Liz Bode
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Replying to scott@vtx-cpd.com 28/08/2021 - 09:18
Hi Scott,
Yes, it appeared that most of them did. My initial thoughts on the whippet I saw was to repeat the haematology and smear in 4-6 weeks. Other blood work was unremarkable, PLI normal, CRP <10 (WNL) and nothing exciting on echo. Of course, doesn't mean there isn't or wasn't something going on, especially given the clinical signs noted by the owner.
I will keep you posted if anything more comes of it.
Liz
Replying to Nathalie Cunha 22/06/2021 - 06:55
Hi Nathalie,
This was indeed what we thought in this case – a focal atrial tachycardia for the reasons you have stated above 🙂 We controlled it with diltiazem and the heart remodelled back to normal (apart from the mass!).
Liz
Replying to Camilla Edwards 24/06/2021 - 20:41
Hi Camilla,
Sorry, this did cause some problems as we switched part way through the course to the new website. The link was on lesson 10, but you had to force completion of lesson 9 (I didn’t realise this until after the session). I will post it soon.
Everyone will have 6 months from the start of the course to access the videos so no rush with those.
Liz
Replying to Gabriela Gonzalez-Ormerod 25/06/2021 - 21:01
Hi Gabriela,
Great questions also. In terms of management of RCHF the best way to monitor successful treatment is via a FAST scan to see if I can still see fluid. I would expect almost complete resolution after a week and by 2 weeks post furosemide there should be no fluid there at all. It is more tricky to monitor than LCHF though. You could also weigh them serially (as you point out ideally you would have the pre-CHF weight) or measure abdominal girth, but ultrasound is going to be most accurate. Similar to LCHF you are looking to remove all of the fluid.
Hope that helps 🙂
Liz
Hi Nathalie,
That really depends on if the flow has fully reversed or is still bidirectional. If bidirectional I would expect that the velocities will start to drop in both systole and diastole. Then you will lose the diastolic component and then both components if the PA pressure increases enough. I would start sildenafil if I documented pulmonary hypertension on echo (or had a high suspicion following the consensus statement). Sometimes there are anomalous vessels called aberrant bronchoesophageal arteries that enter the PA in a similar location to a PDA but have much lower flow around 3 m/s. You can get a murmur but not always – Geoff Culshaw published a case series in JSAP in 2013. In this case the pulmonary artery pressure is normal so there is no evidence of hypertension.
Have you seen a suspicious case?
Liz
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
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