Module 6: Cardiac Diagnosis 2 - Radiography, Biomarkers, and Echocardiography - Rhinehart & Schober (Weeks 9-10) Flashcards
C21: Thoracic Radiography & Biomarkers of CV Disease
C21: Thoracic Radiography & Biomarkers of CV Disease
List the questions you should answer with radiographs:
- What is the global size of the heart (normal, small, large)?
- Is there a specific cardiac chamber enlargement?
- Pulmonary arteries distended
- Pulmonary veins distended
- Pulmonary infiltrates?
- Pleural effusion
- Congestive heart failure?
List the correct “technique” placement of the animal:
- Lateral & ventrodorsal
- Dorsoventral projections
Technique:
Correct “PEP”: Positioning, Exposure, Phase of respiration: ____________
Inspiration
Quantification - Cardiac Mensuration:
What is the correct Method of measuring the heart?
Method of Vertebral Heart Scale, Score, Sum (VHS)
Quantification - Cardiac Mensuration
Term:
A linear relationship between cardiac dimensions and vertebral length (don’t change in length)
Isometric scaling
Quantification - Cardiac Mensuration
What is a normal Right lat film in dogs?
< 10.5
Quantification - Cardiac Mensuration
What is a normal Right lat film in cats?
< 8.1
(T/F) Obesity and breed may influence the VHS score
True
- Obesity: the fat can get around the heart
Radiographic Cardiovascular Anatomy:
Heart on Radiographs = ‘opaque silhouette’
Fill in the blanks thinking of what you would you find in that location (Clock) …
11-1:________
1:________
2-3:________
3-6:________
6-9:________
9-12:________
Aorta
MPA (Main pulmonary artery)
LAA (Left auricle appendage)
LV
RV
RA (enlargement: everything is pushed cranially)
Radiographic Cardiovascular Anatomy:
(T/F) Only their borders can be identified - deviations of the borders suggest the enlargement of a particular structure
True
Location for Lateral Position:
12-3:________
3-6:________
6-9:________
9-12:________
LA (Left Atrium)
LV (Left Ventricle)
RV
RAA (can budge with RA enlargement, one of the most cranial structures)
What can the following cause …
- Bineventricular cardiomyopathy
- Severe mitral and tricuspid regurgitation
- Severe pericardial effusion
- Peritoneo-pericardial diaphragmatic hernia (PPDH)
Generalized (global) Cardiomegaly
- Very very large heart
What can occur from the following …
- Severe mitral regurgitation
- Advanced feline cardiomyopathy
- Congenital heart disease (mitral stenosis, PDA, VSD)
- Dilated cardiomyopathy
LA enlargement
What can occur from the following …
- Moderate to severe mitral regurgitation
- Canine and feline cardiomyopathy
- Congenital heart disease (SAS, PDA, VSD)
- Others
LV enlargement
- “longer than usual”
What can occur from the following …
- Aortic stenosis
- Systemic hypertension
- Idiopathic
- Old age (cats)
Aortic root enlargement
What can occur from the following …
- Moderate to severe tricuspid regurgitation
- Right ventricular cardiomyopathy
- Congenital heart disease (ASD, PS, Tetralogy of Fallot)
- Heartworm disease
RV enlargement
What can occur from the following …
- Moderate to severe tricuspid regurgitation
- Congenital heart disease (tricuspid dysplasia)
- Severe RAAS activation or iatrogenic volume overload
RA enlargement
What can occur from the following …
- Visible in v/d and d/v views (not later; projections)
- Pulmonic stenosis (“post-stenotic dilation”), ASD, VSD, PDA
- Pulmonary hypertension
- Heartworm disease
PA enlargement
Start from the bottom and up
- Left heart enlargement (LV and LA)
- Pulmonary vein enlargement (Congestion)
- Interstitial opacities in lungs (perihilar or diffuse, unstructured)
- Alveolar infiltrates with air bronchograms (often “white” lung)
- Pleural effusion and pericardial effusion can be signs of both l-CHF and r-CHF (in particular in cats)
Left-sided Congestive Heart Failure
Pulmonary vein enlargement (venous congestion) VENTRAL:
dorsal:
middle:
ventral:
artery
bronchus
vein (veins should be wider)
Pulmonary Artery Enlargement (dilation) CENTRAL:
lateral:
middle:
medial:
artery
bronchus
vein
(T/F) Arterial enlargement is often seen in cats with l-CHF
True
Circulating Marker Proteins of Cardiovascular Function:
Cardiac Troponin I (Thin filament bound) ->
- Cardiac specificity
- 3 myocardial sources
- Biphasic release after injury
- membrane integrity
Leakage markers
- Primary myocardial disease
- Toxins/metabolites
- neurohormones
- Trauma
- Cytokines
- Hypoxia/Ischemia-Reperfusion
- Wall Stress
- Infections
- Neoplasms
- Drugs
Circulating Marker Proteins of Cardiovascular Function:
Brain natriuretic peptide (BNP) ->
- Produced in the Atrial (healthy animals)
- Subacute or chronic changes due to volume loading and hypertrophy
- Species-specific assays!
Functional Markers
- Confirmatory test: The cat with a heart murmur
List Specific Clinical Indications to Analyse Circulating Cardiac Troponin I:
- Suspect: Myocardial infarction
- Suspect: Myocarditis
- Arrhythmia of unknown origin
- Chemotherapy with doxorubicin
- Suspect: Ionophore toxicity
CANNOT be used as a screening test for canine DCM and Feline HCM
What is a key-diagnostic method in veterinary cardiology?
Thoracic radiography
(T/F) Orthogonal films of sufficient quality are required for proper interpretation
True
How are the cardiac size and silhouette evaluated and quantified?
Using VHS
What is a clinical syndrome radiographically characterized by LV and LA enlargement, venous engorgement (congestion), and fluid accumulation in the lungs and/or pleural space?
l-CHF
(T/F) Only cTnI (structure) is 100% myocardium-specific
False, Both cTnI and NT-proBNP are 100% myocardium-specific.
- Elevations of cTnI indicate ongoing myocardial injury
What would be an indication of myocardial hypertrophy and wall stress?
Elevations of NTpro-BNP
What is the major clinical indication for the use of NTpro-BNP?
The cat with soft heart murmur - risk stratification
(T/F) Cardiac biomarkers have incremental diagnostic value but CANNOT replace other, more conventional, diagnostic methods
True
C22: Echo Normal
C22: Echo Normal
Echocardiography
- almost 100% diagnostic
- Uses ultra-high frequency sound waves (> 20,000 Hz)
-
Piezo-electrical crystals (in probe)
- Electrical energy -> mechanical (vibration) -> emission -> travel in tissue 1,540 m/s -> reflection at cells | tissue surfaces -> reception (probe) -> generation of image - Frame rate = number of updated images (the higher it is the better)
- High frequency: high resolution, low penetration
- Low frequency: Lower resolution, higher penetration
(T/F) Transesophageal can be done BOTH in the ER and in general practice
False, Only for ER/Extreme situations
Handling of the transducer:
Where is the “Echo windows” located?
- Right parasternal
- Subcostal
- Left parasternal
Red is towards the trasfuser and _________ is away from
blue
Term:
Allows the two-dimensional assessment of single parts of the heart in their anatomically correct position during multiple cardiac cycles
2D (two-dimensional) Echocardiography
Term:
Allows the one-dimensional assessmentof the motion of certain parts of the heart recorded along a single ultrasound line during multiple cardiac cycles with very high temporal resolution (Time-Motion-Graph)
M-mode Echocerdiagraphy
Term:
When ultrasound waves hit moving objects they change their reflected frequency, which is proportional to the velocity of the object
The Doppler Principle of Echocardiography
Flow Qualities:
Laminar
Normal
Flow Qualities:
Turbulent
Abnormal
- Valve stenosis
- Valve insufficiency
- Shunt flow
Assessment of LV diastolic Function & Valve competence:
- Pulsed wave (PW) inflow signals recorded at the level of the opened valve leaflets
Diatolic Function
Assessment of LV diastolic Function & Valve competence:
- Color flow Doppler to detect valve incompetency or stenosis
Valve Function
Dijo que hay cositas que vienen de aqui pero no en mucho detalle
Dijo que hay cositas que vienen de aqui pero no en mucho detalle
C23: Echo diseased animals
C23: Echo diseased animals
Normal systolic LV pressure in a resting dog is:
120 mmHg
(T/F) LV pressure is at all times higher that RV pressure during the cardiac cycle
True
What information should be obtained from an Echocardiographic Study?
- Underlying Disease | lesion
- Current Functional Status
- Estimation of Hemodynamics
- Disease progression
- Response to Therapy
Term:
is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle and the outer covering sac (pericardium) of the heart.
Cardiac Tamponade
E: A < 1.0
Flow pattern of LV relaxation abnormality
E: A = 1.0 to 2.0
Normal (or pseudonormal) transmitral flow pattern
E: A»_space; 2.0
The flow pattern of restrictive LV filling (relaxation abnormality + high LV filling pressure)
- almost always associated with congestive heart failure
Term:
Is used to assess valve function, systolic and diastolic function, the severity of valve lesions, and intra and extracardiac pressures
Doppler Echocardiography
Pressure gradients ( change P) across stenotic or restrictive lesions may be calculated by using the modified:
Bernoulli equation
- changeP = 4 x Vmax^2
Clinical applications:
- Severity of aortic stenosis, pulmonary stenosis, and pulmonary hypertension can be estimated
change P (normal) = 0-10 mmHg
Moderate aortic stenosis
(T/F) Eccentric hypertrophy is a response to pressure load
False, Concentric hypertrophy in a response to pressure load
(T/F) Eccentric hypertophy (dilatation) is a response to volume load
True
Thickened cardiac valves are due to:
- Malformation (dysplasia)
- Degeneration (endocardiosis)
- Inflammation (endocarditits)
How is systolic heart function assessed?
Subjectively by wall motion amplitude or Objectively by M-mode (shortening fraction)
How is diastolic function assessed?
Pulsed-wave Doppler
(T/F) Severity of valve stenosis is assessed by Doppler (Vmax, change P)
True
What does the intracardiac “smoke” in cats indicate?
Low flow state (blood stasis) and thus increased risk of thromboembolic disease
(T/F) Intracardiac smoke in horses is normal
True
(T/F) Heartworm and cardiac masses can’t be seen on echo
False, they can be seen on echo but the sensitivity of echo is below 100% (leading to false negative results)
Which of the following statements regarding central hemodynamics is NOT CORRECT?
a. Normal mean right atrial pressure is between 20 and 30 mmHg.
b. Normal mean left atrial pressure is between 1 and 10 mmHg.
c. Normal LV pressure (systolic/diastolic) is around 130/8 mmHg.
d. Normal right ventricular pressure (systolic/diastolic) is around 22/5 mmHg.
e. Normal mean pressure in the venae cavae is around 0-8 mmHg.
a. Normal mean right atrial pressure is between 20 and 30 mmHg.
List the differentials for Left atrial enlargement:
- Idiopathic left atrial dilation
- Severe mitral regurgitatiion
- Severe LV diastolic dysfunction
- Large left-to-right shunt
Which statement regarding echocardiography in animals with cardiovascular disease is NOT CORRECT?
a. Severe LV pressure overload will lead to concentric chamber hypertrophy.
b. Severe tricuspid regurgitation will lead to right atrial enlargement.
c. Low left ventricular shortening fraction indicates the presence of severe ventricular diastolic dysfunction.
d. Severe dehydration can lead to LV and RV wall thickening.
e. Two-dimensional echocardiography cannot unambiguously distinguish between mitral valve thickening from degeneration (endocardiosis) and mitral valve thickening from inflammation (endocarditis).
c. Low left ventricular shortening fraction indicates the presence of severe ventricular diastolic dysfunction.
(T/F) A large left-to-right shunting ventricular septal defect will cause severe left atrial and left ventricular volume overload
True
- Volume overload of:
- RV
- LA
- LV
In a dog with a VSD, systolic blood pressure is 120 mmHg and VSD flow is left-to-right at 5 m/s. Which statement explaining the central hemodynamic situation is CORRECT?
a. The dog has a large nonrestrictive VSD. Pulmonary hypertension is clearly present.
b. The VSD is likely small (restrictive). The estimated RV systolic pressure (which equals systolic pressure in the pulmonary artery) is around 20 mmHg, which rules out pulmonary hypertension.
c. The estimated RV systolic pressure is around 100 mmHg. As RV systolic pressure equals pulmonary artery systolic pressure it can be concluded that the dog has severe pulmonary hypertension.
d. RV pressure overload and thus pulmonary hypertension is clearly present based on the high velocity of VSD flow.
e. Based on the pressure estimate, LV systolic pressure equals RV systolic pressure. Therefore, there should not be any flow across the VSD. Something with the echocardiographic estimations must be wrong – re-image the dog to come up with more realistic numbers.
b. The VSD is likely small (restrictive). The estimated RV systolic pressure (which equals systolic pressure in the pulmonary artery) is around 20 mmHg, which rules out pulmonary hypertension.
C24: Clinical Examination I
C24: Clinical Examination I
A comprehensive medical history & a through physical examination lead to _________% of your final diagnosis
> 80%
Epidemiology Risk:
Congenital heart disease mostly seen in:
Young dogs
Epidemiology Risk:
Acquired heart disease mostly seen in:
Old dogs
Epidemiology Risk:
Cardiomyopathy mostly seen in:
Large breed dogs
Epidemiology Risk:
Degenerative mitral valve disease is mostly seen in:
Small breed dogs
- tracheal collapse is very commonly seen
(T/F) Tachypnea is a classical sign of CHF
True
If a cat is coughing, it is more than ___% bronchial
90%
Sudden loss of consciousness & postural tone with fast and complete recovery (< 1min)
Syncope (“fainting”)
Causes:
- Vaso-vagal (reflex)
- Arrhythmia
- Decreased CO
(T/F) Cat with syncope due to an arrhythmia
True
Tachypnea:
The rate of respiration is a very sensitive variable in the diagnosis of what?
Left-sided CHF
- Pale mucus membranes
- Anemia
- Vasoconstriction: due to high sympathetic toe (SNS)
Pallor
“Injected” - brick red
- Sign of systemic vasodilatation or periodontal inflammation
Hyperemia
- Increased jugular venous pressure
- Sign of R-CHF
- Others: Large pleural effusion, Mediastinal mass, Thrombosis cran VC
Enlargement (congestion)
Pulsation:
This is due to forceful atrial contraction against stiff RV
Increased a-wave
- Pulmonary stenosis
- Pulmonary hypertension
Pulsation:
This is due to severe tricuspid regurgitation backflow of blood into the veins
Increased v-wave
Aortic thromboembolism (cat) from …
Left-heart disease
Subcutaneous (pitting) edema in a dog with chronic severe …
Right-sided CHF
List the differentials for Subcutaneous edema:
- Decreased Albumin
- Thrombosis of femoral vein
- Congenital lymphedema
Term:
Palpable vibrations from the loud heart murmurs
Thrill (fremitus)
Apex beat is on the …
Left
Increased
- Sympathetic stimulation
- Increased Preload -> Increased systolic Fx
Reduced
- Systolic dysfunction
- Effusion (Pleura| Pericard | PPDH)
- Obesity
What can be seen with wide pulse pressure & “waterhammer” pulse?
- PDA
- Bradycardia
- Aortic insufficiency
List the causes of Hypokinetic pulses (Pulsus parvus, Pulsus filiformis (if in shock):
- Decreased volume (dilated cardiomyopathy)
- Obstruction of the LV outflow tract
- Pulse rate < Heart rate
Eg. Auscultation HR 160 bpm
Pulse Palpation HR 128 bpm
Pulse Deficit 32 bpm
-> Due to arrhytmias = very short diastolic filling intervals lead to decreased filling, poor SV, and no pulse wave in the femoral artery
Pulse Deficit
Hyperthyroidism =>
- LV- hypertrophy
- Tachycardia
- Loss of body weight
- Heart murmur
- Gallop sound
- Systemic hypertension
Term:
Procedure to unmask right-heart failure
- Used only in dogs
Hepato-jugular Reflex
- Lift up abdomen (liver) for 20-30 sec
- Acute increase of venous return to right heart
- Congestion of external jugular vein
- Congestion disappears with a few heartbeats
- If not: right heart failure!
Which statement about cough in cats is Correct?
a. Cough is a common clinical sign of advanced left heart disease.
b. Severe cough is a reliable sign of tracheal collapse.
c. Cough receptors have a particularly high concentration in the peripheral lung fields (around the alveoli).
d. Cough in cats is rare, with inflammatory bronchial disease being the most common cause.
e. Cough in cats is most commonly secondary to right-sided CHF with pleural effusion.
d. Cough in cats is rare, with inflammatory bronchial disease being the most common cause.
(T/F) High sympathetic tone as seen with severe heart failure often leads to systemic (arterial) vasoconstriction and pale mm.
True
(T/F) Pale mm reliably indicate presence of anemia
False
Distended (enlarged) external jugular veins most likely indicate the presence of:
Right-sided CHF
Which of the following matches is Correct?
a. Strong arterial pulse – Pulsus paradoxus
b. Weak arterial pulse – Pulsus parvus
c. Delayed arterial pulse – Pulsus alternans
d. ‘Waterhammer’ pulse – Pulsus filiformis
e. Heart rate < pulse rate – Pulse deficit
b. Weak arterial pulse – Pulsus parvus
Which statement concerning the hepatojugular reflux (HJR) most often used in dogs is Correct??
a. Initiating the HJR is a non-invasive test for left heart failure.
b. It tests the response of the body to sympathetic stimulation.
c. It is a reliable test for the detection of volume overload of the body.
d. The HJR is initiated to identify the presence of right heart failure.
e. The dog’s chest is manually compressed, and the femoral artery is simultaneously palpated. A positive test (= stronger femoral pulse) indicates normal LV systolic function
d. The HJR is initiated to identify the presence of right heart failure.
C25: Clinical examination II: Auscultation
C25: Clinical examination II: Auscultation
Can there be a definitive diagnosis with just auscultation?
Yes
- Examples: Patent ductus arteriosus, Mitral regurgitation
- Helps identify diastolic heart disease (gallops)
Chest Piece:
- Going to use the most
- Good for hearing S1, S2, and murmurs
Diaphragm
Chest Piece:
- Good for hearing gallops (diastolic sounds) (low frequency sounds)
Bell
List the Valve areas:
- Mitral => Left apex
- Aortic => Left base
- Pulmonic => Left base, cranioventral to aortic
- Tricuspid => Right apex
Left apical murmur is found on the …
left apex (S1 - mitral & tricuspid close)
Left basilar murmur is found on the …
Left base
- Aortic (S2 - aortic & pulmonary close)
- Pulmonic
Right apical murmur is found on the …
Right apex
- Tricuspid
Diastole (filling):
S3 => Early/rapid ventricular filling
- High left atrial pressure and CHF (small animals)
- Normal in large animals
S4 => atrial contraction (“atrial kick”)
- Stiff non-compliant ventricle (HCM in cats)
- Normal in large animals
(T/F) Very difficult to differentiate between S3 and S4 in small animals
True
Influenced by respiration
- increases speed when inspiration
- decrease speed when expiration
Sinus arrhythmia
“Tennis shoes in the dryer”
Atrial fibrillation
Bradycardia
Third degree AV block
Definition:
Prolonged audible vibrations heard during a normally quite period of the cardiac cycle
Murmur
- Increased velocity flow
- Increased stroke volume
- Decreased viscosity
*Disease: Flow from HIGH pressure -> low pressure
Murmurs:
- Functional/physiologic (Anemia, fever, fear, etc.)
- Innocent
Non-pathologic
Murmurs:
- Acquired vs. Congenital
- Primary vs. Secondary
Pathologic
- Structurally abnormal going on with the heart
List the common murmurs:
- Functional: Physiologic or innocent
-
Subaortic/pulmonic stenosis: left bas, systolic
- most commonly in dogs
- usually harsh
-
Mitral regurgitation: Left apical, systolic
- common murmur in many species
- Tricuspid regurgitation: Right apex, systolic
-
Aortic regurgitation: left base, diastolic
- most common in horses > 10 years of age
- “dive bomber”
- Patent ductus arterious: Left base (craniodorsal), continuous (throughout systole and diastole) “machinery” or “washing machine”
You are examining a 10-year-old miniature poodle and hear a grade 3/6 left apical systolic murmur. What is this murmur most likely associated with?
Mitral Regurgitation
You are examining a cat and on auscultation, you hear a grade 2/6 left basilar systolic murmur. This murmur could be associated with all of the following EXCEPT:
a. aortic stenosis
b. pulmonic stenosis
c. functional murmur
d. patent ductus arteriosus
d. Patent Ductus Arteriosus
-> Left base (craniodorsal), continuous (throughout systole and diastole) “machinery” or “washing machine”
You are doing a routine examination on an asymptomatic 10-year-old cat and identifying a gallop sound. What is this gallop sound most likely associated with?
a stiff non-compliant ventricle
You are examining a 7-year-old Quarter horse and hear the following murmur: a quiet murmur, softer than the S1/S2 sound but readily heard, localized over the mitral valve. The precordial impulse is normal and you do not feel a thrill. How would you grade the intensity of this murmur?
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