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Small animal Medicine- Cardiology > cardiology unit 2 > Flashcards

cardiology unit 2 Flashcards

1
Q

Why does DCM occur

A

Decreased LV systolic function

myocardial disease (problem with the muscle itself)

Primary DCM: Genetic/idiopathic: Dobermans PDK4 mutation

Secondary DCM: nutritional deficiency, infectious/inflammatory , tachycardia-induced cariomyopathy, sepsis-induced mycardial dysfunction

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2
Q

Histology from cardiac muscle, what is your diagnosis?

A

DCM

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3
Q

What ECG changes do you see with DCM and dobermans?

A

ventricular arrhythmias often precede echo changes in DCM

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4
Q

What ECG changes do you see with DCM and Irish Wolfhounds?

A

Atrial fibrillation

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5
Q

What dogs are the most common to get DCM ?

A

Dobermans >6months ~50% of the time

Great danes

Irish Wolfhounds

Cats: taurine deficiency

Male > Female

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6
Q

How is DCM detected?

A

breeder screenings (especially for dobermans)

Murmurs, or arrhythmias on veterinary screenigns

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7
Q

What do you look for on echocardiography for DCM diagnosis?

A

Decreased LV systolic function

Increased LV size

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8
Q

What is the ECG Holter scale used for DCM diagnosis?

A

Used to determine the probability that a Doberman will develop DCM

>100 VPC’s/24hr 100%

>50 VPC’s/24hr or 1 couplet/triplet: 94%

1+ VPC/5 minutes 96.7%

1+ VPC/24hrs 74%

NO VPCs/24 hrs 42%

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9
Q

True or False

The severity of ventricular arrhythmias is correlated with the severity of myocardial dysfunction in relation to DCM

A

True

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10
Q

What is NT-proBNP

A

DCM biomarker

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11
Q

What nutritional deficiencies are associated with DCM?

A

Taurine/carnitine - measure the blood and supplement if it is low

Plasma carnitine does not correlate with myocardial carnitine

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12
Q

What are the complications of DCM?

A

Left or Right sided CHF

  • dyspnea, tachypnea
  • cough
  • Exercise intolerance/inappetence
  • abdominal distension

Syncope-secondary to ventricular arrhythmias

sudden cardiac death

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13
Q

where does the fluid go for a dog with Left sided CHF

A

Pulmonary edema

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14
Q

where does the fluid go for a Dog with Right-sided CHF

A

Ascites

occasionally pleural effusion

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15
Q

Where does the fluid go for a cat with left-sided CHF

A

pulmonary edema

pleural effusion

pericardial effusion

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16
Q

Where does the fluid go for a cat with right-sided CHF

A

pleural effusion

ascites

pericardial effusion

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17
Q

What is a negative prognostic indicator for DCM

A

severe ventricular arrhythmias:

poorly controlled atrial fibrillation rate:

younger age of onset;

pleural effusion;

being a Doberman or Great Dane

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18
Q

what is the average time to CHF for a dog with DCM?

A

2 years with a doberman

2-5 years for other breeds.

following an episode of CHF 6mo-2 year.

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19
Q

What is the cause of death in a patient with DCM?

A

2/3 of cases end in CHF

1/3 of cases end in sudden cardiac death

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20
Q

What is the treatment protocol for a patient witih DCM?

A

The goal is to optimize the heart rate.

Pimobendan: prolongs time to CHF

ACE inhibitor: prolongs time to CHF

Atenolol is cardioprotective (do not give to acute CHF patient)

Treat arrhythmias

Ventricular arrhythmias: sotalol, mexiletine

Atrial fibrillation: digoxin, diltiazem

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21
Q

dog with acute DCM treatment

A

FOPS:

Furosemide

Oxygen

Pimobendan

Sedation (butorphanol)

centesis if pleural effusion/ascites

dobutamine if in cardiogenic shock- poor CO

lidocaine: if life threatening VT

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22
Q

What is the treatment for a dog with Chronic DCM with CHF

A

“Dogs Are For Special People”

Dietary Na+ restriction

ACEi

Furosemide

Spironolactone

Pimobendan

Diltiazem/Digoxin: rate control in atrial fibrilation

Sotalol/Mexiletine: Ventricular arrhythmias

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23
Q

What is Arrhythmogenic Right ventricular cardiomyopathy ARVC?

A

a disease of the desmosomes

Ventricular arrhythmias with DCM phenotype

signalment: middle-aged Boxers

clinically present with syncope most of the time.

Treatment Sotalol

guarded prognosis

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24
Q

What are congenital pericardial diseases?

A

Absence of pericardium

Peritoneopericardial diaphragmatic hernia PPDH

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25
Q

What are acquired pericardial diseases?

A

Pericardial effusion and cardiac tamponade

constrictive pericarditis

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26
Q

What are the different types of fluid found in pericardial effusion, and differentials for each

A

hemorrhagic

  • neoplasia (#1 cause in dogs)
  • idiopathic (#2 cause in dogs)
  • other

Transudate

  • RCHF
  • Hypoalbuminemia

Exudate

  • infectious
    • FB/hardware disease (#1 cause in cattle)
    • fungal coccidiomycoses
  • Sterile
    • secondary to systemic inflammation
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27
Q

what type of dysfunction do you get with pericardial diseases?

A

Diastolic dysfunction

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28
Q

What is cardiac tamponade

A

the clinical syndrome that occurs when increased intrapericardial pressure interferes with normal cardiac filling

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29
Q

what is the outcome of cardiac tamponade?

A

sudden death

Compensation

Reduced cardiac filling resulting in low CO and Low BP

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30
Q

What are clinical signs of cardiac tamponade?

A

collapse, weakness

decreased appetite, vomiting

lethargy

decreased milk production in cattle

polyurea, polydipsia

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31
Q

What are physical examinatino findings of cardiac tamponade cases?

A

distended jugular veins

pleural effusion

muffled heart sounds

weak femoral arteries

ascites

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32
Q

What is pulsus paradoxus?

A

Changes in cardiac output based on the breathing cycle.

on inspiration, the negative intrathoracic pressure increases the volume of blood in the heart.

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33
Q

What are the 3 hallmark findings of pericardial effusion on radiographs?

A
  1. enlarged rounded cardiac sillhouette
  2. dilated caudal vena cava
  3. Small pulmonary arteries and veins
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34
Q

True/ False

During pericardial effusion, you are not able to make out the underlying structures.

A

True

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36
Q

what are other ECG abnormalities seen with Pericardial effusion

A

decreased QRS amplitude

Variable R wave heights

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37
Q

what are treatments for pericardial effusion

A
  • if unstable/decreased BP IV fluids.
    • if preparing for a pericardiocentesis, administer quarter shock bolus of IV crystalloids
  • Pericardiocentesis
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38
Q

Where do you performa pericardiocentesis?

A

The right side of the chest ICS 3-5

in the intercostal space, go just cranial to the rib to avoid the neurovascular bundle that lies caudal to the rib

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39
Q

What is the pathogenesis of constrictive pericarditis?

A

inflammation or infectious process

thickened, noncompliant pericardium +/- adhesion to the cardiac muscle prevents relaxation of the heart

Reduced cardiac filling results in low cardiac output and low blood pressure

Same clinical signs exam findings, and radiographic findings EXCEPT the heart can be nromal size.

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40
Q

What is PPDH

A

this is an abnormal connection from the abdomen tot he pericardium

Cats> dogs

Clinical signs vary depending on organs affected, tachypnea, dyspnea, vomiting, anorexia, weight loss

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41
Q

What does PPDH stand for

A

peritoneal-pericardial diaphragmatic hernea

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42
Q

What is the normal pulmonary artery pressure and what defines Pulmonary hypertension?

A

normal: 25mmHg

PHT > 30mmHg

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43
Q

Why does Pulmonary hypertension occur?

A
  • idiopathic -retnetion of fetal pulmonary vascular resistance
  • Left sided heart disease -> pulmonary venous hypertension (post capillary disease)
  • Chronic pulmonary disease -> hypoxemia and vasoconstriction
  • Pulmonary thromboembolic disease
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44
Q

Where is pulmonary hypertension localized?

A

precapillary

postcapillary

  • left sided heart disease
45
Q

What happens to pulmonary arteries/arterioles in pulmonary hypertension?

A

medial hypertrophy

Intimal proliferation and fibrosis

“Plexiform” lesions

46
Q

What happens to the heart with pulmonary hypertension?

A

high right ventricular afterload

Right ventricular hypertrophy and dilation, main pulmonary artery enlargement, tricuspid regurgitation, pulmonic regurgitation

47
Q

What are the complications of Pulmonary hypertension?

A

syncope

dyspnea

exercise intolerance

cough

These are often misdiagnosed as L-CHF secondary to mitral valve disease

48
Q

How do you diagnose the PA pressure on echocardiography

A

velocity of blood flow is determined by PRessure Gradient

Estimate PA pressure using velocity of

  • Tricuspid regurgitation (systolic)
  • Pulmonic regurgitation (diastolic)
49
Q

How do you diagnose Chronic bronchopulmonary disease as the primary cause of pulmonary hypertension?

A

thoracic radiographs

fluoroscopy

Bronchoscopy

50
Q

How do you diagnose pulmonary thromboembolic disease as the primary cause of pulmonary hypertension

A

thoracic CT-angiography

D-dimers

51
Q

what medications are for the treatment of pulmonary hypertension in the presence of R-CHF?

A

R-CHF: furosemide, Pimobendan, enalapril

Pulmonary vasodilatior: Sildenafil

52
Q

What is the treatment if pulmonary hypertension is due to chronic bronchopulmonary disease?

A

Bronchodilators (theophyline)

cough suppressants (hydrocodone)

antibiotics (doxycycline

Steroids (prednisone)

53
Q

Treatment of pulmonary hypertension that is due to Left sided heart disease

A

enalapril, pimobendan, furosemide, spironolactone

54
Q

How do you treat pulmonary hypertension due to pulmonary thromboembolic disease

A

Clopidogrel

Aspirin

Treatment of PLE/PLN/Cushing’s

55
Q

How do you traet pulmonary hypertension due to heartworm disease?

A

heartworm preventative

doxycycline

Melarsomine protocol

56
Q

What is cTnl?

A

protein attached to actin/tropomyosin cardiac sarcomere

This is a leakage protein that is released when myocytes are damaged

Sensitive and specific for myocardial injury

this cannot specify what caused the injury

57
Q

What are differentials for increased cTnl?

A

myocarditis

thoracic/cardiac trauma

Cardiotoxicity

cardiac hemangiosarcoma in dogs

DCM in dobermans

CHF

Chronic kidney disease

58
Q

What is the clinical utility of cTnl?

when might you use this test?

A
  • patients with a clinical suspicion of myocarditis
    • fever, arrhythmias, echo abnormalities
  • Dogs with pericardial effusion
  • Asymptomatic Dobermans normal vs. occult DCM
  • Dyspneic cat: CHF vs respiratory disease
    • NT-proBNP is better in this situation
  • Cats with HCM
59
Q

What is NT-proBNP

A

hormone synthesized and released from the ventricles in response to myocardial stretch

Causes diuresis, naturesis, vasodilation (natural “anti-RAAS”) causes vasodilation and excretion of water and Na, this will be elevated in cardiac disease

C-BNP is the active form NT-proBNP is the inactive form

60
Q

What causes NT-proBNP elevation?

A

incresed with cardiac disease such as: Mitral valve disease, DCM, HCM, CHF

Magnitude fo increase correlates with severity of heart disease

Increased wtih some non cardiac diseases such as day-to-day variations, chronic kidney disease, critical illness, pulmonary hypertension

61
Q

What is the clinical utility of NTproBNP?

When woul dyou use this

A
  • Asymptomatic cats with murmurs: occult HCM?
    • high sensitivity/specificity
  • Dyspneic cats: CHF vs respiratory disease
  • Dogs with CHF

Dr. Ward almost never runs this test.

62
Q

What happens if the RAAS system is activated Long Term?

A

cardiac fibrosis

Renal damage

Cytokine activation

63
Q

what activates RAAS system?

A

Juxtaglomerular apparatus releases renin in response to low BP, low renal blood flow, or sodium or high sympathetic nervous system tone

64
Q

What is the outcome of RAAS activation

A

increased volume by causing Na and water retention.

aldosterone release to cause Na and water retention

ADH release increasese thirst

Increased vascular resistance due to ADH

65
Q

Where is Angiotensinogen produced?

A

The liver Constitutively produces it

in the presence of renin, it is converted to Angiotensin I

66
Q

What are the negative effects on the heart due to Angiotensin II?

A

high vascular resistance (increased afterload)

excessive volume retention may lead to CHF in a diseased heart

ATII and aldosterone are cardio-toxic and cause cardiac fibrosis, vascular smooth muscle proliferation leading to systemic hypertension and cytokines and free radical formation that lead to cardiomyocyte death

Renal and arteriolar sclerosis leading to renal damage

67
Q

How can you intervene with the RAAS system?

A

improve pumping functoin

Stop or counteract the RAAS activation/actions with ACE inhibitors

Antihypertensives

Cardioprotective agents.

68
Q

What are common underlying causes of systemic hypertension in dogs

A

Hyperadrenocorticism

Chronic kidney disease

69
Q

What are common underlying causes of systemic hypertension in cats

A

Hyperthyroidism

Chronic kidney disease

70
Q

Why is systemic hypertension bad?

A

Kidney- progression of CKD and proteinuria

Eye- retinal hemorrhage and detachment

Brain- hemorrhagic: stroke

Heart: left ventricular hypertrophy

Blood vessels: hemorrhave

71
Q

what is the “normal” systolic blood pressure?

A

120-130

72
Q

When is blood pressuer considered hypertensive?

A

Above 140

Hypertensive 160-179

Severe >180

73
Q

What patients should be screened for systemic hypertension?

A
  • patients with evidence of target organ damage
  • patients with diseases that cause secondary systemic hypertension
  • Patients receiving vasodilatory therapy
  • Patients with a disease that can be worsened by systemic hypertension

Routine screening recommended for pets >9 y.o

74
Q

When you have a patient that presents with No evidence of target organ disease and a BP greater than 160mmHG, how do you choose to proceed?

A

Repeat the BP twice within 8 weeks.

If it is less than 160mmHg recheck in 3-6months

If greater than 160mmHg Treat!

75
Q

How is systemic hypertension treated?

A

The goal is to control the blood pressure.

  • Enalapril, benazepril are ACE inhibitors that decrease the BP by 10-15 mmHg
    • This decreases glomerular hypertension and proteinuria
    • Inhibits RAAS system
  • Telmisartan- decreases BP by 20-25mmHg, and inhibits RAAS system
  • Amlodipine is a calcium channel blocker that decreases BP by 30-60mmHg. no effect on renal efferent arteriole
    • Activates the RAAS system
76
Q

When should blood pressure be rechecked after antihypertensive medications have been started?

A

Recheck 7-10 days after starting the antihypertensive. If the BP is > 140 mmHg, increase the dose or add a second agent.

77
Q

Why does HCM occur?

A

this is a disease of the sarcomere.

Genetic mutations in MyBPC

Impaired LV myocardial relaxation = DIastolic dysfunction (not enough relaxation/filling)

concentric hypertrophy

78
Q

What is the difference betwween HCM and HOCM?

A

The outflow track is obstructed in HOCM

79
Q

What animals are prone to getting H(O)CM?

A

Cats

Breeds: Maine Coons, Ragdolls

Males have ~75% of acquiring it

80
Q

How is HOCM detected?

A

breeder screening through echocardiogram or genetic testing

Veterinary screeing: Murmur, arrhythmia, cardiac biomarkers

Definitively diagnosed using an Echocardiography and see LV hypertrophy and LV diastolic dysfunction

81
Q

what causes a heart murmur in H(O) CM ?

A

dynamic LVOT obstruction. HOCM Is easier to diagnose than HCM

1 in 7 cats have HCM of those 1 in 2 has a murmur

82
Q

What are complications of HOCM?

A

CHF with dyspnea, tachypnea, inappetence ADR hiding

Arterial thromboembolism -> acute paresis/pain bilateral hindlimb is more common

Sudden cardiac death

83
Q

What are negative prognostic indicators for a patient with H(O)CM?

A

left atrial enlargement, Severe LV hypertrophy, older age.

Asymptomatic cats have an average surgival rate of ~5 years

following left atrial enlargement: 3-6 months

84
Q

What medications are known to decrease the chance of thrombosis?

A

Clopidogrel

Aspirin

Heparin

tPA

85
Q

What medications are used to treat Stage B HCM patients

A
  • Atenolol- LVOT obstruction, severe sinus tachycardia (more likely with HOCM) used to decrease the heart rate and potentially get rid of the outflow blockage
  • Ace inhibitors - Severe LV/LA remodeling and fibrosis
  • Clopidogrel (moderate-severe LA enlargement) decrease the chacne of thrombus formation
86
Q

What medications are used to treat Stage C CHF with HOCM?

A

Acute: O@ supplementation +/- thoracocentesis

Furosemide

Ace inhibitors

pimobendan (may be a concern with HOCM cats)

Spironolactone

87
Q

What medications are used to treat arterial thromboembolism

A

Analgesia

Clopidogrel

Heparin/low molecular weight heparin

Thrombolysis

the goal is to decrease additional thrombus formation

88
Q

What are innocent murmurs?

A

physiological murmurs.

Soft grade I-III/VI

Left sided

Early or mid-systolic

disappear by 4-6 months

89
Q

What are the most common congenital heart disease in puppies?

A

PDA

Pulmonic stenosis

subaortic stenosis

90
Q

PDA

A

failure of closure of ductus arteriosis

Consequences L-R shunt causing L CHF

signalment: poodles yorkies, shelties especially females

Murmurs: continuous “washing-machine” murmur @ left heart base

91
Q

What are treatments for PDA?

A

interventional catheterization

Surgical ligation (thoracotomy)

treatment dramatically improves prognosis

92
Q

Pulmonic stenosis

A

congenital narrowing/thickening of the pulmonic valve

Consequences: RV pressure overload -> RCHF, syncope, arrhythmias

Signalment: Beagle, Boxer, Bulldog

Murmur: systolic ejection murmur @ left heart base

Pronosis: guarded with no treatment, good with balloon vulvoplasty

93
Q

what is the treatment for pulmonic stensosi

A

mild/moderate: atenolol

Severe : balloon valvuloplasty

94
Q

True/ False

It is harmful to wait >6mo. for a referral if the murmur is initially soft

A

False.

there is no harm in waiting

95
Q

Subaortic stenosis

A

congenital ridge/narrowing below the aortic valve. Lesion continues to progress throughout growth

L-ventricular pressure overload ->L CHF, endocarditis

Signalment: Larger breeds (Newfoundland, Boxer, GSD, Golden, Rottweilers)

Murmur: systolic ejection murmur at left heart base

96
Q

Treatment for Subaortic stenosis

A

Atenolol if moderate/severe

No good procedure: baloon valvuloplasty is not effective

97
Q

What monitoring recommenations do you have for owners with a pet that has Subaortic stenosis

A

Disease progresses until the dog is fully grown. i fth emurmur is soft, you must recheck the echocardiograpm as adult to know the disease severity

98
Q

What are other congenital heart diseases in dogs (less common)

A

VSD- right-sided murmur

Tricuspid valve dysplasia

Cyanotic heart defects (right to left shunting)

99
Q

when should you refer a pupy with a murmur?

A
  • refer any murmur that is continuous, diastolic or right sided
  • refer a left-sided systolic murmur if you can heart it on both sides of the chest
  • Refer any murmur still heard after 6 months
100
Q

What are the most common congenital heart diseases in kittens?

A

Ventricular septal defects

AV valve dysplasia (mitral/tricuspid)

101
Q

Ventricular septal defect

A

abnormal communication between left and right ventricles

Consequences: L-R shunting -> L-CHF

Murmur: Systolic plateau or decreschendo murmur @ right side

Prognosis is dependent on the size of the defect

102
Q

What are treatment methods for a VSD in cats?

A

small restrictive (loud murmur) no treatment required

Large/unrestrictive (softer murmur) treat CHF when it occurs. there is no corrective procedure in cats.

103
Q

Mitral and tricuspid valve dysplasia

A

abnormal development and leakage/stenosis of mitral and/or tricuspid valves

consequences: LV or RV volume overload resulting in R or L CHF

Murmur: systolic plateau/regurgitant murmur @ left or right apex

104
Q

How do you treat Mitral and tricuspid valve dysplasia in cats?

A

you treat when CHF occurs

No corrective procedure is available

105
Q

when should you refere a kitten with a murmur?

A

refera a murmur that is continuous, diastolic or right-sided

Refer a left-sided systolic murmur if you can hear it on both sides fo the chest. Refer any murmur still heard after 6 months

There are fewer surgical/treatment options for cats

106
Q

How do you distinguish “innocent” murmurs vs murmurs due to congenital heart disease

A
107
Q

What congenital heart diseases are associated with volume overload?

A

Left side: congenital VDA, VSD, MV dysplasia

Right side: congenital:tricuspid dysplasia

108
Q

what congenital heart diseases are associated with too much afterload (pressure overload)

A

Left: Congenital Subaortic stenosis

Right: Congenital Pulmonic stenosis

Small animal Medicine- Cardiology (3 decks)

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