Cardiopulmonary History and ExamCardiopulmonary History and Exam

Wendy Blount, DVMLufkin TXWendy Blount, DVMLufkin TX

HousekeepingHousekeeping

• PowerPoints and Handouts are on flash drive

• Dylan is our “concierge”

• Course materials are also downloadable at http://wendyblount.com/cardiology.php– Go to http://wendyblount.com

– Click on Presentation Notes

HousekeepingHousekeeping

• PowerPoints and Handouts are on flash drive

• Dylan is our “concierge”

• Course materials are also downloadable at http://wendyblount.com/cardiology.php– Go to http://wendyblount.com

– Click on Presentation Notes

HousekeepingHousekeeping

• Course materials are also downloadable at http://wendyblount.com/cardiology.php– Go to http://wendyblount.com

– Click on Presentation Notes

– Click on the “Practical Cardiology” link at the top of the page

• Course materials are also downloadable at http://wendyblount.com/cardiology.php– Go to http://wendyblount.com

– Click on Presentation Notes

– Click on the “Practical Cardiology” link at the top of the page

– Click on the items that you want to view or download

HousekeepingHousekeeping

• Course materials are also downloadable at http://wendyblount.com/cardiology.php– Go to http://wendyblount.com

– Click on Presentation Notes

– Click on the “Practical Cardiology” link at the top of the page

– Click on the PowerPoint Presentation that you want to view or download

HousekeepingHousekeeping

Following AlongFollowing Along

• Screen at the front of the room

• Flash Drive– .pdfs of PowerPoints - 1 & 6 slides/page

– .pptx of PowerPoints

– Filed in section folders & PowerPoint folder

• Website – updated PowerPoints– http://wendyblount.com/cardiology.php

• Screen Sharing: www.startmeeting.com– Click on the “join” button at the top right

Following AlongFollowing Along

• Screen at the front of the room

• Flash Drive– .pdfs of PowerPoints - 1 & 6 slides/page

– .pptx of PowerPoints

– Filed in section folders & PowerPoint folder

• Website – updated PowerPoints– http://wendyblount.com/cardiology.php

• Screen Sharing: www.startmeeting.com– Click on the “join” button at the top right

• Screen Sharing: www.startmeeting.com– Click on the “join” button at the top right

– Enter meeting ID “practicalvetmed”

– Click the “Submit” button

Following AlongFollowing Along

• Screen Sharing: www.startmeeting.com– Click on the “join” button at the top right

– Enter meeting ID “practicalvetmed”

– Click the “Submit” button

– Enter your screen name and e-mail

– Click the “Join” button

Following AlongFollowing Along

Following AlongFollowing Along

• Screen Sharing: www.startmeeting.com– Click on the “join” button at the top right

– Enter meeting ID “practicalvetmed”

– Click the “Submit” button

– Enter your screen name and e-mail

– Click the “Join” button

Proceedings PacketProceedings Packet

• CE certificate

• List of Abbreviations

• Agenda

• Pen & Paper Pad

• Proceedings – Flash Drive (Table of Contents)

• Evaluation form – Pretty Please!!

• List of upcoming Seminars - *NEW – Clin Path*

• Eli’s Fund

• Instructions for screen sharing

Proceedings PacketProceedings Packet

• Flash Drive Proceedings– Introduction – TOC, Agenda, Abbreviations– Materials by Section/Subject– Duplicated Materials by Type:

• PowerPoints• Laboratory Forms and Information• In Clinic Forms• Vet Handouts – Diagnostic and Treatment Aids• Client Handouts – Disease Conditions and Drugs• Scientific Articles and Guidelines• Audio and Video Files

Proceedings PacketProceedings Packet

• CE certificates– I will time and date my signature, if you leave early

– Check off hours attended on the back, sign and date

– New Board Rule – make sure you have your CE certificates with you

• Evaluations– leave them with Dylan when you go

– Mailing and scan/e-mail is fine, too

– russ@vonallmen.net

Daily ScheduleDaily Schedule

• 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 – Sound® Presentation 12:30-1:20pm

• Sun – Scan-IQ® Dry Lab

AgendaAgenda

• 1 - Intro and Cardiovascular Hx & Exam• 2 – Thoracic Radiology• 3 – ECG Basics• 4 - Sat – Sound® Presentation 12:30-1:20pm• 4 - Sun – Scan-IQ® Dry Lab• 5 – VetBLUE® and TFAST® Ultrasound;

Echocardiogram Basics• 6 – CPR Update• 7 – Heartworm Disease Update• 8 – Cardiology Cases

Practical Medicine PhilosophyPractical 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 imagesand videos, EKGs and listen to heart and lung sounds

Practical Medicine PhilosophyPractical Medicine Philosophy

• Some are already doing these things

– Echocardiograms, GlobalFAST®, reading ECGs, defibrillating

• Some will be ready to begin

• Some will need some hand holding, at least at first

– TexasVets – Yahoogroups

– Moderator Rosemary Lindsey rosemarylindsey@sbcglobal.net

• Some will be happy to be better referring vets

Practical Medicine PhilosophyPractical Medicine Philosophy

Our Goal

• Review common things in detail– Increase and confirm understanding

• Cover uncommon things in less detail– Recognize them and refer to proceedings

• PLEASE PARTICIPATE!!

• But take private conversations out in the hall

Eli’s FundEli’s Fund

• Eli’s Fund is a source of financial support for active duty service men and women, medically retired veterans’ service animals, and retired military animals with veterinary medical bills at the TAMU-VTH

• There is a one page flyer in your packet• Letter from Colton’s mother in packet

• Donation box on Dylan’s desk• give online, to TAMU Office of the Dean:

https://www.txamfoundation.com/give.aspx?c_id=9&d_id=57&sd_id=190

Eli’s FundEli’s Fund

SignalmentSignalment

Age• Congenital disease

– young

• Myxomatous Valvular Disease– old

• Exceptions– Cavalier King Charles Spaniels – mild PDA, PS, SAS– Reverse PDA– HCM in purebred cats

SignalmentSignalment

Breed• Boston Terrier• Cavalier• Cocker Spaniel• Boxer

• Doberman• English Bulldog• Golden Retriever

HBT, ColTrCVDDCM, PS, PDA, 3rdAVHBT, PS, SASDCM, Boxer CM, ASDDCM (Arrhythmia?)

SAS, PS, CVDSAS

SignalmentSignalment

Breed• Great Dane• GSD• Irish Setter• Irish Wolfhound• Keeshond• Labrador• Maine Coon• Newfoundland

DCM, CVDPRAA, SAS, PDAPRAADCMToF (define), MVDTVDHCMDCM, SAS

SignalmentSignalment

Breed• Persian/Himalayan• Pointer• Poodle• St Bernard• Samoyed• Schnauzer• Springer Spaniel• Yorkie

HCMPRAA, SASCVD, PDA, CBDCMASD, PSSSS, CVD, PS, CBVSDCVD, CB, CT

History - CollapseHistory - 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 - CollapseHistory - Collapse

What causes syncope?

1. Bradyarrhythmia2. Period of asystole3. Tachyarrhythmia4. Obstruction of blood flow to or from the heart5. Inability to deliver oxygen to the brain,

especially when there is increased demand• Decreased CO - Heart Failure**• Lung/airway disease• Anemia or other RBC problem

History - CollapseHistory - Collapse

What causes syncope?

– Bradyarrhythmia• 3rd degree heart block (define)• Sick sinus syndrome (define)

– Period of asystole• Sick sinus syndrome (SSS)• Vagal surge (examples)

– Abdominal dz & retching– Intubation (brachycephalic)

History - CollapseHistory - Collapse

What causes syncope?– Tachyarrhythmia burst

• Vtach (define, causes)

–Boxer CardioMyopathy–Myocarditis (Chagas, Parvovirus)–Myocardial hypoxia–Abdominal pathology (spleen)

• Supraventricular tachycardia (SVT) (define)

• Re-entry pathway (define)

• Atrial fibrillation (Afib)• SSS

History - CollapseHistory - Collapse

What causes syncope?

– Obstruction of a great vessel or heart chamber• Thrombus (clot or HWDz)

• Neoplasia• Extramural mass

– Increased oxygen demand can not be met due to severe cardiovascular or pulmonary disease• AKA Exercise intolerance

History - CoughHistory - 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 - CoughHistory - 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 - CoughHistory - 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 – StethoscopesExam – 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 – StethoscopesExam – 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 – StethoscopesExam – Stethoscopes

Cardiology Stethoscope - 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

AuscultationAuscultation

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)

AuscultationAuscultation

• 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

AuscultationAuscultation

• Is the murmur hemodynamically significant?– Prolonged and loud - yes– Pansystolic - yes– Diastolic - yes– Low intensity - maybe– Early systolic - maybe– Musical – maybe not so much

Loudness is not necessarily correlated to presence of heart failure

Auscultation – Lung SoundsAuscultation – 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 SoundsAuscultation - Heart Sounds

Normal Heart Sounds

Auscultation - Heart SoundsAuscultation - 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 (audio)

• Pulse is during systole

Auscultation - Heart SoundsAuscultation - 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 SoundsAuscultation - Heart Sounds

• Quieter S1 (AV softly closing or muffled)– Obesity, barrel chested dogs– Myocardial failure– Pronounced 1st degree heart block– hypervolemia

Auscultation - Heart SoundsAuscultation - 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 SoundsAuscultation - Heart Sounds

Third Heart Sound (Gallop)

S3 (S1-S2-S3)S4 (S4-S1-S2)Split S2Systolic ClickSummation Gallop (S4-S1-S2-S3)

Auscultation - Heart SoundsAuscultation - 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 SoundsAuscultation - Heart Sounds

Third Heart SoundS4 – 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 SoundsAuscultation - 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 SoundsAuscultation - 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 Sounds3 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

1 – left apex (MV)2 – left base (AoV)3 – right base (PV) – ausculted on the left

4 – right apex (TV)5 – left armpit (PDA)

5

Auscultation – Heart SoundsAuscultation – Heart Sounds

PMIleft right

Auscultation – Heart SoundsAuscultation – 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 SoundsAuscultation – Heart Sounds

Muffled Heart Sounds (causes)

• Pleural, Pericardial effusion (*difference*)

• Diaphragmatic hernia, thoracic masses• obesityWhat besides cardiac disease can cause a

pathologic murmur?• Anemia, hypoproteinemiaWhy 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 GradeAuscultation – Murmur Grade

Grade 1• Heard in a very quiet room, concentratingGrade 2• easily heard on the PMIGrade 3• Moderately loudGrade 4• Very loud over much of the chestGrade 5• Heard with edge of stethoscope on chest, palpable thrillGrade 6• Heard with stethoscope off chest, palpable thrill

Auscultation – Murmur GradeAuscultation – 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 murmurCats can have CHF without a murmur

Auscultation – Lung SoundsAuscultation – Lung Sounds

6 points3 Right, 3 Left – correspond to lung lobes

Auscultation – MurmursAuscultation – Murmurs

holosystolic• Starts at the end of audible S1• Ends at the start of audible S2• Murmur between the heart sounds

Auscultation – MurmursAuscultation – Murmurs

pansystolic• Starts at the beginning of S1• Ends at the end of S2• Just hear the murmur with no distinct HS

Respiratory Sinus ArrhythmiaRespiratory 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 ArrhythmiaRespiratory 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 – AscitesPhysical 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 MembranesExam – 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 – PulsesExam – 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 – PulsesExam – 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 – PulsesExam – 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 – PulsesExam – 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 – PulsesExam – 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 – PulsesExam – 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 (audio)

• Lots of multiform VPCs• Atrial fibrillation

Exam – Jugular VeinsExam – 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 VeinsExam – Jugular Veins

Jugular distension, high pulse, +HJR (causes)

• Jugular/caval occlusion– 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 VeinsExam – 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 – ExtremitiesExam – 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 )

AcknowledgementsAcknowledgements

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

SummarySummary

Hidden Slides• List of common cardiovascular diseases by breed

Kittleson M• Small Animal cardiovascular Medicine, Veterinary

Information Network. Chapter 3 – Signalment, History and Physical Examination