Integrated Clinical Reasoning I - Cardiovascular System PDF

Integrated Clinical Reasoning I Cardiovascular system Ana Rita Carvalho DVM, MSc [email protected]  IRC1 BIBLIOGRAPHY 28/11/2024 2  CARDIOVASCULAR SYSTEM EXAMINATION Obje...

Integrated Clinical Reasoning I Cardiovascular system Ana Rita Carvalho DVM, MSc [email protected]  IRC1 BIBLIOGRAPHY 28/11/2024 2  CARDIOVASCULAR SYSTEM EXAMINATION Objectives: Utilise the cardiovascular signs associated with heart disease and formulate a list of potential causes; Obtain a complete clinical history of an animal with suspected heart IRC1 disease; Recognise, through physical examination, signs associated with heart disease. It is important to recognise that heart disease always requires further diagnostic means for a complete investigation (X-ray, ECG, ultrasound, 28/11/2024 etc). 3  Examination of the cardiovascular system Arterial examination (arterial pulsation) Examination of the capillary system IRC-1 (capillary refill time - CRT) Examination of the venous system (palpation of the jugular vein) 28/11/2024 Examination of the heart. 4  THE HEART It is irrigated by a coronary vasculature that uses 10% of the volume of blood released into the circulation in each systole; IRC1 28/11/2024 5  THE HEART LEFT SIDE RIGHT SIDE ▪ Between the 3rd rib and the 6th In the right hemithorax, the right intercostal space. ventricle is found, which occupies In the left hemithorax, the left ventricle is found, almost the entire side, the left IRC1 which occupies almost the entire side due to its ventricle (caudoventrally) and the position in the thoracic cavity, the right ventricle right atrium (dorsally). (in the anterior portion), the left atrium, and the pulmonary trunk. 28/11/2024 6  THE HEART HORSES -LEFT SIDE CATTLE – LEFT SIDE It is located between the 3rd – 5 th Between 3rd – 6 th ribs intercostal space. IRC1 28/11/2024 7 HORSE CATTLE  THE HEART It has four properties (cardiac automatism): Rhythm; Excitability; IRC1 Conductivity; Contractibility. Diseases that interfere with one or more of these properties can lead to heart 28/11/2024 failure; 8  THE HEART The heart has autonomic innervation ❑ Sinoatrial node (SA node); ❑ Atrioventricular node (AV node); IRC1 ❑ Atrioventricular bundle (or Bundle of His): left and right branches; ❑ Purkinje fibers. 28/11/2024 9  THE HEART Sympathetic Nervous System: Conducted by fibers emanating from the spinal cord with the lower roots from the 2nd to the 5th thoracic segment. Increases cardiac output and improves the oxygenation of cardiac fibers due to: 1.Increased heart rate; IRC1 2.Peripheral vasoconstriction; 3.Dilation of the coronary arteries. Parasympathetic Nervous System: Conducted by the right and left branches of the vagus nerve, which terminate in the sinoatrial and atrioventricular nodes, distributing equally. 28/11/2024 The vagus is the moderator of the myocardium, as it decreases cardiac 10 frequency, excitability and contratability.  IMPAIRED CARDIAC FUNCTION: COMPENSATORY MECHANISMS Normal heart function results in: maintenance of blood flow: to the tissues to supply oxygen, nutrients and hormones removing carbon dioxide and the products of cellular metabolism. IRC1 If this function is affected, there are various compensatory mechanisms that operate in both the normal and altered heart in order to maintain the irrigation capacity of the tissues in the short and long term. ANS (Autonomous Nervous System) activity (sympathetic: α and β receptors); help maintain blood pressure and fluid balance kideny release renin: production angio II, BV constrict, increase BP 28/11/2024 RAAS activity (renin-angiotensin-aldosterone system); Stimulation of AVP (arginine-vasopressin). Control water retention to maintain blood volume 11 body release AVP to say kidney to retain water to increase BV  IMPAIRED CARDIAC FUNCTION: COMPENSATORY MECHANISMS ANS IRC1 28/11/2024 12  IMPAIRED CARDIAC FUNCTION: COMPENSATORY MECHANISMS RAAS IRC1 28/11/2024 13 BP - Blood presure  Heart Rate vs Cardiac Rhythm Heart Rate (HR): the number of contractions or systoles in a given period. Cardiac Rhythm: the succession of systoles occurring in specific time intervals between consecutive contractions. DIFFERENT SPECIES: ❑ Adult dogs: 70 - 160 beats/min ❑ Horse: 20-44 beats/min IRC1 ❑ Giant breeds: 60-140 beats/min ❑ Goat and sheep: 70-90 beats/min ❑ Toy breeds: up to 180 beats/min ❑ PIGS: 90-110 beats/min ❑ Puppies: 220 beats/min ❑ Cattle: 60-80 beats/min ❑ Cats: up to 240 beats/min ❑ Usually 140-240 beats/min 28/11/2024 *This values are presentend by Jackson and Cockcroft. This values are presented by Ettinger, (Textbook Clinical Examination of Farm animals. (2002) of Veterinary Internal Medicine (Ettinger for 14 small animals, (2010)),7th ed). *The range values may vary, according different authors  PHYSICAL EXAMINATION AND CLINICAL SIGNS The first step of the physical examination consists of identifying the main cardiovascular signs, taking into account their duration, severity and progression; Regarding clinical signs identified by owners these can include: IRC1 ❑ Dyspnea; ❑ Paralysis of the hind limbs in cats. ❑ Delayed growth; ❑ Syncope/lipothymia; ❑ Exercise intolerance; ❑ Weight loss; ❑ Loss of appetite; 28/11/2024 ❑ Muscle weakness/lethargy; ❑ Depression; ❑ Nasal discharge; 15 ❑ Cough;  PHYSICAL EXAMINATION SIGNALMENT Age: For exemple, Congenital , valvular endocardiosis in older animals Sex: For exemple, atrioventricular valve diseases, IRC1 idiopathic dilated cardiomyopathy are common in males. Patent ductos arterious (PDA) is more common in females Species: DCM more common in dog giant breeds. PDA is more common in calves and cats. 28/11/2024 Breed: some are prone to malformations. 16  IRC1 CLINICAL SIGNS Cor Pulmonale 28/11/2024 17  CLINICAL SIGNS ❑ Exercise intolerance: Arises when compensation mechanisms can prevent clinical signs at rest but not during exertion. ❑ Cough: occurs mainly in dogs. For a better IRC1 diagnosis, it is important to characterize it by the time of day, whether it is associated with exercise, and whether it is productive or not. ❑ Weigh loss: in dogs and cats with chronic, severe right side heart failure 28/11/2024 18  CLINICAL SIGNS ❑ Respiratory type alterations: Dyspnea: related to pulmonary edema Can be accompanied by stridor IRC1 Cough: by left side- hear failure Soft and moist sounding, related to pulmonar edema. Pulmonary edema ❑ Orthopnea: most sever of dyspnea. Includes elevation and streching of the neck out and 28/11/2024 abducting the forelimbs.. 19  CLINICAL SIGNS ❑ SUBCUTANEOUS AND CAVITARY EDEMA Each species develops edemas in specific locations, which have to do with the competence of regional venous valves: Cattle: at the entrance of the chest (Brisket edema), IRC1 before thoracic or abdominal effusion. Small ruminants: between the jaws; Horses: in the ventral abdomen or thorax and limbs (due to gravity); in the male, it is visible at the level of the scrotum and in the female at the mammary gland; 28/11/2024 Dogs and pigs: ascites; 20 Cats: hydrothorax due to heart failure;  CLINICAL SIGNS Fluid wave test technique - ASCITE The clinician stands behind the patient. With one hand placed on one side of the abdomen without exerting pressure, which functions as IRC1 a detector, several light taps are made on the opposite side with the fingers of the other hand. The fluid wave test is positive when the vibration is perfectly felt in the hand that serves as a detector, indicating ascites. 28/11/2024 +: fluid in the abdomen 21  OHTER CLINICAL MANIFESTATIONS ❑ Delayed growth and weight loss ❑ Syncope : Loss of consciouness cause by inadequate blood flow. Usually is brief. It is rare in large animals. It may occur in horses with IRC1 atrial fibrillation or acute heart failure, and in small animals with cardiac arrhythmia or heart diseases ❑ Sudden death: as in the case of white muscle disease and myocardial necrosis in calves, or in cases of copper deficiency in 28/11/2024 adult cattle. 22  PERIPHERAL CIRCULATORY SYSTEM EXAMINATION INSPECTION Mucous membranes (oral, third eyelid, conjunctiva, anal, vaginal): Pale ❑ Pale: due to peripheral vasoconstriction (reduced cardiac output or shock), or anemia; IRC1 ❑ Cyanosis (bluish): due to a decrease in oxyhemoglobin. It may result from right-to-left shunt due to congenital heart disease; ❑ Congested: by venous congestion (right heart failure). Cyanotic ❑ The color of the mucous membranes should normally be associated with capillary refill time, which is usually increased 28/11/2024 (decreased cardiac output). 23 Congestive  PERIPHERAL CIRCULATORY SYSTEM EXAMINATION PALPATION Periferic Arterial Pulse: It is classified in terms of absolute and relative characteristics. You should feel both pulses to assess frequency, rhythm and amplitude. The pressure can also be assessed. IRC1 ABSOLUT CHARACTERISTICS RELATIVE CHARACTERISTICS Amplitude: Strong (Magnus); Thready/ Rate: Tachysphygmia, Bradysphygmia weak Rhythm: Arrhytmias. Respiratory sinus Tension or hardness: tense or hard, soft arrhythmia manifests as an increased pulse rate during the inspiratory phase of Speed: fast/ hyperkinetic, slow (Tardus) respiration, followed by a slowed pulse rate 28/11/2024 during exhalation. This arrhythmia is not considered pathologic and is common in 24 Absent pulses: due to circulatory colapse, dogs. b shock, death  PERIPHERAL CIRCULATORY SYSTEM EXAMINATION PALPATION – SMALL ANIMALS IRC1 Dorsal pedal pulse Femoral pulse 28/11/2024 If the femoral pulse is felt it is because the blood pressure is above 60 mm Hg and if the pedal pulse is 25 felt it is usually above 80 mmHg  PERIPHERAL CIRCULATORY SYSTEM EXAMINATION PALPATION - HORSES ❑ Horses: Facial transverse, Facial, Digital, Coccigea IRC1 28/11/2024 Facial Facial transverse Digital 26  PERIPHERAL CIRCULATORY SYSTEM EXAMINATION PALPATION - RUMINANTS IRC1 28/11/2024 Coccygeal artery 27  PERIPHERAL CIRCULATORY SYSTEM EXAMINATION ❑ Jugular Pulse: the jugular vein is normally palpated to check for pulse and to feel its intensity, rhythm, and frequency. IRC1 ❑ Engorgement/pulsation is usually associated with right heart failure due to cardiac tamponade or tricuspid insufficiency and may arise in association with dysrhythmias. 28/11/2024 28  PERIPHERAL CIRCULATORY SYSTEM EXAMINATION In horses and cattle, there is a normal distension of the jugular at 5-8 cm from the base of the heart. (Fake pulse) IRC1 True jugular pulse- is observed throughout of the neck when the head is horizontal. When if the head is raised, an engorged jugular and with the pulse visible at its greatest extent, sometimes up to jaw in cows or more than the 28/11/2024 last porcion of the neck in horses. 29  HEART EXAM - PALPATION Palpation at the Cardiac Apex (Precordial Thrust – Ictus Cordis). The apex of the heart is located: In the 5th intercostal space, in dogs and cats; Between the 3rd and 6th intercostal space, in horses; In the 3rd or 4th intercostal space in cattle, sheep, and IRC1 goats, under de elbow joint. Why it is important? It allows the strengh of cardiac contraction to be assessed. A stronger ictus may be associated with ventricular hypertrophy. Heart rate and rhythm 28/11/2024 Presence of alterations 30  THE HEART EXAM - AUSCULTATION Physiologic sounds: SMALL ANIMALS IRC1 28/11/2024 31  THE HEART EXAM - AUSCULTATION In small animals, hearing the S3 and S4 sounds has pathological significance. (Gallop sounds) It is characterised by the similarity of the a galloping horse, due to the appearance of a third heart sound, which can be of ventricular or origin (S3 or S4). S3 gallop (ventricular gallop): this is a low noise, just after S2, at the beginning of diastole IRC1 during the filling of the ventricles. It may indicate heart failure, diastolic dysfunction or severe myocardial disease (cardiomyopathy). 28/11/2024 Gallops Sounds: can be difficult to hear at higher heart rates and are most commonly recognized in cats with hypertrophic cardiomyopathy. Any time you hear three heart sounds 32 in small animals, it is abnormal.  IRC1 THE HEART EXAM - AUSCULTATION 28/11/2024 33  THE HEART EXAM - AUSCULTATION SMALL ANIMALS IRC1 28/11/2024 34  THE HEART EXAM - AUSCULTATION In large animals, two additional heart sounds (S3 and S4) can be distinguished and they can are physiological: Heart Sound (S3): when ventricular diastole begins (immediately after S2), some blood flows rapidly into the ventricle. “BE –LUB-DUB-Dhu” IRC1 It is a difficult sound to hear. It also corresponds to the beginning of atrial systole, with the atria contracting to fill the ventricles and the entry of blood into the vena cavas. Common in racehorses and cattle; Heart Sound (S4): corresponds to the atrial contraction to “squeeze” out the rest of the blood; it occurs before S1 and the closure of the valves of the large 28/11/2024 vessels. S4 -S1-S2-S3 35  THE HEART EXAM - AUSCULTATION 28/11/2024 36  THE HEART EXAM - AUSCULTATION Heart Murmurs Whenever there is an abnormal vibration of the blood column, we hear a murmur. They are Heart Murmurs IRC1 mainly audible during the silences and are due ❑ Pathological to the vibration of the intracardiac structures, due to alteration of the blood flow that passes ❑ Non-Pathological in these structures (Turbulence). Functional Murmur Murmurs do not eliminate any previously (extracardiac causes) 28/11/2024 audible heart sound. Innocent Murmur (young animals, cardiovascular 37 inmatury.  THE HEART EXAM - AUSCULTATION It is important to determine the importance of the murmur. To do this, we assess its configuration, location, intensity (maximum intensity point), phase of the cycle, duration, quality, radiation and the presence of a fremitus. ❑ Pathological Murmur IRC1 Changes in blood flow (Turbulence, increased speed, or volume); Valvular alterations (Degeneration,Roughness, or Stenosis); 28/11/2024 Congenital defects. 38  THE HEART EXAM - AUSCULTATION As for the time in the cycle: Lub pff Dub – systolic murmur; Lub Dub pff – diastolic murmur. Systolic murmurs: these are the most common and occur during ventricular contraction. They can IRC1 also occur due to atrioventricular valve insufficiency; Diastolic murmurs: are rare and, when they occur, are due to aortic valve insufficiency. It is heard after S2; Continuous murmurs: common in cases of patent 28/11/2024 ductus arteriosus or multiple valvular lesions. The noise is loudest during systole. 39  THE HEART EXAM - AUSCULTATION Regarding the cycle phase IRC1 28/11/2024 40  THE HEART EXAM - AUSCULTATION Regarding Configuration The manner in which the sound intensity is distributed over time; Crescendo – murmur that progressively increases in intensity. Mitral stenosis (systolic); Decrescendo – progressively decreases in IRC1 intensity. Aortic insufficiency (diastolic); Diamond-shaped (crescendo-decrescendo) – intensity increases at the start, reaches a peak and then progressively decreases. Aortic stenosis (systolic); 28/11/2024 Plateau – maintains a constant intensity throughout the occurrence. Mitral and tricuspid 41 insufficiency (systolic);  THE HEART EXAM - AUSCULTATION ❑ Regarding Duration Holosystolic/diastolic - always IRC1 present; Protosystolic/diastolic - at the beginning; Mesosystolic/diastolic - in the middle; 28/11/2024 Telesystolic/diastolic - at the end. 42  THE HEART EXAM - AUSCULTATION Regarding Degree of Intensity Grade I – very faint murmur that is difficult to hear. Only audible in quiet rooms; Grade II – very faint murmur, but immediately audible on auscultation; IRC1 Grade III – medium intensity. No precordial fremitus; Grade IV – medium intensity. With precordial fremitus; Grade V – high intensity, associated with fremitus, but not audible without a stethoscope; Grade VI – high intensity, associated with fremitus and AUDIBLE without a stethoscope. 28/11/2024 43  THE HEART EXAM - AUSCULTATION https://veterinarypartner.vin.com/default.as IRC1 px?pid=19239&id=4952593 28/11/2024 44  HEART FAILURE Heart failure Heart failure (HF) is a clinical condition in which cardiac output is inadequate to meet the perfusion needs of the tissues and exercise capacity is limited. IRC1 ❑ Congestive heart failure - there is water and sodium retention and increased venous and capillary pressure leading to congestion and cavitary oedema. 28/11/2024 ❑ Output heart failure - cardiac output is maladjusted and blood pressure is reduced. 45  HEART FAILURE – CLINICAL SIGNS Right Ventricular failure Left ventricular failure ❑ Ascites in the Dog (↑Venous and ❑ Pale mucosa; hydrostatic pressure; venous or passive congestion; Portal ❑ Cough; hypertension); ❑ Dyspnoea; IRC1 ❑ Organomegaly (splenic, hepatic and, rarely, nephromegaly); ❑ Cyanosis; ❑ Hydrothorax in cats; ❑ Orthopneic position; ❑ Abdominal dilatation ("frog belly"); ❑ Subcrepitant fervours; ❑ Costal breathing due to an enlarged (respiratory system) abdomen; 28/11/2024 ❑ Syncope ❑ Cyanotic mucosa (hypoxia); 46 ❑ Strokes;  IRC1 HEART FAILURE 28/11/2024 47  COMPLEMENTARY EXAMS – X-RAYS Cardiomegaly Cardiac X-RAY incidences: Pulmonary Toracic X-RAY congestion ❑ Left Latero-lateral ❑ Ventro-dorsal Pulmonar edema ❑ Dorso-ventral IRC1 Pleural effusion Compression of the large bronchi Pulmonary vascular patterns 28/11/2024 48 Cardiomegaly Pleural effusion  COMPLEMENTARY EXAMS Electrocardiography ❑ It detects the heart rate and its alterations, the heart rhythm and its alterations, ❑ the QRS electrical axis and its changes, IRC1 morphological changes in the P wave and QRS complex and ST segment and T wave alterations. FREQUENCY VS CARDIAC RHYTHM Heart rate - Number of systoles/contractions in a given period of time. Cardica Rhythm - Succession of systoles carried out 28/11/2024 in a given period of time between consecutive contractions. 49 Atrial fibrillation  IRC1 COMPLEMENTARY EXAMS -ECG 28/11/2024 50  COMPLEMENTARY EXAMS - ECOCARDIOGRAPHY Observation of the heart's structure: Assessment of parameters such as: ❑ Size, shape and thickness of the heart ❑ The amount of heart muscle chambers; affected; ❑ Cardiac muscle contraction force ❑ Presence of fluid in the pericardium; IRC1 (ejection fraction) ❑ Assessment of parameters such as: ❑ Cardiac muscle (ejection fraction); ❑ The amount of heart muscle ❑ Congenital heart abnormalities; affected; ❑ Functioning of each heart valve. ❑ Presence of fluid in the pericardium; 28/11/2024 ❑ Valve function 51  IRC1 COMPLEMENTARY EXAMS - ECOCARDIOGRAPHY 28/11/2024 52  COMPLEMENTARY EXAMS ❑ Blood pressure ❑ Doppler - better than oscillometry (1) ❑ Oscillometry – easier (2) 1 IRC1 28/11/2024 2 53  IRC1 QUESTIONS? 28/11/2024 54