Failing Heart 2 PDF - 2022

Failing Heart 2 Prof Kamalan Jeevaratnam DAHP, DVM, MMedSc (Mal); PhD (Cambridge), FRCVS (UK) School of Veterinary Medicine, Univeristy of Surrey [email protected]  Learning Outcomes Describe the diagnostic approach for the fai...

Failing Heart 2 Prof Kamalan Jeevaratnam DAHP, DVM, MMedSc (Mal); PhD (Cambridge), FRCVS (UK) School of Veterinary Medicine, Univeristy of Surrey [email protected]  Learning Outcomes Describe the diagnostic approach for the failing heart and the expected outcomes Outline an evidence based treatment plan for congestive hart failure (in line with ACVIM consensus statement) Determine prognosis for congestive heart failure #uniofsurrey 2 The Veterinary Consultation The diagnosis of cardiac disease in animals may involve some or all of the following diagnostic tests: » The signalment of the animal » History taking » Physical examination » Thoracic radiography » Electrocardiography » Laboratory tests » Echocardiogrphy » Cardiac catheterisation » Blood pressure measurement » Post-mortem examination #uniofsurrey 3 The Veterinary Consultation The signalment can help you determine what may be the problem ✓ Species ✓ Breed ✓ Age ✓ Sex Age: young animals are ✓ Purpose more likely to have Working congenital defects Breeding Pet Sex: some diseases have been shown to have a sex predilection – eg patent ductus arteriosus is more common in females, and hypertrophic cardiomyopathy is more common in male cats #uniofsurrey 4 History taking » Start with general history and use your communication skills! » Listen carefully to the owners concern » Use both open questions and closed questions » Remember that negative findings can be just as important as positive ones » Use your clinical and medical knowledge to sort these data into what you think is clinically relevant. » Move to specific questions targeted at the cardiovascular system… #uniofsurrey 5  Vaccination and preventive healthcare – booster, heartworm prevention, deworming. WH questions – When, What, How, Who, Where Changes in attitude, behaviour, and activity level: Exercise intolerance, depression, and fatigue are all signs associated with CHF. Changes in breathing: Laboured breathing or an increased resting respiratory rate can indicate CHF. Changes in appetite and weight: These factors can also signal a heart problem. Coughing: Include evaluation of onset and type of cough. Dogs with pulmonary oedema have acute cough. Dogs with chronic heart disease have mild, intermittent cough. Sleeping habits: Restlessness at night is commonly associated with CHF. Previous evidence of heart disease: Heart murmurs or radiographic changes, such as an enlarged heart, can indicate heart disease. Therapy: Consider any preceding treatments, including compliance with heartworm prevention programs. #universityofsurrey 6 History taking for cardiac cases » Typically assessing evidence of cardiovascular competence / incompetence » Exercise Tolerance How much opportunity for exercise (on a lead, free, vigorous?) Willingness to exercise Tiring at / after exercise » Syncope (transient loss of consciousness TLOC)/ weakness/ collapse To be differentiated from seizures/neurological activity Has no warning, short duration, flaccid, rapid recovery Occurs at exercise or excitement (including getting up after lying down) There is a lack of salivation, vocalisation, urination and defecation, tonic-clinic spasms. Ask client to describe each episode #uniofsurrey 7  History taking for cardiac cases » Breathlessness (when, duration) / coughing How does the cough sound, what time of day does it occur Is caused by left atrial enlargement and may be one of the first clinical signs noticed by owners Concurrent respiratory disease? Rare in cats » Appetite, body condition, weight loss Abdominal enlargement can be the first sign noticed http://sites.tufts.edu/progressnotes/2014/01/current-concepts-16/ by owners. It may be caused by RHS CHF (ascites) but you have to rule out other causes. Cardiac cachexia » Negative answers are as helpful as confirmatory ones https://vcahospitals.com/ Ware, 2011 #uniofsurrey 8 Diagnostic approach Clinical/Physical Examination General examination. System specific examination: Weight and body condition: When cardiac disease occurs, cachexia (weight loss) is more likely to indicate CHF. Respiration: Evaluate rate and effort of respiration. Variation can occur - breed, temperature, and weight. >35/min maybe suggestive of heart failure. Important to know individual baseline for every animal (increases more than 25-50% is indicative) Heart rate: increased heart rate (due to decreased output – compensation). Bradycardia on presentation generally unlikely. Jugular distension: abnormal jugular pulses – persistent distension or intermittent. Mucous membranes and skin turgor: hydration status, peripheral perfusion, and tissue oxygenation. Abdominal distension: check for fluid, pain, enlarged organs – careful palpation! Pulse abnormalities: Identifying arterial pulse abnormalities, such as hypokinetic (small stroke volume), hyperkinetic (large pulse pressure), and pulse deficits (arrhythmias) – practice makes perfect! Develop differential list – vary by species – heart failure technically not a disease – underlying cardiac disorder manifested as failure. http://www.vetmedin.com/ Monday, 21 November 9 Physical Exam for Cardiac Cases » Auscultation of the chest is part of the normal physical exam – be thorough! Take your time Have a good quality stethoscope Have a standard routine and technique » Quiet, cool room – minimise excitement, panting and noise » Standing position » Purring and panting will interfere with auscultation #uniofsurrey 10  Physical Exam for Cardiac Cases Understand the cardiac cycle and how this correlates with sound that you are hearing! » Observe and listen to animal from a distance – RR and effort, pattern, coughing » MM colour and CRT Usually oral membranes Pale MM Can use prepucial or vaginal membranes Cyanosis Slow CRT? Pink, pale, cyanotic MM? Ware, 2011 » Jugular Veins Head is in a normal position these should not be distended Pulsation of the veins higher than the point of the shoulder in a standing animal is abnormal High central venous pressure or obstruction to cranial vena cava flow Hepatojugular reflex – RH failure Ware, 2011 #uniofsurrey 11  Physical Exam for Cardiac Cases » Arterial pulse Femoral pulse usually Strength, regularity, rate Hypokinetic, hyperkinetic Compare L and R and to HR » Palpate the precordium 5th – 6th ICS Strong? Weak? Thrill? » Compressibility of the chest wall and thoracic percussion Sound should resonate and be hollow » Palpate abdomen and ballottement Fluid wave? Organomegally? » Warmth of skin and periphery #uniofsurrey 12 Physical Exam for Cardiac Cases » Thoracic Auscultation Heart rate and rhythm, heart sounds and pulmonary sounds evaluated Mitral valve best heard LHS ~5th ICS ~1/4 way up Aortic valve best heard LHS ~4th ICS ~ 1/3 way up Pulmonic valve best heard LHS ~3rd ICS close to the sternum Tricuspid valve best heard RHS 3rd or 4th ICS ~ 1/4 way up » Cardiac sounds S1,S2, S3, S4, Murmurs » Position of maximum intensity of the sounds & murmurs » Normal/abnormal respiratory sounds http://www.vetvisions.com/p411.htm #universityofsurrey 13 Cardiac Murmurs » Murmurs: turbulent blood flow Pitch (frequency) Intensity (loudness) Duration Quality » Harsh (ejection) murmurs are associated with stenosis of the semilunar valves Aortic stenosis Pulmonic stenosis » Soft (or blowing) murmurs are associated with valvular regurgitation Mitral regurgitation Tricuspid regurgitation Cardiac sounds: S1 S2-“Lub-Dup” - enclosing systole closing of AV valves, then closing of semilunar valves S3 early filling of ventricle(s) in early diastole “Lub-Dup-ud” S4 late diastolic filling (atrial kick) “ooh-Lub-Dup” S3 and S4 “gallops” are always abnormal in small animals #uniofsurrey 14 Cardiac Murmurs Grade of Murmur Description I Very soft, localised murmur, detected in a quiet room after intently listening II Soft murmur, but immediately obvious, quieter than S1 and S2 III Moderate Intensity, as loud as S1 and S2 IV Louder than S1 and S2, but no palpable palpable thrill V Very loud murmur with a palpable palpable thrill VI Very loud murmur that produces a palpable thrill still audible when stethoscope is removed from the chest #uniofsurrey 15 Is it an innocent murmur? The intensity of the murmur doesn’t necessarily correlate with severity of disease, but is always important for serial examinations. Almost all murmurs are clinically significant, at least in adult dogs In young animals (e.g. puppies and kittens at ~6-15wks) the murmur may be innocent Low grade (I or II / VI), systolic Often “dynamic” louder as heart rate increases / during excitement Due to turbulent flow in Aorta and Pulmonary Artery Exacerbated by the physiologic anaemia of adolescence DISAPPEAR by 4-5 months of age A low intensity murmur could also be very bad heart disease.. (large VSD, severe tricuspid insufficiency) Echocardiography! #uniofsurrey 16 Diagnostic approach Radiography Chest X-rays – several views Dorsal ventral view Lateral (Right and Left) Start interpretation with extra-thoracic structures, pleural space, pulmonary parenchyma, cardiac silhouette, shape, size, vessels Vertebral heart score (lateral views) – 8.5-10.5 dogs and 7.5 cats – breed variation http://todaysveterinarypractice.navc.com/heart-failure-in-dogs-6-practical-tips- from-cardiologists/ Monday, 21 November 17 Diagnostic approach Echocardiography Assess the functional and structural capacity of the heart. Determine size, shape, volume, performance. Transthoracic image of the heart – parasternal window: R thorax between sternal border and costochondral junction from 3rd to 6th intercostal space; L thorax close to sternal border between the 5th and 7th intercostal space and between the sternum and costochondral junction at the 3rd and 4th intercostal space. Two dimensional, M-mode, colour Doppler and spectral Doppler Monday, 21 November 18  ECG Right parasternal long axis Right parasternal short axis Right parasternal long axis Monday, 21 November 19 Diagnostic approach Electrocardiogram Assesse for rhythm disturbances, indication of cardiac chamber enlargement. Atrial premature complex: atrial ectopic beat, can be superimposed on preceeding T wave, cause a premature QRS complex (depends on when it occurs – if during ventricular refractory no QRS) – degenerative valve, CHF, COPD Atrial fibrillation: common supraventricular arrhythmia seen in dogs with DCM and MR and cats with cardiomyopathy. Ventricular tachyarrhythmias: also may be present in dogs with heart failure – often will see associated clinical signs. Electrical alternans: pericardial effusions; low amplitude waves (pleural effusion, obesity, subcutaneous oedema) Ventricular pre-excitation syndrome: abnormal accessory pathway bypassing AV node – congenital abnormalities, feline HCM – structural defects in principle Monday, 21 November 20 Diagnostic approach Haematology and serum biomarker Establish minimum database profile for patient. Help identify haematological profile – anaemia (regenerative or non regenerative); erythrocyte sedimentation rate (ESR) – immune-mediated. WBC – inflammatory mediated condition or infectious disease. Biochemistry to assess function of other organs Liver – ALT, AST, ALP Kidney – BUN and creatinine Protein – albumin, globulin Monday, 21 November 21 Diagnostic approach Blood biomarkers Natriuretic peptides Marker of neurohormonal activation – suggestive of cardiac remodelling/ventricular dilation BNP, ANP (NT-proBNP and NT-proANP) Clinical utility likely to be similar. Elevated NT-proBNP can be seen with renal insufficiency and pulmonary hypertension Cardiac troponin Regulatory protein of the contractile apparatus Marker of myocardial tissue injury or necrosis. Increased when there is myocardial damage – ischeamia, myocarditis Can be elevated in cardiac neoplasia, GDV, sepsis https://twitter.com/jama_current/status/58358467694782464 0 Monday, 21 November 22  There can be many reasons why the heart fails – approach to treatment is meant to primarily support the heart in this difficult time and alleviate symptoms with the aim of slowing and if possible halt the progression of heart failure. Monday, 21 November 23 Treatment plan Focus of treatment Regulate patients haemodynamic status by monitoring and pharmacological optimising preload, afterload, heart rate and contractility Key manipulations: Vasodilatory therapy Angiotensin-converting enzyme inhibitions Diuretics Positive inotropes Beta blockers Calcium channel blockers Dietary modifications Lifestyle changes Monday, 21 November 24 Prognosis In companion animal average survival time is 1-2 years (depending on time of diagnosis and approach to treatment) Recurrent clinical signs can lead to rapid progression Typically prognosis – guarded to grave In horses - prognosis is generally very poor once overt heart failure is present. < 1yr with palliative treatment, most get euthanized on presentation Monday, 21 November 25 References Figures, diagrams and other related resources were acquired from the following books: Manual of canine and feline cardiology – 5th edition – Smith, Tilley, Oyama & Sleeper - Elsevier Cardiology of the horse – 2nd edition – Marr & Bowen – Saunders Feline cardiology – 1st edition Cote, Macdonald, Meurs & Sleeper – Wiley Blackwell BSAVA Manual of canine and feline emergency and critical care Clinical medicine of the dog and cat – 3rd edition – Schaer & Gaschen – CRC Press Rapid interpretation of the heart and lung sounds – 3rd edition – Keene, Smith, Tilley & Hansen Monday, 21 November 26