Exam 1 Flashcards
Treatment In Bulldogs with Pulmonic Stenosis and a Single Right Coronary Artery Type R2A
Right Ventricle to Pulmonary Trunk Conduit
*Used for severe stenosis when aberrant left coronary artery precludes use of other techniques
On this EKG, What does the P Wave Indicate?
Right Atrial Enlargement
*The P Wave it too High- Greater than 4mm
_____ -Degree AV Block where there is Intermittent Failure of the AV Node to Conduct Impulses between the Atria and Ventricles, characterized by P Waves Intermitently followed by no QRS Complex
Second
*P Wave, followed by no QRS Complex because the AV Node didn’t Conduct the Signal to the Ventricles
Diseases of Heart Muscle
Cardiomyopathies
*Ex. Dilated and Hypertrophic Cardiomyopathy
Two main Clinical Signs associated with Right Sided Heart Failure
Syncope and Ascites
*When the Right Heart Fails then Less blood will travel through the Lungs to the Left Heart. Therefore, the Left Heart will not be able to supply enough blood to the Brain causing Syncope. Blood will also accumulate in the Great Veins leading to Ascites
Bulldogs with Pulmonic Stenosis commonly have a Single Right Coronary Artery type ___, where the Aberrant Left Coronary Artery comes off the Pulmonary Artery
R2A
In 90% of Dobermans with Dilated Cardiomyopathy, you will see ____ on EKG
Ventricular Premature Depolarizations (VPDs)
Respiratory Sound that Occurs when the Airways are Narrowed due to Inflammation that is commonly seen with Bronchitis and Asthmatic Conditions
Wheezes
*Sounds like Whisteling
True/False: When doing Cardiac Ausculations, The Doctor should gently close the dogs mouth and place a finger across the Dogs Nostrils
True
*Panting can be mistaken for Heart Murmurs
Additive At Home Treatment for Myxomatous Atrioventricular Valvular Degeneration that Decreases the Risk of Death by 18 Months
Spironolactone
*Has Become a Standard of Care
*Side Note: Pimobendan is Controversial but has been Used
Cardiomyopathy characterized by a Lack of Contractility within the Heart Muscle leading to a Volume Overload that is common in Large/Giant Breed Dogs
Dilated Cardiomyopathy
*Enlarged Heart with Thin Walls- Volume Overload- Heart is Almost Twice the Normal Weight
*Common in Dobermans, Boxers, Great Danes and Irish Wolfhounds!!!
Dobermans and Boxers with Dilated Cardiomyopathy commonly have ____ Type Myofibers
Fibro-Fatty
*Fatty Vacuoles within the Myocytes
In Patients with Myxomatous Atrioventricular Valvular Degeneration, with 75% (Large Regurgitation), what Two Clinical things will we see?
Left Sided Congestive Heart Failure
Coughing
*LCHF is usually Slowely Progressive
The Mean Electrical Axis is the Average Direction of Activation of Ventricular Myocardium During Systole. If the Mean Electrical Axis is Less than 70 Degrees, What is Occuring in the Heart?
Left Heart Enlargement
*Normal Mean Electrical Axis is around 70 Degrees
*More “Meat” on the Left Heart if Hypertrophied, and therefore more Electrical Activity so the Mean Electrical Axis will shift towards the Left Heart (Between 60 and 0 Degrees)
Treatment for ARVC in Boxers if Greater than 1000 Ventricular Premature Depolarizations (VPDs)/ Day
Sotalol and/or Mexilitene
*Monitor Treatment- Holter Monitor- 85% Improvement in # VPD’s/Day
*Omega-3 Also Reduces # of VPDs
Spontaneous Ventricular Depolarizations at 60-180bpm that is Mostly Asymptomatic, but must be monitored because Ventricular Tachycardia may be Coming
Accelerated Idioventricular Rhythm
*Not fast enough to be considered Ventricular Tachycardia
*Accelerated Idioventricular Rhythm- Around 100 bpm- Still in the Normal Range of a Heart Rate
Patients in Heart Failure should be Given Supplemental Oxygenation. What is the Best Method of Administering Supplemental Oxygenation?
Nasal Catheter
*Use a Soft Feeding Tube and Feed down the Patients Nasal Passage until it Reaches the Carnassial Tooth Area and Connect the Tube to the Oxygen Source_- Run 50-100 ml/kg/min Oxygen into the Tube_
*Masks and Oxygen Hoods/Cages are Not Efficient
All Patients with Aortic Stenosis are Predisposed to _____
Bacterial Endocarditis
*We need to Control Bacterial Infections in these dogs
Cats with Hypertrophic Cardiomyopathy have Massively Enlarged Left Atriums. Once the Left Atrium Enlarges Greater than ____mm, the Cats Prognosis is Poor
>20 mm = Mod
>25 mm = Severe
*Normal Left Atrium is 15mm
*Prognosis in Cats with Hypertrophic Cardiomyopathy is based on the Size of the Left Atrium- The Larger the Left Atrium, the worse the Prognosis for the Cat
Patients with Sinus Bradycardia have ____ Pulses
Strong
*The Ventricles have had a Long time to Fill during Diastole so the Pulse will be VERY Strong
Patients with the Following Conditions commonly have _____:
- Boxers with Cardiomyopathy
- Dobermans with Dilated Cardiomyopathy
- Aortic Stenosis
- Hypertrophic Cardiomyopathy
Ventricular Premature Depolarizations (VPD’s)
*30% of Dobermans with DCM will Die Suddenly from VPDs
Depolarization of the _____ Produces the P Wave on the EKG, while Depolarization of the ____ Produce the QRS Complex on the EKG
Atria- P Wave
Ventricle- QRS Complex
*T Wave represents Ventricular Repolarization (End of Systole)
The Mean Electrical Axis is the Average Direction of Activation of Ventricular Myocardium During Systole. If the Mean Electrical Axis is Greater than 90 Degrees, What is Occuring in the Heart?
Right Heart Enlargment
*More Electrical Activity on the Right side of the Heart so the Electrical Axis will Shift to greater than 90 Degrees
True/False: If a Patient has Atrial Fibrillation but the Heart Rate is Normal you Monitor the Patient but do not Treat
True
*Moniter- May Develop Dilated Cardiomyopathy in the Future
*Holter Monitor- Measures EKG over 24 hour period
True/False: Congenital Heart Diseases make up 5% of our Patients, and are commonly caused by Inherited Defects, Genetic Mutations or Developmental Accidents
True
*Not Many Heart Conditions are going to be Congenital Heart Diseases
*Dogs > Cats, Dogs more commonly have Congenital Heart Disease
Valves Between the Left Atrium and Left Ventricle of the Heart that Close during Systole
Left Atrio-Ventricular Valve
*Mitral Valve (Humans)
Normal Heart Sound that occurs at the End of Systole due to the Pulmonary Valves and Aortic Valves Snapping Closed
S2 (Dub)
*S1 and S2 sounds are all that we should hear in a normal Heart
Which Cardiomyopathy Has These Signs:
Sudden Death (30%)
Left-Sided Congestive Heart Failure (Predominant)
Right-Sided Congestive Heart Failure (Rare)
Dilated Cardiomyopathy
*Dobermans in Particular, Die Suddenly
True/False: Sudden Death is Always Possible in Boxers with Arrhythmogenic Right Ventricular Cardiomyopathy
True
*Even on Treatment, can still Die from VPD’s
Side Note: Animals with Few VPD’s and Animals with Many VPD’s all can Drop Dead Suddenly! No Correlation between # VPD’s and Sudden Death
Cardiac Output that is Insufficient to meet Body Needs
Heart Failure
*Occurs when Heart Disease is Severe- Enormous Reserve Capacity of the Heart
True/False: Cats with Hypertrophic Cardiomyopathy exhibit these Signs:
Decreased Cardiac Output
Increased Cardiac Oxygen Demand
Ventricular Arrhythmias
Massive Left Atrium
Left Sided Congestive Heart Failure
Dyspnea
True
*15% of Cats with Hypertrophic Cardiomyopathy can Die Suddenly because of VPDs
*Enlarged Left Atrium- Left Ventricle isn’t able to fill Properly
*Dyspnea- Difficult/Labored Breathing. Most Cats with Hypertrophic Cardiomyopathy present with Dyspnea due to Pulmonary Edema
Respiratory Sound that Occurs when there is Fluid Build up in the Lungs leading to Alveolar Collapse
Crackles
*Alveoli are popping open
Surgical Treatment for Tetralogy of Fallot. How Successful is Treatment?
By-Pass Surgery Connecting the Subclavian Artery to the Pulmonary Artery
*Only Works for a Couple of Months- Surgery isn’t very Successful
Phase where the Heart is Not Contracting
Diastole
*Heart is Resting
True/False: In Patients with Congenital Heart Disease, the Ultrasound will provide the Definitive Diagnosis
True
*Ultrasound is how Congenital Heart Diseases are Diagnosed
On This EKG, the S Wave in the QRS Complex has Increased. What does this Indicate?
Right Ventricular Hypertrophy
*Right Ventricle Gives Rise to the S Wave (Negative Deflection). With Right Ventricular hypertrophy, the Duration of the QRS Complex stays the same, only the S Wave becomes Deeper
*Normal S Wave is only 3.5 mm (shown in Picture)
True/False: The Prognosis for Endocarditis if Poor/Grave with Congestive Heart Failure
True
Which Cardiomyopathy has these Clinical Signs:
Thin Patient (Cachexia)
Left-Sided Congestive Heart Failure
Atrial Fibrillation/ VPDs
Soft Systolic Murmur
S3 Gallop
Dilated Cardiomyopathy
Failure of the SA Node that can occur for 1 or more Beats
Sinus Arrest
Two Ways we Monitor if Heart Failure Treatment is Working
Decreased Heart Rate
Decreased Respiratory Rate
*If Heart Failure Treatment is working the animals Heart Rate and Respiratory Rate will both be Decreasing. Animals with Heart Failure have Increased Heart Rate and Respiratory Rates
Most Important EKG lead
Lead II
*Measures the Electrical Activity between the Right Front Leg and the Left Hind Leg. Negative Pole is the Front Leg and the Positive Pole is the Hind Leg
Common Arrhythmia in Patients with Dilated Cardiomyopathy characterized by Random Firing of Atrial Muscles with Multiple Ectopic Foci. The EKG will show No P Waves with Normal Random QRS Complexes and Jumpy Baselines
Atrial Fibrillation
*Differentiate from Electrical Interferance- Electrical Interferance has P Waves Present on EKG
Which of the Following is NOT a Treatment for Tetralogy of Fallot:
A. By-Pass connecting Subclavian Artery to Pulmonary Artery
B. Beta Blockers
C. Phlebotomies
D. Vasodilators
D. Vasodilators
*Vasodilators will Decrease the Resistance in the Aorta and Increase Right-Left Shunting. Vasodilators are CONTRAINDICATED in Tetralogy of Fallot
*Beta Blockers will reduce Right Heart Stiffness. Phlebotomies will get rid of Excess Red Blood Cells
What Condition is Shown in this Ultrasound that is common in Cats with Hypertrophic Cardiomyopathy
Systolic Anterior Motion (SAM)
*Mitral Valve is Blocking Flow
Which Congential Heart Diseases causes:
Left-Sided Eccentric Hypertrophy
Left-Sided Congestive Heart Failure
Right-Sided Systolic Murmur
Ventricular Septal Defect
*Ventricular Septal Defect- The Louder the Murmur the Better the Prognosis (Smaller VSD)
*Blood is Travelling from the Left side of the Heart to the Right- Murmur is Heard on the Right Side of the Patients Heart
Condition in Cats with Hypertrophic Cardiomyopathy, where the Mitral Valve is Pulled into the Way of the Outflow of Blood from the Left Ventrical and Blood Travels back into the Left Atrium rather than the Aorta
Systolic Anterior Motion (SAM)
*Occurs in 65% of Cats with Hypertrophic Cardiomyopathy
*SAM- Cats have Enlarged Left Atrium
Breed of Dog where 13% will Develop Myxomatous Atrioventricular Valvular Degeneration by 3 years of Age
King Charles Cavelier
*Most Small Breed Dogs develop it at 6-9 Years of Age, while King Charles Spaniels develop it earlier at 3 years
_____ Shunted Patent Ductus Arteriosis leads to:
Overcirculation
Left Sided Eccentric Hypertrophy
Left-Sided Congestive Heart Failure
Left-Right
True/False: Patients with Left-Right shunting PDA will have Weaker Pulse Pressures
False
*They will have STRONGER (Hyperkinetic) Pulses- Bounding Pulses in patients with Left-Right shunting PDA’s
*Pulse- Difference between Systolic and Diastolic Pressure
Best Specialized Test for Detecting Arrhythmias
EKG
*Tells what the Cause of the Arrhythmia in the Heart is
True/False: In Patients with Pulmonic Stenosis that have undergone Valvuloplasty or Surgery, the Prognosis is Usually Good/Excellent
True
If the Ventricular Septal Defect is Half the Size of the Aorta, it is known as a ____ Ventricular Septal Defect and won’t cause Significant Problems
Small
True/False: In 50% of Heart Failure Patients, ACE Inhibitors cause Hypotension and Azotemia
False
*Hypotension and Azotemia only occur in 5% of Heart Failure Patients on ACE Inhibitors- Very Rare. Really Only get Hypotension and Azotemia when you start using ACE Inhibitors too Soon
*ACE Inhibitors are Great for Prolonging/Improving the life of Heart Failure Patients
____Cardiomyopathy is a Condition Mainly see in Large/Giant Breed Dogs, while ____ Cardiomyopathy is a Condition mainly seen in Cats
Dilated- Ex. Dobermans, Great Danes
Hypertrophic- Cats
Most common Cause of Pericardial Effusion in Dogs
Neoplasia (70%)
Hemangiosarcoma
*Congestive Heart Failure (10%) cause of Pericardial Effusion
*Hemangiosarcomas causing Pericardial Effusion are common in Retrievers and German Shephards
True/False: Patients with Pulmonic Stenosis will have Weak Pulses
True
*Left Heart is Functioning Normally but the Right Heart isn’t pumping enough blood to the Left Heart
What Drug is Given Per Os Once Daily to Control Arrhythmias (VPDs) in Patients with Aortic Stenosis?
Sotalol
*Sotalol stops VPDs in Majority of Dogs
*Can also use Oral Combination of Mexiletine and Atenolol- Must be Given Per os 3 times daily (Sotalol is Prefered)
Emergency Situations- IV Lidocaine
Blood Pressure in the Aorta
120/80
*120 During Systole and 80 during Diastole
*Left Side of the Heart has the Higher Blood Pressure because it has to Pump blood out to the Entire Body- Generates Intersitial Fluid in the Capillaries
Clinical Sign Associated with Brain Insufficiency due to Left Sided Heart Failure
Syncope
*Syncope- Temporary Lack of Consciousness described as “Fainting”. Caused by a lack of Foward Flow from the Left Ventricle and Decreased Blood Flow to the Brain and other Organs
The ____ Heart Sound is generally associated with Hypertrophic Hearts while the ____ Heart Sound is associated with Dilated Cardiomyopathy
S4- Hypertrophic Cardiomyopathy (in cats)
S3- Dilated Cardiomyopathy (in Dogs)
Treatment for Third-Degree AV Blocks
Pacemaker
Stage of Myxomatous Atrioventricular Valvular Degeneration that is Refractory to Standard Therapy and is considered End Stage
Stage D
*Refer to Cardiologist
Determine the Heart Rate in Beats Per Minute (BPM)
204 BPM
*On Exam and Final- Determining Heart Rate from EKG
*Every 25mm Represents 1 Second- The Arrows Represent 1 Second Intervals. The Overall Strip is 5 Seconds. Count the Number of QRS Complexes = 17 in 5 Seconds. 17 Beats in 5 Seconds (17/5), therefore the Heart Rate per Minute is ((17/5)x 12) = 204/60
*Heart Rate of 204 BPM is too High- Animal has a Tachyarrhythmia
Which Congenital Heart Disease is Characterized by:
Right-Sided Eccentric Hypertrophy
Pulmonic Murmur
Tricuspid Murmur
Atrial Septal Defect
*Left-Right Shunting- Eccentric Hypertrophy of the Right Heart
*Pulmonic Murmur- More blood than usual is Going through the Pulmonary Artery
*Tricuspid Murmur- More blood flowing through the Tricuspid Valve
Two Pacemakers in the Heart that Can Take over when the SA Node Fails to Work (Sinus Arrest)
Juctional (AV Node) Escape
Ventricular Escape
*Junctional Pacemaker works at 40-60 BPM
*Ventricular Pacemaker Works at 20 BPM
On EKG, if the P Wave is too Wide, What does that Indicate?
Left Atrial Enlargement
*Normal P Wave is around 0.04 Seconds ( 2 Boxes Wide)
Phase where the Heart is Contracting
Systole
Heart Rhythm that Sounds like DUB LUB DUB due to Audible forced filling of Blood into the Already Filled Ventricle due to Atrial Contraction
S4 Gallop Rhythm
*We typically hear the S4 Heart Sound in Cats with Hypertrophic Cardiomyopathy
Beat that can be Measured when the Left Side of the Heart Beats against the Inside of the Chest
Apex Beat
*Hypertrophic Cardiomyopathy- Increased Apex Beat
*Dilated Cardiomyopathy- Decreased Apex Beat
Diagnosis of EKG
Ventricular Premature Depolarization Initiated in Left Ventricle
*Left Ventricle- Negative at the Beginning
True/False: All of these are Considered Normal QRS Complexes
True
*Sometimes the Q or S Wave may be Missing, but is still normal and still considered a QRS Complex
Delay or Failure of Transmission at the AV Node that can be caused by factors outside the heart such as Drugs, Hypothyroidism and Increased Vagal Tone as well as Ischemia and Trauma within the Heart
AV Block
Most Widely used Drug used to Treat Ventricular Premature Depolarizations in Non-Emergency Situations
Sotalol
*Sotalol is sometimes combined with Mexiletine
What are the Prognosis for Cats with:
A. Asymtomatic Hypertrophic Cardiomyopathy
B. Hypertrophic Cardiomyopathy with CHF
C. Hypertrophic Cardiomyopathy with Thromboembolism
A- Good/Guarded (Average 5 Years of Age)
B. 3 Months (20% > 3 Years)- Dependant on Left Atrium Size
C. Grave (Normally Euthanized)
Drugs used to Treat Atrial Fibrillation and Other Arrhythmias in Patients with Dilated Cardiomyopathy
Digoxin + Diltiazem
Heart Sound that is normally Audible in Large Animals but abnormal in Small animals that occurs just after the Atrium Contracts when Blood is Forced into the already Filled Ventricle
S4
We Treat Patients with Aortic Stenosis if they have ____, such as Syncope, Weakness, and Ventricular Premature Depolarizations (VPDs) or if the Stenosis is Severe at Greater than 4 meters/second
Clinical Signs
*Even with Treatment the Patient can still Die Suddenly from Arrhythmias
Cats with Hypertrophic Cardiomyopathy have ____ Failure
Diastolic
*The Heart cannot Fill during Diastole because there is Decreased Space
True/False: Capillary Refill time is a Good Indicator of Cardiac Output and is a good indicator of Heart Failure Treatment
True
*Best Place to Check Capillary Refill Time- Lip
_____ Commonly have these Congenital Heart Diseases:
Patent Ductus Arteriosis
Aortic/Pulmonic Stenosis
Atrial Septal Defects (ASD)
Mitral Dysplasia
Dogs
Pacemaker Escape Beat that is Characterized by an Abnormal QRS Complex and Absent P Wave
*Shown in Picture by Arrow Head
Ventricular Escape
Drugs used to Treat Hypertrophic Cardiomyopathies in Cats, while treating the Ventricular Premature Depolarizations simultaneously
Atenolol / Propanolol
In 75-100% of Wolf hounds and 30% of Dobermans with Dilated Cardiomyopathy you will see _____ on EKG
Atrial Fibrillation
*Atrial Fibrillation- Mainly in Giant Breed (Wolf hounds)
*No P-Wave, Jumpy Baseline and Random R-R Intervals
Patients with Left-Right Shunted Patent Ductus Arteriosis will have Characteristic Continuous Murmurs during Diastole and Systole (Machinery Murmur). Where will the Murmur be Loudest?
Heart Base
*These Murmurs are often so Loud that they produce a Thrill- Can feel Murmur with Hand on the side of the Patients Chest
An EKG with Short QRS Complexes that Change in Height. What is this Indicative of?
Pericardial Effusion
*Heart is Floating in Pericardial Sac
Heart Sound that Occurs at the Beginning of Diastole that is a period of passive Filling of the Ventricle
S3
*Audible in Large animals but you should not be able to hear the S3 sound in small animals. When you do hear the S3 sound in small animals it is an indication that the heart is massively enlarged- Typically in dogs with Dilated Cardiomyopathy
Which side of the Heart is Strained and undergoes Eccentric Hypertrophy if you have a Left-Right shunting Patent Ductus Arteriosis (PDA)
Left Heart
*Left Heart is going to have a Volume Overload because blood keeps getting pumped back resulting in Left Heart Enlargment (Eccentric Hypertrophy) and eventually leads to Left-Sided Congestive Heart Failure in these dogs
*Blood Shunted from Aorta to Pulmonary Artery (Left-Right Shunt)
Treatment for Endocarditis
Stabilize CHF (If Present) - Furosemide
High Levels of Serum Bactericidal IV Antibiotics- Kill Infection
What is the Treatment for Cats with Hypertrophic Cardiomyopathy that have Developed Thromboembolism
Analgesia/Fluids/Acepromazine ??
*Most Veterinarians Euthanize- Poor Prognosis- 100% Reoccurance within 6 months of Treatment
String of Ventricular Premature Depolarizations at a Rate Greater than 160-180 bpm that is considered a Serious Condition that may be Prefibrillatory and lead to Sudden Death
Ventricular Tachycardia
Two Most Common causes of Pericardial Effusion in Cats
FIP and Lymphoma
Test that Measures Electrical Activity in the Heart and is Fantastic for Picking up Accurate Heart Rates and Conduction Disturbances such as Arrhythmias
Electrocardiography (EKG or ECG)
What is Recommended as Additional Treatment for Cats with Hypertrophic Cardiomyopathy that are Obstructed (HOCM)
Atenolol (Beta Blocker)
*Murmurs get Softer if the Patient is put on Beta-Blockers
*Side Note- Beta Blockers also Diminish VPD’s in patients with Hypertrophic Cardiomyopathy
Two Drugs used in Emergency Situations to Treat Superventricular Tachycardia when the Underlying Cause cannot be Treated
Esmolol/ Diltiazem
Summary Slide:
- When Patient is in Heart Failure, initially Furosemide is Given in Larger Doses
- Once the Respiratory Rate Decreases by 25-50%, the Patient is only given Furosemide Per os Three times Daily
- Once Heart Failure begins to get better, the Patient is Switched to ACE Inhibitors for the Long term to Prolong/Improve life
Prognosis for Myxomatous Atrioventricular Valvular Degeneration
Good (70-90%) Die Before CHF
*If Patient Develops LCHF- 1 Year
If Patient Develops RCHF- Poor Prognosis
Clinical Sign associted with the Lungs in Left Sided Heart Failure
Dyspnea/ Cough
*Dyspnea- Increased Effort in Respiration/Shortness of Breath
*In Left Sided Heart Failure if Blood is not Flowing Forward as it should then it will back up into the Lungs through the Pulmonary Veins- Lungs will be full of Blood (Heavy Lungs)
True/False: Tachycardia and Bradycardia can lead to Syncope
True
*Tachycardia- Not enough Time for the Ventricles to Fill before each beat, therefore not enough blood being pumped to the Brain
Cardiomyopathy that is Common in Cats where the Heart Develops Concentric Hypertrophy characterized by Large, Branching, and Fibrotic Myocytes
Hypertrophic Cardiomyopathy
Patients with Large Ventricular Septal Defects or____ Shunting carry a Poor Prognosis
Right-Left
*90% of Ventricular Septal Defects are Left-Right Shunting. If Right-Left Shunting occurs in a Patient with VSD, it carries a very poor Prognosis
*Mild to Moderate Ventricular Septal Defects have Good Prognosis
If the Murmur is loudest over the Apex of the Heart, what is that Characteristic of?
Mitral Valve Insufficiency (usually Endocardiosis)
Patient is in the Arrythmogenic Stage of Dilated Cardiomyopathy. Atrial Fibrillation is Detected with an Increased Heart Rate
( 150 bpm). What two Drugs can be used for Treatment?
Diltiazem or Beta-Blocker
*Usually Diltiazem is Used- Works very Well
*We need to Slow the Heart Down
Heart Condition that Leads to:
Congestive Heart Failure
Dysrhythmias
Septic Emboli
Polyarthritis + Glomerulonephritis
Endocarditis
*Cord Rupture could lead to Acute Onset of Heart Failure
*Parts of Vegetation with Bacteria can break off and got the Brain, Kidney ect. Causing Seizures and Renal Problems
What Drugs do we use to Improve Diastolic Function in Patients with Aortic Stenosis
Beta-Blockers (Atenolol)
*Beta-Blockers take away the Sympathetic tone of the heart and allow it to expand more during Diastole
*We want to Relax/Dilate the Heart and take the Tone out of the muscle so that it can dilate and Fill during Diastole
Abnormal, extra Heart Sounds caused by Distrubed Blood Flow, such as narrowing of a vessel, valvular insufficiency, increased rate of blood flow and decreased blood Viscosity
Heart Murmurs
*Narrowing of Vessels and Valvular insufficiency are the Two Main causes of Murmurs
Pericardial Effusions lead to ___-Sided Congestive Heart Failure
Right
On this EKG, What do the P Waves Indicate?
Bi-Atrial Enlargement
*The P Wave is Peaked (Too High) and Too Wide- Left and Right Atrial Enlargement
True/False: In Most cases, Atrial Septal Defects are Asymptomatic and don’t cause Significant Clinical Problems
True
Ventricular Septal Defects (VSD) lead to a Volume Overload in the ____ Heart and eventually Left-Sided Congestive Heart Failure
Left
*VSD causes Eccentric Hypertrophy of the Left Heart
_____-Degree AV Block caused by Delayed Conduction through the AV Node characterized by a Prolongation of the PR Interval
First
*Delayed Conduction through the AV Node
*Normal PR Interval is around 0.13 Seconds. If the PR Interval is Greater than 0.13 Seconds = First-Degree AV Block
*Usually Caused by Increased Vagal Tone- No Treatment
True/False: 90% of Patent Ductus Arteriosis Cases will be Left-Right Shunted
True
*Right-Left PDA only makes up 10% of PDA Cases
Patient is in the Classic Failure Stage of Dilated Cardiomyopathy. What is the Treatment?
Furosemide + ACE Inhibitors
*Furosemide Orally 3 Times Daily. Once Respiratory Rate gets to the Normal Zone, then Start Decreasing the Furosemide. ACE Inhibitors used for Long Term Treatment
*Put these Patients on Restricted Sodium Diets
True/False: Patients in Heart Failure with Dilated Cardiomyopathy and Mitral Valve Disease have a fairly good Prognosis with a Life Expectancy of 1 year Following Heart Failure
True
Normal Heart Rate (BPM) for a Dog
70-170 BPM
*120-240 BPM is Normal Heart Rate in Cats
Part of the Stethoscope that Picks up High Frequency Sounds that is commonly used to Listen to Respiratory and Heart Sounds
Diaphragm
Condtion in which Part of the Septum is Damaged that leads to a Prolonged QRS with normal Height on EKG
Left Bundle Branch Block
*Left Ventricle will take Longer to Depolarize
*Wide QRS with Normal Height = Left Bundle Branch Block
Murmur in which you cannot hear the LUB and DUB sounds but only the Whishing Sound
Pansystolic Murmur
*WHISH WHISH WHISH
Bartonella, Strep, Staph, E.Coli, Corynebacterium, and Pseudomonas are all Bacteria that can lead to _____ in the Heart
Endocarditis
Diuretic that is used to Reduce Edema in Heart Failure Patients that have Mitral Valve Disease
Spironolactone
*Extends and Improves Quality of Life in Patients that are in Heart Failure with Mitral Valve Disease
Patient is in the Arrythmogenic Stage of Dilated Cardiomyopathy. Atrial Fibrillation is Detected with Ventricular Premature Depolarizations (VPDs). What is the Treatment?
Sotalol/Mexiletine
*Sotalol and Mexiletine are used to Decreased the # of VPDs- Cannot Completely Get rid of VPDs
*Treatment of VPDs Does NOT Prevent Sudden Death- No correlation between # VPD’s and Sudden Death
EKG shows that the Baseline after the QRS Complex is More than 2mm Below the Baseline before the QRS Complex Began. What is this Indicative of?
Myocardial Hypoxia
* Baseline after the QRS is Allowed to be 2mm Lower or 1.5mm Higher than the Baseline before the QRS to be considered Normal
*Heart is Not getting the Oxygen it needs
Arrhythmia characterized by an Interchanging of Abnormal and Normal Beats
Bigeminy
*Abnormal Beat, Normal Beat, Abnormal Beat….ect.
True/False: Animals in Heart Failure should be Handled with Care, so as to not Stress the Patients out Further
True
____ Commonly have these Congential Heart Diseases:
AV Dysplasia
Ventricular Septal Defects (VSD)
End Fibroelast
Patent Ductus Arteriosis (PDA)
Aortic Stenosis
Cats
*Congenital Heart Diseases are Rare in Cats
Premature Beat that Occurs in the Ventricle that occurs due to Hypertrophy, Inflammation, Trauma, ect. in the Heart that is Characterized on the EKG by Premature/No P Wave with Wide and Bizarre QRS Complexes
Ventricular Premature Depolarizations (VPD)
*If Arises in Left Ventricle- Negative
*If Arises in Right Ventricle- Positive
Heart Condition with these Results on Physical Exam:
Intermittent Fever
Shifting Lameness
Sudden Loud Murmur
Pounding Pulse
Dysrhythmias
Congestive Heart Failure
Endocarditis
*Shifting Lameness- Occurs in 44% of Patients with Endocarditis due to Polyarthritis that can occur
*Very Diagnostic- Dramatic Murmur that wasn’t there a month ago. Ex. Dog now has Grade 5 Murmur that wasn’t there a month ago. Very Diagnostic for Endocarditis
Congential Heart Disease characterized by a Connection between the Aorta and Pulmonary Artery in the Fetus/Newborn
Patent Ductus Arteriosis
*Connection between the Pulmonary Artery and the Aorta- Blood coming up the Aorta is going to get pushed into the Pulmonary Artery, which will circulate back to the Left heart
*Caused by a Lack of Smooth Muscle in the Ductus Arteriosis in the Fetus leading to inability to Close and form the Ligamentum Arteriosus
Most of the Clinical Issues associated with Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) in Boxers are associated with _____ coming from the Right Ventricle
Ventricular Arrhythmias (VPD’s)
*VPD’s coming from Right Ventricle- Sudden Death can Occur
* 1 out of Every 3 Beats is a Ventricular Arrhythmia in Boxers with ARVC
Substance in the Blood with Osmotic Pressure that Sucks Blood back into the Capillaries to Travel back to the Heart
Albumin
If Giving IV Fluids to a Heart Failure Patient, _____ should be given as a Constant Rate Infusion (CRI) and not exceed 25% of Daily Maintenance Requirements
5% Dextrose
*Maintenance Fluid Requirements = 1ml/lb/hour
*Heart Failure Patients- Need Low Sodium Fluid = 5% Dextrose
*Side Note: Try to avoid giving IV fluids to dogs in Heart Failure- Better to Give Fluids Subcutaneously
True/False: The Louder the Murmur the Worse the Prognosis
True
True/False: Sinus Bradycardia can be caused by Drugs, Hyperkalemia, Hypothyroidism, and Vagal Nerve Problems
True
*Terbutaline is used to Treat Vagal Nerve Problems
How we get Definitive Diagnosis of Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) in Boxers
Holter Monitor
What is the Recommended Treatment for a Cat with Hypertrophic Cardiomyopathy with a Murmur Only (Subclinical)
No Treatment
*57% of Cardiologists say Not to Treat, while 29% of Cardiologists would Treat with Beta Blockers (Atenolol). No evidence that Beta Blockers Help
In Dogs with Dilated Cardiomyopathy that are in Heart Failure, which Drug is commonly used to Increase the Depressed Heart Contractility?
Pimobendan
*Makes the Heart more sensitive to Calcium- Very powerful Positive Inotrope
*Pimobendan has extended the Life of Dogs with Dilated Cardiomyopathy over 9 Months
Condition where P Waves Originate from Pacemakers outside the SA node where the P Wave gets smaller and Eventually turns Negative on the EKG
Wandering Atrial Pacemaker
*Just means there is Increased Vagal Tone- No Treatment
Hormonal System responsible for Long Term Changes in Blood Pressure. Decreased Blood pressure activates Angiotensin II leading to Vasoconstriction while activated Aldosterone Increases Circulatory Volume
Renin-Angiotensin-Aldosterone System (RAAS)
*Increases Preload and Venous Return to the Heart
Condition with Abnormal Sinus Node and AV System characterized by Alternating Periods of Sinus Arrest, AV Block and Tachycardia where the Patient experiences Intermittent Weakness and Syncope
Sick Sinus Syndrome
*This Patient can Pass out due to Sinus Arrest or Tachycardia
*Treament of Sick Sinus Syndrome- Pacemaker to treat Sinus Arrest and Drugs to Control the Tachycardia!!!
Starting Point of Cardiac Auscultation Exams in Canines, where the Mitral Valve can be Found
Apex Beat
*Area where we Begin our Canine Heart Ausculation Examination. The Mitral Valve is found near the Apex Beat because the Left Side of the Heart is Beating against the Inside of the Chest
*The Mitral Valve can be Found by Locating the Apex Beat
True/False: When Compensatory Mechanisms fail to Maintain Cardiac Output, the Patient will show signs of Congestive Heart Failure
True
*Exacerbated by normal compensatory responses
Condition that occurs in 5-12% of Cats with Hypertrophic Cardiomyopathy characterized by a Blood Clot at the Iliac Bifurcation that cuts the Blood Flow to the Hind Legs
Aortic Thromboembolism (ATE)
*Severe Hypoxia in the Hind Limb leading to Pain and Necrosis- Cats will be Dragging Hind Legs- VERY Painful. No Pulse in the Hind Limb
Greater than ____% of All Dogs over the Age of 12 will have Myxomatous Atrioventricular Valvular Degeneration
35%
*Small Breed/Med Breed = 85% will have Myxomatous Valvular Degeneration
*Does not Occur in Cats- Not a Cat Disease
Stage of Myxomatous Atrioventricular Valvular Degeneration where Murmurs are Present, but No signs of Heart Failure and Rads and Echo are Abnormal
Stage B2
*No Consensus on Treatment- ACE Inhibitors
______ commonly leads to Dynamic Obstruction causing Infundibular (Unequal) Hypertrophy in the Walls of the Right Ventricle
Pulmonic Stenosis
What is this EKG Artifact?
60 Hz Electrical Interference
*Baseline looks Fuzzy and filled with tiny Spikes- 60 spikes per second
*Electrical Interference from Lights, Refrigerator, Opthalmoscope ect. leading to 60 Hz of Electrical Interference
Which Congenital Heart Disease is Characterized These Three Problems:
Pulmonary Valvular Dysplasia
Hypoplastic Annulus
Dynamic Obstruction
Pulmonic Stenosis
*Dynamic Obstruction caused by Infundibular Hypertrophy
Sound that we Hear Between the LUB and DUB in the early stages of Mitral Insufficiency where part of the valve closes later than the rest of the valve
SPLIT CLICK
*Sounds like LUB CLICK DUB- Mitral Insufficiency
*LUB as main valve Closes and CLICK as prolapsing valve closes
Two Types of Premature Depolarizations (Beats)
Ventricular Premature Depolarization (VPD)
Superventricular Premature Depolarization (SPD)
*VPD- Abnormal QRS Complex
*SPD- Normal QRS Complex
In Heart Failure Patients, it is Important to Reduce Edema. Which Powerful Diuretic is commonly given IV every 1-2 Hours to Reduce Edema in Heart Failure Patients?
Furosemide
*Furosemide gets Rid of Edema in the Lungs- Powerful Diuretic. Makes the Lungs Lighter so the patient can breathe easier and the Heart works better (Decreases Preload)
*Maintenance- When Patient is sent home on Furosemide they will be Urinating in the House- Put them on Lowest Dose possible
*FONS- Furosemide Oxygen Nitroglycerine Cream Sedation
Laboratory Results in a Patient with Endocarditis will show Increased Number of _____, most likely Toxic
Neutrophils
*May see Thromobocytopenia and Renal and Liver Dysfunction
*Definitive Diagnosis for Endocarditis- Blood Cultures and PCR of Bacteria
Cardiomyopathy that is Commonly found in Boxers characterized by Fibrosis and Fat Infiltration that mainly affects the Right Side of the Heart
Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)
*Boxer Cardiomyopathy- Right Heart Problem- Arrhythmias
At Home Treatment for Patients with Dilated Cardiomyopathy
Furosemide (Maintenance Dose)
ACE Inhibitors
*Exercise Restriction and Restricted Sodium Diet also Recommended!!
On EKG Paper, when doing Height measurements to determine if there is Chamber Enlargment the Patient must be in _____Recumbancy
Right Lateral
*Height Measurements on EKG Paper are only Used for Determining Chamber Enlargement, however is not as efficient as Ultrasound
*On EKG Paper Every Outlined Box is 5mm x 5mm. Vertical Direction of Lines gives an Indication of Voltage coming through Leads. Usually Set Voltage to 1cm = 1mV. Horizontal Scale Represents “Time”
*If we Want to see the Details of the EKG we run it at 50mm/sec. Most EKG Measurements are Taken at 50mm/sec
In All Patients with Aortic Stenosis, ____% of Cases will Die before 3 years of Age
20%
* 1 out of 5 will die Suddenly because of Ventricular Arrhythmias
*In Patients with Severe Aortic Stenosis, 70% will Die before 3 years of Age
*Once a Patient with Aortic Stenosis lives past 3 Years, they will most likely Survive and die of something else
____ -Sided Congestive Heart Failure leads to:
- Hypotension (Weakness/Syncope)
- Pulmonary Edema (Dyspnea and Coughing)
Left
*Dyspnea- Shortness of Breath
____-Sided Congestive Heart Failure leads to:
- Ascites
- Distention of Jugular Veins
- Hepatosplenomegally
- Pleural Effusion
- Hypotension (Syncope)
Right
*Syncope is a sign of Left and Right Heart Failure
Review Anatomy of the Heart
Oxygenated Blood comes from the Lungs and enters the Left Atrium via the Pulmonary Vein
Blood Pumps from the Left Atrium into the Left Ventricle through the Left Atrio-ventricular Valve (Mitral Valve)
Blood Travels from the Left Ventricle into the Aorta via the Aortic Valves. Oxygenated Blood Travels to the Tissues of the Body
Great Veins and Lymphatics take the Blood back to the Heart and enters the Right Atrium
When the Right Ventricle Goes into Systole blood travels into the Pulmonary Artery through to the Lungs
Match the Phases of Heart Failure:
Phase I Disease but no Signs
Phase II Cough, Dyspnea/ Orthopnea at Night/with Exercise
Phase III Cough, Dyspnea/Fatigue with Exercise
Phase IV Cough, Dyspnea, Cyanosis at Rest
Gene Mutation Found to Decrease Connexin 43 and Calstabin Protein Levels in Boxers with Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) that may lead to Fainting and Death in Boxers
Striatin
Blood Cultures and ___ of Bacteria give us Definitive Diagnosis for Endocarditis
PCR
*PCR- Especially Bartonella
What are the Three Stages of Dilated Cardiomyopathy
Arrhythmogenic Stage - Patient _2-5 Years Old (_Arrhythmia but Normal Heart)
Occult Stage- Patient _3-6 Years Old (_Arrhythmia and Dilation)
Classic Failure- Patient 6-9 Years Old (Systolic Failure)
True/False: You can use Furosemide to Treat Pericardial Effusion and Clear the Fluid
False
*Furosemide is not a Treatment. Treatment for Pericardial Effusion is Pericardiocentesis
Which Congenital Heart Disease leads to:
Right-Sided Concentric Hypertrophy
Ventricular Premature Depolarizations (PVDs)
Sudden Death
Weakness/Syncope
Pulmonic Stenosis
* 30% of These Patients will die Suddenly because of Ventricular Arrhythmias
Condition that Occurs in Cats with Hypertrophic Cardiomyopathy, when the Hypertrophic Ventricular Wall blocks the Outflow of the Blood through the Aorta
Hypertrophic Obstructive Cardiomyopathy (HOCM)
*HOCM Patients tend to have Murmurs
Most Reliable Indicator if our Treatment of Heart Failure is Working
Decreasing Pulse Rate
*During Heart Failure the Sympathetic System is Simulated leading to Increased Cardiac output and Increased Pulse Rate. If our Heart Failure Treatment is Working then the Animals Sympathetic System will Decrease along with the Cardiac Output and Pulse Rate
Dilated Cardiomyopathy in Felines is caused by ____ Deficiency, which is Characterized by Bands of Focal Retinal Degeneration
Taurine
If a Patient has Atrial Fibrillation with an Increased Heart Rate
(> 150 bpm) and a Normal Heart Function, how would you Treat the Patient?
Diltiazem
*Need to Slow the Ventricular Reponse Rate
True/False: Only 50% of Cats with Hypertrophic Cardiomyopathy Have Heart Murmurs
True
*Murmurs only Occur in Cats with HOCM or SAM
_____- Degree AV Block where there is No Conduction through the AV Node characterized on EKG by P Waves followed by Junctional or Ventricular Escapes
Third
*P Waves followed by Wide Bizarre QRS Complexes- Ventricular
*P Waves followed by Normal QRS Complexes- Junctional (AV)
*Picture Above- Ventricular Escape Beats
*Picture Below- Junctional Escape Beats
Stage of Myxomatous Atrioventricular Valvular Degeneration, where Patients are At Risk, such as King Charles Spaniels, but No Murmur is Present and No Treatment is Recommended
Stage A
Special Examination that is Best at Figuring out what is Occuring within Blood Vessels, Lungs, and the Pleural Space
Radiographs
*Radiographs are the Gold Standard for Blood Vessel Pathology and Lung Edema due to Congestive Heart Failure
Giant Breed Dogs with Dilated Cardiomyopathy commonly have _____ Type Myofibers
Wavy
Murmur in which you hear LUB WHISH DUB
Holosystolic Murmur
Congenital Heart Disease common in Larger Breed Dogs (Newfoundland, Boxer, Rotweilers) where a Band of Fibrocartilage forms just below the Aortic Valve (Subvalvular), which Constricts the Area and narrows the Outflow track from the Left Ventricle into the Aorta
Aortic Stenosis
*Creates Pressure Overload in the Left Ventricle- Eccentric Hypertrophy
Two Main Clinical Signs associated with Left Sided Heart Failure
Syncope (Fainting)
Dyspnea/Cough
What condition will create a Murmur that is Loudest over the Heart Base?
Aortic Stenosis and Pulmonic Stenosis
*LUB is Loudest by the Apex and DUB is Loudest by the Base
Congenital Heart Disease that is more common in Cats where there is a Failure of Septal Development (Hole in the Heart) leading to a Connection between the Left and Right heart
Ventricular Septal Defect
*Blood is going to Travel from the Left Heart to the Right Heart
*Very rarely see congenital heart disease in Cats
In Dogs with Myxomatous Atrioventricular Valvular Degeneration that are Regurgitating 50% of the Blood Back into the Left Atrium, Cardiac Contractility is _____
Increased!!!!
*These Hearts are Working Overtime- Keeping the Dog Alive. These Hearts that are Enlarged, the Elevated Contracility is a compensatory Mechanism to keep the Animal Going
*A dog with Mitral Insuffiency DOES NOT have a Hypocontractile Heart, rather they have Increased Contractility
*KNOW THIS
Treatment for Inherited Ventricular Arrhythmias in Young German Shepherds
Sotalol + Mexilitene
*Sotalol with Mexilitene Controls VPDs and is used until around 18 Months of Age
_____ Shunted Patent Ductus Arteriosis leads to :
Right Sided Eccentric Hypertrophy
Erythrocytosis (Increased PCV)
Cyansosis
Right Sided Congestive Heart Failure
Right-Left
*Cyanosis- Pink in the Front Mucous Membranes (Gums) and Blue in the Back Mucous Membranes (Vulva)- De-oxygenated blood that should have gone to the lungs is now gone into the Aorta and being pumped to Distal Limbs
*Erythrocytosis- Kidneys produce Erythropoeitin in response to Hypoxia. Deoxygenated Blood travelling to the Kidneys leads to Increased level of Erythropoetin Production and therefore Increased level of Red Blood Cells.
In Patients with Ventricular Septal Defect, Large Murmurs will be the Result of a ____ VSD, while Soft Murmurs will be the Result of a ____ VSD
Small
Large
*Small Ventricular Septal Defects = Large Murmurs (More Turbulance)
*Large Ventricular Septal Defects = Softer Murmurs (Less Turbulance)
*In Patients with VSD, Softer Murmurs have a Worse Prognosis!!!
Animals in Heart Failure will have an _____ Respiratory Rate
Increased
*Its easier for Animals with Heart Failure to breath if they take Short Shallow Breaths so our Respiratory Rate increases in Heart Failure
On this EKG, What does the P Wave Indicate?
Left Atrial Enlargement
*The P Wave is 3 boxes Wide (normal is 2 Boxes). The P Wave is too Wide
Most Patients with Tetralogy of Fallot have a Severe Pulmonic Stenosis, which can lead to _____
Cyanosis
*Right to Left Shunting- Blue blood from the Right Ventricle going out the Aorta and Patient will Be Cyanotic in the Front and Back
*Tetralogy of Fallot = Blue Puppies/Kittens (Cyanotic all the Time)
Review Card of Normal Conduction through the Heart
Conduction Begins in the Right Atrium with Spontaneous SA Node Depolarization. Sends wave of Depolarization through the Atria causing the Right Atrium to Contract, forcing Blood into the Ventricles
When the SA Node Fires it activates the Muscle Cells next to it. The Muscle Cells Depolarize and subsequently continue to Depolarize the Proximal Muscle Cells until all the Muscle Cells in the Atrium have Fired. Once all the muscle Cells have Fired, Atrial Contraction Ceases
Once Impulses arrive at the AV Node they are Conducted Very Slowely through the AV Node- Conduction moves slowely to give time for the Blood to move from the Atrium down into the Ventricles
Followed by the Rapid Depolarization of the Septum Leading to Activation of the Bundle of His, L and R Bundle Branches and Purkinje Fibers. The Impulses from the Purkinje Fibers spread out along the Ventricle leading to Ventricular Depolarization and Contraction
What is the Recommended Treatment for a cat with Hypertrophic Cardiomyopathy that is in Heart Failure?
Furosemide (FONS)
*Give Furosemide very Every Hour/ 2 Hours until the Respiratory Rate Comes down to Normal Levels. When Respiratory Rate has decreased, only give Furosemide 3 times daily
*Furosemide Oxygen Nitroglycerine Sedation
True/False: Patients with Aortic Stenosis will have Weak (Hypokinetic) Pulses
True
*No Blood going into the Aorta leading to Terrible Pulses
True/False: The T Wave, which Represents Ventricular Repolarization, can be Positive or Negative in an animal
True
*Normal T Wave can be either Positive or Negative
*T Wave should be less than 1/4 of the R Wave and around 0.3mV
Aortic Stenosis results in a Pressure Overload in the ____ Ventrical leading to Eccentric Hypertrophy
Left
*Narrows the Outflow tract between the Left Ventricle and the Aorta
Heart Rhythm that Sounds like LUB DUB DUB due to the Audible Sound of the Passive Filling of the Ventricles
S3 Gallop Rhythm
Congenital Heart Disease Only seen In Young German Shepherds that occurs around 3 months of Age characterized by Ventricular Premature Depolarizations (VPDs) where 10% of Cases die Suddenly
Inherited Ventricular Arrhythmias
When doing a Cardiac Work up, if you hear that the Patient has a Murmur, What Three Tests will you have done on the Patient?
Chest Radiographs
Ultrasound
EKG
True/False: Heart Failure is Exacerbated / Made Worse by Normal Compensatory Neuroendocrine Mechanisms (RAAS and Sympathetic)
True
*Make Heart Failure Worse. Treatment will be aimed at trying to Block these Neuroendocrine Mechanisms
On this EKG, the Height of the R Wave in the QRS Complex is Increased. What does this Indicate?
Left Ventricular Enlargment
*Normal R Wave is 25-30mm High. If R Wave is Greater than 30mm High = Left Ventricular Enlargement
*In this Picture the P Wave is also much wider than it should be- Left Atrial Enlargment as well
*KNOW THIS SLIDE- Very common to have Left Ventricular and Left Atrial Enlargement related to Mitral Valve insufficiency
Common Gene that is Found in Cats with Hypertrophic Cardiomyopathy that can be used to Prevent Further Cases
MyBPC3
*Mutation in Myosin Binding Protein- Don’t Breed Cats with this Mutation
If the Ventricular Septal Defect is Greater than the Diameter of the Aorta, it is known as a ____ Ventricular Septal Defect and will cause Significant Clinical Issues
Severe
Diagnosis of EKG
Ventricular Premature Depolarization initiated in Right Ventricle
*Right Ventricle- Positive
Irregular and Disorganized Ventricular Activity characterized by No Cardiac Output and No Coronary Flow
Ventricular Fibrillation
*Usually Fatal
Condtion in which Part of the Septum is Damaged that leads to a Deep S Wave, Prolonged QRS and Decreased R Wave on EKG
Right Bundle Branch Block
*Activation of the Right Ventricle will be Delayed- Right Bundle Branches carry the impulses down into the Right Ventricle. Right Ventricle will take longer to Contract
*If you have a Deep S Wave, measure the QRS Duration and if it is too long then its a Bundle Branch Block. If the QRS Duration is normal then its Right Ventricular Enlargement
Gold Standard Test for Determining Heart Enlargment
Ultrasound
*Ultrasound is the BEST to determine Heart Size and measuring Blood Flow through the Heart
*Side Note- If you have a coughing dog and you want to see if the Dog is in Heart Failure and what is occuring in the lungs, DO NOT use Ultrasound- Cannot Ultrasound tissues with Gas in them, such as Lungs
Diagnosis on this EKG
Superventricular Premature Depolarization (SPD)
*Premature Beat with Normal QRS Complex
Patient with Severe (Hospitalized) Case of Dilated Cardiomyopathy. What is the Appropriate Treatment?
A. Supplementary Oxygen and Sedation
B. IV Furosemide
C. Pimobendan
D. Sodium Nitroprusside CRI
E. All of the Above
E. All of the Above
*Sodium Nitropursside CRI- Decreases Preload
*IV Furesemide- Treats Pulmonary Edema
*Pimobendan- Drug of Choice to Increase Heart Contractility. Increases Patient Survival up to a Year
Hyperkalemia is commonly caused by Renal Failure and Aortic Thromboembolism (ATE). Hyperkalemia leads to _____ characterized by Tall T Waves, Absent P Waves, and at very High Potassium Levels, Prolonged QRS Complexes
Bradycardia
*Hyperkalemia- T Waves will become Tall and Pointed at the Top, P Waves Disappear
*Hyperkalemia is mainly caused by Renal Failure and ATE
*Photo- At Very High Levels of Potassium the QRS Complex becomes Distorted- Sinusoidal Shape
What Breed of Dog is the Poster Child for Patent Ductus Arteriosis?
Miniature/Toy Poodles
*Also Occurs in German Shepards and Collies (Can occur in any breed)
*Polygenetic Trait in Poodles
True/False: 99% of Murmurs we hear in Dogs and Cats are Systolic Murmurs
True
*Occur sometime between the S1 and S2
*Only Hear Diastolic Murmurs if there is a leaky Aortic Valve or Pulmonic Valve
_____ Shunted Patent Ductus Arteriosis is characterized by:
Loud Machinery Murmur
Thrill
Water-Hammer Pulses
Left-Right
*Machinery Murmur- Murmur during Systole and Diastole
Which Shunted Patent Ductus Arteriosis has a Better Prognosis?
(Left-Right or Right-Left)
Left-Right
Left-Right = Excellent Prognosis with Treatment (Ligation or Amplatz Occluders)
Right-Left = Poor Prognosis- Lungs are a High Resistance Pathway. If Right-Left PDA is Ligated the Right Heart will Fail acutely because it won’t be able to push the Blood into the Lungs due to Lung Hypertrophy
Dropped Heart Sounds, Irregular/Dropped Pulses, and Sudden Death are common Signs associated with _____
Ventricular Premature Depolarization (VPD)
*VPD’s are common in Dobermans with Dilated Cardiomyopathy
*Patients with VPD have Increased Chance of Fibrillation and Sudden Death because Depolarization of the Ventricle Occurs before the Ventricle has Completely Repolarized from the Last Beat
Pulse Generator that Creates a Shock leading to Heart Contraction that can be used to treat Clinical Sinus Bradycardia
Pacemaker
*Lead of the Pacemaker runs through the Jugular Vein and ends up in the Right Heart and is screwed into the Apex of the Heart
In Moderate/Severe cases of Pulmonic Stenosis, ___% will die suddenly due to Ventricular Arrhythmias by 3 years old
30%
*Mild Cases Live Normal lives
Stage of Myxomatous Atrioventricular Valvular Degeneration characterized by Past or Current Signs of Failure
Stage C
Increased Fluid in the Pericardial Sac that causes Diastolic Failure particularly in the Right Heart
Pericardial Effusion
*Increased Fluid Squeezes the Heart and stops the heart from Filling during Diastole
Congentical Heart Disease characterized by Pulmonary Valve Dysplasia, where the Valves are Thickened and Fused resulting in a Stenosis and Hypoplastic Annulus
Pulmonic Stenosis
*90% of cases of Pulmonic Stenosis will be a problem with the Valves
Second-Degree AV Block characterized by No PR Changes before Dropped QRS Complex
Mobitz Type II
*No Elongation of PR Intervals
*Mobitz Type II- More Likely associated with Disease in the AV Node- Poor Prognosis
Example- 6:4 Means that out of 6 P Waves, Only 4 Conducted into QRS Complexes
Condition where the Heart Rate is below 60-70 bpm in Dogs or Below 100 bpm in Cats
Sinus Bradycardia
*Normal Heart Rate for Dogs- >60-70 bpm
Normal Heart Rate for Cats- >100 bpm
*Sinus Bradycardia occurs for many reasons Inside and Outside the heart including Drugs, Hypothyroidism, Cardiac Fibrosis, Trauma and Neoplasia
Clinical Signs of ______ Include:
Left Atrium Eccentric Hypertrophy
Coughing
Left-Heart Failure
Sudden Death (Cardiac Tamponade)
Murmur
Myxomatous Atrioventricular Valvular Degeneration
*Left-Heart Failure develops Slowely- Exercise Intolerance, Syncope, Coughing
*Difference between Left Atrial Induced Cough and Heart Failure Cough: With Left Atrial Cough the Dog will still be Happy and Eating Normally. With Heart Failure Cough the Dog will be Unhappy and Not Eating
*Murmur will be Loudest over Left Side of the Heart
Determine the Heart Rate
160 BPM
*Total of 75 mm = 1.5 Seconds
4 QRS Complexes
(4/1.5) x 40 = 160/60
Treatment for a Patient with Hyperkalemic Bradycardia that is at Risk of Fibrillation?
Calcium Gluconate
*Give Calcium Intravenously- Lowers Resting Membrane Potential and Reduces Risk of Fibrillation in the Patient
*We can also Give Bicarb and Glucose to Bring Potassium Levels Down
Which Drugs are commonly Given to Patients in Heart Failure that:
- Slows Progression of Failure
- Lowers Furosemide Dose Needed
- Prolongs/Improves Life
- Blunts Heart Remodeling
- Decreases Preload and Afterload
ACE Inhibitors
*Work over the Long Term to prolong and improve life
*Blunts Heart Remodeling- Stops Hypertrophy and Fibrosis of the Heart
*Side Note- Furosemide is the Wonder Drug that gets Patients out of Heart Failure in the Short Term, while ACE Inhibitors Improve the Patient in the Long Term and Prolong their life during Heart Failure
Cats with Hypertrophic Cardiomyopathy commonly have ____ Gallop Rhythms on Physical Exam
S4
*Need to Ultrasound to Difinitely Diagnosis Hypertrophic Cardiomyopathy- Only way to be 100% Accurate on Diagnosis
Patient is in the Arrythmogenic Stage of Dilated Cardiomyopathy. Atrial Fibrillation is Detected with a Normal Heart Rate (90-100bpm). What is the Treatment?
Nothing (Monitor)
*Patient has Atrial Fibrillation but Normal Heart Otherwise
Baroreceptors detect drops in Blood Pressure that activates the ____ Nervous system, leading to Vasoconstriction and Increased Heart Contractility and Rate (Positive Inotropy + Chronotropy)
Sympathetic
*Short Term Changes
Murmur that continous through Systole and Diastole that is very characteristic of Patent Ductus Arteriosis
Continuous Murmur
This is an Example of ____ of Ventricular Premature Depolarizations (VPD) on an EKG
Doublets
*Two VPD’s in a Row
Clinical Signs associated with ____ Include:
Syncope (Fainting)
Weakness
Acute Sudden Death
Systolic Murmur
Ventricular Premature Depolarizations (VPDs)
Aortic Stenosis
*Syncope- Lack of Cardiac Output to the Brain and the Animals Faint
*Most Animals with Aortic Stenosis will Die Suddenly before Developing Heart Failure
*Patients with Aortic Stenosis commonly have VPDs
A Radiograph of a Patient with Pulmonic Stenosis, will show _____ Pulmonary Vessels. A Radiograph of a Patient with Ventricular Septal Defect, wil show _____ Pulmonary Vessels
Decreased
Increased
_____ Commonly Leads to :
Increased Afterload
Left-Sided Concentric Hypertrophy
Decreased Cardiac Output
Hypoxia (Decreased Perfusion)
Sudden Death
Aortic Stenosis
*Sudden Death- Caused by Arrhythmias
*Big Heart working Harder with Decreased Cardiac Output where the Heart is Predisposed to Developing arrhythmias, Particularly Ventricular Premature Depolarization (VPDs). These animals tend to Die Suddenly
What is the Cause of this Electrical Activity on the EKG?
Shivering
*Muscles causing Electrical Activity
True/False: Left-Right Shunted PDA’s are Treated by Surgically Ligating the Patent Ductus Arteriosis
True
*Surgery is followed by PU/PD for 24 hours
*Side Note: Embolization Coils and Amplatz Occluders are a Less Invasive Treatment, where a Coil is Fed into the Carotid Artery and Positioned into the PDA
Premature Ventricular Deplolarization Initiated in Left Ventricle
* 3 in a Row = Triplet
*More than 3 in a Row = Ventricular Tachycardia
At Home Treatment for Chronic Cases of Stage C Myxomatous Atrioventricular Valvular Degeneration
Oral Furosemide
Followed by ACE Inhibitors and a Sodium Restricted Diet
*No Consensus on Spironolactone- but decreases risk of Death by 17%. Has Become part of the Treatment and Most Patients will also be put on Spironolactone
Ectopic Focus of Atria that Depolarizes before the SA Node leading to Conduction in the Wrong Direction, Giving rise to a Premature Negative P Wave and Normal QRST Interval on EKG. This Condition is Commonly Found in Patients with Enlarged Atrias
Superventricular Premature Depolarizations (SPD’s)
*Begins with Abnormal P Wave. Once Conduction reaches the AV Node then the EKG Returns to Normal
*SPD- Premature Negative P Wave and Normal QRST Interval
AV Valve Insufficiency (Endocardiosis) Murmurs have a _____ Frequency, while Aortic Stenosis and Pulmonic Stenosis Murmurs have a ____ Frequency
AV Valve- Plateau Frequency
Aortic Stenosis/ Pulmonic Stenosis- Crescendo-Decrescendo Frequency
*Plateau- Same Intensity all the Way Through
First, Loudest and Longest Normal Heart Sound that Occurs during Ventricular Repolarization due to the closure of the AV Valves
S1 (Lub)
*Left and Right AV Valves Snapping Closed Together
Animals in Heart Failure should be put on Restricted _____ Diets of only 220mg/day
Sodium
*Avoid Salty snacks
*Kidney/Senior Diets = Restricted Sodium
Stage Prior to Atrial Fibrillation where the Baseline has a “Sawtooth” Appearance
Atrial Flutter
Treatment for Atrial Fibrillation with Hypertrophic Cardiomyopathy in Cats
Propanolol
At 6-8 Weeks of Age, Patients who are born with Left-Right Patent Ductus Arteriosis may develop a High Resistance pathway in the Lungs and as a Result of this Increased Resistance, the Blood Begins to Shunt ____
Right-Left
*Right-Left Shunting (Blood travels from the Right Heart through the Pulmonary Artery and into the Aorta)
Patients that develop Right-Left Shunting have NO Smooth Muscle in the Ductus Arteriosis
Treatment for Myxomatous Atrioventricular Valvular Degeneration if the Patient is in Mild to Moderate Congestive Heart Failure
Oral Furosemide
*Once Furosemide is at the Lowest Dose, we Switch to ACE Inhibitors to prolong Life in these Animals. Also put Patient on Restricted Sodium Diet
*Surgery is Possible- Mechanical/Bioprosthetic Mitral Valve Replacement- 75% Recover (Not Advanced in Vet Med)
When a Patient is in Heart Failure, Rather than Normal Bronchovesicular Sounds, you will Hear ____ when listening to the Lungs
Crackles
*Listen at Bottom of Lungs- Fluid gravitates Downward
Heart Condition caused by Bacteremia that is Characterized by Vegetation of the Aortic Valve that is commonly seen in Large Breed Dogs (German Shepards, Boxers)
Endocarditis
*Particularly on the Aortic Valve- Aortic Valve will not get out of the way during Systole causing a Volume and Pressure Overload leading to Rapid Failure of the Heart
*Caused by Infections
Collagen Abnormality that affects the Valves Resulting in Blood Regurgitation from the Left Ventricle into the Left Atrium during Systole
Myxomatous Atrioventricular Valvular Degeneration
*Mainly a Mitral Valve Problem
What is Occuring in this EKG of a Cat?
Purring
*Prevent the Cat from Purring for a Few Seconds when taking EKG
Grade ____/6 Murmur is Soft over a Larger Area that is Almost Immediately Heard
2
If a Patient with Aortic Stenosis is in Congestive Heart Failure, What drugs do we use to Treat the Patient?
Furosemide + Ace Inhibitors
*Use normal Congestive Heart Failure Treatment
Blood Pressure in the Pulmonary Artery
30/15
*Blood Pressure in the Right Side of the Heart is a low pressure system
Most EKG Measurements are taken at 50 mm/sec, where 1mm is Equivalent to ____ seconds
0.02
Which Congential Heart Disease has these FOUR Characteristics:
Pulmonic Stenosis
Ventricular Septal Defect
Overriding Aorta
Enlarged Right Ventricle
Tetralogy of Fallot
*Right-Left Shunting
*Concentric Hypertrophy of the Right Ventricle
Grade ____/6 Murmur is very Soft, over a Small area that you hear with Prolonged Auscultation
1
*Have to Listen very Hard to Hear the Murmur
Additive Treatment for Myxomatous Atrioventricular Valvular Degeneration if the Patient becomes Refractory to the Therapy
Thiazide
*Diuretic that is Added to Furosemide Treatment to Increase Diuresis
Treatment for Myxomatous Atrioventricular Valvular Degeneration if the Patient doesn’t have Congestive Heart Failure, but is Coughing
Antitussives/Bronchodilators
Drug that we use in Emergency Situations to treat Ventricular Premature Depolarizations that are leading to “R on T” Phenomenons and Fibrillations
Lidocaine
*“R on T” Phenomenon- T Wave (Ventricular Repolarization) and R Wave (Ventrciular Depolarization) are mixed due to Premature Beat. Repolarization has not Completed before the Depolarization occurs again- Can lead to Fibrillations and Sudden Death
Grade ____/6 Murmur is Very Loud off the Chest wall and can be heard over the Entire Thorax with a Palpable Thrill
6
*Grade 5 and 6 Murmurs- if you put your hand against the Side of the Animals chest you can feel the Heart Beating against the Chest as well as the Thrill- Vibrations
Heart Failure will ____ the Pulse Rate in an Animal
Increase
*When an Animal Goes into Heart failure the Sympathetic Nervous System is Stimulated leading to an increase in Heart Rate
*Fear and Pain will also increase and Animals Pulse Rate
An Electrical Depolarization moving Parallel to the Direction of a Lead towards the ____ Pole Gives a Positive Deflection
Positive
*EKG Recording moves in the Direction from the Negative Pole to the Positive Pole causing a Large Positive Signal
*Picture- First Heart Shows the Correct Direction of Depolarization
Second-Degree AV Block Characterized by Progressive Elongation of the PR Interval until the QRS Complex Eventually “Drops Out”
Mobitz Type I
*PR increases until QRS Drops
*Mobitz Type I- Often due to Increased Vagal Tone or Drugs. Not often caused by Pathology of the AV Node- Better Prognosis
Diagnosis of this EKG
Superventricular Tachycardia
*More than 3 Superventricular Premature Depolarizations (SPDs) in a Row = Superventricular Tachycardia
True/False: 75% of Cardiovascular Disease is Myxomatous Atrioventricular Valvular Degeneration and makes up 10% of Total Patients
True
*Will make up 10% of Client Base- Very Prominent Disease
Which Congenital Heart Disease has these Clinical Signs:
Right-Sided Eccentric Hypertrophy
Syncope/Weakness
Erythrocytosis (Increased PCV)
Cyanosis
Pulmonic Stenosis/VSD Murmur
Tetralogy of Fallot
*Erythrocytosis- Increased PCV caused by Hypoxia in the Kidney
Heart Disease where Blood is Regurgitated from the Left Ventrical back into the Left Atrium during Systole, Resulting in a Volume Overload and Huge Hearts tha are Severly Dilated
Myxomatous Atrioventricular Valvular Degeneration
*About 35% of Stroke Volume can be Regurgitated back into the Left Atrium
Increased Heart Rate, Greater than 160-180 bpm, With a Normal P Wave and QRST Interval that is most commonly caused by Fear, Pain, Fever or Anemia
Sinus Tachycardia
*Treat Tachycardia by Treating the Underlying Cause
Summary for Myxomatous Atrioventricular Valvular Degeneration
*Stage A: At Risk, King Charles Caveliers, No Murmers
Stage B- Heart Murmur but No Sign of Failure
Stage C- Past or Current Failure
Stage D- End Stage
True/False: Patients with Dilated Cardiomyopathy have Guarded to Very Poor Prognosis with a Good Quality of life for up to a Year after Diagnosis
True
*Can’t stop Dilated Cardiomyopathy, but we can keep the patients alive for up to a year if they survive the initial Heart Failure
Valves between the Right Atrium and Right Ventricle that close during Systole
Tricuspid Valves or Right Atrio-Ventricular Valves
Pacemaker Escape Beat that is Characterized by a Normal QRS Complex and Absent P Wave
*Shown by Arrow in Picture
Junctional (AV) Pacemaker
*Occurs after a Long Pause. No P Wave because the Atrium is not Contracting
In Patients in Heart Failure, we want to Decrease Preload. Which Venodilator is commonly used in Heart Failure Patients to Further Decrease Preload?
Nitroglycerine Cream
*Or can give Nitroprusside IV (Works Great!)- Not found in many practices
True/False: Puppies are Born with Aortic Stenosis
False
*Puppies do not Develop Aortic Stenosis until around 3 weeks of Age and is particularly progressive in the first year of the Dogs Life
*We cannot Certify Dogs free of Congenital Heart Disease until they are of 1 Year of Age because of Aortic Stenosis
Best Treatment in Patients that have Pulmonic Stenosis due to Valvular Dysplasia
Balloon Valvuloplasty
*This treatment Does Not Work if the Patient also has Hypoplastic Annulus
What Kind of Beat is that in between the Two Normal QRS Complexes?
Fusion Beat
* P Wave followed by a Mixture of a Ventricular Premature Depolarization (VPD) and a Normal QRS Complex
Treatment for Myxomatous Atrioventricular Valvular Degeneration if the Patient has Severe (Hospital) Congestive Heart Failure
Supplemental Oxygen/ IV Furosemide
(FONS)
*At Home- Low Dose of Furosemide then ACE Inhibitors
What does the Rectangular Shape Represent on this EKG?
1 Milivolt Pulse
Treatment for Patients with Pulmonic Stenosis that have Valvular Dysplasia and Hypoplastic Annulus
Patchgraft Valvuloplasty
With What Condition will the Physical Exam show:
Muffled Heart Sounds
Weight Loss
Weak Pulses
Ascites (40%)
Pericardial Effusion
*When you try to listen to the Heart, it sounds Far Away!
Drug of Choice to Increase Heart Contractility in Patients with Dilated Cardiomyopathy
Pimobendan
*Downfall- Expensive
Treatment for Acute Cases of Stage C Myxomatous Atrioventricular Valvular Degeneration
Furosemide
*FONS- Oxygen, Sedation, Nitroprusside
*Pimobendan can Also be Given- Controversial
Patient is in the Occult Stage of Dilated Cardiomyopathy. Atrial Fibrillation and Increasing Heart Size with Decreased Contractility is Present. What Two Drugs can be used for Treatment?
ACE Inhibitors -Delays Heart Failure by around 3 Months
Pimobendan- Delays Heart Failure by 9 Months
*Pimobendan- Wonder drug that has made a Huge Difference with Dilated Cardiomyopathy
In Patients with Myxomatous Atrioventricular Valvular Degeneration, with 50-60% (Little Regurgitation), what Two Clinical things will we see?
Eccentric Hypertrophy Left Atrium
Coughing
*Large Atrium Compresses mainstem Bronchi leading to Coughing
Stage of Myxomatous Atrioventricular Valvular Degeneration where Murmurs are Present, but No signs of Heart Failure and Rads and Echo are Normal
Stage B1
*No Treatment Needed
If a Patient has Atrial Fibrilation with an Increased Heart Rate ( >150 bpm) and Dilated Cardiomyopathy (Decreased Contractility), how would we Treat this Patient?
Digoxin w/ Added Diltiazem
*Digoxin Slows the Heart Rate Down
*KNOW SLIDE- Will ask Question on Exam
A Type of Bradyarrhythmia caused by Increased Vagal Tone where the Distance between the R Intervals Vary with Respiration that is very common in Animals that are very Fit and Brachycephalic Breeds
Sinus Arrhythmia
*Shorter and longer Distances between R Waves. In the Picture the R Intervals at the Beginning and End of the EKG are Longer than those in the Middle
*As the Animal Inspires the Heart Rate Increases and as the Animal Expires the Heart Rate Decreases- No Treatment Required for Sinus Arrhythmias
What Artifact is Occuring on this EKG?
Breathing
*Occurs when Animal is having Difficulty Breathing- Need to Give the Patient Oxygen and Settle them Down if they are Stressed
Three Forms of Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) in Boxers
Concealed Form - 6 y/o, Arrhythmias with No Clinical Signs
Overt Form- Episodes of Weakness/ Syncope
Myocardial Dysfunction Form- Develop Dilated Cardiomyopathy
*Only 5% of Boxers develop Myocardial Form
In Patients with Myxomatous Atrioventricular Valvular Degeneration, When ___% of the Cardiac Output is Regurgitated back into the Left Atrium, is when the Patient will start to Fail
75%
*Patients that have 35-50% of Regurgitation are Fine/Asymptomatic
Congenital Heart Disease Characterized by an Opening between the Left and Right Atrium where Blood Flows from the Left Atrium into the Right Atrium
Atrial Septal Defect
*Left-Right Shunting
On an EKG, if the P Wave is too High, what does that Indicate?
Right Atrial Enlargement
*Normal P Wave is Around 0.3-0.4 mV
On an EKG, what do these jumps on the Chart Represent?
First small Bump = P Wave- Contraction of the Atrium
Spike = QRS complex- Ventricular Contraction (Depolarization)
Downward Spike = T Wave- Ventricular Repolarization
*Systole goes from the beginning of QRS to the End of the T wave
*Area from the End of the T wave to the Beginning of the next QRS is Diastole
