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Practical Cardiology Case Studies Wendy Blount, DVM Nacogdoches TX Jake Signalment • 9 year old male Boxer Chief Complaint • Deep cough when walking in the morning, for about one week • Appetite is good Jake Exam • Weight 81.9 – has lost 5 pounds in 3 months (BCS 3) • Temp 101.4 • Mucous membranes pink, CRT 3.5 seconds • Subtle dependent edema on the lower legs • Jugular veins normal • Harsh lung sounds • 3/6 holosystolic murmur, PMI left apex • Heart rate 160 per minute • Respirations 55 per minute • Femoral pulses somewhat weak Jake Differential Diagnosis - Cough • Respiratory Disease • Cardiovascular Disease • Both Jake Diagnostic Plan (B Client) • Blood Pressure – 150 mm Hg systolic (Doppler) • Chest X-rays – – – – – Massively enlarged heart (VHS 12.5) Enlarged LA, LV (dorsally elevated trachea) Enlarged pulmonary veins Perihilar pulmonary edema Left congestive heart failure Jake Immediate Therapeutic Plan (10 am) • Furosemide – 80 mg IM • 4 hours later – Respiratory rate is 36 per minute Jake Diagnostic Plan – 2nd Wave (2 pm) • EKG – Normal Sinus Rhythm • Echocardiogram (video) Jake - Echo Transverse - LV Apex • LV Looks Big Transverse - LV Papillary Muscles • LV looks REALLY big • Myocardium is hardly moving • Flat papillary muscles Jake - Echo Transverse - LV Papillary Muscles • • • • • • IVSTD – 9.7 mm (n 10.8-12.3) LVIDD – 72.1 mm (n 43-48) LVPWD – 15.1 mm (n 8.7-10) IVSTS – 11.9 mm (n 16.5-18.1) LVIDS – 67.1 mm (n 27.4-30.4) LVPWS – 13.0 mm (n 14-15.6) FS = LVIDD – LVIDS LVIDD (72.1-67.1)/72.1 = 7% (n 30-46%) EF = 15% (n >70%) Jake - Echo Transverse - Mitral Valve • No increased thickness of MV • No vegetations on the MV • EPSS – 12 mm (n <6 mm) Transverse – Aortic Valve/RVOT • LA at least Double Big Jake - Echo Transverse - Aortic Valve/RVOT • AoS – 23.1 mm (n 27.4-30.4) • LAD – 44.7 mm (n 25.8-28.4) • LA:Ao = 44.7/23.1 = 1.9 (n 0.8-1.3) Transverse – Pulmonary Artery • No abnormalities noted Jake - Echo Long – 4 Chamber • LV massively enlarged • Poor systolic function • LA 2x enlarged • IVS is bowed toward the right, due to LV dilation Long – LVOT • No abnormalities in LVOT (video) Jake – Dx & Tx Recommendations • Left Congestive Heart Failure – – – – – Mini-panel and electroytes Furosemide 80 mg PO BID Enalapril 20 mg PO BID Recheck mini-panel and electrolytes in 3-5 days Recheck chest rads 3-5 days • Dilated Cardiomyopathy – Pimobendan 10 mg PO BID (declined) – Carnitine 2 g PO BID – Recheck echo, chest rads, EKG, mini-panel/lytes 60 days (sooner if respiratory rate >40 at rest) Jake - Bloodwork CBC • normal Mini-panel - BUN, creat, glucose, TP, SAP, ALT • Normal Electrolytes • Not done Jake – Follow-Up Recheck – 6 days • BUN 30 (n 10-29) • Creat normal • Electrolytes not done • Chest x-rays not done No additional rechecks were done, owner did not monitor respiratory rate at home Jake – Follow-Up 4 months later… • Chief complaint – – Doing well until last week – poor energy, coughing again, not eating • Chaotic heart sounds with pulse deficits on auscultation – “tennis shoes in a dryer” ECG Jake – Follow-Up 26 ECG • Heart Rate 200 bpm (tachycardia) • Rhythm – irregularly irregular, no P waves, irregular pattern to PR interval • P wave – not present – can not measure • PR interval – no P wave – can’t measure • QRS – 0.084 sec x 2.6 mV • ST segment - <-0.2mV depression 2.1 o • MEA – 90 Dilated Cardiomyopathy Common Historical and PE findings • Onset seems rather acute – signs of LHF – Coughing, dyspnea, exercise intolerance, weak pulses, poor appetite and energy • Sometimes RHF also – Ascites, pleural rubs, jugular vein distension, peripheral edema, diarrhea • Syncope • Mitral murmur – Holosystolic, PMI left apex • Chaotic heart sounds with pulse deficits if A-fib Dilated Cardiomyopathy Common Radiographic Findings • Generalized cardiomegaly - Increased VHS • Enlarged LV – elevated trachea • Enlarged LA – compressed left bronchus • + RA/RV enlargement • + Left Heart Failure – lobar veins > arteries, pulmonary edema • + Right Heart Failure – enlarged caudal vena cava, ascites, pleural effusion, hepatosplenomegaly Dilated Cardiomyopathy Common Echocardiographic Lesions • Dilation of all 4 heart chambers • Large LVIDD (eventually large LVIDS also) • Hypokinesis of LV wall and IVS • Reduced FS • Paradoxical septal motion • Increased EPSS • Normal looking MV and TV leaflets • Papillary muscle flattening Dilated Cardiomyopathy Common ECG Findings • Wide P wave • Tall R wave • Atrial fibrillation • VPCs • Ventricular arrhythmias Dilated Cardiomyopathy Treatment • Pimobendan 0.2-0.3 mg/kg PO BID – Inodilator – positive inotrope and vasodilator • Treat left heart failure if present – Diuretics – ACE inhibitor if tolerated • 0.5 mg/kg PO SID-BID – Nitroprusside CRI if critical – Dopamine or dobutamine CRI if critical – Thoracocentesis if pleural effusion in cats – Oxygen, of course Dilated Cardiomyopathy Treatment • Furosemide boluses for fulminant LHF – – – – – – 80% effective 6-8 mg/kg IV Q1-2 HR UNTIL RR<50 4 mg/kg IV q1-2h until RR<40 4 mg/kg PO q4-6 hr until RR<30 Then PO q6-12 hrs to maintain RR<30 Give IM if placing IV cath might be fatal • Furosemide CRI may be more effective – 0.5 to 1.0 mg/kg/hr Dilated Cardiomyopathy Treatment • Monitoring fulminant LHF – Lactate (return to normal) – blood gases (resolution of acidosis and hypoxemia) – Respiratory rate – PROVIDE WATER & WATCH URINE PRODUCTION – Check electrolytes at least daily – Central line can make blood draws easy Dilated Cardiomyopathy Treatment • Taurine – if whole blood taurine levels low – – – – – 250-500 mg PO BID Cats fed low taurine diets, or with genetic defect American cocker spaniels Dogs fed vegetarian diets Large and giant breed dogs fed lamb and rice diet • Carnitine – 500-1000mg PO BID – Boxers with genetic defect – Plasma levels have low sensitivity – Myocardial biopsy is usually required • Thyroxine – if hypothyroid Dilated Cardiomyopathy Monitoring patients in chronic LHF • Chest x-rays and exam every 6 months • Echocardiogram when chest x-rays change – Every 6 months with cardiomyopathies • ECG when arrhythmia ausculted, syncope, or if disease which predisposed to arrhythmia – Boxer cardiomyopathy – Dilated cardiomyopathy • Recheck sooner if RR at rest is >40 per minute Dilated Cardiomyopathy Monitoring patients in chronic LHF • BUN, creat – 3-4 days after starting or increasing ACE inhibitor – Every 6 months when doing well – Sooner if things get worse • Electrolytes and blood gases – – – – Every 6 months when doing well Sooner if things get worse Potassium supplementation is often necessary Untreated hypokalemia can predispose to arrhythmia, especially if on digitalis Dilated Cardiomyopathy Prognosis • Most dogs are done within 3 months of becoming symptomatic, if treated properly. • Survival is likely much shorter – days to weeks – if untreated. • Median survival for dogs with DCM and Afib is 3 weeks. • All of these numbers prior to Pimobendan. Dilated Cardiomyopathy Screening • Predisposed dog breeds show decreased fractional shortening for many years prior to onset of clinical signs and/or murmur – FS has to fall <15% to cause CHF • Screening by echocardiogram at young adult to middle age is effective. • No one knows whether early intervention changes outcome. Dilated Cardiomyopathy Beta Blocker Therapy • Seems counterintuitive for DCM – Negative inotrope • In people, chronic stimulation of B1 receptors is cardiotoxic – Improved survival when people with mycoardial failure are put on beta blockers (carvedilol) • No similar success with canine DCM – Pharmakokinetics of carvedilol in dogs have been studied, and are unpredictable Atrial Fibrillation Why Treat?? • Heart rate around 250 beats per minute – Myocardial failure will result within 3-6 weeks – Ventricles can not fill properly – forward heart failure Treatment – – – – – Conversion would be ideal But this is not easy to accomplish in very sick hearts Big dogs with normal hearts – primary Afib Medical conversion with quinidine Anesthesia and conversion with electric shock Atrial Fibrillation Treatment – Afib in unhealthy hearts – Slow the heart rate at the AV node (goal 150 bpm) – Digoxin • Weak positive inotrope – Beta blockers • Negative inotrope • Propranolol 0.1-0.2 mg/kg PO TID • Titrate up to effect to 0.5 mg/kg PO TID – Calcium channel blockers • Diltiazem 0.5 mg/kg PO TID (titrate up to 1.5 mg/kg) DON’T USE BETA BLOCKER AND CALCIUM CHANNEL BLOCKER TOGETHER!! Tom 5 year old neutered male DSH Chief Complaint • Outdoor cat, owners think he was hit by a car • Tom is laterally recumbent, and breathing hard Exam • T 96.5, P- 100, R – 66 • No evidence of trauma Tom ECG 1 • Heart Rate - 120 • Rhythm – regular, no P waves • QRS – deep S wave, wide, bizarre QRS • idioventricular rhythm i-STAT EC8+ • K 10.9 mEq/L, iCa++ 0.96 mmol/L • pH 7.08, HCO3 11 mEq/L • Grapefruit sized very firm bladder Tom Treatment • Place indwelling urinary catheter • Place IV catheter • Begin 0.9% NaCl at 15 ml/hr • 1 unit regular insulin IV • 5cc 50% dextrose diluted in 15 cc fluids, given over 1 hour; added 5%dextrose to fluids ECG 2 – 6 minutes later • Heart rate 140 • No P waves, QRS less abnormal Tom ECG 3 – 1 hour after presentation • Heart rate 120 • No change for the past 45 minutes Treatment • Ca-gluconate 2cc IV slowly over 20 minutes ECG 4 – 1 hour after presentation – T 98.9 • Heart rate 120 • P waves have returned, normal sinus rhythm Tom ECG 5 – 5 hours after presentation • Heart rate 130 • Normal sinus rhythm • P waves have returned to normal i-STAT EC8+ • iCa++ normal, K 6.6 mEq/L • HCO3-- 16.3 mEq/L, pH 7.29 Pockets Signalment • 11 year old spayed female yorkie (5 pounds) Chief Complaint • Harsh cough several times daily for 2 months • History of chronic inflammatory liver disease, luxating patellas, severe chronic periodontal disease and multiple allergies; these problems clinically well managed at this time. • Mammary carcinoma removed one year previously, at the time of OHE. Pockets Exam • Temp 100.3, P 110, R 26, BP 110, BCS 3.5 • BAR, well hydrated, in good body condition • Crackles in the small airways, especially at peak inspiration • Pronounced respiratory sinus arrhythmia • Normal heart sounds • Pulses normal, CRT < 2 sec • Mature cataract right eye Pockets Differential Diagnoses - Cough • Chronic Bronchitis • Collapsing trachea Diagnostic Plan - initial • Chest and cervical x-rays • Inspiratory - VD and right lateral • Expiratory - left lateral Pockets Thoracic and cervical radiographs • No collapse of the trachea • Vertebral heart score 10 • Normal cardiac silhouette and pulmonary vasculature • Pronounced peribronchiolar pattern • Shoulder arthritis • Vertebral arthritis • Normal sized liver Pockets Diagnostics – 2nd round • Transtracheal wash • Cytology – suppurative inflammation (mature neutrophils) • Culture negative Treatment – Diagnosis Chronic Bronchitis • Hydrocodone as needed for cough suppression • Inhaled steroids PRN for cough • Not tolerated – Temaril P instead Pockets Long term outcome – 4 years (handout) • Monitoring – chest rads every 6 months • Dental cleaning every 4-6 months • 1 episode of bacterial bronchpneumonia after dental, despite treatment with metronidazole • Amoxicillin 1 week before and after dental • Increase cough suppressants for 3 days after dental • Hydrocodone almost every day • Temaril P for flare-ups – Repeat transtracheal wash when severe • Coughs once or twice almost every day Daisy Signalment • 15 year old spayed female mixed terrier • 11 pounds Chief Complaint • Became dyspneic while on vacation, as they drove over a mountain pass • Come to think of it, she has been breathing hard at night for some time Daisy Exam • T 100.2, P 185, R – 66, BP – 145, BCS – 3.5 • Increased respiratory effort • 3/6 holosystolic murmur loudest at left apex • Mucous membranes pale pink • Crackles in the small airways • Pulses weak • CRT 3.5-4 seconds Daisy Differential Diagnosis - Dyspnea • Suspect congestive heart failure • Suspect mitral regurgitation • Concurrent respiratory disease can not be ruled out Initial Diagnostic Plan • Chest x-rays • CBC, mini-panel, electrolytes Daisy CBC, mini-panel, electrolytes • Normal Thoracic radiographs • • • • • • • Markedly enlarged LA Compressed left mainstem bronchus Perihilar edema Vertebral heart score 11.75 Elevated trachea – LV enlargement Right heart enlargement Mildly enlarged liver Daisy Initial Therapeutic Plan • Lasix 25 mg IM, then 12.5 mg PO BID • Enalapril 2.5 mg PO BID • Owner is a lab tech, and set up oxygen mask to use PRN at home • Recheck BUN, potassium, chest rads 3-5 days • Come back sooner if respiratory rate at rest is above 40 per minute without oxygen Daisy Recheck – 4 days • Daisy’s breathing is much improved (30-40 at rest) • Lateral chest x-ray • Electrolytes normal • BUN 52 Daisy Diagnostic Plan - updated • Decrease enalapril to SID • Recheck BUN 1 week • Recheck chest rads 1 week Recheck – 1 week • BUN – 37 • Thoracic rads no change • Request recheck in 3 months, or sooner if respiratory rate at rest is above 40 per minute Daisy 2 months later • Daisy is breathing hard again at night Exam • Same as initial presentation Diagnostic Plan • CBC, mini-panel, electrolytes • Chest x-rays Daisy Bloodwork • CBC, electrolytes normal • BUN 88 Therapeutic Plan • Increase furosemide to 18.75 mg PO BID • Add hydralazine 2.5 mg PO BID • Recheck chest rads, BUN, electrolytes, blood pressure 1 week Daisy Recheck – 1 week • Clinically much improved – respiratory rate 3040 per minute at rest • electrolytes normal • BUN 58 • Blood pressure 135 • Chest x-rays • Recommend recheck in 3 months, or sooner if respiratory rate above 40 per minute at rest Daisy Recheck – 6 months • Daisy dyspneic again Exam • Similar to last crisis – BP 90 Diagnostic Plan • CBC, mini-panel, electrolytes • Echocardiogram, ECG, chest x-rays Daisy Bloodwork • CBC, electrolytes normal • BUN 105, creat 2.1 Chest x-rays • Similar to last crisis ECG • Sinus tachycardia, wide P wave Daisy - Echo Short Axis – LV apex (video) • LV looks big Short Axis – LV papillary muscles • • • • • • IVSTD – 6.0 mm – low normal LVIDD – 35 mm (n 20.2-25) LVPWD – 4.3 mm – low normal IVSTS – 9.4 mm – normal LVIDS – 25 mm (n 11.1-14.6) LVPWS – 8.4 mm - normal Daisy - Echo Short Axis – LV papillary muscles • • • • • • IVSTD – 6.0 mm – low normal LVIDD – 35 mm (n 20.2-25) LVPWD – 4.3 mm – low normal IVSTS – 9.4 mm – normal LVIDS – 25 mm (n 11.1-14.6) LVPWS – 8.4 mm – normal • FS – (35-25)/35 = 29% (normal 30-46%) Daisy - Echo Short Axis - MV • MV leaflets hyperechoic and thickened • EPSS – 8 mm (n 0-6) Short Axis – Aortic Valve/RVOT • LA appears 2-3x normal size • AoS – 13.0 – normal • LAD – 33 mm (n 12.8-15.6) • LA/Ao = 2.5 (n 0.8-1.3) Daisy - Echo Long View – 4 Chamber • LV and LA both appear large • MV is very thick and knobby, with some prolapse into the LA Long View – LVOT • Large LA, Large LV (video) Daisy Therapeutic Plan • Increase hydralazine to 5 mg PO BID • Add spironolactone 12.5 mg PO BID • Add pimobendan 1.25 mg PO BID • Increase furosemide to 18.75 mg PO TID x 2 days, then decrease to BID if respiratory rate decreases to less than 40 per minute at rest. • Recheck 1 week – BUN, creat, phos, electrolytes, chest rads, BP Daisy Recheck – 1 week • Clinically improved again • BP - 125 • BUN 132, creat 2.6, phos 6.6 • Electrolytes normal • chest rads improved pulmonary edema Therapeutic Plan – Update • Add aluminum hydroxide gel 2 cc PO BID Daisy 5 Months later • Coughing getting worse • Chest rad show no pulmonary edema • LA getting larger Therapeutic Plan – Update • Add torbutrol 2.5 mg PO PRN to control cough Daisy 18 Months after initial presentation • Owner discontinue pimobendan due to GI upset 28 months after initial presentation • Daisy finally took her final breath • BUN >100 for 22 months Chronic MV Disease • May be accompanied by similar TV disease (80%) • TV disease without MV disease is possible but rare • LHF and/or RHF can result • Right heart enlargement can develop due to pulmonary hypertension due to LHF • Myocardial failure and CHF are not directly related Chronic MV Disease Thoracic radiograph abnormalities: • LV enlargement – Elevated trachea – increased VHS • LA enlargement – often largest chamber – Compressed left bronchus • + left heart failure – Pulmonary edema – Lobar veins larger than arteries Chronic MV Disease Echo abnormalities: • • • • • LA and/or RA dilation, LV and/or RV dilation Exaggerated IVS motion (toward RV in diastole) Increased FS first, then later decreased FS Thickened valve leaflets If TV only affected, left heart can appear compressed, small and perhaps artifactually thick • Ruptured CT – – MV flips around in diastole – MV flies up into LA during systole – May see trailing CT, or CT floating in the LV Chronic MV Disease ECG abnormalities: • Wide or notched P wave – Enlarged LA • Tall R wave – Enlarged LV • Right Bundle Branch block – Wide QRS – Deep S wave • Left Bundle Branch Block – Wide QRS – Tall R wave Chronic MV Disease Right Heart Failure • Medications similar to LHF • Medications not as effective at eliminating fluid congestion – More effective at preventing fluid accumulation, once controlled • Periodic abdominocentesis and/or pleurocentesis required • Prognosis for RHF and LHF is extremely variable NTproBNP ELISA N-terminal pro-B type Natriuretic Peptide • In clinic test to distinguish cardiac from respiratory dyspnea • Validated in dogs JACVIM January 2008 • <210 pmol/L – more likely respiratory disease • >210 pmol/L – more likely cardiac disease • Falsely elevated by increased creatinine • Helpful in distinguishing cardiac from respiratory dyspnea when creatinine is not elevated