Cardiovascular examination Flashcards
What are important aspects to beginning a cardiovascular examination?
- Signalment
- History
- Observation
- Physical examination/Cardiovascular examination
Questions to get on history
**Basic questions but also:
- Is the pet coughing? Frequency? Gagging?
- Is there heavy breathing or excessive panting?
- Episodes of weakness or collapse?
- Medications? When? How much? Response?
Things to observe
- Mentation
- Respiratory pattern
- Conformation
Components of a cardiovascular examination
- Mucous membranes (+CRT)
- Jugular veins
- Thorax/precordium
- Abdomen
- Peripheral pulses
- Auscultation
Mucous membranes normal
- Pink, CRT <2 sec.
Meaning of pale mucous membranes
- Anemia, peripheral vasoconstriction
Meaning of bright red mucous membranes
- Excitement, peripheral vasodilation, sepsis, polycythemia
Meaning of blue/grey mucous membranes
- Airway disease
- Pulmonary parenchymal disease
- Right to left cardiac shunt
- Hypoventilation
- Shock
- Methemoglobinemia
Meaning of icterus mucous membranes
- Hepatobiliary disease
- Hemolysis
Are jugular vein pulsations normal?
- NOT normal in standing small animals
Meaning of jugular pulses
- They do NOT indicate congestive heart failure
- They DO indicate elevated right heart filling pressures or obstruction to filling of the right heart
Causes of jugular pulsations
- Tricuspid valve insufficiency
- Hypertrophied right ventricle (pulmonic stenosis, pulmonary hypertension)
- Certain arrhythmias (complete heart block)
Causes of jugular distention (+/- pulses)
- Occlusion of the cranial vena cava or right ventricle by external compression, mass, or thrombosis
- Very high right heart filling pressure (e.g. severe pericardial effusion)
Hepatojugular reflex
- Positive result when you press on the liver and see a jugular pulse that was not present prior to the maneuver
Pseudo-jugular pulsation
- Pulsation of the carotid artery sometimes seen at the thoracic inlet in thin dogs - can be mistaken for a jugular pulse
- If you palpate, you would feel an arterial pulse
- A jugular pulse you should not feel
Where is the normal precordium?
- LEFT
What are causes of shifted precordial impulse (to the right)?
- Cardiac enlargement (e.g. right heart hypertrophy –> prominent right)
- Mass lesions displacing the heart
- Collapsed lung lobes allowing for cardiac displacement
- Focal accumulations of air or fluid
What can cause a decreased precordial impulse intensity?
- Pericardial effusion
- Pleural effusion
- Obesity
- Weak cardiac contractions
- Thoracic masses
- Pneumothorax
Precordial thrill
- Loud murmurs have a palpable buzzing sensation on the chest wall over the heart (palpable murmur) called a precordial thrill
- Allows you to grade a murmur as a 6
CV disease things to look for with abdominal distension
- Organomegaly
- Fluid wave
- Distension
What are general categories of things you can feel with peripheral pulses?
- Hyperkinetic pulses
- Hypokinetic pulses
- Pulse deficits
What are the characteristics that make a pulse strong or weak?
- Pulse pressure or the difference between systolic and diastolic pressure
- Anything that increases systolic portion (e.g. excitable, energetic, or exercising pet) to increase the difference would feel like a strong pulse
- If the animal has a lower systolic pressure due to blood loss and diastolic pressure is the same, there can be a hypokinetic pulse
Hyperkinetic pulse definition
- Pulses that feel more prominent than normal
Causes of hyperkinetic pulses (general and specific)
- Wide separation between diastolic and systolic ARTERIAL pressure
- Common causes: high adrenergic tone, PDA (blood goes down arterial side of femoral artery and also pulmonary system, which decreases diastolic pressure), and aortic regurgitation (diastolic blood leaving the system)
Hypokinetic pulses definition
- Feel weaker than normal
Hypokinetic pulses causes (general and specific)
- Reduced stroke volume or narrower pulse pressure
- Heart failure, hypovolemia, some arrhythmias
Pulse deficit definition
- Fewer femoral pulses than palpable or auscultable heart beats
Pulse deficit causes
- Usually indicates an arrhythmia such as ventricular premature contractions
What should you do diagnostically if you feel pulse deficits?
- ECG
What should precede cardiac auscultation?
- General physical exam
- Mucous membranes
- Arterial pulse
- Jugular distension
- Precordial palpation
What can you identify with cardiac auscultation?
- Heart murmurs
- Transient sounds (clicks, rubs)
- Gallops (S3, S4)
- Irregular rhythm
- Evaluate lung sounds
Rules for cardiac auscultation
- Rule #1: Find a quiet room
- Rule #2: Need a standing patient
What is the most common cause of a murmur?
- Turbulent blood flow
- Normal blood flow is smooth/laminar and silent
Causes of turbulent blood flow (and which cause is most common)?
- Increased velocity (Narrowed vessels, abnormal valves, shunts)
- Decreased viscosity (anemia is most common cause)
- Large diameter vessels (horses, cows; normal or “physiologic” murmurs)
Etiology of S1
- Closing of AV valves and vibrations of cardiac walls caused by abrupt deceleration of blood flow
- S1 is longer and lower pitched than S2
Split S1
- Heard with conduction alterations between the two sides (right bundle branch block, ventricular premature contractions) or can be normal in very large dogs
S2 Etiology
- Produced by closure of the semilunar valves
- Best heard over aortic area
Split S2
- Can occur due to delayed closure of the pulmonic valves (right bundle branch block, VPCs, right ventricular hypertrophy) or of the aortic valve (left bundle branch block, VPCs, left ventricular hypertrophy)
S3 etiology
- Vibrations in the heart wall associated with rapid ventricular filling
- Can be normal in very large animals
S3 gallop
- S3 is heard with very dilated ventricles (e.g. DCM)
- Diastolic sound AFTER S3
S4 etiology
- Atrial contraction
- Normal in large animals
S4 gallop in small animals
- Heard with contraction of very dilated atria - secondary to hypertrophic cardiomyopathy (HCM)
Systolic click etiology and definition
- Transient click can be heard over AV valves in mid-late systole due to delayed closure or prolapse of the valve
Which disease in dogs is most associated with a systolic click?
- Mitral valve endocardiosis (early)
- Can occasionally affect the tricuspid valve
What are the three most important things you need to describe a murmur?
- Timing (systolic vs diastolic)
- PMI
- Pitch and quality
What are five ways to describe a murmur (including the three that you just described)?
- Timing*
- Point of maximal intensity*
- Pitch and quality*
- Radiation
- Intensity
Murmurs and disease severity
- NOT CORRELATED
Systolic murmur definition
- Between S1 and S2
Diastolic murmur definition
- After S2 and before S1
Which murmur type is most common?
- Systolic (90%)
Continuous murmur type
- During systole and diastole
Other descriptors of timing
- Proto-: early
- Meso-: Middle
- Tele-: late
Point of maximal intensity descriptions
- Hemithorax
- ICS
- valve area
- Apical/basilar
Basilar murmurs
- Pulmonic and aortic valve
Apical murmurs
- Mitral valve
- Below the costochondral junction
Location of different murmurs
- SEE THE DIAGRMAS
PMI for VSD
- Right sided apical murmur
PMI for PDA
- Left sided basilar murmur
Murmur qualities
- Regurgitant
- Ejection
- Blowing
- Continuous
- “To and Fro”
- SEE SLIDE
Causes of regurgitant murmurs
- Mitral valve regurgitation
- Tricuspid valve regurgitation
- “Flat or plateau”
Ejection murmur type causes
- Pulmonic stenosis
- Sub-aortic stenosis
- Physiologic murmur
- Crescendo, decrescendo, or crescendo-decrescendo
Regurgitant murmur most common timing
- Systole
Ejection murmur most common timing
- Systole
Blowing murmur timing
- Diastole
Blowing murmur examples
- Aortic regurgitation
- Pulmonic regurgitation
Continuous murmur example
- PDA
“To and Fro” murmur example
- Subaortic stenosis and aortic regurgitation
Left base continuous murmur type disease to rule out
- PDA, typically heard very high on left base
- Small breeds of dogs and herding breeds most typical signalment
Left base systolic ejection murmur disease to rule out
- SAS or PS or possibly physiologic murmur (softer)
- PS typically more cranial than SAS
- PS: Small breeds, brachiocephalics, terriers
- SAS: Large, sporting breeds
Left basilar diastolic or blowing murmur disease to rule out
- Aortic regurgitation, typically heard best over aortic valve area
- Rarely may hear high velocity pulmonic valve regurgitation
Left apical systolic ejection murmur rule out
- Early mitral regurgitation may sometimes manifest as a harsher sound
- SAS is sometimes best heard over the CCJ
Systolic plateau left apical murmur rule out
- Endocardiosis of the mitral valve
- Consider endocardiosis if small breed
- Consider endocarditis if larger breed with “new” murmur or if fever
- Consider DCM in large/giant breeds with softer murmurs
Right apex to sternum systolic ejection murmur rule out
- VSD, heard best at right sternal border (most common congenital heart defect in the cat, horse, and cow)
- Occasionally high velocity tricuspid regurgitation may have an ejection quality, but PMI should be higher at the right apex
Systolic plateau on right apex to sternum causes
- Tricuspid regurgitation classically
- Endocardiosis or TR 2° to pressure overload (e.g. pulmonary hypertension or pulmonic stenosis or congenital valve dysplasia) - Labs, great dane, Borzoi, Boxer, other large/sporting breeds
Grade 1 murmur
- Soft, localized to one region
Grade 2 murmur
- Soft, radiates to 2 heart regions
Grade 3 murmur
- Moderate, radiates to 3 heart regions
Grade 4 murmur
- Loud, radiates to all four heart regions
Grade 5 murmur
- Loud, radiates to all regions, precordial thrill
Grade 6 murmur
- Hear when stethoscope is removed from chest wall
Which cardiovascular diseases may not have murmurs?
- Tetralogy of Fallot
- Cardiomyopathies
- Pericardial effusion
- Pulmonary hypertension (e.g. with heartworm and other causes)
- Systemic hypertension
- Arrhythmias
Normal respiratory bronchial sounds
- Tubular sounds (centrally)
Normal respiratory vesicular sounds
- Soft, breezy (peripherally)
Sounds with left sided congestive heart failure
- Pulmonary edema (parenchymal disease)
- End-inspiratory/initial expiratory fine crackles
- Lung sounds may be harsher or quieter than expected (especially with cats)
PRACTICE LISTENING TO HEART SOUNDS
- DO IT; there is a slide in the PDF
Crackles description
- Nonmusical, discontinuous sounds (crumpled paper)
Wheezes description
- Musical, continuous sounds
Stertor and stridor description
- Discontinuous sounds and wheezes heard without a stethoscope
