen in inflammatory conditions
What are differentials for cachexia
- end stage cardiovascular disease
- neoplasia
- renal disease
- chronic inflammatory conditions
What are differentials for abdominal distension
abdominal fluid (a sign of R-CHF) organomegaly weakened abdominal muscles
Define fluid wave and what are differentials for a fluid wave
vibration of fluid palpated on ballottment of moderate to severe abdominal fluid - Right sided CHF - Liver disease, protein losing entero/nephropathies - Neoplasia - Trauma, bleeding mass, coagulopathies
When evaluating Mucous membranes, what do you consider as a differential when you have pale mucous membranes?
- poor perfusion* peripheral vasoconstriction anemia
When evaluating mucous membranes, what do you consider as a differential when you see blue/gray colored mucous membranes
R to L shunting, pulmonary parenchymal disease (such as pulmonary edema from left sided congestive heart failure) airway disease, hypoventilation, shock
What are differentials for cyanosis
pink MM cranially and blue MM caudally. This is a finding in dogs with a R to L shunting in a patent ductus arteriosus (Reverse PDA)
What is the status of your patient when you see brick red or “injected” Mucous membranes
Early phases of Shock
What are differentials for yellow mucous membranes
hemolysis, hepatobiliary disease
What is peripheral pitting edema, and list differentials
- Edema (fluid in tissues) in the ventral extremities or ventral thorax/abdomen Differentials: An uncommon seen sign in patients with right sided congestive heart failure. More common in horses and cattle. Non-cardiac differentials include hypoalbuminemia and rarely renal disease.
Precordium definition
to palpate the precordium is to palpate the heart beat on the chest wall. It is normally felt strongest on the L hemithorax
What side is the precordium stronger on?
Left side is generally strongest
What does it mean if there is a stronger Right sided precordium than the left side?
Right sided heart enlargement
What is a precordial thrill?
ability to palpate the fine vibrations of a murmur ont he chest wall. Precordial thrills may be palpated in patients with very loud murmurs. (grade V or VI)
What sounds are systolic sounds?
S1- closure of the mitral and tricuspid valves causes an abrupt deceleration of blood flow resulting in vibrations of the cardiac walls and blood S2- produced by the closure of the aortic and pulmonic valves and is best heard over the aortic area.
What sounds are considered Diastolic sounds
S3 - rapid ventricular filling S4- atrial contraction
Define murmur
A prolonged, audible vibration of blood in the heart or great vessels that can be associated with turbulent blood flow or abnormal blood flow
What is Grade 1/VI heart murmur
soft murmur heard in only 1 valve location, only in very quiet room; may only be intermittent
What is Grade II/VI heart murmur
soft murmur heard consistently, but only in 1 valve area Heard in 2 quadrants
What is a Grade III/VI heart murmur?
Moderate murmur heard in multiple valve locations on one side of the chest. Heard in 3 quadrants
What is a Grade IV/VI heart murmur?
Loud murmur heard on both sides of the chest. Heard in all 4 quadrants
What is a Grade V/VI heart murmur?
Loud murmur heard at all valve locations, associated with precordial thrill. Heard in 4 quadrants + thrill.
What is a Grade VI/VI heart murmur?
Loud murmur heard at all valve locations, even with stethoscope held 1cm from the chest wall. Heard in 4 quadrants + thrill + audible with stethoscope off chest
PMI
point of maximal intensity - describes the locatino on the heart where the murmur is most audible. This helps determine what valve the murmur is originating from.
what does “Radiation” mean when ausculting a heart?
This describes where else you can heart the murmur other than the PMI
When using the term “base” when describing the location of the PMI, what does it mean
this desecribes the upper half of the heart (above the costochondral junction). Murmurs that are the loudest at the base originate from the aortic or pulmonic valves
When using the term “apex” to describe the PMI, what does it mean?
this describes the lower half of the heart (below the costochondral junction). Murmurs loudest at the apex originate from the mitral or tricuspid valves.
How do you describe a ejection murmur?
this is a murmur that increases in intensity or who’s sound changes over time.
How do you describe a regurgitant murmur?
A consistent intensity and sound throughout the murmur
What are potential differentials for a jugular pulsation?
Eleveated R heart pressures (tricuspid regurgitation, other R sided volume or pressure overload disease, R sided CHF) - Pericardial disease - Inflow obstruction (mass or thrombus) - Arrhythmias (AV block, ventricular tachycardia)
Jugular distention definition
the jugular vein remain full of blood as if someone was holding off for blood
How do you describe normal arterial strength of arterial pulses?
This is Normokinetic, strong, or adequate
How do you describe a weaker strength arterial pulse? List some differentials
hypokinetic caused by a reduced stroke volume and narrowed pulse pressure. Subaortic stenosis, hypovolemia and some arrhythmias
How do you describe a stronger arterial pulse than normal?
Hyperkinetic caused by a widened pulse pressure. Bounding, or water-hammer pulses.
What are clinical signs associated with pulmonary edema?
- Tachypnea at rest
- Short, shallow respiratory pattern with inspiratory effort
- signs of severe dyspnea
- orthopneic (elbows pointed out and abducted)
- Wide eyed
- Neck outstretched
- Open mouthed breathing in cats
Pleural effusion clinical signs
- Tachypnea at rest
- Inspiratory and expiratory effort
- Abdominal component to breathing
What respiratory sounds do you hear with Pulmonary edema?
This is commonly associated with Left sided heart failure.
Respiratory exam: soft crackles at the end of inspiration and beginning of expiration are typical of patients with cardiogenic pulmonary edema from left sided CHF>
What respiratory sounds do you hear with Pleural effusion
reduced or absent breath sounds ventrally due to fluid accumulation
What does TPR stand for in thoracic radiograph film quality?
T = technique
P = Positioning
R = Respiratory phase
What vertebral heart score is considered normal?
8.5-10.5
What is the appropriate heart size for a cat when looking at a lateral and VD of a cat?
Lateral 2/3 the height of the chest cavity
VD 1/2 the width of the chest cavity
If a dog has a wide heart, where is the enlargement?
Generally RV is too wide
If a dog has a heart that is too tall, where is the enlargement?
Left ventricular enlargement is more common than a right ventricular enlargement.
on the “clockface” where are the following heart structures located at? Lateral positioning
LA
LV
RV
Aortic Arch
When a VD radiographic picture of a heart is present, where are the structures located in regards to a clock face?
Aortic arch
Left Auricle
LV
RV
RA
When evaluating a vd and you see a reverse D appearance, what does it indicate
Right sided Heart enlargement commonly associated with a:
Right heart pressure overload disease causing enlargement of the Main pulmonary artery, right atrium and right ventricle
What are the 3 radiographic features of left sided CHF?
- Moderate to severe left atrial dilation
- Pulmonary venous dilation
- Interstitial to alveolar pulmonary pattern (pulmonary edema)
- increased soft tissue opacity. There is an alveolar pattern
What are the radiographic features of right sided congestive heart failure?
- Moderate to severe right heart enlargement
- Dilated caudal vena cava
- Fluid accumulation
- Ascites, pleural effusion, small volume of pericardial effusion
- Pulmonary vasculature sizes varies depending on the type of right heart disease
What side of the heart is affected here?
Describe the changes seen
The right side of the heart is affected.
- Retraction of the lung lobes away from the thoracic wall or pleural fissure lines
- Soft tissue opacity ventrally + scalloped margins created by the lung lobes
- Border effacement with the cardiac silhouette and diaphragm
- Elevation of the trachea
What does dilation of the Caudal vena cava indicate
Venous congestion
What type of descriptive information is used to stage heart disease patients using the ACVIM classification system?
Structural or Functional?
ACVIM classification system - structural descriptions of what the heart looks like
you have an 8 year old FS mixed breed dog with mitral valve disease and moderate left atrial enlargement on an echocardiogram. Stage the heart disease using the ACVIM Staging system
B2
Describe Stage A heart disease
These are breeds that are at risk of cardiac disease.
- no known heart disease
- no murmur/arrhythmia
- no cardiomegaly on radiographs
- no clinical signs
Describe Stage B heart disease
- Structural heart disease present
- Heart murmur or imaging evidence (echo, radiographs)
- No clinical signs
Explain Stage B1 Heart disease
No hemodynamic compromise
- none to mild heart enlargement
Recommendations:
- no medical treatment or dietary restrictions
- Annual monitoring
Describe Stage B2 heart disease
-
Relevant hemodynamic compromise
- Significant heart enlargement (echo or radiographic)
- DMVD: specific cutoffs for LA and LV size
- Recommendations
- Ace inhibitors
- Pimobendan
- Not indicated: Furosemide, spironolactone *no clinical signs yet”
Describe Stage C heart disease
Patient is currently showing or in the past had signs of CHF.
- Left-sided: pulmonary edema
- Right-sided: cavitary effusions
Recommendations: furosemide, pimobendan, Ace inhibitors, spironolactone, dietary Na restrictions
Describe Stage D heart disease
- Current or past signs of CHF refractory to standard treatment
- Furosemide
- Pimobendan
- Ace inhibitors
- Spironolactone
- Recommendations: “tools in the toolbox”
- Increase the furosemide dose
- increase pimobendan dose
- amlodipine
- Hydrochlorothiazide
What is the definition of “heart failure”?
clinical syndrome wherein the heart pumps an inadequate volume of blood to meet O2 demands of tissue and prevent fluid accumulation.
- occurs in the face of adequate/high venous return
- Common end result of many different cardiac diseases NOT a primary diagnosis
What factors determine cardiac output
Heart rate
Stroke volume which is determined by preload, afterload and inotropy
What are clinical signs of heart failure with a low output
syncope
pallor (pale apperance)
cyanosis
hypokinetic pulses
azotemia
What are the exam findings of a patient with congestive heart failure
pulmonary edema
pleural effusion
ascites/hepatomegaly
pericardial effusion
peripheral edema
Where does the fluid go in Left sided CHF. Differentiate between a dog and a cat.
Dog - Pulmonary edema
Cat- pulmonary edema, pleural effusion, pericardial effusion. Cats don’t follow the exact same pattern as dogs do
Where does the fluid go for Right sided CHF? differentiate between dogs and cats.
Dog- ascites
Cats- Pleural effusion, ascites, pericardial effusion
What are long term effects of RAAS activation?
Myocardial remodeling and fibrosis
renal and arteriolar sclerosis
cytokine activation
What pathophysiologic parameters can we alter pharmacologically to treat heart failure?
increase inotropy
decrease preload
decrease afterload
optimize HR
Blunt RAAS
Blunt SNS
The presence of fluid accumulation in the form of pulmonary edema, pleural effusion, ascites/hepatomegaly, pericardial effusion and or peripheral edema are clinical signs of ______ heart failure.
A) forward (low output)
B) backward (congestion)
B) backward (congestion)
What drugs do we use to decrease preload?
Furosemide
Spironolactone
Hydrochlorthiazide
Which Diuretic is the 1st line in CHF? How does it work.
Furosemide - Loop diuretic targeting the ascending loop of henle. Targets the Na/K/2Cl cotransporter
Side effects: activates RAAS (need Ace inhibitors), azotemia, hypokalemia
What is DMVD?
degeneration of the heart valves that results in valve regurgitation. This causes a progressive heart dilation and ultimately results in congestive heart failure.
What is the order that heart valves are affected for DMVD?
Mitral > tricuspid > aortic >> Pulmonic in dogs
What is another name for Endocarditis
Degenerative mitral valve disease
Degenerative valve disease
what type of hypertrophy occurs with DMVD?
eccentric hypertrophy due to the volume overload
What is the common signalment for DMVD?
CKCS in particular -> More common in small breeds
middle aged to old
Male > Female dogs
How would you desecribe Stage B2 DMVD?
Murmur with moderate or severe left atrial dilation. This is at risk for progression to stage C
When evaluating radiographs for DMVD, what do you look for?
You look at the structure of the heart. A leaky mitral valve would result in a dilation of the left side of the heart
When diagnosing a dog with DMVD, what does stage B1 look like on Echocardiography
thickened valve leaflets with mitral regurgitation
Normal heart size or mild L atrial dilation
When diagnosing a patient with DMVD with Echocardiography, what would stage B2 look like?
Eccentric hypertrophy that appears as dilated LA and LV with normal wall thickness
Thickened valve leaflets with regurgitation
+/- valve prolapse or ruptured chordae tendinae
What can you look for on the electrocardiogram for a patient with DMVD in regards to chamber enlargement patterns?
Wide P wave is indicative of Left atrial enlargement
Tall R wave, wide QRS indicates left ventricular enlargement
How do you recommend treating a patient in Stage B2 DMVD?
pimpbendan with an ACE inhibitor
+/- antihypertensive therapy if indicated by the BP
Avoid high salt diets and treats.
Re-evaluate the patient every 6-12 months while it remains assymptomatic. follow up with thoracic radiographs, etc.
What is the treatment protocol for a stage C DMVD?
Left sided CHF: diuretic (furosemide, spironolactone), ACEi, pimobendan
What can the ECG tell us?
heart rate, arrhythmias, conduction abnormalities
Good at chamber enlargement
true/false An ECG tells us about the mechanical activity of the heart
false
what is an arrhythmia
electrical activity that has an irregular rhythm and/or an abnormal heart rate
What does each wave in an electrocardiograpm tell us about the electrical activity? (polarization/depolarization)
P wave
PR interval
QRS complex
T wave
P wave = atrial depolarization
PR interval = electric activity moves Slowly through AV node
QRS complex = ventricular depolarization
T wave = ventricular replarization
how long is a BIC pen?
150 mm
what is bradyarrhythmia
Low calculated heart rate
What does it mean to have a regularly irregular rhythm?
This is an irregular rhythm with a discernable pattern to the regularity. This is a characteristic of sinus arrhythmias.
What is an irregularly irregular arrhythmia?
Irregular rhythm without a discernable pattern to the irregularity.
This is a characteristic of atrial fibrilation
Evaluate the heart rhythm
Supraventricular heart rhythm.
Evaluate the heart rhythm
Ventricular rhythm
Wide and bizarre QRS
QRS does not have an associated P wave
Transient atrial standstill differentials
Seen in patients with severe hyperkalemia.
Dogs= Addisons
Cats= Urethral blockage
Treatment: atrial standstill can be resolved by correcting the hyperkalemia and underlying cause
this ECG: atrial standstill with evidence of right ventricular enlargement (with a deep S wave)
What are indications for echocardiography
To assess the cardiac structure and function
- assess the heart chamber size
- wall thickness
- systolic and diastolic function
- valve anatomy and valve regurgitation
Provides definitive diagnosis of most cardiac diseases
Where on a thoracic cavity is a parasternal view in regards to echocardiography?
next to the sternum
How do you achieve a subcostal view for echocardiography?
place the transducer on the abdomen and direct it cranially. The ultrasound should go through the liver and diaphragm
What is the difference between a long axis and short axis echardiography orientation?
Long axis shows all 4 chambers
What do you evaluate on a Right parasternal Long axis view?
LV should be 3-4x the size and thickness of RV in long-axis
LA and LV should be roughly the same maximum height
LA and Ao should be roughly same diameter
Valve thickening/regurgitation?
LV systolic function
what do the colors on dopler mean?
B.A.R.T.
Blue = away
Red = towards
Party colors = turbulance
What is fractional shortening in regards to Echocardiography
echocardiographic index of LV systolic function
what is the green arrow pointing to in this Right Parasternal Short axis M mode view?
Mitral valve as it opens and closes
Identify each Letter
What is a benefit of using the subcostal approach during echocardiography?
It allows you to see the aorta and aortic valve
Name the chambers of this LA 4-chamber view
