1. 1. CARDIOLOGY BASICS: AT THE HEART OF THE MATTER Jason M . Chin, DVM Oradell Animal Hospital
2. 2. Why is the heart so important? It pumps blood to organs to provide: Oxygen Nutrients Removes waste (biproducts of metabolism) Provides means for signaling/communication
3. 3. Perfusion Determined by Cardiac Output: CO = SV x HR SV = Preload x Contractility Afterload Why are these important to think about?
4. 4. A & P
5. 5. A & P
6. 6. A & P Electrical Conduction Basic Pathway: SA node to AV node to Bundle of His/Purkinje fibers (ventricles)
7. 7. A & P Electrical Conduction Systole: The active, contraction phase of the heart cycle Diastole: The relaxed, filling phase of the heart cycle
8. 8. A & P Electrical Conduction
9. 9. The Physical Exam History: As important as any physical parameter Syncope Exercise intolerance Difficulty/Labored breathing Weight loss (cachexia) Observation: What does your patient look like? Dyspnea Coughing Weak Abduction of elbows/Extended head Cheek puffing/Open mouth breathing
10. 10. Dyspnea http://www.youtube.com/watch?v=aqWiWlKv7OE
11. 11. Dyspnea http://www.youtube.com/watch?v=Zp7CiC7SXjk
12. 12. PE Vital Parameters http://www.cvmbs.colostate.edu/clinsci/wing/fir staid/vital.htm Dog Cat Heart Rate 70-160 bpm 160-240 bpm Respiratory Rate 10-30 bpm 20-30 bpm Temperature 100.0 102.5 F 100.0 102.5 F
13. 13. PE Vital Parameters Pulses Strong and Synchronous Mucus Membranes Pink and Moist CRT < 2s
14. 14. PE - Auscultation Cardiac: Murmurs Arrhythmias Pulmonary: Crackles (rales) Wheezes (rhonchi) r/o Upper Airway (referred)
15. 15. Murmurs How do you describe a murmur? Intensity (Grade 1-6) Location (PMI point of maximal intensity; right/left/sternal, apical/basilar) Timing (Systolic v. Diastolic v. Continuous) Pitch/Frequency (high/med/low, musical/harsh) Shape (plateau v. decrescendo v. crescendo- decrescendo)
16. 16. Murmurs Grading System: Freeman and Levine I/VI Very focal; faint II/VI Faint, but more easily heard than a grade I III/VI Moderately loud and easily heard (over larger area on same side) IV/VI Loud murmur heard over large area including the opposite side (discern between 2 murmurs) V/VI Palpable thrill over PMI VI/VI Audible with stethoscope off of body wall
17. 17. Murmurs http://www.littmann.com/wps/portal/3M/en_US/3M- Littmann/stethoscope/littmann-learning-institute/heart- lung- sounds/?mmmSsoError=1010|Invalid%20Username%2 0and%20Password%20combination. Early Systolic Pansystolic
18. 18. Murmurs Some Causes Valve insufficiency/regurgitation (Chronic Valve Disease) Valve stenosis Septal defects Anemia (physiologic murmur)
19. 19. Lung Sounds Location of sounds is important to note Normal bronchovesicular sounds Crackles (rales) Wheezes (rhonchi) r/o stridor & stertor (upper airway)
20. 20. Arrhythmias Causes of arrhythmias: Primary conduction disturbance SA Node, AV Node, fibers (blocks) Secondary to heart disease Enlarged heart (dilated, thicker, etc) Secondary to systemic illness Endocarditis, GDV, splenic disease, hyperthyroid, pheochromocytoma, anemia Secondary to electrolyte imbalances Potassium, Calcium, Sodium Secondary to toxin/drug ingestion
21. 21. Arrhythmias Sinus rhythm (normal) Respiratory sinus arrhythmia (normal) Faster on inspiration vagal tone is inhibited Tachyarrhythmia SVT, V-Tach/AIVR, A-Fib Bradyarrhythmia AV Blocks, Sick Sinus Syndrome, SA disease, escape rhythms Premature Beats APC v. VPC Gallop Rhythm
22. 22. Arrhythmias Normal ECG
23. 23. Arrhythmias VPCs, (Ventricular Premature Contractions)
24. 24. Arrythmias V-Tach (Ventricular Tachycardia)
25. 25. Arrhythmias APCs (Atrial Premature Contractions)
26. 26. Arrhythmias AV Block (1st Degree & High Grade 2nd Degree)
27. 27. Arrhythmias A-Fib (Atrial Fibrillation)
28. 28. Gallop Rhythm Gallop (S3 sound)
29. 29. Types of Cardiac Disease Congential Defects (ASD/VSD, PDA, Tetrology of Fallot) Endocardiosis/Chronic Valve Disease (insufficiency) Valvular Stenosis (congenital v. acquired) Dilated Cardiomyopathy (dogs) Hypertrophic Cardiomyopathy (cats) Pulmonary Hypertension Systemic Hypertension (primary v. secondary)
30. 30. Pathophysiology of Disease Abnormal blood flow (can be d/t arrhythmia, cardiomyopathy, etc) decreased perfusion Stimulates RAAS (Renin-Angiotensin- Aldosterone System) Hormones increase preload, vascular tone, and affect heart myocytes Structural changes ensue: Eccentric hypertrophy Concentric hypertrophy Chamber dilation
31. 31. Pathophysiology of Disease
32. 32. Congestive Heart Failure (CHF) Left sided Dyspnea Pulmonary Edema Nasal fluid/discharge Right sided Dyspnea Ascites Jugular Pulses
33. 33. CHF Chest rads (needed for diagnosis)
34. 34. CHF
35. 35. CHF Treatment: Oxygen Therapy Lasix (furosemide) 2mg/kg IM or IV (dog) 1mg/kg IM or IV (cat) Nitroprusside CRI Sedation (Torb beware Ace and Dexdomitor)
36. 36. Atrial Thromboembolism aka Saddle Thrombus - Cats!! Gallop rhythm, often underlying heart disease like HCM/RCM/HOCM Due to hypercoagulable blood in chambers (pooling) Hind end paralysis (bilateral > unilateral), usually deep pain negative Cold limbs, cyanotic pads Painful!!
37. 37. ATE Negative Prognostic Indicators: Decreased Temperature, HR Bilateral (versus unilateral) In CHF Treatment: Pain management (hydromorphone, fentanyl) Oxygen therapy Lasix (if in CHF 1mg/kg) +/- Thrombolytic therapy (aspirin, clopidogrel, heparin)
38. 38. What does it all mean?? Do we have lung disease or is it something else? Primary v. secondary diseases (asthma/pneumonia v. non-cardiogenic pulm edema/pleural effusion/pericardial effusion v. CHF) Is cardiac disease the underlying cause? What diagnostics and treatments are
39. 39. Weve got a code 1 trouble breathing
40. 40. References Braunwald, E. Heart Disease: A Textbook of Cardiovascular Medicine 5th Ed. Philadelphia: W.B. Saunders Co., 1997 Fox, Sisson, Moise. Textbook of Canine and Feline Cardiology: Principles and Clinical Practice 2nd Ed. Philadelphia: W.B. Saunders Co., 1999. Drobatz, J.K. Emergency Management of Respiratory Distress. In: Proceedings of the District of Columbia Academy of Veterinary Medicine; 2004.
41. 41. Questions?