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Practical Cardiology Case Studies

Practical Cardiology Case Studies. Wendy Blount, DVM Nacogdoches TX. Jasper. Signalment: Middle Aged Adult Norwegian Forest Cat Male Castrated 13 pounds Chief Complaint: Acute Dyspnea 1 day after sedation with ketamine and Rompun for grooming

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Practical Cardiology Case Studies

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  1. Practical CardiologyCase Studies Wendy Blount, DVM Nacogdoches TX

  2. Jasper Signalment: • Middle Aged Adult Norwegian Forest Cat • Male Castrated • 13 pounds Chief Complaint: • Acute Dyspnea 1 day after sedation with ketamine and Rompun for grooming • Cannot auscult heart or lung sounds well - muffled

  3. Jasper Immediate Diagnostic Plan: • Lasix 25 mg IM – then in oxygen cage • When RR <50, lateral thoracic radiograph Differential Diagnosis – Pleural effusion • Transudate - Hypoalbuminemia • Modified Transudate – Neoplasia, CHF • Exudate – Blood, Pyothorax, FIP • Chylothorax (chart)

  4. Jasper Initial Therapeutic Plan: • Thoracocentesis • Tapped both right and left thorax • Removed 400 ml of pink opaque fluid that resembled pepto bismol • Fluid had no “chunks” in it Differential Diagnosis – updated • Pyothorax • Chylothorax

  5. Jasper Initial Diagnostic Plan: • Fluid analysis • Total solids 5.1 • SG 1.033 • Color- pink before spun, white after • Clarity – opaque • Nucelated cells 8500/ml • RBC 130,000/ml • HCT 0.7%

  6. Jasper Initial Diagnostic Plan: • Fluid analysis • Lymphocytes 5600/ml • Monocytes 600/ml • Granulocytes 2300/ml • No bacteria seen • Triglycerides 1596 mg/dl • Cholesterol 59 mg/dl Chylothorax

  7. Jasper DDx Chylothorax • Trauma – was chewed by a dog 2-3 mos ago • Right Heart Failure • Pericardial Disease • Heartworm Disease • Neoplasia • Lymphoma • Thymoma • Idiopathic

  8. Jasper Diagnostic Plan - Updated • PE & Cardiovascular exam • CBC, general health profile, electrolytes • Occult heartworm test • Post-tap chest x-rays • Echocardiogram

  9. Jasper Exam • Temp 100, P 180, R 48, BCS 3, BP 115 • 3/6 systolic murmur • Anterior mediastinum compressible • Pleural rubs • No jugular pulses, no hepatojugular reflux • Peripheral pulses slightly weak • Mucous membranes pink, CRT 3 sec

  10. Jasper Bloodwork • Occult Heartworm Test - negative • CBC – normal • GHP – • Glucose 134 (n 70-125) • Cholesterol 193 & TG 137 (both normal) Chest X-rays • Post-tap chest x-rays

  11. Jasper Chest X-rays • Minimal pleural effusion • No cranial mediastinal masses • Normal cardiac silhouette (VHS 7.5) • Normal pulmonary vasculature • Lungs remain scalloped

  12. Jasper – Echo Short Axis – LV apex (video of similar cat) • No abnormalities noted Short Axis – LV PM • No abnormalities noted • IVSTD – 8.8 mm (n 3-6) • LVIDD – 16.2 mm (normal) • LVPWD – 7.2 mm (n 3-6) • IVSTS – 9.8 mm (n 4-9) • LVIDS – 10.5 mm (normal) • LVPWS – 10.1 mm (n 4-10) • FS – 35%

  13. Jasper – Echo Short Axis – MV • No abnormalities noted Short Axis – Ao/RVOT • Smoke in the LA • AoS – 11.7 mm ( normal) • LAD – 10.5 (normal) • LA/Ao – 0.9 (normal)

  14. Jasper – Echo Short Axis – PA • Difficult to evaluate due to “rib shadows” Long Axis – 4 Chamber • Hyperechoic “thingy” in the LA, with smoke Long Axis – LVOT • Aortic valve seems hyperechoic, but not nodular • 2-3 cm thrombus free in the LA

  15. Jasper – Echo Short Axis – Ao/RVOT - repeated • LA 2-3x normal size, with Smoke • AoS – 11.7 mm ( normal) • LAD – 29 mm (n 7-17) • LA/Ao – 2.5 (n 0.8-1.3)

  16. Jasper – Echo Therapeutic Plan - Updated • Furosemide 12.5 mg PO BID • Enalapril 2.5 mg PO BID • Rutin 250 mg PO BID • Low fat diet • Plavix 18.75 mg PO SID • Lovenox 1 mg/kg BID • Fragmin 1 mg/kg BID • Clot busters only send the clot sailing

  17. Jasper – Echo Recheck – 1 week • Jasper doing exceptionally well –back to normal. • Lateral chest radiograph • Jasper declined all other diagnostics, without deep sedation/anesthesia • Will do BUN, Electrolytes, BP, recheck echo to assess thrombus in one month

  18. Jasper – Echo Recheck – 1 month • Jasper doing exceptionally well • Lateral chest radiograph – no change • Jasper declined all other diagnostics, without deep sedation/anesthesia • Will do BUN, Electrolytes, BP, recheck echo to assess thrombus at 6 month check-up.

  19. Jasper – Echo Recheck – 6 months • Jasper doing exceptionally well • BP – 140, chext x-rays no change • Jasper declined all other diagnostics, without deep sedation/anesthesia • May never do BUN, Electrolytes, recheck echo Long Term Follow-up • Jasper still doing well 18 months later • On lasix & enalapril only

  20. Hypertrophic Cardiomyopathy Clinical Characteristics • Diastolic dysfunction – heart does not fill well • Poor cardiac perfusion • Most severe disease in young to middle aged male catss • Can present as • Murmur on physical exam • Heart failure (often advanced at first sign) • Acute death • Saddle thrombus

  21. Hypertrophic Cardiomyopathy Radiographic Findings • + LV enlargement • Elevated trachea, increased VHS • LA + RA enlargement seen on VD in cats • + LHF • Pleural effusion • Pulmonary edema • Lobar veins >> ateries

  22. Hypertrophic Cardiomyopathy Echocardiographic Abnormalities • LV and/or IVS thicker than 6 mm in diastole • Symmetrical or asymmetrical • Can be only a thick IVS • Can be primarily very thick papillary muscles • LVIDD usually normal to slightly reduced • FS normal to increased, unless myocardial failure developing • LVIDS sometimes 0 mm

  23. Hypertrophic Cardiomyopathy Echocardiographic Abnormalities • LA often enlarged • RA sometimes also enlarged • “Smoke” can be seen in the LA • Rarely a thrombus in the LA • Transesophageal US more sensitive at detecting LA thrombi • Borderline thickened LV should not be diagnosed as HCM without LA enlargement

  24. Hypertrophic Cardiomyopathy DDx LV thickening • Hypertension • Hyperthyroidism • (Chronic renal failure) • Only HCM causes severe thickening of LV Dogs can rarely have HCM • Cocker spaniels

  25. Hypertrophic Cardiomyopathy Treatment • Manage heart failure • Therapeutic thoracocentesis in a crisis • Diuretics • ACE inhibitors • Beta blockers – if persistent tachycardia • Calcium channel blockers – if thickening significant • Treat hypertension if present

  26. Hypertrophic Cardiomyopathy Treatment • Q6month rechecks • Chest x-rays • CBC, GHP, electrolytes, blood gases • ECG if arrhythmia ausculted or syncope • BP • Sooner if RR >40 at rest • Sooner if any open mouth breathing ever

  27. Hypertrophic Cardiomyopathy Prognosis • Q6month rechecks • Chest x-rays • CBC, GHP, electrolytes, blood gases • ECG if arrhythmia ausculted or syncope • BP • Sooner if RR >40 at rest • Sooner if any open mouth breathing ever

  28. Hypertrophic Cardiomyopathy Screening • Genetic test is available at Washington State U • http://www.vetmed.wsu.edu/deptsvcgl/ • Auscultation not always sensitive • Echocardiogram can detect early in breeds predisposed • No evidence that early intervention changes outcome

  29. Hypertrophic Cardiomyopathy HOCM with SAM • Hypertrophic Obstructive Cardiomyopathy • Systolic Anterior Motion • The septal leaflet of the mitral valve is sucked into the LVOT instead of moving back toward the atria during systole • If it happens intermittently, it can cause an intermittent murmur

  30. Ginger Signalment • 12 year old SF cocker spaniel Chief complaint • Several episodes of collapse during the past month • Description matches partial seizure • Rear legs get weak on walks • Lethargic and dull in general

  31. Ginger Exam • Dark maroon oral mucous membranes • Rear foot pads cyanotic • Split S2 • Neurologic exam normal, except dull mental status Differential Diagnosis - cyanosis • Respiratory hypoxia • Cardiac hypoxia

  32. Ginger Initial Diagnostic Plan • CBC, GHP, electrolytes • Arterial blood gases, Pulse oximetry • ECG • Thoracic radiographs Bloodwork • Tech couldn’t get enough serum for serology • CBC – PCV 73% • GHP and electrolytes - normal

  33. Ginger Arterial blood gases • pO2 – 55 mmHg • pCO2 – 38 mmHg • all else normal Pulse oximetry • Lip – O2 sat 89% • Vulva - O2 sat 67%

  34. Ginger Thoracic radiographs • Normal great vessels • Normal heart size (VHS 9.5) • aortic bulge on VD • No evidence of severe respiratory disease which might cause hypoxia • No evidence of heart failure

  35. Ginger ECG • S wave mildly deep in leads I,, II, III, aVF • MEA 90o • Arrhythmia doesn’t seem likely Differential Diagnoses • Right to left shunt • Pulmonary hypertension

  36. Ginger Right to Left Shunt • Reverse PDA • Eisenmeinger’s physiology • Tetralogy of Fallot • AV fistula with pulmonary hypertension Echocardiogram • RV thickening • RV normally thinner than LV • No PDA seen without Doppler

  37. Ginger Bubble Study • Place venous catheter • Shake 5-10 cc saline vigorously • Place US probe where you can look for shunting • Long 4 chamber view • Abdominal aorta • Inject IV quickly • Bubbles normally appear on the right • Watch for bubbles on the left • False negatives when bubbles disperse quickly

  38. Ginger Bubble Study • Place venous catheter • Shake 5-10 cc saline vigorously • Place US probe where you can look for shunting • Long 4 chamber view • Abdominal aorta • Inject IV quickly • Bubbles normally appear on the right • Watch for bubbles on the left • False negatives when bubbles disperse quickly

  39. Reverse PDA Treatment • Ligation of right to left shunting PDA results in death due to pulmonary hypertension • Has been ligated in stages without causing death • Cyanosis and symptoms usually persist • Managed Medically by periodic phlebotomy • Remove 10 ml/lb and replace with IV fluids • Eliminate hyperviscosity without inducing hypoxia • Goal for PCV is 60-65% • Excellent blood for RBC transfusion ;-) • Repeat when clinical signs return

  40. Reverse PDA Treatment • Managed Medically by periodic phlebotomy • Remove 10 ml/lb and replace with IV fluids • Eliminate hyperviscosity without inducing hypoxia • Goal for PCV is 60-65% • Excellent blood for RBC transfusion ;-) • Repeat when clinical signs return

  41. Reverse PDA Treatment • Hydroxyurea • 30 mg/kg/day for 7 to 10 days followed by 15 mg/kg/day. • CBC q1-2 weeks • D/C when Bone marrow suppression • Resume lower dose • Some dogs require higher doses • side effects – GI and sloughing of the nails

  42. Reverse PDA Prognosis • Can do well short term • Poor prognosis long term • Survival months to a year or two • Phlebotomy interval is progressively shorter

  43. Gabby 6 month female DSH Presented for OHE Exam - HR 100 • No other abnormal findings

  44. Gabby ECG • Heart rate – 100 per minute – QRS complexes • 170 per minute – P waves • Rhythm – no consistent PR interval • P and QRS complexes are disassociated, but each regular • All other measurements normal • 3rd degree AV block

  45. 3rd degree AV block Treatment- cats • Avoid drugs that increase vagal tone • Alpha blockers – Domitor, Rompun • Often no treatment needed for cats • AV node pacemaker is 100 per minute • AV node pacemaker is 40-60 per minuted in the dog • Surgery can be supported with temporary pacemaker in cats

  46. 3rd degree AV block Treatment and Prognosis - Dogs • Usually presents for syncope • “Cannon wave” jugular pulses • Treated with pacemaker implantation • Drug therapy not usually successful • Usually no response to atropine • Atropine often makes 2nd degree block go away • Some have tried theophylline • Prognosis poor without pacemaker • If lactate is high, emergency pacemaker is needed

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