Transcript Name of presentation

Practical Cardiology
Case Studies
Wendy Blount, DVM
Nacogdoches TX
Jake
Signalment
• 9 year old male Boxer
Chief Complaint
• Deep cough when walking in the morning, for
about one week
• Appetite is good
Jake
Exam
• Weight 81.9 – has lost 5 pounds in 3 months (BCS 3)
• Temp 101.4
• Mucous membranes pink, CRT 3.5 seconds
• Subtle dependent edema on the lower legs
• Jugular veins normal
• Harsh lung sounds
• 3/6 holosystolic murmur, PMI left apex
• Heart rate 160 per minute
• Respirations 55 per minute
• Femoral pulses somewhat weak
Jake
Differential Diagnosis - Cough
• Respiratory Disease
• Cardiovascular Disease
• Both
Jake
Diagnostic Plan (B Client)
• Blood Pressure
– 150 mm Hg systolic (Doppler)
• Chest X-rays
–
–
–
–
–
Massively enlarged heart (VHS 12.5)
Enlarged LA, LV (dorsally elevated trachea)
Enlarged pulmonary veins
Perihilar pulmonary edema
Left congestive heart failure
Jake
Immediate Therapeutic Plan (10 am)
• Furosemide
– 80 mg IM
• 4 hours later
– Respiratory rate is 36 per minute
Jake
Diagnostic Plan – 2nd Wave (2 pm)
• EKG
– Normal Sinus Rhythm
• Echocardiogram
(video)
Jake - Echo
Transverse - LV Apex
• LV Looks Big
Transverse - LV Papillary Muscles
• LV looks REALLY big
• Myocardium is hardly moving
• Flat papillary muscles
Jake - Echo
Transverse - LV Papillary
Muscles
•
•
•
•
•
•
IVSTD – 9.7 mm (n 10.8-12.3)
LVIDD – 72.1 mm (n 43-48)
LVPWD – 15.1 mm (n 8.7-10)
IVSTS – 11.9 mm (n 16.5-18.1)
LVIDS – 67.1 mm (n 27.4-30.4)
LVPWS – 13.0 mm (n 14-15.6)
FS = LVIDD – LVIDS
LVIDD
(72.1-67.1)/72.1 = 7%
(n 30-46%)
EF = 15% (n >70%)
Jake - Echo
Transverse - Mitral Valve
• No increased thickness of MV
• No vegetations on the MV
• EPSS – 12 mm (n <6 mm)
Transverse – Aortic Valve/RVOT
• LA at least Double Big
Jake - Echo
Transverse - Aortic Valve/RVOT
• AoS – 23.1 mm (n 27.4-30.4)
• LAD – 44.7 mm (n 25.8-28.4)
• LA:Ao = 44.7/23.1 = 1.9 (n 0.8-1.3)
Transverse – Pulmonary Artery
• No abnormalities noted
Jake - Echo
Long – 4 Chamber
• LV massively enlarged
• Poor systolic function
• LA 2x enlarged
• IVS is bowed toward the right, due to LV dilation
Long – LVOT
• No abnormalities in LVOT
(video)
Jake – Dx & Tx
Recommendations
• Left Congestive Heart Failure
–
–
–
–
–
Mini-panel and electroytes
Furosemide 80 mg PO BID
Enalapril 20 mg PO BID
Recheck mini-panel and electrolytes in 3-5 days
Recheck chest rads 3-5 days
• Dilated Cardiomyopathy
– Pimobendan 10 mg PO BID (declined)
– Carnitine 2 g PO BID
– Recheck echo, chest rads, EKG, mini-panel/lytes 60 days
(sooner if respiratory rate >40 at rest)
Jake - Bloodwork
CBC
• normal
Mini-panel - BUN, creat, glucose, TP, SAP, ALT
• Normal
Electrolytes
• Not done
Jake – Follow-Up
Recheck – 6 days
• BUN 30 (n 10-29)
• Creat normal
• Electrolytes not done
• Chest x-rays not done
No additional rechecks were done, owner did
not monitor respiratory rate at home
Jake – Follow-Up
4 months later…
• Chief complaint –
– Doing well until last week
– poor energy, coughing again, not eating
• Chaotic heart sounds with pulse deficits on
auscultation
– “tennis shoes in a dryer”
ECG
Jake – Follow-Up
26
ECG
• Heart Rate 200 bpm (tachycardia)
• Rhythm – irregularly irregular, no P waves,
irregular pattern to PR interval
• P wave – not present – can not measure
• PR interval – no P wave – can’t measure
• QRS – 0.084 sec x 2.6 mV
• ST segment - <-0.2mV depression
2.1
o
• MEA – 90
Dilated Cardiomyopathy
Common Historical and PE findings
• Onset seems rather acute – signs of LHF
– Coughing, dyspnea, exercise intolerance, weak pulses, poor
appetite and energy
• Sometimes RHF also
– Ascites, pleural rubs, jugular vein distension, peripheral edema,
diarrhea
• Syncope
• Mitral murmur
– Holosystolic, PMI left apex
• Chaotic heart sounds with pulse deficits if A-fib
Dilated Cardiomyopathy
Common Radiographic Findings
• Generalized cardiomegaly - Increased VHS
• Enlarged LV – elevated trachea
• Enlarged LA – compressed left bronchus
• + RA/RV enlargement
• + Left Heart Failure – lobar veins > arteries,
pulmonary edema
• + Right Heart Failure – enlarged caudal vena
cava, ascites, pleural effusion,
hepatosplenomegaly
Dilated Cardiomyopathy
Common Echocardiographic Lesions
• Dilation of all 4 heart chambers
• Large LVIDD (eventually large LVIDS also)
• Hypokinesis of LV wall and IVS
• Reduced FS
• Paradoxical septal motion
• Increased EPSS
• Normal looking MV and TV leaflets
• Papillary muscle flattening
Dilated Cardiomyopathy
Common ECG Findings
• Wide P wave
• Tall R wave
• Atrial fibrillation
• VPCs
• Ventricular arrhythmias
Dilated Cardiomyopathy
Treatment
• Pimobendan 0.2-0.3 mg/kg PO BID
– Inodilator – positive inotrope and vasodilator
• Treat left heart failure if present
– Diuretics
– ACE inhibitor if tolerated
• 0.5 mg/kg PO SID-BID
– Nitroprusside CRI if critical
– Dopamine or dobutamine CRI if critical
– Thoracocentesis if pleural effusion in cats
– Oxygen, of course
Dilated Cardiomyopathy
Treatment
• Furosemide boluses for fulminant LHF
–
–
–
–
–
–
80% effective
6-8 mg/kg IV Q1-2 HR UNTIL RR<50
4 mg/kg IV q1-2h until RR<40
4 mg/kg PO q4-6 hr until RR<30
Then PO q6-12 hrs to maintain RR<30
Give IM if placing IV cath might be fatal
• Furosemide CRI may be more effective
– 0.5 to 1.0 mg/kg/hr
Dilated Cardiomyopathy
Treatment
• Monitoring fulminant LHF
– Lactate (return to normal)
– blood gases (resolution of acidosis and
hypoxemia)
– Respiratory rate
– PROVIDE WATER & WATCH URINE
PRODUCTION
– Check electrolytes at least daily
– Central line can make blood draws easy
Dilated Cardiomyopathy
Treatment
• Taurine – if whole blood taurine levels low
–
–
–
–
–
250-500 mg PO BID
Cats fed low taurine diets, or with genetic defect
American cocker spaniels
Dogs fed vegetarian diets
Large and giant breed dogs fed lamb and rice diet
• Carnitine – 500-1000mg PO BID
– Boxers with genetic defect
– Plasma levels have low sensitivity
– Myocardial biopsy is usually required
• Thyroxine – if hypothyroid
Dilated Cardiomyopathy
Monitoring patients in chronic LHF
• Chest x-rays and exam every 6 months
• Echocardiogram when chest x-rays change
– Every 6 months with cardiomyopathies
• ECG when arrhythmia ausculted, syncope, or if
disease which predisposed to arrhythmia
– Boxer cardiomyopathy
– Dilated cardiomyopathy
• Recheck sooner if RR at rest is >40 per minute
Dilated Cardiomyopathy
Monitoring patients in chronic LHF
• BUN, creat
– 3-4 days after starting or increasing ACE inhibitor
– Every 6 months when doing well
– Sooner if things get worse
• Electrolytes and blood gases
–
–
–
–
Every 6 months when doing well
Sooner if things get worse
Potassium supplementation is often necessary
Untreated hypokalemia can predispose to arrhythmia,
especially if on digitalis
Dilated Cardiomyopathy
Prognosis
• Most dogs are done within 3 months of
becoming symptomatic, if treated properly.
• Survival is likely much shorter – days to weeks –
if untreated.
• Median survival for dogs with DCM and Afib is 3
weeks.
• All of these numbers prior to Pimobendan.
Dilated Cardiomyopathy
Screening
• Predisposed dog breeds show decreased
fractional shortening for many years prior to
onset of clinical signs and/or murmur
– FS has to fall <15% to cause CHF
• Screening by echocardiogram at young adult to
middle age is effective.
• No one knows whether early intervention
changes outcome.
Dilated Cardiomyopathy
Beta Blocker Therapy
• Seems counterintuitive for DCM
– Negative inotrope
• In people, chronic stimulation of B1 receptors is
cardiotoxic
– Improved survival when people with mycoardial
failure are put on beta blockers (carvedilol)
• No similar success with canine DCM
– Pharmakokinetics of carvedilol in dogs have been
studied, and are unpredictable
Atrial Fibrillation
Why Treat??
• Heart rate around 250 beats per minute
– Myocardial failure will result within 3-6 weeks
– Ventricles can not fill properly – forward heart failure
Treatment
–
–
–
–
–
Conversion would be ideal
But this is not easy to accomplish in very sick hearts
Big dogs with normal hearts – primary Afib
Medical conversion with quinidine
Anesthesia and conversion with electric shock
Atrial Fibrillation
Treatment – Afib in unhealthy hearts
– Slow the heart rate at the AV node (goal 150 bpm)
– Digoxin
• Weak positive inotrope
– Beta blockers
• Negative inotrope
• Propranolol 0.1-0.2 mg/kg PO TID
• Titrate up to effect to 0.5 mg/kg PO TID
– Calcium channel blockers
• Diltiazem 0.5 mg/kg PO TID (titrate up to 1.5 mg/kg)
DON’T USE BETA BLOCKER AND CALCIUM CHANNEL
BLOCKER TOGETHER!!
Tom
5 year old neutered male DSH
Chief Complaint
• Outdoor cat, owners think he was hit by a car
• Tom is laterally recumbent, and breathing hard
Exam
• T 96.5, P- 100, R – 66
• No evidence of trauma
Tom
ECG 1
• Heart Rate - 120
• Rhythm – regular, no P waves
• QRS – deep S wave, wide, bizarre QRS
• idioventricular rhythm
i-STAT EC8+
• K 10.9 mEq/L, iCa++ 0.96 mmol/L
• pH 7.08, HCO3 11 mEq/L
• Grapefruit sized very firm bladder
Tom
Treatment
• Place indwelling urinary catheter
• Place IV catheter
• Begin 0.9% NaCl at 15 ml/hr
• 1 unit regular insulin IV
• 5cc 50% dextrose diluted in 15 cc fluids, given over 1
hour; added 5%dextrose to fluids
ECG 2 – 6 minutes later
• Heart rate 140
• No P waves, QRS less abnormal
Tom
ECG 3 – 1 hour after presentation
• Heart rate 120
• No change for the past 45 minutes
Treatment
• Ca-gluconate 2cc IV slowly over 20 minutes
ECG 4 – 1 hour after presentation – T 98.9
• Heart rate 120
• P waves have returned, normal sinus rhythm
Tom
ECG 5 – 5 hours after presentation
• Heart rate 130
• Normal sinus rhythm
• P waves have returned to normal
i-STAT EC8+
• iCa++ normal, K 6.6 mEq/L
• HCO3-- 16.3 mEq/L, pH 7.29
Pockets
Signalment
• 11 year old spayed female yorkie (5 pounds)
Chief Complaint
• Harsh cough several times daily for 2 months
• History of chronic inflammatory liver disease, luxating
patellas, severe chronic periodontal disease and multiple
allergies; these problems clinically well managed at this
time.
• Mammary carcinoma removed one year previously, at
the time of OHE.
Pockets
Exam
• Temp 100.3, P 110, R 26, BP 110, BCS 3.5
• BAR, well hydrated, in good body condition
• Crackles in the small airways, especially at peak
inspiration
• Pronounced respiratory sinus arrhythmia
• Normal heart sounds
• Pulses normal, CRT < 2 sec
• Mature cataract right eye
Pockets
Differential Diagnoses - Cough
• Chronic Bronchitis
• Collapsing trachea
Diagnostic Plan - initial
• Chest and cervical x-rays
• Inspiratory - VD and right lateral
• Expiratory - left lateral
Pockets
Thoracic and cervical radiographs
• No collapse of the trachea
• Vertebral heart score 10
• Normal cardiac silhouette and pulmonary
vasculature
• Pronounced peribronchiolar pattern
• Shoulder arthritis
• Vertebral arthritis
• Normal sized liver
Pockets
Diagnostics – 2nd round
• Transtracheal wash
• Cytology – suppurative inflammation (mature
neutrophils)
• Culture negative
Treatment – Diagnosis Chronic Bronchitis
• Hydrocodone as needed for cough suppression
• Inhaled steroids PRN for cough
• Not tolerated – Temaril P instead
Pockets
Long term outcome – 4 years
(handout)
• Monitoring – chest rads every 6 months
• Dental cleaning every 4-6 months
• 1 episode of bacterial bronchpneumonia after dental,
despite treatment with metronidazole
• Amoxicillin 1 week before and after dental
• Increase cough suppressants for 3 days after dental
• Hydrocodone almost every day
• Temaril P for flare-ups
– Repeat transtracheal wash when severe
• Coughs once or twice almost every day
Daisy
Signalment
• 15 year old spayed female mixed terrier
• 11 pounds
Chief Complaint
• Became dyspneic while on vacation, as they
drove over a mountain pass
• Come to think of it, she has been breathing
hard at night for some time
Daisy
Exam
• T 100.2, P 185, R – 66, BP – 145, BCS – 3.5
• Increased respiratory effort
• 3/6 holosystolic murmur loudest at left apex
• Mucous membranes pale pink
• Crackles in the small airways
• Pulses weak
• CRT 3.5-4 seconds
Daisy
Differential Diagnosis - Dyspnea
• Suspect congestive heart failure
• Suspect mitral regurgitation
• Concurrent respiratory disease can not be ruled
out
Initial Diagnostic Plan
• Chest x-rays
• CBC, mini-panel, electrolytes
Daisy
CBC, mini-panel, electrolytes
• Normal
Thoracic radiographs
•
•
•
•
•
•
•
Markedly enlarged LA
Compressed left mainstem bronchus
Perihilar edema
Vertebral heart score 11.75
Elevated trachea – LV enlargement
Right heart enlargement
Mildly enlarged liver
Daisy
Initial Therapeutic Plan
• Lasix 25 mg IM, then 12.5 mg PO BID
• Enalapril 2.5 mg PO BID
• Owner is a lab tech, and set up oxygen mask to
use PRN at home
• Recheck BUN, potassium, chest rads 3-5 days
• Come back sooner if respiratory rate at rest is
above 40 per minute without oxygen
Daisy
Recheck – 4 days
• Daisy’s breathing is much improved (30-40 at
rest)
• Lateral chest x-ray
• Electrolytes normal
• BUN 52
Daisy
Diagnostic Plan - updated
• Decrease enalapril to SID
• Recheck BUN 1 week
• Recheck chest rads 1 week
Recheck – 1 week
• BUN – 37
• Thoracic rads no change
• Request recheck in 3 months, or sooner if respiratory
rate at rest is above 40 per minute
Daisy
2 months later
• Daisy is breathing hard again at night
Exam
• Same as initial presentation
Diagnostic Plan
• CBC, mini-panel, electrolytes
• Chest x-rays
Daisy
Bloodwork
• CBC, electrolytes normal
• BUN 88
Therapeutic Plan
• Increase furosemide to 18.75 mg PO BID
• Add hydralazine 2.5 mg PO BID
• Recheck chest rads, BUN, electrolytes, blood
pressure 1 week
Daisy
Recheck – 1 week
• Clinically much improved – respiratory rate 3040 per minute at rest
• electrolytes normal
• BUN 58
• Blood pressure 135
• Chest x-rays
• Recommend recheck in 3 months, or sooner if
respiratory rate above 40 per minute at rest
Daisy
Recheck – 6 months
• Daisy dyspneic again
Exam
• Similar to last crisis – BP 90
Diagnostic Plan
• CBC, mini-panel, electrolytes
• Echocardiogram, ECG, chest x-rays
Daisy
Bloodwork
• CBC, electrolytes normal
• BUN 105, creat 2.1
Chest x-rays
• Similar to last crisis
ECG
• Sinus tachycardia, wide P wave
Daisy - Echo
Short Axis – LV apex
(video)
• LV looks big
Short Axis – LV papillary muscles
•
•
•
•
•
•
IVSTD – 6.0 mm – low normal
LVIDD – 35 mm (n 20.2-25)
LVPWD – 4.3 mm – low normal
IVSTS – 9.4 mm – normal
LVIDS – 25 mm (n 11.1-14.6)
LVPWS – 8.4 mm - normal
Daisy - Echo
Short Axis – LV papillary muscles
•
•
•
•
•
•
IVSTD – 6.0 mm – low normal
LVIDD – 35 mm (n 20.2-25)
LVPWD – 4.3 mm – low normal
IVSTS – 9.4 mm – normal
LVIDS – 25 mm (n 11.1-14.6)
LVPWS – 8.4 mm – normal
• FS – (35-25)/35 = 29% (normal 30-46%)
Daisy - Echo
Short Axis - MV
• MV leaflets hyperechoic and thickened
• EPSS – 8 mm (n 0-6)
Short Axis – Aortic Valve/RVOT
• LA appears 2-3x normal size
• AoS – 13.0 – normal
• LAD – 33 mm (n 12.8-15.6)
• LA/Ao = 2.5 (n 0.8-1.3)
Daisy - Echo
Long View – 4 Chamber
• LV and LA both appear large
• MV is very thick and knobby, with some
prolapse into the LA
Long View – LVOT
• Large LA, Large LV
(video)
Daisy
Therapeutic Plan
• Increase hydralazine to 5 mg PO BID
• Add spironolactone 12.5 mg PO BID
• Add pimobendan 1.25 mg PO BID
• Increase furosemide to 18.75 mg PO TID x 2
days, then decrease to BID if respiratory rate
decreases to less than 40 per minute at rest.
• Recheck 1 week – BUN, creat, phos,
electrolytes, chest rads, BP
Daisy
Recheck – 1 week
• Clinically improved again
• BP - 125
• BUN 132, creat 2.6, phos 6.6
• Electrolytes normal
• chest rads improved pulmonary edema
Therapeutic Plan – Update
• Add aluminum hydroxide gel 2 cc PO BID
Daisy
5 Months later
• Coughing getting worse
• Chest rad show no pulmonary edema
• LA getting larger
Therapeutic Plan – Update
• Add torbutrol 2.5 mg PO PRN to control cough
Daisy
18 Months after initial presentation
• Owner discontinue pimobendan due to GI upset
28 months after initial presentation
• Daisy finally took her final breath
• BUN >100 for 22 months
Chronic MV Disease
• May be accompanied by similar TV disease
(80%)
• TV disease without MV disease is possible but
rare
• LHF and/or RHF can result
• Right heart enlargement can develop due to
pulmonary hypertension due to LHF
• Myocardial failure and CHF are not directly
related
Chronic MV Disease
Thoracic radiograph abnormalities:
• LV enlargement
– Elevated trachea
– increased VHS
• LA enlargement – often largest chamber
– Compressed left bronchus
• + left heart failure
– Pulmonary edema
– Lobar veins larger than arteries
Chronic MV Disease
Echo abnormalities:
•
•
•
•
•
LA and/or RA dilation, LV and/or RV dilation
Exaggerated IVS motion (toward RV in diastole)
Increased FS first, then later decreased FS
Thickened valve leaflets
If TV only affected, left heart can appear compressed,
small and perhaps artifactually thick
• Ruptured CT –
– MV flips around in diastole
– MV flies up into LA during systole
– May see trailing CT, or CT floating in the LV
Chronic MV Disease
ECG abnormalities:
• Wide or notched P wave
– Enlarged LA
• Tall R wave
– Enlarged LV
• Right Bundle Branch block
– Wide QRS
– Deep S wave
• Left Bundle Branch Block
– Wide QRS
– Tall R wave
Chronic MV Disease
Right Heart Failure
• Medications similar to LHF
• Medications not as effective at eliminating fluid
congestion
– More effective at preventing fluid accumulation, once controlled
• Periodic abdominocentesis and/or pleurocentesis
required
• Prognosis for RHF and LHF is extremely variable
NTproBNP ELISA
N-terminal pro-B type Natriuretic Peptide
• In clinic test to distinguish cardiac from respiratory
dyspnea
• Validated in dogs JACVIM January 2008
• <210 pmol/L – more likely respiratory disease
• >210 pmol/L – more likely cardiac disease
• Falsely elevated by increased creatinine
• Helpful in distinguishing cardiac from respiratory
dyspnea when creatinine is not elevated