Liz Bode
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Replying to Liz Bode 21/06/2021 - 20:43
Final ECG for your thoughts – I can bring some to live Q and A too…
This is from a 10 yo Chocolate Lab with a right atrial mass. It is a tricky one, but you have been spot on so far!!!
https://drive.google.com/file/d/1fgdpTfhpq_1vhj7vRv3tf6Z0kG7dUuoP/view?usp=sharing
Liz
Replying to Liz Bode 21/06/2021 - 20:40
Sorry, thought I could edit my message but you can’t (note for developers!)
So there is a slight slurring of the ST segment but not of note. It is relevant (a sign of hypoxia/ ischaemia) when it is elevated/ depressed >0.2mV.
You can get marked right axis deviation with any right-sided disease, but pulmonic stenosis does seem to do it more consistently. That said, I saw a French bulldog today with normal axis and severe PS, so shows that MEA is not very reliable.
I will post one more ECG for consideration.
Liz
Replying to Liz Bode 21/06/2021 - 20:40
Sorry, thought I could edit my message but you can’t (note for developers!)
So there is a slight slurring of the ST segment but not of note. It is relevant (a sign of hypoxia/ ischaemia) when it is elevated/ depressed >0.2mV.
You can get marked right axis deviation with any right-sided disease, but pulmonic stenosis does seem to do it more consistently. That said, I saw a French bulldog today with normal axis and severe PS, so shows that MEA is not very reliable.
I will post one more ECG for consideration.
Liz
Replying to Alice L 20/06/2021 - 21:38
Hi both,
Thanks for great answers, once again. You should be able to subscribe to topics when you reply to a thread and that way you will get an email notification. There are a few glitches with the website which we are working through but PLEASE flag any you come across as we have 20 days to get the changed for free 🙂
In terms of the ECG – spot on this is a dog that had tricuspid valve dysplasia. There is a publication that reports the splintered QRS complexes that we see here are frequently found in cases with marked dysplasia. There is also P pulmonale (increased P wave height) suggestive of right atrial enlargement.
Hi Scott,
Good post! I had heard that it has now been linked to several well known brands of food, or at least that is what they are investigating. A friend of mine had 2 cats die from this, it really is very tragic.
Liz
Hi all,
Here is another ECG for your thoughts, this time from a 1yo Labrador.
What is your ECG diagnosis (and thoughts) and what is the most likely cardiac disease process in this dog?
Enjoy!
Liz
Replying to Alice L 17/06/2021 - 21:35
Hi both,
Thanks for your answers, both excellent. It was indeed a tricky one (and is made harder by the video as I like to count boxes/ do the paper mark test to see how regular the P waves are etc).
It is a bradyarrhythmia with splintered QRS complexes that are indicative of some sort of myocardial abnormality meaning conduction is not taking the usual path. There are some positive P waves and these can be seen both in the ST segment, in the T wave and occasionally look like they have the right relationship with the QRS (so therefore could be causing the QRS). There are also some negative P waves later on, which suggest a different part of the atrium is generating the P wave.
3rd degree AV block, at least in the first portion is a consideration. We would also need to look at the paper trace in better detail to determine if some of the P waves are captured and cause the QRS complexes. My interpretation is that the sinus rate is VERY slow and that we have an escape rhythm associated with this slow sinus rate. Sometimes the P waves occur and capture the rhythm but other times they happen just after the ventricle has decided to stop waiting and fire. In 3rd degree AV block I would expect a much faster P wave rate as the baroreceptors will be telling the sinus node that the heart rate needs to be speeded up. The rhythm at the end seems to suggest a new atrial focus taking over from the sinus node that is at a faster rate than the positive P waves.
I would agree, you could do an atropine response test, and in act this dog may benefit from atropine! It needs a faster heart rate.
I suggested that they check acid-base status and electrolytes as hypokalaemia could cause this. I also wondered about the impact of opioids on the rate as I have seen sinus bradycardia with these before. It could also be vagal, but I think this is less likely.
Hope that all makes sense! I will post a different case now…
Liz
Hi Nathalie,
These are generally only used with ventricular premature beats. I think that is because when you have more than 3 escape beats in a row then that would become an idioventricular rhythm (an escape rhythm). I think it would be unusual to see only two escape beats, usually there is just a single one or an idioventricular rhythm. How many did you see together?
Liz
Hi Nathalie,
I’ve finally read it (thanks for asking this question as it made me read it in detail!). So for those of you not familiar with this score the paper can be found here:
This is a scoring system based on echo that uses the LA:Ao, fractional shortening, E wave peak velocity and LVIDDn.
The authors have chosen parameters that are relatively easy to measure, with experience of Doppler. It is interesting that in dogs with stage B1 disease that 6 dogs would have been classified as severe using this system. This shows how the staging system we use currently is probably not a perfect reflection of the disease process.
It is difficult to say how useful it is without using it in practice. I am not sure it will be very useful to predict whether a dog will die of cardiac death or not as the ROC values were not great and the sensitivity and specificity were only moderate (around 78-87%) .
It would be interesting to use it in cases to see how you get on with it. Perhaps this is paving the way for more studies from this group about progression of disease and the MINE score, which would be more useful clinically than what they have done currently. This is because some dogs will stay mild or moderate for their life whilst others will move through the scoring system. What they have shown in this paper is just one time point on echo and so that is less useful.
Interested to hear other people’s thoughts too.
Liz
Hi Nathalie,
I would agree with you. I would not start furosemide unless I had strong evidence for CHF on rads or thoracic ultrasound. IVRT can be difficult to interpret/ measure accurately and interpretation is challenging with E and A wave summation. An LA:Ao of 1,7 is not massive (although it is usually better to use various measures of LA size when evaluating it so I would also look at the 2D on long axis measurement). CLopidogrel might be indicated. There is no clear cut-off of LA size to start this, the consensus just says stage B2 which is moderate enlargement (but I think we take an LA:Ao of 1.9). I would start it if left auricular velocities were <0.4m/s (as we have previously discussed).
Hope that is helpful.
Liz
Hi Alice,
Sorry for the delay in replying to this. I think it sounds most likely GA related. Would be interesting to see what the troponin was afterwards (although I appreciate that’s more of an academic exercise), but I have seen this in other dogs and could be related to transient myocardial hypoxia with a lower BP given ACP and iso. Your plan sounds excellent. I guess this dog could also have an area of abnormal myocardium that was irritated by the GA in some way.
I think in future the anaesthetic protocol would depend on what the dog was going to have done. Id monitor BP throughout and pre-oxygenate. Perhaps don’t use ACP and give an opioid only or combine with an alpha-2. To be honest though it was probably just one of those things and may not happen again so I wouldn’t be changing things too dramatically.
We could revisit this after lesson 8 which covers anaesthesia too 🙂
Liz
Hi Nathalie,
I still need to read this paper, job for this week and I’ll get back to you 🙂
Liz
Hi Anna,
Ooh!!! SVT in a cat, nice case 🙂 do you think she has an accessory pathway? It’s unusual to get an SVT with a normal looking heart in a cat otherwise. Perhaps you could post an ECG here if you can?
Diltiazem might work definitely worth a try. Can you get HyperCard? It was out of stock before I went on maternity leave. Other options to look into would be Summit and BOVA both (I think and if you’re in UK) do, or have been asked to do, re-formulations of diltiazem. If not then I’ve used 3mg/kg in a cat before so that would be 1/4 of 90mg tablet.
Let me know how you go as I’d be interested to find out.
Liz
Hi Francois,
Great questions, as always.
In terms of RCHF I would just start using furosemide. Sometimes, it’s nice to hospitalise these patients for 24hours to give IV furosemide to ensure that it is being delivered to the kidneys effectively and to improve any associated bowel oedema. However, if the ascites is relatively mild you could just send them home with furosemide too. I’d definitely give them pimobendan, probably and ACE inhibitor as we don’t have evidence for or against this currently, and spironolactone. I’d give the spiro less for the portal hypertension (furosemide will sort this out) and more for its other effects.
Matt’s lecture covers a lot of questions but I would use alfaxalone in this instance. I’d use it IV (unless you can’t get access – just IM requires large volumes). I’d draw up approximately 0.5mg/kg and just give to effect after giving an opioid.
I really like alfaxalone.
Liz
Hi Nathalie,
Yes, that’s my go to dose for both cats and dogs.
In dogs that are very stressed or panting a lot I’ll give them it half an hour before their echo. It can REALLY help!
I’ll also give anxious cats gabapentin prior to coming in and I’m going to try trazadone at some point in them too. I’ll also give trazadone to a dog if it’s coming for a recheck and I’ve had to give butorphanol to echo before.
Liz
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