Failing heart 1

Question 1

What are the three functions of the cardiovascular system?

Answer 1

• Delivery of substances
• Removal of substances
• Distribution (heat, hormones, cells, bioactive agents)

Question 2

What are the two fundamental mechanical functions of the heart?

Answer 2

1. Eject enough blood into the aorta in order to meet perfusion requirements
   2.To receive blood from the systemic and pulmonary veins in order to provide adequate drainage of capillary beds

Question 3

What is preload?

Answer 3

The volume of blood returning to the ventricle (ventricular enddiastolic volume)
* Affected by venous blood pressure and the rate of venous return, which are affected by venous tone and
volume of circulating blood.

Question 4

What is afterload?

Answer 4

The tension, force or stress acting on ventricular wall myocytes
after onset of shortening.
* Affected by arterial and arteriolar vascular smooth muscle constriction or dilation

Question 5

What is heart rate?

Answer 5

: Determined by the rate of spontaneous sinoatrial nodal discharge
* Under autonomic control

Question 6

What is the frank starling law?

Answer 6

» Greater amount of blood in the ventricles
results in greater contractile strength of the
ventricles and therefore increase in stroke
volume.
» Due to the more cross-bridges cycling, and a
greater availability of Ca++ to initiate this
cycling.

Question 7

What is the definition of heart failure?

Answer 7

Heart failure – pathophysiological state when it is unable to function to meet the animals requirements.

Question 8

what is myocardial failure

Answer 8

Impaired contractility – primary (dilated cardiomyopathy) or secondary (related to causes below leading
to myocardial failure)

Question 9

what are the two common causes of volume overload

Answer 9

• valvular insufficiency
• shunts

Question 10

What are the main causes of valvular insufficiency?

Answer 10

• Most common cause of volume overload
• Incompetence of atrio-ventricular valves (endocardiosis, endocarditis, congenital) – allow for regurgitation to
  occur
• Can be primary (myxomatous valve degeneration) or secondary (ventricular hypertrophy, ischemia, obstruction)

Question 11

What are the main causes of shunts?

Answer 11

• Septal defects
• Overloading a particular heart chamber

Question 12

What does excessive afterload cause?

Answer 12

• Short increases in afterload helps with contractility but chronic increases will depress myocardial
  contractility.
• Overtime – reduced rate of ejection if afterload is always high, leads to also reduced volume of ejection.
• Pulmonary or systemic hypertension, obstruction of ventricular outflow tracts, stenosis cause increase
  afterload

Question 13

What does inadequate preload and diastolic dysfunction cause?

Answer 13

• Reduction in preload represent inability to adequately fill the heart and diastolic dysfunction represent the
  inability to relax (expand the chambers) – somewhat interrelated.
• Inadequate preload – pericarditis, pericardial effusion.
• Diastolic dysfunction – myocardial fibrosis, restrictive cardiomyopathy, failure of adequate ventricular
  relaxation.
• Increases in ventricular end diastolic pressure which exerts stress on the heart and lead to remodelling.

Question 14

When would a cardiac cough most typically occur?

Answer 14

Typically occurs when there is pulmonary oedema and the fluid accumulates in the airway
* occurs with tachypnoea and dyspnoea
* acute onset, soft, moist, blood tinged sputum

Question 15

How might an enlarged atrium cause coughing?

Answer 15

mechanical compression of the trachea

Question 16

What are the four different types of dyspnoea?

Answer 16

• Acute – pulmonary oedema (cardiac or non cardiac), pneumonia, airway obstruction, pneumothorax, pulmonary embolism.
• Chronic (progressive) – right sided heart failure with ascites, pleural effusion, pericardial disease, bronchial disease, anaemia.
• At rest – mix of the above depending on severity.
• Exertional/on exercise – cardiomyopathies, heart failure, obstructive lung disease.

Question 17

What is suggested when dyspnoea resolves with diuretic therapy?

Answer 17

left sided heart failure

Question 18

What is suggested when dyspnoea resolves with bronchodilators?

Answer 18

Suggests respiratory disease

Question 19

What is oedema/ ascites?

Answer 19

Pulmonary oedema
* Ascites – accumulation of fluid in the abdomen – typically seen in
dogs less common in cats (is it right or left heart failure?)
* Ascites not so obvious in horses - in horses classic oedema sites
ventrum, limbs, prepuce, throat latch and muzzle.
* In dogs sometimes decompensated heart failure can occur
without a murmur – if ascites in seen – include RHF as
differentials.

Question 20

What is cyanosis associated with?

Answer 20

associated with decreased oxygenation and blue tinged mucous membranes
* occurs secondary to left sided heart failure
* insensitive indicator of deoxygenation and cardiac function- O2 saturation needs to be low to see changes
* some animals have pigmented/ dark mucous membranes

Question 21

What is syncope?

Answer 21

• Loss of consciousness due to reduction of cerebral blood flow – can recur and typically brief in duration.
• Animals fall over suddenly but able to get back up fairly quick (depending on severity of impeded blood flow).
• There maybe involuntary urination and vocalisation – brief confusion on waking up

Question 22

Why does syncope occur with heart failure?

Answer 22

In heart failure it occurs because the muscles are weak and the heart is unable to pump blood effectively
reduced pumping of blood to the brain leads to a reduced oxygen supply thus the brain shuts down momentarily
commonly associated with cardiac arrhythmia

Question 23

What heart sounds should be present in all normal animals and therefore identified in auscultation?

Answer 23

S1 and S2

Question 24

What might a change to S1 mean?

Answer 24

splitting of S1 can occur if mitral and tricuspid don’t close at the same time – valvular stenosis, ventricular ectopic beats.
* can also be soft due to pleural effusion, decreased cardiac output in late stage failure.

Question 25

What might a change to S2 mean?

Answer 25

• splitting of S2 can occur when pulmonic valve closes after aortic valve – pulmonary hypertension, structural defects, stenosis.
• paradoxical splitting occurs when aortic valve closes after pulmonic – left ventricular failure, systemic hypertension.

Question 26

When might S3 in dogs occur?

Answer 26

S3 in dogs occurs with dilated cardiomyopathy, hyperthyroidism, decompensated valvular regurgitation.

Question 27

When might S4 in dogs occur?

Answer 27

S4 in dogs & cats caused by atrial contraction into an over-distended/stiff ventricle – e.g hypertrophic cardiomyopathy.

Question 28

When does a gallop rhythm occur?

Answer 28

merging S3 and S4 – low frequency, difficult to hear and an early sign of heart failure and precedes its clinical
signs.

Question 29

What causes a murmur?

Answer 29

turbulent blood flow through blood and vessels

Question 30

What is weakness and exercise intolerance a sign of?

Answer 30

Early sign of decompensated heart failure

Question 31

When does weight loss tend to occur?

Answer 31

Tends to occur in dogs with chronic , severe right sided heart failure (RHF) - Weight loss not so much
in cats.
* Cardiac cachexia – loss of total body fat and lean mass despite normal appetite and adequate
therapy.

Question 32

What are the two main causes of right hand side heart failure?

Answer 32

congestion of pancreas – disrupt enzyme secretion – altered digestion. Malabsorptive disorders leading to
ascites as well.
* Systemic venous and lymphatic hypertension – lymphangiectasia leading to protein losing enteropathy

Question 33

What is venous distension?

Answer 33

Key part of the physical examination.
* Jugular vein examined whilst animal is standing with head in
neutral position.
* Pulse extending above lower third of neck – abnormal and could
be related to heart failure(right) – tricuspid regurgitation (as
primary issue).
* Pulsation not typical of chronic heart failure – normally persistent
distension in heart failure.
* Generalized jugular distension can occur – indicative of systemic
hypertension secondary to right sided heart failure.
* Horses with right heart failure – jugular or lateral thoracic
distension

Question 34

What is a class 1 heart failure?

Answer 34

• Patients with asymptomatic heart disease (e.g –
  chronic valvular heart disease (CVHD) is present
  but no clinical signs are evident with exercise

Question 35

What is a class II

Answer 35

• Patients with heart disease that causes clinical
  signs only during strenuous exercise

Question 36

What is the Class III classification of heart failure

Answer 36

Patients with heart disease that causes clinical
signs with routine daily activities or mild exercise

Question 37

What is the class IV classification of heart failure?

Answer 37

Patients with heart disease that causes severe
clinical signs even at rest