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Cardiopulmonary
History and Exam
Wendy Blount, DVM
Nacogdoches TX
Housekeeping
• All Handouts Including the PowerPoints are on you
Flash Drive Proceedings
– Or in your Printed Proceedings if you chose to
purchase
• Course materials are also downloadable at
http://wendyblount.com
Housekeeping
• All Handouts Including the PowerPoints are on you
Flash Drive Proceedings
– Or in your Printed Proceedings if you chose to
purchase
• Course materials are also downloadable at
http://wendyblount.com
Housekeeping
• All Handouts Including the PowerPoints are on you
Flash Drive Proceedings
– Or in your Printed Proceedings if you chose to
purchase
• Course materials are also downloadable at
http://wendyblount.com
Housekeeping
• All Handouts Including the PowerPoints are on you
Flash Drive Proceedings
– Or in your Printed Proceedings if you chose to
purchase
• Course materials are also downloadable at
http://wendyblount.com
Housekeeping
• Proceedings
– TOC, Abbreviations, Evaluation
– Put each PowerPoint handout behind the colored tab for
that section and in front of the first blue subdivider
– Then you will find client handouts, diagnostic and
treatment aids, lab submission forms, etc.
• CE certificates & evaluations in your notebook/packet
– I will time and date my signature
– Check off hours attended on the back, sign and date
– Please complete the evaluation & turn it in when you get
your certificate signed
Housekeeping
•
•
•
•
•
•
•
•
•
Breakfast, coffee and registration 7:30-8am
Morning Session 8am-12noon
We’ll break the last 10 minutes of every hour
Lunch break 12-12:30pm
Afternoon Session 12:30-5pm
Sat - Oncura Presentation 12:30-1:30pm
PLEASE PARTICIPATE!!
But take private conversations out in the hall
Gold brads in bowls on the table to recycle
Practical Medicine Philosophy
• As referral medicine becomes more advanced, it by
default becomes more expensive
• Growing gap between general practice and
specialty practices
• These seminars help us fill those gaps
• Everything we talk about this weekend can be done
in a rural mixed animal practice
• We will look at lots of x-rays, ultrasound images
and videos, EKGs and listen to heart and lung
sounds
Practical Medicine Philosophy
• Some are already doing these things
– Echocardiogram, reading ECGs, defibrillating
• Some will be ready to begin
• Some will need some hand holding, at least at first
– TexasVets – Yahoogroups
– Moderator Rosemary Lindsey
[email protected]
– Oncura
• Some will be happy to be better referring vets
Agenda
Saturday – 8am-12noon, 12:30-5pm
• Cardiovascular History and Exam
• ECG
• Thoracic Radiographs
• Cardio Lab work
• Cases
• (Sign CE Certificates)
Agenda
Sunday – 8am-12noon, 12:30-5pm
• Update on CPR
• Infectious Disease (cases)
• Congenital & Valvular Disease (cases)
• Heartworms in Dogs and Cats
• Pericardial Disease, Hypertension (cases)
• Neoplasia & Arrhythmias (cases)
• Sign CE Certificates
Signalment
Age
• Congenital disease
– young
• Myxomatous Valvular Disease
– old
• Exceptions
– Cavalier King Charles Spaniels
– mild PDA, PS, SAS
– Reverse PDA
Signalment
Breed
• Boston Terrier
• Cavalier
• Cocker Spaniel
• Boxer
• Doberman
• English Bulldog
• Golden Retriever
HBT, ColTr
CVD
DCM, PS, PDA, 3rdAV
HBT, PS, SAS
DCM, Boxer CM, ASD
DCM
(Arrhythmia?)
SAS, PS, CVD
SAS
Signalment
Breed
• Great Dane
• GSD
• Irish Setter
• Irish Wolfhound
• Keeshond
• Labrador
• Maine Coon
• Newfoundland
DCM, CVD
PRAA, SAS, PDA
PRAA
DCM
ToF (define), MVD
TVD
HCM
DCM, SAS
Signalment
Breed
• Persian/Himalayan
• Pointer
• Poodle
• St Bernard
• Samoyed
• Schnauzer
• Springer Spaniel
• Yorkie
HCM
PRAA, SAS
CVD, PDA, CB
DCM
ASD, PS
SSS, CVD, PS, CB
VSD
CVD, CB, CT
History - Collapse
How can you tell the difference between
seizure and syncope?
– Urination/defecation/vocalization/paddling
– Stiff/opisthotonus or flaccid
• narcolepsy
– Twitching and muscle fasciculations
– Cyanosis, pallor
– Abnormal behavior before and after
– Duration of stiffness/opisthotonus
Many times, you can’t (especially when short)
History - Collapse
What causes syncope?
– Bradyarrhythmia
• 3rd degree heart block
• Sick sinus syndrome
(define)
(define)
– Period of asystole
• Sick sinus syndrome
• Vagal surge
(examples)
– Abdominal dz & retching
– Intubation (brachycephalic)
History - Collapse
What causes syncope?
– Tachyarrhythmia burst
• Vtach (define, causes)
– BCM
– Myocarditis (Chagas, Parvovirus)
– Myocardial hypoxia
– Abdominal pathology (spleen)
• Supraventricular tachycardia (SVT) (define)
• Re-entry pathway (define)
• Atrial fibrillation (Afib)
• SSS
History - Collapse
What causes syncope?
– Obstruction of a great vessel or heart chamber
• Thrombus
• Neoplasia
• Extramural mass
– Increased oxygen demand can not be met due
to severe cardiovascular or pulmonary disease
• AKA Exercise intolerance
History - Cough
How can you tell the difference between
cardiac and respiratory cough/dyspnea?
– Honking cough, soft moist cough, dry hacking
cough
– Coughing/gagging up white foamy fluid, acting
like something caught in the throat
– Coughing up blood tinged fluid
– Cough when drinking water, on tracheal
palpation, or exercise induced cough
– Presence of a murmur (big dog, little dog, cat)
Many times, you can’t without PE/diagnostics
History - Cough
Cough on tracheal palpation
– Any dog or cat will cough a few times on
vigorous tracheal palpation
– Prolonged coughing after tracheal palpation
often indicates pathology
(cardio or resp?)
• equally likely with airway disease and
cardiovascular disease
History - Cough
Dogs vs Cats
– Coughing cats
• much more likely to have respiratory
disease than heart failure
• Cats with heart failure more often present
with acute and severe dyspnea, with no
cough
• Some cat owners can find it difficult to
distinguish vomiting from coughing
– Coughing dogs can have either or both
Exam – Stethoscopes
•
•
•
•
Ear pieces fit snugly in the ears
Angle fits your ear canals
Poor fit, and you’ll miss low intensity murmurs
Tubing longer than 18 inches will dampen sounds
Electronic stethoscopes (microphone based)
• Difficult to distinguish heart from lung sounds
• Difficult to distinguish patient from background noise
• Meditron sensor based scope eliminates problems
– Connect to computer & record for PCG consult
Exam – Stethoscopes
Pediatric stethoscope
• For cats and small dogs
• Will distort and decrease sound intensity if used on
a medium or large dog
Adult stethoscope
• For medium to large dogs
• Won’t localize murmurs properly in cats and small
dogs
Exam – Stethoscopes
Diaphragm
• Filters out low frequency sounds to hear high
frequency sounds better
• Press firmly against the chest
Bell
• For low frequency sounds (S3 S4 in dogs)
• Press gently against the chest
Auscultation
Minimizing patient noise
• Panting, whining – close mouth, occlude nostrils
• Purring
–
–
–
–
Aversives – turn water on, show another animal
Gentle pressure on the larynx
Cotton ball with alcohol to the nose
Jiggle the doorknob
• Sometimes sedation is needed (chart)
– Acepromazine 0.0125-0.025 mg/lb, maximum 1 mg
per dog
– Butorphanol 0.1 mg/lb or buprenorphine 0.01-0.02
mg/kg
– IV the fastest and most profound (30-45 minutes)
Auscultation
• Patient is standing in a quiet place
– R Lateral recumbency and listen from bottom if muffled
• Firm pressure with the diaphragm to avoid
hair noises
• get comfortable ausculting heart and
palpating pulses at the same time
• Listen for at least 2 minutes
– Heart - R and L apex, L bases
– L armpit
– Lungs – RCr, RMidVentral, RDCd, LCr,
LMidVentral, LDCd
Auscultation
• Is the murmur hemodynamically significant?
–
–
–
–
Prolonged and loud - yes
pansystolic - yes
Diastolic - yes
Low intensity, early systolic – maybe not so
much
Loudness is not necessarily correlated to
presence of heart failure
Auscultation – Lung Sounds
• Snaps crackles and wheezes
(cardio or resp?)
– More likely respiratory in dogs
(audio)
– Not very sensitive for pulmonary edema
– Beware similar hair rubbing noises
• Pleural/pericardial Rubs (pleural rubs) (pericardial rubs)
• Dull/absent lung sounds
(dog vs cat) (causes)
– Lung consolidation
– Pneumothorax, pleural effusion
• Harsh lung sounds with no murmur in cat
– think asthma or heartworm disease
(audio)
Auscultation - Heart Sounds
Normal Heart Sounds
Auscultation - Heart Sounds
Normal Heart Sounds
• S1
– AV Valves close
– Beginning of systole
• S2
– Semilunar valves close
– beginning of diastole
• Tachycardia – which is which?
– S2 shorter and higher frequency
• Pulse is during systole
(audio)
Auscultation - Heart Sounds
• Variable intensity S1
– arrhythmia
• Louder S1 (AV slamming)
–
–
–
–
–
–
Young, narrow chested dogs (Doberman)
Increased sympathetic tone
Anemia
Fever
Hypertension
Advanced mitral valve disease
Auscultation - Heart Sounds
• Quieter S1 (AV softly closing or
muffled)
–
–
–
–
Obesity, barrel chested dogs
Myocardial failure
Pronounced 1st degree heart block
hypervolemia
Auscultation - Heart Sounds
• Louder S2 (SL slamming)
–
–
–
–
Hyperthyroidism
Fever, anemia
Heartworm Disease
Cor pulmonale (define)
• Quieter S2 (SL softly closing)
– Myocardial failure (DCM, severe MR)
Auscultation - Heart Sounds
Third Heart Sound (Gallop)
S3 (S1-S2-S3)
S4 (S4-S1-S2)
Split S2
Systolic Click
Summation Gallop (S4-S1-S2-S3)
Auscultation - Heart Sounds
Third Heart Sound
S3 – protodiastolic gallop (S1-S2-S3)
– Rapid LV filling – early diastole (audio)
– PMI R or L apex – low frequency (best heard with
the bell)
– At maximal mitral opening (E point on echo)
– stiff LV or large diastolic volume
– HCM, RCM, DCM, severe MR
– Indicates myocardial failure
– Usually a bad mamma jamma
Auscultation - Heart Sounds
Third Heart Sound
S4 – presystolic gallop (S4-S1-S2)
–
–
–
–
Atrial contraction - Late diastole (audio)
PMI R or L apex, low frequency (bell)
Stiff LV (HCM)
Increased afterload
• 3rd degree AV block
• Myocardial failure (DCM, bad MR)
– Sometimes heard in normal cats & giant dogs
– not necessarily a bad mamma jamma
Auscultation - Heart Sounds
Third Heart Sound
• Split S2
–
–
–
–
–
–
–
PMI right heart base (left side)
AoV PV don’t close at same time (PV later)
Reverse PDA
Pulmonary hypertension (HWDz, COPD)
Severe RBBB
relative PS of right to left shunts (ASD)
normal variation in large dogs (audio)
Auscultation - Heart Sounds
Third Heart Sound
Systolic Click
– Very sharp, high frequency click of Mitral valve
prolapse, in early CVD
• Snapping of the chordae tendinae as they go
taught
– PMI left apex
– Mid-Systolic
(audio)
(audio)
– May be accompanied by a systolic murmur
• Early, late, or holosystolic
– Often years until CHF develops, if at all
3 Heart Sounds
How Can you tell the difference?
Does it Matter?
– Systolic less likely pathogenic
– Systolic Click sounds sharper
– Diastolic more likely pathogenic
– PMI heart base less likely pathogenic
How Can you tell if S3 or S4?
– Can’t tell if heart rate is > 160-180 (summation)
– just do a cardio work-up
Auscultation – Heart Sounds
left
PMI
right
5
1 – left apex (MV)
4 – right apex (TV)
2 – left base (AoV)
5 – left armpit (PDA)
3 – right base (PV) – ausculted on the left
Auscultation – Heart Sounds
PMI (Point of Maximal Intensity)
Left Apex – at palpable apical beat
– S1 - MR
(mild MR)
(severe MR)
Left Base – slide cranially & dorsally
– S2 - SAS
(audio)
– S1, S2 - Ao endocarditis
(audio)
Right Base (left side)
– S2 - PS
(mild PS)
(severe PS)
Left Axilla
– continuous - PDA (PDA)
(severe PDA)
Right Apex
– S1 – TR – like MR but often quieter (audio)
Auscultation – Heart Sounds
Muffled Heart Sounds (causes)
• Pleural, Pericardial effusion (*difference*)
• Diaphragmatic hernia, thoracic masses
• obesity
What besides cardiac disease can cause a
pathologic murmur?
• Anemia, hypoproteinemia
Why do puppies have innocent murmurs?
• Musical, grade 1-2, short (audio) (mild MR)
• Larger SV relative to great vessel size
• Lower PCV and plasma proteins
• Artifact – high frequency breath sounds
Auscultation – Murmur Grade
Grade 1
• Heard in a very quiet room, concentrating
Grade 2
• easily heard on the PMI
Grade 3
• Moderately loud
Grade 4
• Very loud over much of the chest
Grade 5
• Heard with edge of stethoscope on chest, palpable thrill
Grade 6
• Heard with stethoscope off chest, palpable thrill
Auscultation – Murmur Grade
High grade murmurs are more likely to be associated
with severe disease
Severe disease can also be present with low grade
murmur
• Occasionally no auscultable murmur in the cat
• DCM
• ASD
• VSD
• Reverse PDA (right to left shunting)
Dogs almost never have CHF without a murmur
Cats can have CHF without a murmur
Auscultation – Lung Sounds
6 points
3 Right, 3 Left – correspond to lung lobes
Auscultation – Murmurs
holosystolic
• Starts at the end of audible S1
• Ends at the start of audible S2
• Murmur between the heart sounds
Auscultation – Murmurs
pansystolic
• Starts at the beginning of S1
• Ends at the end of S2
• Just hear the murmur with no distinct HS
Respiratory Sinus Arrhythmia
•
•
•
•
•
Heart rate increases during respiration
Due to increased vagal tone
Normal variation in dogs (not cats)
No pulse deficits
If present, heart failure is not likely
– Increased sympathetic tone overrides
• Pronounced in disease processes of
increased vagal tone
–
–
–
–
Increased CSF pressure
Chronic respiratory disease
Thoracic or abdominal disease
After sedation
Respiratory Sinus Arrhythmia
• DDx
– Afib with a normal ventricular rate
– Frequent APCs or VPCs (maybe pulse deficits)
– Intermittent SSS
None of these vary consistently with
the respiratory cycle
• RSA is regularly irregular
• Others are usually irregularly irregular
(RSA)
(PS with RSA)
Physical Exam – Ascites
• most common cause of cardiogenic ascites
in cats
– TVD
• Tap and do fluid analysis to distinguish
between transudate, modified transudate
and exudate
(handout)
• Usually accumulates slowly, though owners
often don’t notice until huge
• If truly does develop over days, think
pericardial tamponade or caval syndrome
Exam – Mucous Membranes
Cyanosis
• > 4 g/dL of deoxygenated Hb in the blood
– Severely anemic animals don’t turn blue
– Even with life threatening hypoxia
• Differential cyanosis
(define)
– Front of body pink, back of body blue
– Reverse PDA, FATE
(why rPDA)
– Compare pulse oximetry or blood gases from front of body
with rear of body
– Weak or no femoral pulses, pain, paresis with FATE
Exam – Pulses
Technique
• Occlude the pulse
• Then slowly release pressure until maximum pulse
is detected
Pulse Pressure = Systolic – Diastolic
• Femoral pulse usually not palpable when MAP
<50mmHg
• Dorsal pedal pulse not palpable when SAP
<80mmHg
Exam – Pulses
Bounding Pulses (water hammer)
• Increased systolic pressure (increased SV)
–
–
–
–
–
(causes)
Aortic regurgitation
Severe bradycardia
Thyrotoxicosis
(define EF, FS)
Fever
Anemia/hypoproteinemia
• decreased diastolic pressure (diastolic runoff)
– PDA
– AV fistula
– Aortic regurgitation
(most common cause)
• Aortic endocarditis > SAS
Exam – Pulses
Weak Pulses
• Severely decreased SV – severe HF
• Acutely decreased SV – hypovolemia
• Decreased peripheral vascular resistance (shock)
• Decreased arterial compliance (hypertension)
Pulse peaks slowly and late in systole
• Pulsus parvus et tardus (cause)
• Severe SAS
Exam – Pulses
Short, Brisk Pulses (snappy)
• Short, fast systole
• Compensated MR
(what happens to FS with MR)
Pulse weak or absent during inspiration
• Pulsus paradoxus
• Systolic pressure falls during inspiration
• With pronounced respiratory sinus arrhythmia
• Exaggerated by pericardial effusion
Exam – Pulses
Alternating Weak and Normal Pulses
• Pulsus alternans
• Severe myocardial failure (define MF vs CHF) (causes)
– DCM
– RCM, UCM (define)
– End stage valvular disease
– Prolonged tachyarrhythmia or tachycardia
Exam – Pulses
Pulse Deficits (heart beat generates no pulse)
• VPCs
• Atrial fibrillation with VPCs
• Tachyarrhythmia (inadequate filling)
• Every other heart beat has a pulse deficit
– Pulsus bigeminis
– Caused by ventricular bigeminy
(define)
Totally chaotic heart sounds and pulses
• Lots of multiform VPCs
• Atrial fibrillation
(audio)
Exam – Jugular Veins
• Clip or wet the fur over the jugular veins
• Evaluate sitting or standing (not sternal)
• Jugular Distension (causes)
– suggests increased RA pressure
(normal dogs cats?)
• 2-3 cm H20 in cats, 5-8 cm H20 in dogs
– Or less often jugular or caval occlusion
• Jugular Pulse
(normal dogs cats)
– 5-8cm dorsal to RA in dogs, 2-3 cm in cats
– Too high indicates increased right heart pressure
• If abnormalities above not noted, occlude at
thoracic inlet, and release
• Hepatojugular reflux
Exam – Jugular Veins
Jugular distension, high pulse, +HJR
• Jugular/caval occlusion
(causes)
– Heartworm disease
– External mass (cyst, abscess, granuloma, neoplasia)
– Thrombus
(causes)
• Decreased RV compliance
– RV hypertrophy
• PS, TOF, pulmonary hypertension
– Restrictive CM
– RVOT obstruction
• Heartworm disease, neoplasia, thrombus
Exam – Jugular Veins
Jugular distension, high pulse, +HJR
• RV volume overload
– TR with RHF
– VSD
– HWDz
• Compression on the RV, so it can’t fill
– Pericardial effusion
– constrictive pericarditis
– Pericardial mass
Evaluation of hepatic & splenic veins on US are
even more sensitive for increased RV pressure
Exam – Extremities
Peripheral edema
• rare
• Often accompanied by diarrhea
• Due to RHF
Cold extremities
• Due to RHF and venous stasis
• Or saddle thrombus
– Acutely painful, followed by lack of pain
( Cardiovascular Exam form )
Acknowledgements
Smith FWK, Keene BW, Tilley LP
• Rapid Interpretation of Heart and Lung Sounds, 2nd
ed, 2006
Kvart C & Haggstrom J
• Cardiac Auscultation and Phonocardiography,
Veterinary Information Network
Kittleson M
• Small Animal cardiovascular Medicine, Veterinary
Information Network. Chapter 3 – Signalment,
History and Physical Examination