CardioResp Disease Flashcards
Congenital and infectious diseases are more commonly related to which age group of dogs?
Young
Why is breed an important signalment to note in terms of respiratory diseases?
Brachycephalic versus dolichocephalic, brachy → anatomical issues; doli → infectious esp fungi
An animal presents to you with sneezing and/or coughing, what about the sneezes/coughs should you ask about?
Characteristics (ex. honking) and triggers
Is a cough being productive versus nonproductive a very reliable way to differentiate disease?
No
Productive coughs MAY be seen more with what two general abnormalities/diseases?
Inflammation or pneumonia
Where in the respiratory system is associated with the highest prevalence of cough receptors? Three answers.
Larynx, carina, and bronchioles
Tachypnea and short inspiration and expiration are indicative of what general category of respiratory disease?
Restrictive
What respiratory pattern is resultant of an intrathoracic airway obstruction?
Normal inspiration, prolonged expiration and increased effort
What general category of respiratory disease results in increased duration and effort on inspiration?
Extrathoracic airway obstructions
What respiratory sound is generated by vibrations of the pharynx and/or nasopharynx and is a low frequency snoring inspiratory sound?
Stertor
What is stridor and which phase of respiration (inspiration or expiration) is it related to?
Stridor is sound resulting from impaired airflow through the larynx or trachea; inspiratory or expiratory
Where does stertor localize a respiratory issue to in the respiratory system?
Nasal, nasopharynx, or pharynx
Where does stridor localize a respiratory issue to in the respiratory system?
Larynx or trachea
Respiratory distress is common with diseases of the larynx, what two things can exacerbate laryngeal respiratory disease?
Exercise or heat
(T/F) Any cough elicited on tracheal palpation is abnormal.
F, if you press hard enough on a healthy dogs trachea, they will cough
What is indicated by the presence of jugular vein distension/pulse?
Increased pressure in the right heart
In which species can you artificially create a murmur when auscultating the heart with a stethoscope?
Cats
What is a high-pitched continuous musical sound that is indicative of air movement through very narrowed airways?
Wheezes
Is crackles always indicative of fluid in the airways?
No, could be chronic bronchitis
If you hear a dorsal decrease in lung sounds, what disease might be indicated?
Pneumothorax, might because not every case follows the rules 100% of the time
If you hear a ventral decrease in lungs sounds, what disease might be indicated?
Pleural effusion
(T/F) Nasal discharge is most associated with disease localized to the nasal cavity and paranasal sinuses.
True
Though not always true, bilateral nasal discharge is more likely to be what general categories of disease?
Systemic and/or infectious
What abnormalities is unilateral nasal discharge resultant of?
Foreign bodies, polyps, and tooth root abscesses
Nasal discharge related to neoplasia typically takes what presentation in terms of location?
Unilateral progressive to bilateral
What are possible intranasal causes for stertor sounds? Four answers.
Congenital deformities, masses, exudate, and blood clots
Ulceration and depigmentation of the planum nasale in a dolichocephalic dog is highly indicative of what disease?
Aspergillosis
You have a cat presenting with polypoid masses protruding from the external nares, what would be at the top of your differential list?
Cryptococcosis
What is indicated if you attempted to retropulsed an dogs eyes and one of them did not retropulse as much as the other?
Mass lesions
How is feline upper respiratory tract disease spread primarily?
Direct contact
What two viruses are involved in feline upper respiratory tract disease?
FHV-1 and calicivirus
What three bacteria are involved in feline upper respiratory tract disease?
Bordetella, chlamydophila, and mycoplasma
Are signs often mild or severe in kittens with FHV-1?
Severe
Though signs related to FHV-1 infections typically resolve in 1-3 weeks, what is the chronic disease that may develop?
Chronic rhinosinusitis
(T/F) A carrier state occurs in most FHV-1 infected cats and viral shedding can follow stress.
True
Are feline calicivirus signs less or more severe than FHV-1?
Less
What is the uncommon disease associated with FCV infections that results in fever, edema of face and paws, icterus, pneumonia, URI, and death?
FCV associated virulent systemic disease
What is the chronic disease that may develop with FCV infections?
Chronic gingivostomatitis
What clinical sign predominates with B. bronchiseptica infections in kittens?
Rhinitis
What clinical sign predominates with C. felis infections in kittens?
Conjunctivitis
Where do you want to collect samples when PCR testing for feline upper respiratory tract disease? Two answers.
Oropharynx or conjunctiva
What is the primary treatment for feline upper respiratory tract disease?
Supportive care
When are doxycycline, fluoroquinolone, and azithromycin indicated in a case of feline upper respiratory tract disease?
When nasal discharge becomes purulent → likely bacterial infection
What antiviral is reserved for severe cases of FHV-1?
Famciclovir
What is important for preventing feline upper respiratory disease?
Vaccination
How are nasal foreign bodies diagnosed?
Visualization
What is the treatment course for nasal foreign bodies?
Removal and short course of broad spectrum abx
Is the nasal airflow preserved in tooth root abscesses aka oronasal fistulas?
Yes
What is the treatment course for tooth root abscesses?
Removal of the affected tooth and short course of abx
What causes acquired nasopharyngeal stenosis?
Inflammation
What is the treatment for nasopharyngeal stenosis?
Balloon dilation or surgery
What fungal infection is more common in cats and is associated with facial distortion, sneezing, chronic mucopurulent nasal discharge, and stertor?
Cryptococcosis
What diagnostic options are there for diagnosing cryptococcosis? Three answers.
Cytology, serology, and culture
What drug is used most commonly for treatment of cryptococcosis and what is the duration?
Fluconazole, 4 month duration
What is indicative of aspergillosis in a radiograph or CT scan?
Severe turbinate destruction
What drug is used via topical infusion in treatment for aspergillosis, in combination will debridement of fungal plaques?
Clotrimazole
Erosion of what bony structure may make aspergillosis treatment risky?
Cribriform plate
How can you confirm the above structure is intact in your aspergillosis patient? (Cribriform Plate)
CT scan
What neoplasia type is most common in nasal neoplasia of cats?
Lymphosarcoma
Is surgery a good option for treatment of nasal neoplasia in most cases?
No, only good for rostral neoplasia
What are the causes of canine lymphoplasmacytic rhinitis?
Unknown
What should be present on a nasal biopsy of suspect canine lymphoplasmacytic rhinitis?
Lymphoplasmacytic inflammation
(T/F) In treatment for canine lymphoplasmacytic rhinitis, no treatment routinely provides a response
True
What is feline chronic rhinosinusitis a possible sequela of?
Previous viral infection → FHV-1
Where do feline nasopharyngeal polyps originate?
Auditory tube or tympanic bulla
In what cases is traction avulsion best used for treatment of feline nasopharyngeal polyps?
In cats without external ear canal masses
What surgery is performed for feline nasopharyngeal polyps after avulsion fails?
Bulla osteotomy
What transient side effect is possible with the removal of nasopharyngeal polyps?
Horner’s syndrome
Where is a majority of the airway resistance associated with brachycephalic obstructive airway syndrome?
Nasal passages
The increased effort related to BOAS is typically present on inspiration or expiration?
Inspiration
What can the increased negative pressure subsequent to BOAS lead to?
Collapse of airways
Why might a BOAS dog have inspiratory stridor in addition to stertor?
Increased negative pressure leading to collapse of the larynx
What results from congenital malformations of the nasal cartilages and resultant medial collapse and occlusion of the nares?
Stenotic nares
What is the treatment for stenotic nares?
Resection of portion of dorsolateral nasal cartilages
How is elongated soft palate treated?
Staphylectomy → soft palate resection
What is the pathogenesis of laryngeal collapse?
Chronic upper airway obstruction causes cartilage fatigue and degeneration → collapse
What do GI signs related to BOAS result from?
Chronic increased negative pressure in the thorax
The dysfunction of what two structures can result in laryngeal paralysis?
Recurrent laryngeal nerve or CAD m
Abnormal adduction or abduction leads to airflow obstructions in laryngeal paralysis?
Abduction
Abnormal adduction or abduction leads to aspiration in laryngeal paralysis?
Adduction
What abnormal nasal sound is caused by laryngeal paralysis?
Stridor
What medication can be given to stimulate laryngeal movement when sedation can minimize laryngeal movement?
Doxapram
When you are doing a laryngeal exam on a patient with suspected laryngeal paralysis, what might you expect the arytenoid cartilages to look like?
Edematous and erythematous
(T/F) Unilateral paralysis is an indication for laryngeal paralysis surgery.
F, bilateral
Why should you take thoracic radiographs on all laryngeal surgery patients?
Prone to aspiration pneumonia and esophageal dysmotility, would be evident on radiographs
What are the three primary, common things that need to be done to manage acute respiratory distress in a patient with laryngeal paralysis?
Sedation, oxygen, anti-inflammatories
Laryngeal paralysis can be an early manifestation of what disease?
GOLPP → geriatric onset laryngeal paralysis polyneuropathy
What do you have to differentiate feline laryngeal paralysis from?
Laryngeal masses → more common than laryngeal paralysis
What are the most common neoplasms that cause laryngeal masses in cats?
Squamous cell carcinoma or lymphoma
What are the most common neoplasms that cause laryngeal masses in dogs?
Squamous cell carcinoma, adenocarcinoma, and sarcoma
What is tracheal collapse?
Dorsoventral flattening of the tracheal rings with laxity of the dorsal tracheal membrane
What is the main pathogenesis for tracheal collapse?
Softening of the cartilage rings
In dynamic collapse of the trachea, which portion (cervical versus thoracic) collapses during inspiration?
Cervical
What is the common signalment in a patient with tracheal collapse? Age and size/breed.
Middle aged to older, miniature/toy/small breed dogs, yorkshire terriers
What can initiate the cough clinical sign in patients with tracheal collapse?
Excitement, drinking, eating, pulling on leash
Why might you find concurrent myxomatous/degenerative mitral valve disease in a patient with tracheal collapse?
Due to similar population → middle aged to older small breed dogs
What do radiographs in tracheal collapse cases underestimate?
Frequency and severity of tracheal collapse
What diagnostic test should be performed prior to consideration of stent placement? (Tracheal)
Tracheobronchoscopy
Extraluminal tracheal rings are reserved for cervical or thoracic tracheal collapse?
Cervical
What surgical option is used for intrathoracic inlet to thoracic tracheal collapse?
Intraluminal self-expanding stenting devices
What does the severity of canine infectious respiratory disease depend on? Two answers.
Coinfections and age
What antibiotic is most commonly used in treatment of canine infectious respiratory disease, though this is often unnecessary?
Doxycycline
How is canine infectious respiratory disease prevented?
Vaccination and limiting exposure
What abnormal sound is the hallmark of chronic bronchitis, though it may not always be present?
Expiratory wheezes
What lung pattern is associated with chronic bronchitis, though they can be completely normal?
Bronchial pattern
What do you see on cytology of airway samples in dogs with chronic bronchitis? Three answers.
Non-degenerative neutrophils, eosinophils, and mucus
What are the goals of treatment of chronic bronchitis? Two answers.
Control signs and reduce inflammation/disease progression
In what age, sex, and breed is feline asthma/bronchitis more frequent?
Middle aged, female, siamese
Which phase of respiration will typically be prolonged with feline asthma?
Expiration
(T/F) Diagnostics should be kept to a minimum in an emergent situation.
True
What are the two common causative viruses for canine viral pneumonia?
Canine distemper and influenza viruses
What is the common causative virus for feline viral pneumonia?
Feline calicivirus
Although viral pneumonias are typically associated with puppies and kittens, which virus would be indicated in an older dog with a suspected viral pneumonia?
Canine influenza
In addition to the fever, tachypnea, harsh lung sounds, and tracheal sensitivity found with viral pneumonia, what additional clinical sign may be present with canine distemper virus infections?
Neurologic signs
What lung pattern is associated with viral pneumonia?
Diffuse interstitial pattern
Alveolar infiltrates on radiographs of viral pneumonia cases are indicative of what complication?
Secondary bacterial infection
Is antiviral therapy in treatment for viral pneumonia recommended?
No
What acute CBC change can be seen with bacterial pneumonia?
Neutropenia
What other abnormality can be seen on CBC with bacterial pneumonia?
Leukocytosis with left shift
What changes can be seen on bacterial pneumonia radiographs?
Interstitial infiltrates, alveolar infiltrates with air bronchograms, and lobar consolidation
What are the two more commonly used antibiotics for empirical therapy to treat bacterial pneumonia?
Fluoroquinolones and penicillins
What are antibiotics discontinued based on?
Clinical signs, pulse oximetry, and radiographs
What is coupage and when should it not be used?
Forming a cup with your hands and then gently patting the dogs chest to aid in breaking up material inside of the chest; should not be used in animals with GI signs, can induce vomiting
What are the two common causative agents for fungal pneumonia in our current area?
Histoplasma and blastomyces
Are dogs or cats more frequently presenting with fungal pneumonia?
Dogs
Lymphadenopathy of which thoracic lymph nodes can be related to fungal pneumonia?
Hilar/tracheobronchial
What other fungal agent does the blastomyces galactomannan antigen test cross react with, which will prevent you from differentiating between them using this test?
Histoplasma
Is the test for coccidioidomycosis an antigen or antibody test?
Antibody
Antifungal treatments are typically long/short term.
Long
What does the prognosis related to fungal infections/pneumonia depend on? Two answers.
Severity of lung disease and presence of other organ involvement
What is the pathogenesis of eosinophilic bronchopneumopathy?
Poorly understood → eosinophilic infiltration without inciting cause
What age group is more commonly affected by eosinophilic bronchopneumopathy?
Young
Are the clinical manifestations of eosinophilic bronchopneumopathy (harsh, unrelenting cough that is moist and productive and exercise intolerance) acute or chronic?
Chronic
What should you see on a cytology of airway samples in a case of eosinophilic bronchopneumopathy?
Up to 90% eosinophils
Because this disease is related to increased eosinophils, what other infection should be tested for and ruled out?
Parasitic infection
Why are dogs with suspected eosinophilic bronchopneumopathy prophylactically treated with dewormer prior to starting steroid therapy?
Steroids = immunosuppression; if they have a parasitic infection and you suppress their immune system, whoopsies
What is the pathogenesis of aspiration pneumonia?
Aspiration leads to pulmonary injury which then leads to an inflammatory response and development of bacterial pneumonia
Are cats or dogs more frequently presenting with aspiration pneumonia?
Dogs
What lung pattern is seen on radiographs of aspiration pneumonia patients and which lung lobes are typically affected?
Alveolar pattern; cranioventral or middle lung lobe
Why are airway wash samples rarely obtained in cases of aspiration pneumonia?
Risk of further aspiration
Interstitial lung disease is associated with which age groups?
Middle aged to older
What two clinical findings of interstitial lung disease can cause syncope?
Hypoxemia or pulmonary hypertension
What abnormal heart sound can be indicative of the pulmonary hypertension caused by interstitial lung disease?
Right sided systolic heart murmur
What test gives you a definitive diagnosis of interstitial lung disease?
Lung biopsy
What age group is associated with neoplastic lung disease?
Older
What is a clinical presentation of neoplastic lung disease that is exclusive to feline patients?
Lameness associated with digital metastasis
Lung lobe torsion of which lung lobe is seen more commonly in large breed dogs?
Right middle
Lung lobe torsion of which lung lobe is seen more commonly in small breed dogs?
Left cranial
What is the treatment for lung lobe torsion?
Lung lobectomy
Pulmonary thromboembolism is a primary/secondary disease.
Secondary
What age group is associated with pulmonary thromboembolisms?
Older
The respiratory distress and tachypnea due to pulmonary thromboembolism is acute/chronic.
Acute
What is important when diagnosing pulmonary thromboembolisms?
Determining the underlying cause for the embolization
What does noncardiogenic pulmonary edema progress into as a patient gets worse?
Acute respiratory distress syndrome
Of the three causes of noncardiogenic pulmonary edema (overexpansion of extracellular fluid volume, decreased oncotic pressure, and damage to the permeability of alveolocapillary membranes) which is the most serious?
Permeability edema
What is the radiographic presentation of noncardiogenic pulmonary edema?
Bilateral alveolar pattern in caudodorsal lung fields
(T/F) Diuretics, positive inotropes, and corticosteroids have not been proven efficacious in treatment of noncardiogenic pulmonary edema.
True
What three diagnostics are used to confirm pleural disease diagnosis?
Radiography, thoracic ultrasound, or thoracocentesis
Of the diagnostics listed in the above answers, which would you choose first in an unstable patient and why?
Thoracocentesis → diagnostic and treatment, provides patient comfort as opposed to having them on their back for radiographs, etc.
Even if you had a stable patient that you took radiographs on then performed a thoracocentesis on, you should consider retaking radiographs, why is that?
Effusion or air may have been obscuring the cause for the abnormality in the first place, should wait for full expansion of the lungs after thoracocentesis to retake the radiographs
Where should you insert your needle when performing a thoracentesis?
7-8th ICS at level of or above CCJ on the cranial border of the a rib
What three scenarios indicate the use of a thoracostomy/chest tube?
Recurrence of pleural effusion/pneumothorax, pyothorax, and thoracic surgery
What are the differences (in protein, TNCC, and predominant cell types) between transudate and modified transudates?
Transudates - low protein, low TNCC, and mononuclear cells predominate; modified transudates - slightly higher protein, higher TNCC, neutrophils and mononuclear cells predominate
Albumin values have to be lower than what (in g/dL) before transudation is caused primarily by hypoalbuminemia?
<1 g/dL
What is the difference between the predominant cell types in septic versus nonseptic exudates?
Septic - degenerative neutrophils and bacteria present in neutrophils and macrophages; nonseptic - nondegenerative neutrophils and macrophages, no bacteria present
The cell type present in chylous effusions is different as disease progresses, give the predominant cell type early versus later in disease.
Early - small lymphocytes; later - nondegenerative neutrophils
How does a chylothorax lead to fibrosing pleuritis?
Chyle induces inflammation and chronic pleural inflammation results in fibrosis of the lungs
What is the drug that enhances protein removal and phagocytosis of chyle but that has an unproven efficacy that is used in treatment of chylothorax patients?
Rutin
How can you tell the difference between hemorrhagic effusion and a traumatic thoracentesis? Three answers.
Hemorrhagic effusion → erythrophagocytosis and inflammation seen, does not clot, and PCV is lower than peripheral blood
What type of neoplasia can be diagnosed based on cytology performed on thoracentesis fluid?
Lymphoma
What is a congenital heart disease?
A structural abnormality of the heart that the animal is born with
(T/F) Mild congenital heart disease rarely causes more than a heart murmur.
True
Young animals with symptoms of heart disease usually have mild/moderate/severe congenital heart disease?
Severe
Can radiographs estimate the severity of volume overload diseases?
Yes
What are the four congenital volume overload diseases of the heart?
Patent ductus arteriosus, ventricular septal defect, atrioventricular valve dysplasia, and atrial septal defect
Congenital volume overload diseases cause eccentric or concentric hypertrophy?
Eccentric
Which congenital volume overload heart diseases primarily impact the left heart? Three answers.
Patent ductus arteriosus, ventricular septal defect, and mitral valve dysplasia
What are the common presenting complaints associated with the above diseases? Two answers.
(Patent ductus arteriosus, ventricular septal defect, and mitral valve dysplasia)
Cough and tachypnea
What radiographic changes would you expect to see with the above diseases? (Patent ductus arteriosus, ventricular septal defect, and mitral valve dysplasia)
Left heart enlargement → tall heart
How do you distinguish between the congenital volume overload heart diseases that primarily impact the left heart?
Timing and location of murmur
Which of the congenital volume overload heart diseases that primarily impact the left heart causes bounding pulses?
PDA
What structures are enlarged in an ‘overcirculation’ pattern?
Pulmonary arteries and veins
What congenital volume overload heart disease is the most common congenital heart disease for all species other than the dog?
Ventricular septal defect
The pathophysiology and symptoms for PDA and VSD are exactly the same, how do you distinguish between them? Two answers.
Signalment and listening to the heart; PDA → left axilla, continuous; VSD - right sternal border, systolic ejection murmur
What radiographic abnormality is present for PDA cases but not in VSD cases?
Ductus bump
You can determine the velocity of the abnormal flow on an echocardiograph of a VSD patient, high velocity flow equates to what size of VSD?
Small
What secondary anatomic changes result from mitral valve dysplasia?
Left atrial and ventricular dilation +/- left heart failure
At what location and timing would you hear a mitral valve dysplasia murmur?
Left apical systolic murmur
Which congenital volume overload heart diseases primarily impact the right heart? Two answers.
Tricuspid valve dysplasia and atrial septal defects
What are the secondary anatomic changes resulting from tricuspid dysplasia?
Right atrial and ventricular dilation +/- right congestive heart failure → ascites
Describe a tricuspid dysplasia murmur including location.
Systolic regurgitant murmur at the right CCJ
What client complaint can indicate congenital pressure overload diseases?
Syncope
Generally, larger or smaller breeds of dogs are affected by subaortic stenosis?
Larger
What are the two secondary anatomic changes resulting from subaortic stenosis?
Concentric left ventricular hypertrophy and post stenotic dilation of the ascending aorta d/t turbulence
Why does subaortic stenosis decrease stroke volume and cardiac output?
Because it increases afterload
Subaortic stenosis causes _____________ which can result in both syncope or sudden death?
Ventricular tachyarrhythmias → results from ventricular hypertrophy)
Where else can you hear a murmur in a case of subaortic stenosis (besides the typical systolic ejection murmur at the left base of the heart)?
Carotid arteries
Animals with subaortic stenosis have an increased risk of what disease?
Endocarditis
Generally, smaller or larger breed dogs are affected by pulmonic stenosis?
Smaller
Give the two ways you can distinguish between subaortic and pulmonic stenosis (without imaging) since they both have systolic ejection murmurs at the left heart base.
Signalment → SAS = larger breed, PS = smaller breed; presence of other sequelae → carotid murmur = SAS, jugular pulses = PS
With myxomatous mitral valve degeneration, afterload is increased/decreased.
Decreased
What is the systolic pressure associated with the left atrium?
5mmHg
A dog with myxomatous mitral valve degeneration whose heart has compensated for the abnormal blood flow will have an increased or decreased fractional shortening?
Increased
Describe a murmur associated with myxomatous mitral valve degeneration.
Grade III-V, systolic, left apex
Listed below are the definitions of the different ACVIM classifications for dogs with MMVD, give the stage:
Dogs at risk for developing MMVD that have no identifiable cardiac structural disorder.
Stage A
Listed below are the definitions of the different ACVIM classifications for dogs with MMVD, give the stage:
Dogs with MMVD and past or current clinical signs of heart failure associated with structural heart remodeling.
Stage C
Listed below are the definitions of the different ACVIM classifications for dogs with MMVD, give the stage:
Dogs with MMVD that have never developed clinical signs and have no radiographic or echocardiographic evidence of cardiac remodeling.
Stage B1
Listed below are the definitions of the different ACVIM classifications for dogs with MMVD, give the stage:
Dogs with end-stage MMVD and heart failure that is refractory to standard therapy.
Stage D
Listed below are the definitions of the different ACVIM classifications for dogs with MMVD, give the stage:
Dogs with MMVD that have never developed clinical signs but have radiographic or echocardiographic evidence of cardiac remodeling.
Stage B2
What are the four criteria that are measured to classify a dog as ACVIM stage B2?
Murmur intensity, left atrial size, left ventricular size, and vertebral heart score
What is the first ACVIM stage in which you should consider starting treatment?
Stage B2
Dogs in stage B1 and B2 are considered to be in a long asymptomatic period and about 70% of them do not progress to heart failure in how many years?
Five years
(T/F) The presence of a heart murmur and cough does not imply the patient is in heart failure.
True
Cough can be present in patients with or without heart failure, how can you determine if they are in heart failure so you can start the appropriate treatment → furosemide + other meds?
Radiographs
What should you tell owners to monitor at home when you have a stage C myxomatous mitral valve disease patient?
Respiratory rate
Do cats get myxomatous mitral valve degeneration?
Rarely
A cat presents to you with heart disease and has a cough, is that cough related to the heart disease?
No
What are the main three clinical signs of heart disease in cats?
Tachypnea, open mouth breathing, and signs associated with feline aortic thromboembolism
(T/F) A cat with a murmur will have heart disease.
F, murmur in 50% of cats w/ normal heart
What is the most common congenital heart disease in cats?
Ventricular septal defect
What are the four primary acquired heart diseases found in cats and which is the most common?
Most common → hypertrophic cardiomyopathy; restrictive cardiomyopathy, dilated cardiomyopathy, and arrhythmogenic right ventricular cardiomyopathy
What are the two causes of secondary left ventricular hypertrophy in cats?
Systemic hypertension and hyperthyroidism
What is the term for a myocardial disorder in which the heart muscle is structurally and functionally abnormal in absence of other disease that might cause this abnormality?
Cardiomyopathy
What are the two possible etiologies for feline cardiomyopathy?
Genetic and idiopathic
What is the definition of hypertrophic cardiomyopathy?
Concentric left ventricular hypertrophy in absence of physiologic condition that can cause hypertrophy
What two components does normal diastolic function of the heart, the ability of the heart to fill without inordinate increase in pressure, depend on?
Myocardial relaxation and compliance
Why does diastolic dysfunction lead to left atrial enlargement in cats with hypertrophic cardiomyopathy?
Atria are trying to push their blood into a ventricular that doesn’t want it → enlargement of the atria
What two additional diagnostic tests would you run on a geriatric cat that you suspect has left ventricular hypertrophy?
Test blood pressure and T4
Although murmurs are not always indicative of heart disease in cats, what type of arrhythmia is more suggestive of heart disease in a feline patient?
Gallop
Why can radiographs not be useful in diagnosing hypertrophic cardiomyopathy?
Concentric hypertrophy → walls are thickening inward so lumen is getting smaller but heart is not actually getting bigger, won’t see abnormalities until you get atrial enlargement
Pleural effusion in a feline patient is indicative of failure of which side of the heart?
Could be either
If a cat has spontaneous contrast on echocardiography, what are they at risk for developing?
Blood clots
What drug should be administered to cats with hypertrophic cardiomyopathy that has no clinical signs and just left ventricular hypertrophy?
None
What drug should be administered to cats with left ventricular hypertrophy and left atrial enlargement?
Clopidogrel
What drugs should be administered to cats with left ventricular hypertrophy, left atrial enlargement, and congestive heart failure? Three answers.
Furosemide, enalapril, and clopidogrel
You are presented with a non-emergency feline patient with congestive heart failure and you are planning to start furosemide. What should you do prior to starting furosemide that you will never be able to do again while this cat is on furosemide?
Evaluate renal function
What is the most important prognostic indicator in cases of hypertrophic cardiomyopathy?
Left atrium size
What is restrictive cardiomyopathy?
Increased myocardial stiffness that leads to impaired ventricular filling
Which of the atria will be enlarged in relation to restrictive cardiomyopathy?
Can be both
If you have a patient with left sided restrictive cardiomyopathy and subsequent left atrial enlargement, how do you distinguish between restrictive cardiomyopathy and hypertrophic cardiomyopathy on echocardiography?
Restrictive → left ventricular wall size will be completely normal; hypertrophic → left ventricular wall will be thickened
What is the term for left ventricular dilation and systolic dysfunction in the absence of abnormal loading conditions?
Dilated cardiomyopathy
What deficiency used to be the inducing factor for DCM in cats?
Taurine
s idiopathic DCM in feline patients possible?
Yes
What additional detailed examination should be performed in cats with DCM?
Optic exam, taurine deficiency also causes retinal degeneration
Can a cat be cured of DCM if given taurine supplements and changing its diet to include taurine?
Yes
What is the myocardium replaced by in arrhythmogenic cardiomyopathy? Two answers.
Fibrous and/or adipose tissue
Why do you get ventricular arrhythmias with arrhythmogenic cardiomyopathy?
The replacement of myocardium by non conductive tissue (fat or fibrous tissue) means the signal doesn’t reach the entire ventricle
What are the three fundamental components of the formation of a clot?
Platelets, coagulation factors, and endothelial surface
What prevents the formation of clots when everything is normal in the body?
Antithrombin III
What occurs when a clot forms when everything is normal in the body to prevent it from causing an issue?
Fibrinolysis
What are two possible causes of stasis?
Enlarged heart chambers and tumor arterial invasion
Besides stasis, what are the other two components of virchow’s triad?
Vessel wall injury and hypercoagulability
Pulmonary thromboembolisms are more common in cats or dogs?
Dogs
What disease are pulmonary thromboembolisms an important etiology for?
Pulmonary hypertension
What are the six diseases that pulmonary thromboembolisms are typically a secondary condition to?
Protein-losing nephropathy/enteropathy, immune mediated diseases, hyperadrenocorticism, paraneoplastic disease, heartworm disease, and right atrial enlargement
How does protein losing nephropathy/enteropathy lead to an increased tendency to form clots?
Antithrombin III is a protein, will have decreased levels in protein losing dzs
The activation of what process is associated with immune mediated diseases such as IMHA in dogs that leads to an increased tendency to form clots?
Activation of coagulation cascade
Beside increasing the production of procoagulant factors, what else does hyperadrenocorticism do to increase the tendency to form clots?
Impairs fibrinolytic capacity
Clinical signs for pulmonary thromboembolisms are secondary to development of pulmonary hypertension so they are nonspecific, what are the three main clinical signs associated with PTE?
Respiratory distress, exercise intolerance, and syncope
How are pulmonary thromboemboli diagnosed?
Based on nonspecific echocardiographic signs secondary to pulmonary hypertension → right ventricular hypertrophy and dilation of the pulmonary trunk
What is the most common predisposing factor for feline arterial thromboembolism?
Left heart enlargement d/t cardiomyopathy
What three things do the clinical manifestations of FATE depend on?
Site of embolization, duration of the occlusion, and degree of collateral damage
What are the 5 P’s associated with FATE?
Paresis, pain, pulselessness, pallor, and poikilothermia
What is the gold standard method for determining if an animal is in heart failure?
Radiography
What is the term for dissolution of a clot using drugs, something that is usually never recommended?
Thrombolysis
What is primary thromboprophylaxis?
Prevention of clot formation in subjects with risk factors
What is secondary thromboprophylaxis?
Prevention of a recurrence of clot formation
What does anticoagulant therapy do when used in patients with an already present thromboemboli?
Prevents or reduces the extension of the thrombi that is already there
Thromboprophylaxis is suggested in patients with arterial thromboemboli and with what two risk factors?
Left atrial enlargement and spontaneous contrast on echo
What is the current 1st choice drug to use for thromboprophylaxis?
Clopidogrel
What are the three other drug options for thromboprophylaxis, though some are not routinely used?
Heparin, coumadin, and aspirin
What is the most common cause of natural death in cats with FATE?
Reperfusion injury
Aortic-iliac thrombosis in equine patients has a possible association with what parasite?
Strongylus vulgaris
How is aortic-iliac thrombosis diagnosed in equine patients?
Rectal palpation of the aortic quadrification → thrombosed vessel might be enlarged and firm
Would you start primary thromboprophylaxis in a dog with left atrial enlargement and no other diseases?
No
What are the two more commonly identified cardiomyopathies of canines?
Dilated cardiomyopathy and arrhythmogenic ventricular cardiomyopathy
Dilated cardiomyopathy is impared systolic or diastolic function of the ventricles?
Systolic
What size of dog is typically affected by dilated cardiomyopathy?
Large
Is there a genetic test available to test for DCM?
No
What is the first step in the pathophysiology of dilated cardiomyopathy?
Systolic dysfunction
Why does eccentric hypertrophy occur secondary to systolic dysfunction?
Systolic dysfunction → decreased cardiac output → ventricle dilates to compensate for the decreased cardiac output
What occurs secondarily to the dilation of the left ventricle?
Mitral regurgitation
What is the end stage of the pathophysiology of dilated cardiomyopathy?
Atrial enlargement
If you have a doberman with DCM, what should you see on an ECG?
Ventricular arrhythmias
What is usually the first clinical sign to pop up in a dog with DCM?
Syncope → they will have a syncopal episode
What other four clinical signs/hx is associated with clinical DCM?
Tachypnea, weight loss, exercise intolerance, and abdominal distention
What might you hear on auscultation of a clinical DCM patient? Five answers.
Tachycardia, irregular rhythm, +/- soft apical murmur, S3 gallop rhythm, and muffled lung sounds d/t pleural effusion
What imaging modality is used to diagnose DCM and can it be used to tell if a patient is in heart failure?
Echocardiography, no → clinical signs/hx and/or need radiographs
What is the difference between dilated cardiomyopathy and tachycardia induced cardiomyopathy?
TICM - tx tachycardia and heart can return to normal so prognosis is much better; not possible for DCM, prognosis not as good
DCM is a diagnosis of exclusion, what other diseases/abnormalities can cause systolic dysfunction in dogs? Six answers.
Hypothyroidism, hypertension, tachycardia, ischemia, myocarditis, and decompensated subaortic stenosis
What drugs can be used to prolong the long asymptomatic period associated with DCM?
Ace inhibitors and/or pimobendan
What is arrhythmogenic ventricular cardiomyopathy?
Cardiomyopathy characterized by a fatty or fatty/fibrous infiltration replacement of the ventricular myocardium
What is required for the diagnosis of arrhythmogenic ventricular cardiomyopathy?
Holter
What drug combination is used in treatment for dogs with arrhythmogenic ventricular cardiomyopathy and clinical signs such as syncope or exercise intolerance?
Atenolol and mexiletine
What are the five functions of the pericardium?
Prevent acute overdistension, barrier to infection, lubrication, stabilization, and diastolic coupling of the ventricles
What is the most common pericardial disorder in dogs and cats?
Pericardial effusion
What modality exam is the gold standard for diagnosis of pericardial effusion?
Echocardiography
What species, age range, and animal size is more prevalently affected by pericardial effusion?
Dogs, older ages, and larger breeds
What is the most common etiology for pericardial effusion in dogs?
Neoplastic
What is the most common neoplasm that causes pericardial effusion?
Hemangiosarcoma
What are the four etiologies for pericardial effusion in cats?
Cardiomyopathy, lymphosarcoma, FIP, foreign bodies → purulent pericardial effusion
What are the two most common locations for cardiac hemangiosarcomas?
Right atrium and atrioventricular junction
What ECG abnormalities are a common finding with cardiac hemangiosarcomas?
Ventricular arrhythmias
Chemodectomas are associated with which breed group of dogs?
Brachycephalic dogs
What is the treatment for chemodectomas?
Pericardiectomy
How is mesothelioma diagnosed presumptively and definitively?
Presumptively - based on history of exposure to asbestos, definitively - histopath
Why do dogs with cardiac tamponade present with exercise intolerance, weakness, and syncope?
They have reduced cardiac output
Why do dogs with cardiac tamponade present with edema, congestion of systemic veins, and ascites?
Elevated filling pressure in the heart
What makes up Beck’s triad?
Muffled heart sounds, venous congestion/jugular pulses, and weak femoral pulses
What is pulsus paradoxus?
When the femoral pulses are absent when a patient is inspiring
How is pericardial effusion treated (nonrecurrent, not related to a chemodectoma, so essentially what do you do when you don’t want to do a pericardiectomy)?
Pericardiocentesis
Where should you insert your 14G over the needle catheter when performing a pericardiocentesis?
Right 5th ICS at the level of the CCJ cranial to the 6th rib
How can you tell if you have just tapped the pericardium or accidentally penetrated the heart when performing a pericardiocentesis?
If it clots → you’ve gone a stabbed the heart
What type of drugs are contraindicated in patients with pericardial effusion?
Diuretics
Infective endocarditis is defined as infection of one or more of the endocardial surfaces in the heart and almost always involves what structure of the heart?
Valves
What are the three common bacterial agents indicated in a case of infectious endocarditis?
Strep, staph, E. coli
What two factors need to be present to induce infectious endocarditis?
Bacteremia and endothelial injury
What cardiac disease is a predisposing factor for vegetative valvular endocarditis?
Subaortic stenosis
re dental diseases a predisposing factor for endocarditis?
No
(T/F) There is no correlation between oral procedures and development of endocarditis in dogs.
True
Murmurs associated with endocarditis in canine patients are typically systolic or diastolic?
Systolic
What two things are the presumptive diagnosis of endocarditis based on?
Presence of predisposing condition and echocardiographic evidence of vegetative lesions on the aortic or mitral valve
What is the term for the complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood?
Heart failure
(T/F) All patients with heart failure have decreased myocardial contractility.
False
To diagnose a patient with heart failure, it depends on the presence of what two things?
Cardiac disease and symptoms/clinical signs
What are the four symptoms of heart failure?
Exercise intolerance, weakness, increased respiratory rate/effort, and anorexia
(T/F) The presence of a cough in a patient with a heart murmur implies the patient has heart failure.
False
Fluid retention is possible with heart failure, if you identify pulmonary edema on radiography, what side of the heart has failed?
Left
Why should you evaluate your patient for the presence of concomitant disease before administering/prescribing heart failure drugs? Three answers.
Heart failure clinical signs are no pathognomonic → could be caused by another disease; cardiovascular drugs are eliminated by the liver and/or kidneys → need to make sure they are healthy or adjust dose as needed; drugs cost money → may not be worth tx with drugs to the owner
Investigation of the cause of heart failure is important in what type of patients?
Asymptomatic patients
Why else is investigation of the cause of heart failure important?
Prognosis is different for different diseases
What are the two goals of heart failure treatment?
Improve quality of life and increase survival expectancy
What is the hallmark for treatment of acute heart failure?
Oxygen treatment
What is the mandatory drug to reduce acute onset of heart failure and control symptoms chronically?
Furosemide
Why should you monitor renal function when administering furosemide to acute heart failure patients?
Can develop azotemia
What two drugs are used in patients with acute heart failure and systolic dysfunction?
Dobutamine and pimobendan
Dobutamine is a positive inotropic drug at a dose of 5-10 mcg/kg/min, what occurs if you dose above that range that you do not want?
Vasoconstriction
Dobutamine is a sympathomimetic at what beta receptor?
Beta 1
Does the monotherapy administration of furosemide increase or decrease renal perfusion and RAAS activation?
Decrease renal perfusion and increases RAAS activation
When is hydrochlorothiazide used in chronic heart failure patients?
Refractory cases
Can you use ace inhibitors in feline patients?
No
What is an aldosterone breakthrough?
When administering ace inhibitors alone, the body has other methods of forming aldosterone for survival purposes so aldosterone is still made, needs to add in another drug to prevent this
What drug is used to prevent aldosterone breakthrough in patients given ace inhibitors?
Spironolactone
What two drugs are used chronically as positive inotropes?
Digoxin and pimobendan
How does digoxin increase contractility of myocardiocytes?
Increase intracellular calcium
What electrolyte should you monitor when administering digoxin to a patient?
Potassium
Which of the following is incorrect about the effects of pimobendan:
a) Inhibition of cytokines
b) Restore baroreceptor sensitivity
c) Increase platelet aggregation
d) Improve diastolic function
C, should be decrease
What is enhanced automaticity, one of the mechanisms of arrhythmogenesis?
Cells that are normally capable of spontaneous depolarization depolarize abnormally
What are triggered activity arrhythmias?
Premature activation of cardiac tissues by depolarizations triggered by afterdepolarizations
What are the two types of afterdepolarizations?
Early and delayed
What are reentry arrhythmias?
An action potential fails to extinguish itself and reactivates a region that has recovered from refractoriness
What are the three indications for antiarrhythmic treatment?
Clinicals signs associated with tachyarrhythmia → syncope, evidence of hemodynamic compromise, and rhythm associated with high risk of sudden death → ventricular tachycardia
Class I antiarrhythmics are blockers of what?
Sodium channels
What phase of the working cardiomyocyte action potential is delayed by class I antiarrhythmic drugs?
Depolarization
Listed below are the different subclasses of class I, give the strength of their action on sodium channels (weak, moderate, and strong) and their effect on the effective refractory period:
- Class IA
- Class IB
- Class IC
- Class IA (moderate, increases)
- Class IB (weak, decreases)
- Class IC (strong, nothing)
The more you increase the effective refractory period of a working cardiomyocyte action potential, say with drugs, you are increasing the chance for what to occur?
Spontaneous depolarization
Class II antiarrhythmics are blockers of what?
Beta receptors
Class III antiarrhythmics are blockers of what?
Potassium
What class III antiarrhythmic drugs delay in terms of working cardiomyocytes action potentials?
Repolarization
Class IV antiarrhythmics are blockers of what?
Calcium channels
Calcium is more important for action potentials in working or specialized myocytes?
Specialized
Why do class IV antiarrhythmics decrease contractility of the heart?
Does not just block calcium used for action potentials in specialized myocytes, also blocks calcium from entering cells which is important for contraction
Listed below are the different types of antiarrhythmics, give the tachyarrhythmia they can be used to treat:
- Sodium channel blockers/Class I
a) Class IA; procainamide, quinidine
b) Class IB; lidocaine, mexiletine
a) Supraventricular tachycardia and ventricular tachycardia
b) Ventricular tachycardia
Listed below are the different types of antiarrhythmics, give the tachyarrhythmia they can be used to treat:
Beta blockers/Class II; atenolol
Supraventricular tachycardia and ventricular tachycardia
Listed below are the different types of antiarrhythmics, give the tachyarrhythmia they can be used to treat:
Potassium channel blockers/Class III; sotalol, amiodarone
Supraventricular tachycardia and ventricular tachycardia
Listed below are the different types of antiarrhythmics, give the tachyarrhythmia they can be used to treat:
Calcium channel blockers; diltiazem
Supraventricular tachycardia
Is digoxin a parasympathomimetic or parasympatholytic?
Parasympathomimetic
Is digoxin a positive or negative inotrope?
Positive
When is digoxin primarily indicated?
Atrial fibrillation particularly in patients with DCM
If you have an ECG with wide QRS complexes and a regular rhythm, what arrhythmia do you have until proven otherwise?
Ventricular tachycardia
If you have an ECG with narrow QRS complexes and an irregular rhythm, what arrhythmia do you have?
Atrial fibrillation
If you are presented with a patient with wide complex tachycardia, you know it is usually ventricular tachycardia so what drug would you administer?
Lidocaine
If the above patient doesn’t respond to the drug you chose (Lidocaine - wide complex tachycardia, you know it is usually ventricular tachycardia ), what drug should you give next and why?
Procainamide, will cover supraventricular tachycardias in case that is the cause
If you are presented with a patient with narrow complex tachycardia with a regular rhythm, you know this presentation is indicative of atrial tachycardia so what drug would you administer?
Procainamide
If you are presented with a patient with narrow complex tachycardia with an irregular rhythm, you know this presentation is indicative of atrial fibrillation so what drug would you administer?
Oral digoxin and diltiazem
If the lidocaine successfully treated your patient with ventricular tachycardia, which drug would you send them home with to use for chronic management?
Mexiletine
The owner tells you they can’t dose mexiletine appropriately (every 8 hours) and the dog has GI issues anyway, what three other drugs can you reach for chronic management of ventricular tachycardia?
Sotalol, atenolol, and amiodarone
How do vagal maneuvers work as acute treatments for supraventricular tachycardia?
Vagal maneuvers trigger vagal stimulation and decreased conduction at the SA and AV nodes
When using a vagal maneuver, how can you tell on ECG if the tachycardia is supraventricular tachycardia versus sinus tachycardia?
Sinus → vagal stimulation of SA node leads to decrease in heart rate and then it should increase as vagal stimulation stops; Supraventricular → SA node not involved, random group of cells in atrium are firing, vagal stim. will block the AV node from the abnormal conduction, will see an AV block on ECG
(T/F) All agents other than digoxin that slow AV conduction are negatively inotropic.
True
When treating atrial fibrillation, is the goal to reach sinus rhythm?
No, goal is to control the rate at which the conductions pass through the AV node to trigger the ventricles; achieving sinus rhythm is difficult especially in patients who have had afib for some time
Digoxin can cause any arrhythmia, what disease can increase the risk specifically for ventricular arrhythmia when a patient is on digoxin?
Hypokalemia
What is the treatment of choice for sick sinus syndrome, third degree AV blocks, or symptomatic second degree AV block patients?
Pacemaker
Why aren’t beta agonists or sympathomimetic drugs used to treat bradyarrhythmias?
Benefit is short term
Why should you not perform jugular blood draws on patients with a pacemaker?
One jug has the pacemaker wire, the other needs to be preserved in case anything happens to the other
If there is a normal P for every QRS on an ECG, what does this mean?
Every beat is originating from the sinus node
If there is a QRS for every P wave, what does this mean?
Every beat is being conducted to the ventricles
If you are presented with a dog that has tachycardia and also suspected heart disease and heart failure, should you treat the heart failure or tachycardia first and why?
Heart failure → heart failure increases sympathetic tone which increases conduction at the SA and AV nodes (AV node is really what matters here but you should know it influences both nodes), if you treat the heart failure, the sympathetic tone will decrease and typically that can solve the tachycardia; if it doesn’t, should do a Holter monitor test to determine if the tachycardia is present even at home where sympathetic tone will be low
What would you do to treat the above abnormal rhythm in a canine patient? (2nd degree AV block)
Atropine challenge
How can you tell the difference between ventricular tachycardia and ventricular fibrillation?
Ventricular tachycardia is very regular, vfib is not
What is the definition of pulmonary hypertension?
Mean pulmonary arterial pressure greater than or equal to 25 mmHg AT REST / or a systolic pulmonary arterial pressure > 35 mmHg
What are the three main etiologies of pulmonary hypertension?
Increased pulmonary blood flow, increased pulmonary vascular resistance, or increased pulmonary venous pressure
What would cause increased pulmonary blood flow?
Any kind of shunt such as ASD, VSD, PDA
What is a classical example of a disease that would increase pulmonary vascular resistance in canine patients?
Heartworm disease → causes inflammation of the pulmonary arteries → increased pulmonary vascular resistance
Diseases of which side of the heart leads to increased pulmonary venous pressure?
Left heart disease
Listed below are the different classifications of pulmonary hypertension in dogs, give their pertinent category number:
- Pulmonary arterial hypertension
- Pulmonary hypertension due to left heart disease
- Pulmonary hypertension secondary to respiratory diseases or hypoxia (or both)
- Pulmonary arterial hypertension (Category I)
- Pulmonary hypertension due to left heart disease (Category II)
- Pulmonary hypertension secondary to respiratory diseases or hypoxia (or both) (Category III)
Listed below are the different classifications of pulmonary hypertension in dogs, give their pertinent category number:
- Pulmonary emboli, thrombi, and/or thromboemboli
- Parasitic diseases
- Pulmonary hypertension with multifactorial or unclear mechanisms
- Pulmonary emboli, thrombi, and/or thromboemboli (Category IV)
- Parasitic diseases (Category V)
- Pulmonary hypertension with multifactorial or unclear mechanisms (Category VI)
What is the pathophysiologic process of category I pulmonary hypertension? Three steps.
Increased pulmonary blood flow → increased vascular resistance → reversible/irreversible pulmonary arterial remodeling
What does the increased left atrial pressure due to left heart disease lead to in the lungs?
Increased pulmonary venous pressure → appropriate pulmonary hypertension/increased alveolar capillary pressure with eventual failure → lung capillary and alveolar remodeling → impairment of gas exchange
Where in the above timeline can the administration of furosemide prevent the furthering of the cascade/disease?
(Increased pulmonary venous pressure → appropriate pulmonary hypertension/increased alveolar capillary pressure with eventual failure → lung capillary and alveolar remodeling → impairment of gas exchange)
At the appropriate pulmonary hypertension stage, can prevent the damaging steps that lead to remodeling and permanent impairment of gas exchange
What can lung diseases change characteristically about blood that can lead to pulmonary hypertension?
Viscosity
What is the most common category of pulmonary hypertension in dogs?
Category II
(T/F) In areas with high prevalence of dirofilaria, category IV represents the most common cause of pulmonary hypertension in dogs.
F, category V
What two things are necessary for a diagnosis of pulmonary hypertension?
Clinical signs and echocardiography
What clinical signs are strongly suggestive of pulmonary hypertension?
Syncope, respiratory distress at rest, activity/exercise ending in respiratory distress, and right sided heart failure
What are the anatomical echocardiographic signs of pulmonary hypertension related to the right heart? Three answers.
Right atrial enlargement, right ventricular hypertrophy, and due to the right heart abnormalities/failure → pericardial, pleural, or peritoneal effusion
The pulmonary artery is typically enlarged due to pulmonary hypertension, how could you determine this on an echocardiograph?
Compared it to the aorta on a short axis view, they should be the same size in a normal patient so if pulmonary artery is larger than aorta, it is enlarged
Besides anatomical abnormalities, echocardiography can be used to determine hemodynamic abnormalities associated with pulmonary hypertension. Regurgitation present at what valve is used for this?
Tricuspid/right AV valve
What is the simplified Bernoulli formula that is used to determine the pressure gradient from the right ventricle to the right atrium based on the velocity of the regurgitation through the tricuspid valve?
Pressure gradient = 4*v squared
What is the calculated pressure gradient in the above question equate to in terms of the lungs?
(Pressure gradient = 4*v squared)
Pulmonary systolic pressure
What is used in treatment of category I pulmonary hypertension? Two answers.
Phosphodiesterase-5 inhibitors and oxygen
What additional non-drug treatment can be done for category I pulmonary hypertension?
Treat underlying cause for increased pulmonary blood flow → close shunt
What should be done to treat category II pulmonary hypertension?
Treat left sided heart failure
What should be done to treat category III pulmonary hypertension? Two answers.
Oxygen and weight loss for obese patients
What should be done to treat both category IV and V pulmonary hypertension?
Treat the underlying condition; category IV → anticoagulants; category V → dewormer/melarsomine tx
A heartworm patient with what syndrome cannot be treated with melarsomine treatment?
Caval syndrome
