Clinical Pearls for the Cardiac Patient Jonathan C. Goodwin DVM, MS, DACVIM Goodwin Veterinary Cardiology

Mucous Membranes Color Perfusion – Pallor – Prolonged capillary refill – Cyanosis

Neck Thyroid tumors Jugular pulse – Right heart failure – Pericardial effusion – Complete heart block

Jugular Venous Evaluation Jugular Veins – Level of venous distension Not normally distended Should empty quickly Pulsations don’t typically extend past 1 st 1/3 of neck

Jugular Venous Evaluation Estimation of right ventricular filling pressures – Dog and Cat distension should not exceed point of shoulder – Horse and Cow distension should not exceed 1/3 distance of neck when head is in normal position

Palpation Tracheal Thoracic – Thrill – Compression in cats – Point of maximal intensity Abdominal – Organomegaly – Ascites

Heart Rate Normal heart rates – Dogs bpm – Cats bpm Home vs. Clinic Heart vs. Lung Sympathetic drive vs. Vagal tone

Thoracic Auscultation Pulmonary – pattern and effort noted before touching animal – auscult entire lung field periphery vs central dorsal vs ventral – which phase of respiration are sounds accentuated

Thoracic Auscultation Pulmonary – Abnormal lung sounds Wheeze – high-pitched, high frequency, airway narrowing Stridor – loud low frequency, vibrations within the upper airways Crackles – “scrunching of cellophane”, disease of small airways/parenchyma

Thoracic Auscultation Cardiac – Quiet room with minimal distractions – Real life – Stethoscope diaphragm – accentuates high frequency sounds bell – accentuates low frequency sounds

Thoracic Auscultation Cardiac sounds – vibrations from blood or other cardiac structures – many cannot be heard – acoustical amnesia – transient S1, S2, S3, S4 – murmurs

Cardiac Sounds S1- First heart sound closure of the AV valves (mitral and tricuspid) signals beginning of systole high frequency right and left apices

Cardiac Sounds S2- Second heart sound closure of the semilunar valves (aortic and pulmonic) signals end of systole high frequency; slightly shorter duration left heart base

Cardiac Sounds S3- Third heart sound early diastolic sound rapid cessation of blood flow into the ventricle occurs more readily with a dilated or large ventricle low frequency sound left cardiac apex

Cardiac Sounds S4- Fourth heart sound late diastolic sound atrial kick into an already full and stiff ventricle occurs more readily with a thickened or large ventricle low frequency sound left cardiac apex

What Are Murmurs??? Turbulent blood flow Created from pressure gradient Larger gradient = more turbulence Systolic murmurs- coarse Diastolic murmurs- soft Dependent on pressure

Timing/Duration of Murmurs

Murmurs Timing – systolic, diastolic, continuous Location – Basilar or apical – Point of Maximal Intensity (PMI) P, A, M, T – Grade I (softest)  VI (loudest) does not necessarily correlate to severity of lesion

Grading Murmur Intensity Grade I – Very soft, often intermittent Grade II – murmur that is slightly softer than the heartbeat, usually persistent Grade III – murmur as loud as the heartbeat

Grading Murmur Intensity Grade IV – murmur louder than the heart beat with no palpable thrill Grade V – very loud murmur with palpable thrill Grade VI – very loud murmur, palpable thrill, can be ausculted with the stethoscope off the thorax or with the naked ear

Disease Determination Valve functions Types of dysfunction – Insufficiency – Stenosis Knowledge of physiologic function

Diagnosis MURMURS SYSTOLIC Ejection diamond SAS PS Regurgitant plateau MR TR VSD CONTINUOUS PDA DIASTOLIC Arterial decrescendo AI PI Atrioventricular decrescendo/crescendo MS TS

What Is the Pulse??? Peripheral pulse pressure difference Systolic pressure Diastolic pressure Origins of pressure

Systemic Arterial Pulse Normal pulse – gradual ascent, gradual descent Reduced pulse – reduced systolic pressure reduced cardiac output Hyperkinetic/bounding/waterhammer pulse – increased systolic pressure – reduced diastolic pressure – PDA, severe aortic insufficiency

Systemic Arterial Pulse Normal pulse Hyperkinetic pulse Weak/reduced pulse Pulsus alternans Pulsus bigeminus Pulsus paradoxus

Cardiac Disease in Dogs Most common cardiac disease – Valvular degeneration Mitral Tricuspid Aortic Most common clinical signs – Decreased energy – Cough

Cardiac Disease in Cats Most common cardiac disease – Hypertrophic cardiomyopathy Most common clinical signs – Urination/hiding/vomition/behavior – Tachypnea/dyspnea – Murmur – Gallop heart sounds/arrhythmias

Hypertrophic Cardiomyopathy Pathophysiology – Diastolic dysfunction – LA – Myocardial ischemia – Arrhythmias – Thromboembolism – Myocardial failure – Congestive heart failure

Diagnostics Radiographs CBC and Chemistry panel Blood pressure Brain natriuretic peptides (BNP) Electrocardiogram (ECG) Echocardiogram

QUESTIONS??????? Jonathan C. Goodwin DVM,MS, DACVIM-Cardiology Goodwin Veterinary Cardiology