COMMON CARDIAC SCENARIOS

Transcription

1 COMMON CARDIAC SCENARIOS What do we know and how do we treat? FRED C. BREWER IV, DVM, DACVIM (CARDIOLOGY)

2 OVERVIEW INCIDENTAL MURMURS CONGESTIVE HEART FAILURE AND THE COUGHING DOG SYNCOPE AND ARRHYTHMIAS

3 WHAT DO WE KNOW? MURMURS

4 INCIDENTAL MURMURS Sources of murmurs PATHOLOGIC: Myxomatous degeneration Pulmonic stenosis Sub aortic stenosis Dysplastic valves Endocarditis REYNOLD S NUMBER= V X D X D VISCOSITY AUSCULTATION CLUES: 1) Harsh (plateau) murmurs 2) 3/6 or greater (anywhere) 3) Diastolic 4) Continuous 5) Right sided murmurs 6) Left/Right apical

5 INCIDENTAL MURMURS Sources of murmurs FUNCTIONAL VS. INNOCENT (NO echo evidence) Anemia Bradycardia REYNOLD S NUMBER= V X D X D VISCOSITY Hyperthyroidism Athletic heart DRVOTO (cats) Aortic hypoplasia (Boxers) AUSCULTATION CLUES: 1) 2/6 systolic or less 2) Basilar 3) Localized, Soft 4) Changes w/respiration or HR

6 INCIDENTAL MURMURS Grading SUBJECTIVE ASSESSMENT MURMUR GRADES: 1- soft focal; audible in quiet room 2- soft easier to auscult; localized 3- moderate intensity; easily ausculted in multiple chest regions 4- Loud and radiating 5- Palpable Thrill 6- Stethoscope off chest

7 INCIDENTAL MURMURS DIFFERENTIALS-PATHOLOGIC MURMURS Left SYSTOLIC MURMURS Right Apex Base Apex Base MMVD PS (PULMONIC STENOSIS) MTVD VSD MVDysplasia SAS (SUBAORTIC STENOSIS) TVDysplasia SAS/PS IE VSD PH (PULMONARY HYPERTENSION) (MYXOMATOUS MITRAL VALVE DEGENERATION) (infective endocarditis) DCM (VENTRICULAR SEPTAL DEFECT)

8 INCIDENTAL MURMURS DIFFERENTIALS-PATHOLOGIC MURMURS DIASTOLIC MURMURS Left Right Apex Base Apex Base MVStenosis AI (AORTIC INSUFFICIENCY) TVStenosis AI PI (PULMONIC INSUFFICIENCY) PI IE (INFECTIVE ENDOCARDITIS) CONTINUOUS MURMURS: THINK PDA! (AORTIC INSUFFICIENCY) (PULMONIC INSUFFICIENCY)

9 INCIDENTAL MURMURS: Scenario 1-PEDIATRIC (CANINE) MURMUR: FUNCTIONAL 2/6 Left basilar systolic murmur intensity increases after exercise ASYMPTOMATIC 6 WEEKS-6 MO (TOY BREED) (Root Kustritz 2011) 6 WEEKS 1+ YR (GIANT BREED) MURMUR: PATHOLOGIC 3/6 or greater Diastolic, Continuous Right/Left Apex Echocardiogram Wait and Watch-Functional vs. Trivial Congenital Defect Thoracic radiographs?- Correct diagnosis for congenital defects is on differential list 37-40% (Lamb et al, JSAP 2001)

10 INCIDENTAL MURMURS: Scenario 2-ADULT (CANINE) Small Breed MURMUR:(PATHOLOGIC) 3/6 left apical systolic SYMPTOMATIC ASYMPTOMATIC TREAT CHF + THX RADS + ECHO + BLOODWORK THX RADS + ECHO BLOODWORK ECHOCARDIOGRAM THORACIC RADIOGRAPHS NT-Pro BNP WATCHFUL WAITING

11 INCIDENTAL MURMURS: Scenario 2-ADULT (CANINE) Small Breed MURMUR:(PATHOLOGIC) 3/6 left apical systolic ASYMPTOMATIC ECHOCARDIOGRAM ACCURATE (Tse et al JVECC 2013) DISEASE SEVERITY CONCURRENT DISEASE PROGNOSIS CKCS MMVD VHS: 11 at 3.5-4yr before CHF 11 at 2.5-3yr before CHF yr before CHF yr before CHF at time of CHF (Lord et al JVIM, 2011) THORACIC RADIOGRAPHS NT-Pro BNP CARDIOMEGALY= 634pmol/L ( pmol/L) NO CARDIOMEGALY= 378pmol/L ( pmol/L) (Chetboul et al, JVIM 2009) WATCHFUL WAITING MURMUR INTENSITY AND DISEASE SEVERITY LOUDER=MORE SEVERE (Lungvall et al AJVR 2009)

12 INCIDENTAL MURMURS: Scenario 3-ADULT (CANINE) Large Breed 2/6 LEFT APICAL SYSTOLIC MURMUR FUNCTIONAL VS. PATHOLOGIC OVERLAP THINK: CHRONIC VALVE DISEASE VS. DILATED CARDIOMYOPATHY (LESS LIKELY: INFECTIVE ENDOCARDITIS) AUSCULTATION: UNRELIABLE THORACIC RADIOGRAPHS: LACKS DETAIL TO ASSESS SEVERITY NT-Pro BNP-DOBERMAN- >550pmol/L suggest occult DCM (Sen (78.6%), Sp (90.4%)) (Wess et al AJVR 2011) ECHOCARDIOGRAM

13 INCIDENTAL MURMURS: Scenario 4-GERIATRIC Large/Small Breed MEDIUM TO LARGE BREED DOGS SMALL BREED DOGS LEFT APICAL SYSTOLIC MURMUR >20kg THORACIC RADIOGRAPHS + ECHOCARDIOGRAM THORAX RADIOGRAPHS <20Kg ECHO THINK: MMVD VS. DCM (RARELY INFECTIVE ENDOCARDITIS) THINK: MMVD

14 INCIDENTAL MURMURS: Scenario 5-PEDIATRIC (FELINE) UP TO 6 MONTHS OF AGE (Root Kustritz 2011) ANEMIA (LOW HCT AND THIN CHEST WALL) INDUCIBLE MURMURS DRVOTO (DYNAMIC RIGHT VENTRICULAR OUTFLOW TRACT OBSTRUCTION) HYPERTROPHIC CARDIOMYOPATHY SYSTOLIC ANTERIOR MOTION (DLVOTO, SAM( OF THE MITRAL VALVE ) CONGENITAL DEFECTS (VSD) DRVOTO (DYNAMIC RIGHT VENTRICULAR OUTFLOW TRACT OBSTRUCTION) SOFT, MUSICAL HIGH FREQUENCY MID-SYSTOLIC <2/6 USUALLY SYSTOLIC >3/6 AUSCULTATION-LIMITED VALUE THORACIC RADIOGRAPHS-R/O SEVERE DISEASE-ALSO LIMITED NT-Pro BNP-NO PUBLISHED DATA ECHOCARDIOGRAM-RECOMMENDED

15 INCIDENTAL MURMURS: Scenario 6-ADULT/GERIATRIC (FELINE) ANEMIA (LOW HCT AND THIN CHEST WALL) INDUCIBLE MURMURS DRVOTO (DYNAMIC RIGHT VENTRICULAR OUTFLOW TRACT OBSTRUCTION) HYPERTHYROIDISM SYSTEMIC HYPERTENSION HYPERTROPHIC CARDIOMYOPATHY SYSTOLIC ANTERIOR MOTION (DLVOTO, SAM( ) OF THE MITRAL VALVE CONGENITAL DEFECTS (VSD) DRVOTO (DYNAMIC RIGHT VENTRICULAR OUTFLOW TRACT OBSTRUCTION)

16 INCIDENTAL MURMURS: Scenario 6-ADULT/GERIATRIC (FELINE) SYSTOLIC MURMURS ARE COMMON: 1) OVERTLY HEALTHY CATS (16-44%) 1 2) ASYMPTOMATIC, MURMUR, HEART DISEASE (31-77%) 2 3) HCM AND INCIDENTAL MURMURS (18-62%) 3 4) DRVOTO AND INCIDENTAL MURMURS (19-35%) 3 5) MURMURS ARE DYNAMIC 4 CATS DO WHAT THEY WANT! 1) Cote et al JAVMA 2004, Drourr et al JVIM 2010, Paige et al JAVMA 2009, Wagner et al JVIM ) Bonagura 2011,Cote et al JAVMA 2004, Dirven et al JVIM 2010, Paige et al JAVMA 2009, Wagner et al JVIM 2010, Nakamura ) Bonagura 2011, Rishniw 2002, Cote et al JAVMA 2004, Allen et al JVIM 2009, Paige et al JAVMA 2009, Wagner et al JVIM 2010, Nakamura et al JVFS ) Paige et al JAVMA 2009

17 INCIDENTAL MURMURS: Scenario 6-ADULT/GERIATRIC (FELINE) 1) AUSCULTATION-LIMITED VALUE 2) THORACIC RADIOGRAPHS-HELPFUL A) VHS > 9.3 SUGGEST CARDIAC CAUSE FOR DYSPNEA (Sleeper et al JAVMA 2013) B) 28-72% accuracy (Schober et al JVIM 2007) 3) NT-Pro BNP- HAS VALUE <50pmol/L cardiomyopathy unlikely (Fox et al JVIM 2011) >100pmol/L suggests structural heart disease 4) ECHOCARDIOGRAM-DIAGNOSTIC TEST OF CHOICE

18 INCIDENTAL MURMURS CLINICAL PEARLS FUNCTIONAL VS. PATHOLOGIC WHEN TO PURSUE DIAGNOSTICS: 1) CLINICAL SIGNS 2) ANESTHESIA 3) BREEDING 4) CONCERNED OWNER USE YOUR TOOLS: 1) SIGNALMENT PROFILING 2) BLOODWORK 3) THORACIC RADS 4) NT-Pro BNP

19 INCIDENTAL MURMURS AND ANESTHESIA HEALTHY PATIENTS: DOG: BEGIN <10ML/KG/HR THEN 5ML/KG/HR CAT: BEGIN <10ML/KG/HR THEN 3ML/KG/HR 2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats* CARDIAC COMPROMISE PATIENTS: DOG: 2-5ML/KG/HR, THEN STOP CAT: 1-2ML/KG/HR, THEN STOP (ANECTDOTAL)

20 OVERVIEW INCIDENTAL MURMURS CONGESTIVE HEART FAILURE AND THE COUGHING DOG SYNCOPE AND ARRHYTHMIAS

21 CONGESTIVE HEART FAILURE Scenario 1- GERIATRIC DOG COUGH AND A MURMUR WHICH ONE IS A CARDIAC COUGH?

22 CONGESTIVE HEART FAILURE Scenario 1- GERIATRIC DOG COUGH AND A MURMUR COUGH = NOT ALWAYS A SPECIFIC FINDING

23 CONGESTIVE HEART FAILURE Scenario 1- GERIATRIC DOG WHICH ONE IS A CARDIAC COUGH? AIRWAY COUGH No murmur (or soft murmur in small breed) Sinus arrhythmia (HR<140bpm) RR<40breaths/min PHYSICAL EXAM CLUES CHF COUGH Murmur (soft vs. loud) Tachypneic (RR>40breaths/min) Tachycardic (HR>140bpm) +/- Crackles Dyspnea

24 CONGESTIVE HEART FAILURE Scenario 1- GERIATRIC DOG WHAT ABOUT RESPIRATORY RATES? 1) OUTPERFORM LABORATORY (BIOMARKERS) AND DOPPLER ECHOCARDIOGRAPHIC VARIABLES (Schober et al, JAVMA 2011) AT HOME RESP RATES 2) PREDICT CHF WITH HIGH ACCURACY MMVD: RR >40 BREATHS/MIN DCM: RR >26 BREATHS/MIN (100%SP/100%SEN) (Schober et al, JAVMA 2011) MMVD: RR >41 BREATHS/MIN (96%SP/92%SEN) DCM: RR >34 BREATHS/MIN (100%SP/100%SEN) IN CLINIC RESP RATES (Schober et al, JVIM 2010)

25 YES, THERE S AN APP FOR IT! CARDALIS BOEHRINGER INGELHEIM CALCULATOR

26 SLEEPING RESPIRATORY RATES NORMAL HEALTHY DOGS dogs Breaths/min average SD Max Min Rishniw et al, RVS 2011

27 SLEEPING RESPIRATORY RATES NORMAL VS SUBCLINCAL HEART DISEASE Subclinical MMVD and DCM dogs dogs NORMAL Ohad D et al JAVMA 2013 Rishniw et al, RVS Breaths/min Average SD Max Min 93% of dogs had RRR mean <30 98% of dogs had RRR mean <35 0 average SD Max Min

28 RESPIRATORY RATES IN CATS HEALTHY AND SUBCLINICAL HEART DISEASE SLEEPING AND RESTING RESPIRATORY RATES < 30 BREATHS/MIN Respiratory rate (breaths/min) CATS SRR mean EN SRR mean SHD RRRmean EN RRRmean SHD Ljungvall et al, JFMS 2013

29 RESPIRATORY RATES (SSR AND RRR) DOGS AND CATS CLINICAL PEARLS SINGLE MOST SENSITIVE AND SPECIFIC DIAGNOSTIC TEST FOR IDENTIFYING LEFT SIDED CONGESTIVE HEART FAILURE SRR AND RRR <30 BREATHS/MIN (I STILL USE 40 BREATHS/MIN) (TRENDS MAY BE MORE IMPORTANT)

30 CONGESTIVE HEART FAILURE Scenario 1- GERIATRIC DOG COURTESY OF MARC KRAUS (DVM, DACVIM) COURTESY OF MARC KRAUS (DVM, DACVIM)

31 O 2 P A C RELOAD CONGESTIVE HEART FAILURE ACUTE AND CHRONIC THERAPY -PREVENT HYPOXIA DIURETICS (VENODILATORS) FUROSEMIDE SPIRONOLACTONE CATS=THINK THORACOCENTESIS! CRI mg/kg/hr DOG: 2-4MG/KG (4-6mg/kg if needed) CAT: 1-2MG/KG DOG: 1-2MG/KG BID CAT: 1MG/KG BID USE REMAINS EMPIRICAL WHY?à 69% REDUCTION IN RISK OF CARDIAC RELATED DEATHS (Bernay et al JVIM 2010) M TORSEMIDE 1/10 TH THE DAILY FUROSEMIDE DOSE BID An

32 CONGESTIVE HEART FAILURE ACUTE AND CHRONIC THERAPY O 2 -PREVENT HYPOXIA P A RELOAD C M An FTERLOAD VENODILATORS ARTERIODILATORS MIXED NITROGLYCERINE PASTE ISOSORBIDE DINITRATE ACE-INHIBITORS-ENALAPRIL/BENAZEPRIL AMLODIPINE NITROPRUSSIDE HYDRALAZINE

33 CONGESTIVE HEART FAILURE ACUTE AND CHRONIC THERAPY O 2 -PREVENT HYPOXIA P A RELOAD FTERLOAD INODILATOR CATS? YES. AND NO. CATS TOLERATE SIMILAR CANINE DOSES. (Gordon et al JAVMA 2012) (Macgregor et al JVC 2011) PIMO LASTS LONGER (Hanzlizek et al JVC 2012) C M An ONTRACTILITY PIMOBENDAN DIGOXIN DOBUTAMINE DOPAMINE PROTECT TRIAL: (Summerfield et al JVIM 2012) 76 DOBIES OCCULT DCM PIMO VS. NO PIMO (623 VS. 466 DAYS) QUEST TRIAL: (Haggstrom et al JVIM 2008) 260 DOGS (MMVD+CHF+CONVENTIONAL THERAPY) PIMO VS BENAZEPRIL (267 VS. 140 DAYS)

34 CONGESTIVE HEART FAILURE ACUTE AND CHRONIC THERAPY O 2 -PREVENT HYPOXIA P A RELOAD FTERLOAD WHAT ABOUT HCM CATS? ATENOLOL HAD NO EFFECT ON 5YR SURVIVAL IN SUBCLINICAL HCM CATS (Schober et al JVC 2013) C M ONTRACTILITY YOCARDIAL OXYGEN DEMAND HEART RATE CONTRACTILITY ATENOLOL AMLODIPINE An SYSTEMIC VASCULAR RESISTANCE

35 CONGESTIVE HEART FAILURE ACUTE AND CHRONIC THERAPY O 2 -PREVENT HYPOXIA P A C RELOAD M An FTERLOAD ONTRACTILITY ANTI-ANXIETY YOCARDIAL OXYGEN DEMAND ANTI-ARRHYTHMICS ANTI-THROMBOTICS 18.75MG SID BUTORPHANOL: MG/KG IM/IV MIDAZOLAM: 0.2MG/KG IM/IV ACEPROMAZINE: MG/KG IM/IV DEXMEDITOMIDINE: (CATS) 3MCG/KG (GRUMPY) 5MCG/KG (FRACTIOUS) 7MCG/KG (EVIL) LIDOCAINE MEXILETINE PROCAINAMIDE SOTALOL PLAVIX VS. ASPIRIN HEPARIN (UF VS LMWH) WARFARIN tpa VS STREPTOKINASE 81MG EVERY 3 DAYS

36 CONGESTIVE HEART FAILURE ACUTE AND CHRONIC THERAPY CATS CLINICAL PEARLS ACUTE CHF: DON T FORGET SEDATION! DOGS FUROSEMIDE (1-2MG/KG) SID-BID ACE-INHIBITOR SID-BID +/- ANTI-THROMBOTICS (PLAVIX) CARDIAC TRIFECTA: FUROSEMIDE (2-4MG/KG) BID ACE-INHIBTOR SID-BID PIMOBENDAN ( MG/KG BID

37 OVERVIEW INCIDENTAL MURMURS CONGESTIVE HEART FAILURE AND THE COUGHING DOG SYNCOPE AND ARRHYTHMIAS

38 SYNCOPE VS. SEIZURES DOGS AND CATS 1) TRIGGER-SITUATIONAL SYNCOPE 2) ORAL MUCOSA BLANCHING 1) EXTENSOR RIGIDITY 2) URINATION/DEFECATION 3) TREMORS/TWITCHING 1) POST-ICTAL PERIOD 2) SEEKING WATER/FOOD AFTER AN EPISODE CATS!-SEIZURE-LIKE EPISODES WITH INTERMITTENT HIGH GRADE AVB AND A POST-ICTAL PERIOD (Penning et al JVIM 2009)

39 SYNCOPE DOGS AND CATS NEURALLY MEDIATED NEUROCARDIOGENIC SITUATIONAL SYNCOPE VASOVAGAL CARDIAC STRUCTURAL/FUNCTIONAL DCM/ARVC PERICARDIAL EFFUSION PULMONIC STENOSIS SUBAORTIC STENOSIS PULMONARY HYPERTENSION NON CARDIAC HYPOGLYCEMIA (INSULINOMA) ELECTRICAL DISEASE ADDISONS DISEASE HIGH GRADE 2 ND AVB SEVERE ANEMIA (IMHA) 3 RD AVB EXERCISE-INDUCED-(LABS) SICK SINUS SYNDROME VENTRICULAR TACHYCARDIA SUPRAVENTRICULAR TACHYCARDIA

40 SYNCOPE NEURALLY MEDIATED SYNCOPE SINUS TACHYCARDIA HR=219BPM SINUS BRADYCARDIA HR=42BPM

41 SYNCOPE DOGS NEURALLY MEDIATED NEUROCARDIOGENIC SITUATIONAL SYNCOPE (VASOVAGAL) SMALL BREED DOGS W/ MMVD LOUD LEFT APICAL SYSTOLIC MURMUR TRIGGER (EXCITEMENT/COUGH/MICTURITION/DOORBELL/DEFECATION) C FIBERS (MECHANORECEPTORS) TRIGGER VAGAL RESPONSE HYPOTENSION BRADYCARDIA TREATMENT? PRELOAD REDUCTION= FURSOSEMIDE!

42 ARRYTHMIAS SUPRAVENTRICULAR UPRIGHT AND NARROW COMPLEXES +/- P WAVES VENTRICULAR WIDE AND BIZARRE COMPLEXES +/- P WAVES

43 ARRHYTHMIAS ATRIAL FIBRILLATION (SNEAKERS IN A DRYER) THINK: A-B-C-D! A=ATRIAL FIBRILLATION B=BETA BLOCKERS (ATENOLOL) C=CALCIUM CHANNEL BLOCKERS D=DIGOXIN DILTIAZEM XR (3MG/KG BID) DIGOXIN ( MG/KG BID) HR<140->80% 24HR PERIOD (Gelzer et al JVIM 2009)

44 ARRHYTHMIAS VENTRICULAR ECTOPY WHEN TO TREAT: CLINICAL SIGNS, HEMODYNAMIC STATUS, FAST, COMPLEX (POLYMORPHIC) ECTOPY IDEALLY HOLTER FIRST! IV OPTIONS: CRI: 50-80MCG/KG/MIN 1) LIDOCAINE (2MG/KG) DOSE 2-3 TIMES 2) PROCAINAMIDE (6-8MG/KG) GIVE SLOW! ORAL OPTIONS: THINK SPAM! 1) SOTALOL (2MG/KG) Q 12HR 2) PROCAINAMIDE (8-20MG/KG) Q6-8HR 3) AMIODARONE (LOAD THEN REDUCE) 4) MEXILETINE (5-8MG/KG) Q 8HR

45 ARRHYTHMIAS VENTRICULAR ECTOPY TOP REASONS NOT TO TREAT VENTRICULAR ARRHYTHMIAS: 1) SLOW V-TACH- (ACCELERATED IDIOVENTRICULAR RHYTHM-AIVR)- HR BPM POST-OP SPLENECTOMY, SPLENIC DISEASE, GDV, MYOCARDITIS, CARDIOMYOPATHY

46 ARRHYTHMIAS VENTRICULAR ECTOPY TOP REASONS NOT TO TREAT VENTRICULAR ARRHYTHMIAS: 2) VENTRICULAR ESCAPE BEATS: 3 RD AV BLOCK AND SICK SINUS SYNDROME NO LIDOCAINE! NEEDS PACEMAKER!!

47 ARRHYTHMIAS VENTRICULAR ECTOPY TOP REASONS NOT TO TREAT VENTRICULAR ARRHYTHMIAS: 3) SUPRAVENTRICULAR WITH ABERRANCY 90% OF THE TIME ITS VENTRICULAR IF NO RESPONSE TO LIDOCAINE/PROCAINAMIDE THINK SUPRAVENTRICULAR WITH BBB! VT VS. SVT WITH LBBB? VT VS. SINUS RHYTHM WITH RBBB?

48 ARRHYTHMIAS: SUPRAVENTRICULAR ANDVENTRICULAR ECTOPY CLINICAL PEARLS ATRIAL FIBRILLATION (A-B-C-D) DILTIAZEM XR (3MG/KG BID) DIGOXIN ( MG/KG BID) VENTRICULAR ARRHYTHMIAS ORAL OPTIONS: THINK SPAM! 1) SOTALOL (2MG/KG) Q 12HR 2) PROCAINAMIDE (8-20MG/KG) Q6-8HR 3) AMIODARONE (LOAD THEN REDUCE) 4) MEXILETINE (5-8MG/KG) Q 8HR FUROSEMIDE!

49 QUESTIONS?