Certificate in Advanced Veterinary Practice

C-VC.2 Veterinary Cardiology

Cardiovascular Diagnostics

Module Outline

Module Leader:

Simon Dennis BVetMed MVM MRCVS DipECVIM-CA (Cardiology)

European Veterinary Specialist in Small Animal Cardiology

CPD Unit

Royal Veterinary College

Hawkshead Lane

North Mymms

Hertfordshire

AL9 7TA

Tel: +44 (0)1707 666201

Fax: +44 (0)1707 666877

Email: certavp@rvc.ac.uk

www.rvc.ac.uk/certavp

LEARNING OUTCOMES

The module is focused on making a diagnosis of cardiovascular disease using the appropriate

techniques. It is not concerned with the therapeutics or management of animals with cardiovascular

disease as this is the concern of modules C-VC.3.

The module is aimed at veterinary surgeons in private practice, or at a veterinary school with a

substantial case load of small or large animals, or a mixture, of which a significant number have

primary cardiovascular disease, or require thorough examinations of their cardiovascular system for

investigation of other systemic illnesses, or injury. At least 200 of these should be examined and

assessed primarily by the candidate.

The module may be taken from a large animal or a small animal perspective, or a mixture of the two.

It is suggested that candidates intending to proceed to a Certificate in Advanced Veterinary Practice

(Cardiology) via modules C-VC.1 and C-VC.3, will present a C-VC.1 made up of a balanced

distribution of species with at least 2 being represented. Alternatively, if candidates are intending to

proceed to the advanced clinical practice (cardiology) with a large animal/equine bias) via Equine

Practice, the case diary should be made up of 90% large animals. Candidates not wishing to use the

module to attain the certificate in advanced Veterinary Practice (Cardiology) can present case books

made up exclusively from small, or large animal cases.

Module C-VC.2 is mandatory for those aiming to achieve the CertAVP (Cardiology).

LEARNING TOPICS

At the end of the module, candidates should be able to:

To select appropriate diagnostic techniques for small or large animal patients based on their

history and clinical findings (auscultation, physical examination)

To be able to diagnose acute cardiac failure and shock

To show an understanding of the balance between patient care and patient stabilisation before

extensive diagnostic procedures are undertaken

To show competence in acquiring the appropriate diagnostic materials from the tests and

procedures selected, for example, electrocardiographs, radiographs and echocardiographs

must all be of diagnostic quality and the scope of each examination sufficient to satisfy the

diagnostic question being asked

To have the ability to critically assess and measure the diagnostic material once it has been

derived

To show competence in interpreting all of the diagnostic material that the candidate has

acquired from each case and integrating all of the elements of their diagnostic work up to

determine a final diagnosis

To provide an accurate diagnosis after their series of diagnostic tests have been completed

For the purposes of the case log the candidate MUST have performed a full clinical examination on

each animal entered

1. Clinical examination:

Auscultation—presence of murmurs, gallop sounds, arrhythmias or inappropriate rates,

examination of the respiratory system

Pulse palpation—rate, character and rhythm

Mucous membranes and peripheral perfusion—assessment of mucous membrane colour and

refill time and adequacy of peripheral perfusion

Examination for extra-cardiovascular manifestations of cardiovascular disease and failure

The candidate is then expected to choose appropriately from the following core list of ancillary

diagnostic aids, or if clinical examination is sufficient to make a final diagnosis of the cardiovascular

abnormality e.g. in a case of hypovolaemic shock, the candidate can proceed to this as a final

diagnosis in the case log.

2. Ancillary Diagnostic aids

a) Electrocardiography

The candidate must then be able to:

- Calculate heart rate

- Assess heart rhythm

- Assess cardiac conduction and waveform shapes

- Detect evidence of cardiac enlargement

- Understand the application of Holter or other long term ECG monitors

b) Measurement of arterial blood pressure

Direct and indirect methods

c) Radiology

The candidate should understand the basic principles of radiography and recognise

common film faults

Additionally the candidate should demonstrate an understanding of:

radiographic anatomy of the cardiovascular and respiratory system

radiographic changes in all organs associated with cardiovascular disease

radiographic changes in cardiac failure

principles and indications for angiography

d) 2-D and M-mode Echocardiography—acquisition, recognition, measurement and interpretation of

standard 2D and M-mode images;

The candidate should

- understand the basic principles of echocardiography, recognise common faults and

be familiar with and capable of obtaining the standard views of the heart

appropriate to their species bias

recognise and describe normal echocardiographic anatomy. (Candidates should

possess a detailed knowledge of normal cardiac anatomy of the dog, cat and horse

and of the variations with breed and age, as appropriate to the case log

an understanding of how common cardiovascular diseases affect the cardiac

chambers and the standard measurements made

a knowledge of common artefacts and an understanding of the potential pitfalls of

an echocardiographic study

e) The basic principles and applications of Doppler echocardiography including knowledge of

common artefacts and an understanding of the potential pitfalls of Doppler

echocardiographic methods.

f) Laboratory tests—in particular renal function, liver enzymes, electrolytes, blood gases and

haematology. Knowledge of specific laboratory tests for cardiac disease e.g. cardiac

troponins etc.

For radiography and echocardiographic images, the candidate will be expected to demonstrate via

their case reports that they are able to recognise and explain faults, when present in their

diagnostic material

ASSESSMENT

Case log of 50 cases with broad range of tests - list the case details and diagnostic procedures

used for each case.

At the end of the case log candidates should include a 1,000 word synopsis of what they have

learned from the cases. This might include what has changed in their approach to a case, any

new procedures or investigations that are now considered, any additional reading which was

helpful, and/or any unexpected features of a case which will influence decision making in the

future.

Two case reports, each of up to 2,000 words in length. These cases should be selected to

demonstrate that the candidate has developed proficiency in the skills and understanding of

the learning objectives outlined in the module content. It should include personal reflection

which should critically evaluate their management of the case. Appropriate cases might

include those where a candidate can discuss what went well, what went badly, challenging

decision making and alternative management options.

Article critique (up to 800 words) from a chosen list of journal articles about an aspect of

diagnosis in veterinary cardiology and how this article would alter their management of

cases. Include comments on how the paper had affected the candidates own practising of

cardiology in relation to diagnosis and how this may have informed their learning.

Candidates are encouraged to make reference to related veterinary literature in the reference

critique. The selection of articles will be emailed to candidates.

A one hour examination to consist of multiple answer questions and/or short answer

questions.

ANNUAL ASSESSMENT TIMETABLE

1st March Case log, synopsis, two reports and reference critique to be submitted

by 1st March

July Formal examination to be held in July - date to be confirmed

Candidates are strongly advised to have a supervisor with which they can discuss cases. Ideal

supervisors would have post-graduate qualifications in your area of interest. The module leader will

not be discussing case management with any candidate.

CASE REPORT GUIDELINES

The case report should be written in the third person in a style suitable for publication in a Journal

(for example Journal of Small Animal Practice).

The following frame work should be used as a guide to the structure of the case report:

Identification of patient

History

Clinical signs

Problem list and differential diagnoses

Investigation

Diagnosis

Treatment (including postoperative care/instructions)

Follow up

Result

Discussion

References

INSTRUCTIONS FOR SUBMITTING CASE REPORTS / ESSAYS

Please ensure that at the beginning of your case report/reflective essay is included:

your name

module name

title

word count (excluding the above, tables, photo titles and references)

Case reports/reflective essays should be referenced and references cited in a standard format.

Use The Veterinary Record or The Journal of Small Animal Practice as guidance to both

citation of references within the text and format of references in the reference list.

The Harvard Guide to Referencing is also available to candidates enrolled for learning

support or online (various web sites allow the guide to be downloaded).

Please submit your case report/reflective essay as a

MS Word document (97-2003 format or later)*

and your case logs as a

MS Excel spreadsheet (97-2003 format or later)*

attached to an e-mail and send it to: certavp@rvc.ac.uk

Please ensure digital images are submitted in a compressed format so that they can be easily

transferred via e-mail.

*(Please note that as case reports/essays in alternative formats have been unreadable in MS Office any

other format will be sent back to the candidate)

SUGGESTED READING

General cardiology:

BSAVA Manual of Canine and Feline Cardiorespiratory Medicine, 2nd edn. Eds: V Luis Fuentes,

LR Johnson, S Dennis. 2010, BSAVA, Gloucester.

Topics in Cardiology. An Issue of Veterinary Clinics: Small Animal Practice (The Clinics:

Veterinary Medicine). Volume 40, Number 4, July 2010. Ed: JA Abbott. TheClincs.com.

Manual of Canine and Feline Cardiology, 4th edn. Eds: LP Tilley, FWK Smith Jr, M Oyama, MM

Sleeper. 2008, Elsevier Ltd, London.

Cardiovascular Disease in Small Animal Medicine. Ed: WA Ware. 2007, Manson Publishing Ltd,

London.

Notes on Cardiorespiratory Diseases of the Dog and Cat, 2nd edn. Eds: M Martin, B Corcoran.

2006, Blackwell Publishing, Oxford.

Textbook of Canine and Feline Cardiology: Principles and Clinical Practice, 2nd edn. Eds: PR Fox,

D Sisson, NS Moïse. 1999, W.B. Saunders, Philadelphia.

Cardiac auscultation:

Cardiac Auscultation and Phonocardiography in Dogs, Horses and Cats. Eds: C Kvart, J

Häggström. 2002, Clarence Kvart, Uppsala.

Electrocardiography:

Small Animal ECGs: An Introductory Guide, 2nd edn. Ed: M Martin. 2007, Blackwell Publishing

Ltd, Oxford.

ECG: Electrocardiography for the Small Animal Practitioner (Made Easy). Eds: LP Tilley, NL

Burtnick. 1999, Teton New Media, Jackson.

Radiography:

BSAVA Manual of Canine and Feline Thoracic Imaging. Eds: T Schwarz, V Johnson. 2008,

BSAVA, Gloucester.

Textbook of Veterinary Diagnostic Radiology, 5th edn. Ed: DE Thrall. 2007, Saunders Elsevier, St

Louis.

Echocardiography:

Manual of Veterinary Echocardiography. Ed: JA Boon. 1998, Williams & Wilkins, Baltimore.

Small Animal Diagnostic Ultrasound, 2nd edn. Eds: TG Nyland, JS Mattoon. 2002, WB Saunders,

Philadelphia.

CRITERIA FOR THE CASE LOG OF THE VETERINARY CARDIOLOGY C MODULES

The scope of the examination is related to the recognition and diagnosis of conditions that commonly affect the cardiovascular systems of the domestic species

that are regularly encountered in general veterinary practice. Therefore, in selecting cases for the log, candidates should choose a representative sample of

cases to encompass these conditions:

acute cardiac or cardiovascular failure

chronic cardiac failure

acquired heart disease, including valvular and myocardial disease

congenital heart disease

pericardial disease

cardiac arrhythmias

thromboembolic disease

cardiac disease secondary to other systemic diseases

An acceptable case log should have at least one case representing each of the preceding conditions. Case logs representing only one species and cases

presenting for screening are not acceptable. Cases with the same disease (e.g. degenerative mitral valve disease) should not represent more than 20% of the log

and no more than 10% of cases should be listed as second surgeon. All abbreviations should be explained

The diary is meant to be a continuous log of all cardiology cases performed by the candidate up to the time of submission therefore they should be listed in

chronological order. The same procedure in a different patient can be used again. Cases can be collected from up to 12 months prior to the date of enrolment

on the CertAVP programme.

Information to be included in the log:

a) Date

b) Name / case number / unique identifier

c) Signalment: inc. breed, age

d) Brief list of presenting signs e.g. cough, collapse, exercise intolerance

e) Abnormal auscultation and physical exam findings pertinent to the cardiovascular system; murmur, gallop, arrhythmia, Heart rate if abnormal,

other; e.g. inspiratory rates. Increased respiratory rate, abdominal distension, pyrexia etc.

f) List of ancillary diagnostic tests in the order in which they were performed and their most significant outcomes, for example:

- ECG: sinus rhythm

- Radiographs: slight LA enlargement

- Echocardiography : irregular mitral valve thickening and left atrial enlargement on 2D, MR detected by pulsed wave Doppler

g) Final diagnosis

EXAMPLE CARDIOLOGY CASE LOG (BASED ON ACVIM CARDIOLOGY CASE LOG)

Date Case

number

and

client

name

Age,

sex,

breed

EC

G

XR

AY

MM

OD

E

2D

DO

PP

LE

R

Other diagnostics Diagnosis Treatment and follow-up

5.1.09 697708

Smith

12 yo

MC

LABR

x x x x x Blood tests DCM, left sided CHF,

VPCs

Furosemide,

Pimobendan,

Benazepril

Recheck 1

Week

5.1.09 697718

Brown

9 yo

FS

DSH

x x x x x Doppler

systolic blood

pressure

HCM Benazepril

Example key:

MC male castrated FS female spayed

LABR Labrador retriever DSH Domestic Shorthair

CHF Congestive heart failure VPCs Ventricular premature complexes

HCM Hypertrophic cardiomyopathy

Version 3 19/07/2011

Marking Regulations

1.

Course: RCVS – Certificate of Advanced Veterinary Practice

2.

Section: C Module C-VC.2 Veterinary Cardiology Cardiovascular Diagnostics

3.

Applicable to Academic Year: 2010/11 onwards

4.

Aspects of course covered by Examination CertAVP C-VC.2 Veterinary Cardiology Cardiovascular Diagnostics learning outcomes

and topics

5. Requirement to be completed to permit entry to the examination:

1. Appropriate enrolment to the C module

2. Candidates are advised that they should achieve a pass grade in the B Practice

Module

6.

Form of Examination

1. Case log (50 cases)

2. 1,000 word synopsis

3. 2 x 2000 words case reports

3. Reference critique (800 words)

4. One hour exam – short answer and extended matching questions

7.

Marking Criteria

1. Case log – approval of appropriate numbers and timeline as described in course

literature

2. Case log synopsis – grading on the RVC 0-100 (17 point) marking scheme

3. Case reports – grading on the RVC 0-100 (17 point) marking scheme

4. Reference critique – grading on the RVC 0-100 (17 point) marking scheme

8.

Allocation of Marks and any additional requirements

First Submission

- Re-submission Only those parts of the module identified as failing in the initial submission will be re-

marked.

Version 3 19/07/2011

9.

Requirements to Pass Overall Work must be submitted and assessed within the 10 year registration period, or if

enrolled after 1st July 2010, within the 2 year registration period.

First Submission

Approval of the case log 50% or greater in the grading of the case log synopsis

50% or greater in the grading of each case report

50% or greater in the grading of the reference critique

50% or greater in the examination

Re-submission

Sections graded below 50% in the first submission are re-graded on re-

submission and the following criteria must be reached taking that new grading

into account: - Approval of the case log - 50% or greater in the grading of the case log synopsis - 50% or greater in the grading of each case report - 50% or greater in the grading of the reference critique - 50% or greater in the examination

10.

Consequences of Failure

1. A candidate who fails at their first submission will be required to re-submit or re-

sit the sections they have failed in the next or a future assessment cycle, or

withdraw from the Certificate.

2. A candidate who does not meet the requirements to pass overall after taking all the

allowed opportunities to resubmit their work will normally be required to

relinquish the course of study but s/he will have the right of appeal as described in

the College Regulations.

3. Should a candidate successfully appeal to be re-admitted to the Certificate they

would normally have to repeat the entire module with new case material and

would incur a further assessment fee.

11.

Classification

The examination is only classified as a Pass or a Fail. Candidates that pass the

examination will be allocated 10 credits in the CertAVP structure and the RCVS will be

appropriately informed.

12. Disclosure of Marks Candidates will be advised of their marks by email and they can request a letter

confirmation.

13. Late submission of work Work that is submitted after the annual deadline cannot be accepted for grading in that

year. Work may stay on file for grading at the next submission date or the candidate

may re-submit before that date.