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Liz Bode

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  • Liz Bode
    Keymaster
    20:05 14/03/22

    Hi Kerry,

    I am just sneaking on here as I also saw this paper (CRP in pneumonia). Some useful information and another way in which CRP may benefit our patients, they use it a lot in human medicine. I don’t see that many pneumonia cases as a cardiologist but it is something that I will definitely bear in mind in future.

    I also think there may be some utility in the cases of suspected myocarditis and endocarditis that we/I see. Particularly endocarditis to guide us a little about antibiotic use. Obviously, this is not founded on any scientific evidence other than they use CRP in human medicine for suspected cases of myocarditis and it is one of the recommendations in the 2013 consensus statement.

    Liz 🙂

    • This reply was modified 2 years, 9 months ago by Liz Bode.
    Liz Bode
    Keymaster
    16:14 09/02/22

    Replying to Nathalie Cunha 09/02/2022 - 04:54

    Hi Nathalie,

    That is super interesting! Very similar to the case that I mentioned. It will be interesting to see how these cases do long term as acute myocarditis can be reversible, but if recurrent reactivation of the virus/ pro-inflammatory state then chronic myocarditis is not good news!

    We have asked the web developers to allow uploading of images to the forum as we realise that this is an issue. They are supposed to be coming back to us this week with a timeline for a few changes that we have been asking for.

    Thank you for sending me the images. I have added a link here to the radiographs and echo loops for anyone that wants to see Nathalie’s cases.

    radiograph
    Echo loop
    Echo loop 2
    Echo loop 3

    Thanks for all your valuable comments/ contributions.

    Liz

    Liz Bode
    Keymaster
    16:06 09/02/22

    Replying to Emma Holt 08/02/2022 - 15:44

    Hi Emma and Scott,

    It helps make us suspicious of myocarditis. That being said a dog or cat with chronic disease might have normal troponin, so it isn’t very specific. I would also monitor it in individuals where it is very high, so this cat for example I might advise we repeat in a month.

    I just submitted a rectal swab in the end as didn’t want to sedate the cat again for an oropharyngeal one. Idexx said if we can send both that it may improve detection rates. It would be nice to have a commercially available blood test!

    Liz

    Liz Bode
    Keymaster
    21:27 07/02/22

    Replying to Emma Holt 07/02/2022 - 21:21

    Hi Emma,

    This cat had an HCM-phenotype. What made it slightly unusual is the age and sex (although young cats of any sex can get HCM). It didn’t look ischaemic as you normally see some form of regional hypokinesis but I didn’t observe that. It could potentially be irreversible. Myocarditis in the acute phase can be but if it develops into chronic disease and a DCM phenotype then it doesn’t tend to be.

    To be honest I check troponin in all my arrhythmia and most my heart failure cases. I send to Idexx as they have a high sensitivity assay. If I were being more specific I’d say I run it in any case that is slightly out of the ordinary e.g this young female cat, one with an arrhythmia, or a dog with unexpected appearance on echo such as HCM or DCM phenotype (chronic myocarditis can cause DCM but troponin isn’t always elevated).

    Liz

    • This reply was modified 2 years, 10 months ago by Liz Bode.
    Liz Bode
    Keymaster
    13:24 31/12/21

    Replying to Francois Ravier 04/12/2021 - 13:19

    Hi Francois,

    Sorry again for not getting back to you sooner.

    I thought I had replied in more detail to Emma, but some of my explanation is missing!

    If we look at lead II there is a P for almost every QRS (apart from the wide and bizarre looking complex that does have a P wave at the very start but the P runs in to the QRS so they are not related to each other, if that makes sense!). Therefore this is a sinus rhythm. The P wave is normal. There is no R wave in lead II (an R wave is always a positive deflection) and there is an S wave only. Then from the S wave the trace doesn’t return to baseline until after the end of the T wave. There is marked ST elevation here, which is a sign of hypoxia/ ischaemia. This cat, I think, had infarcted almost all of the free wall of the LV. He survived for about 2 months 🙁

    Happy New Year to you,

    Liz

    Liz Bode
    Keymaster
    13:19 31/12/21

    Replying to Francois Ravier 11/12/2021 - 14:35

    Hi Francois,

    Sorry for the delay in replying, I hope that you have had a good Xmas.

    Yes, RBBB has been associated with MMVD and many other disease processes in dogs, but the mechanism is unclear. RBBB does not require treatment, but I have seen dogs progress to complete AV block after being diagnosed with MMVD and RBBB so it is worth keeping an eye on them. We presumed in that dog that it had conduction system disease that eventually degenerated and required pacemaker implantation.

    Happy New Year 🙂

    Liz

    Liz Bode
    Keymaster
    13:04 31/12/21

    Replying to Gabriela Gonzalez-Ormerod 07/12/2021 - 18:49

    Hi Gaby,

    Scott has asked me to answer your question on rivoroxaban vs clopidogrel in cats with HCM.

    Rivoroxaban is a factor Xa inhibitor, therefore it is a true anti-coagulant as it targets the coagulation cascade but in a much more reliable way than heparin (plus it is in oral form so can give to dogs and cats at home). Clopidogrel, on the other hand, is an anti-platelet drug that binds to the P2Y12 receptor on the platelet. This blocks the effect that ADP has on the platelet (as the P2Y12 receptor is the ADP receptor), preventing platelets changing shape and so sticking to each other. It is irreversible and so binds to platelets for their lifespan.

    We only have evidence for clopidogrel use in cats with HCM and FATE – this was called the FATCAT study and the abstract is here:

    FATCAT study

    In brief, they showed that clopidogrel increased the time to recurrence of FATE when compared to aspirin (443 vs 192days). Therefore, our preference is to use clopidogrel at the moment. It has to be remembered that this study was in a certain population though i.e. cats that had already suffered a FATE episode and we have no other evidence for other stages of disease.

    We advise starting clopidogrel in any cat that has a dilated left atrium (usually a 2D left atrial size of >19mm and LA:Ao >1.7) with reduced LA function. There is currently a study underway comparing clopidogrel with rivoroxaban in cats with FATE (SUPERCAT study) but results have not been released yet and I think it will be awhile until they are available as these cats don’t tend to get referred. It might turn out that rivoroxaban is superior to clopidogrel. In people, rivoroxaban is preferred over drugs like warfarin as it has a safer profile, but obviously we don’t use warfarin in our patients.

    In cats that are at high risk of FATE i.e. have had an episode, or have a thrombus/ smoke you could combine both drugs together. I tend to start with clopidogrel and if I have a cat with FATE then I might use both together.

    Hope that helps,

    Liz

    • This reply was modified 2 years, 11 months ago by Liz Bode.
    Liz Bode
    Keymaster
    20:44 08/12/21

    Replying to Francois Ravier 07/12/2021 - 13:17

    Hi Francois,
    Thanks for commenting 🙂
    I agree, the HR is approx 100-120bpm with an irregular rhythm.
    There is a P:QRS of 1:1, and the P waves are positive in lead II so they have a normal origin (from the SAN).
    The QRS complexes are negative in lead II and positive in aVR, so we have a right axis shift, and the QRS complexes are wide and bizarre (so look ventricular in origin). They measure 70ms.
    The P wave is normal in size.
    The presence of a P wave with a normal PQ interval suggests that the atrial and ventricular activity are connected. You are right in thinking that there is a conduction abnormality, in this case right bundle branch block. So the time it takes for ventricular depolarisation is prolonged, hence the wide QRS.
    Great job!
    Liz

    Liz Bode
    Keymaster
    22:49 26/11/21

    Replying to scott@vtx-cpd.com 26/11/2021 - 15:36

    Hi all,

    The device is the same as the medical one but as it has been validated in dogs, cats abs horses they market it as a veterinary device separately (this is my understanding at least).
    You can buy it for your iPhone and there is a vet/owner specific app for the phone. You can use it without clipping I think and the trace you get is equivalent to lead II and is good for arrhythmias and normal rhythms. It doesn’t replace a Holter or Linq device (3 year microchip ECG) but still def has its place if owners can’t afford these.

    Liz

    Liz Bode
    Keymaster
    07:13 12/11/21

    Replying to Megan B. 11/11/2021 - 22:46

    Hi Megan,

    Thanks for the question. Scott might have more to add but a game changer is using gentle suction (if you have this available) and a mucus trap. You attach the mucus trap directly to the scope and the longer end to suction. Place 1ml/kg saline in a syringe with some air also, inject where you want it to go, coupage the chest as you inject and then as soon as you’ve stopped injecting apply the mucus trap with very gentle suction. Carry on with the coupage until you start to see a bit of foam – which is surfactant. You know you’ve sampled the alveoli then. There is no need to use a catheter with this technique.
    If you don’t have suction then you will have to use a BAL catheter. Do the same with fluid and coupage but you’ll get much less fluid back.
    Once you have fluid ensure it goes directly into a plain and an EDTA pot.
    Hope that’s helpful

    Liz

    Liz Bode
    Keymaster
    16:51 10/11/21

    Replying to Emma Holt 10/11/2021 - 16:45

    Hi Emma,

    Not any more significant than saying ‘this cat most likely has heart disease’. It isn’t haemodynamically significant as it appears on its own and at a rate that is similar to the sinus rate.

    Liz

    Liz Bode
    Keymaster
    14:57 10/11/21

    Replying to Emma Holt 09/11/2021 - 23:02

    Hi Emma,

    Yes, sorry this slipped off the radar but I was thinking yesterday that I hadn’t put up an explanation.

    This ECG shows a heart rate of around 220bpm. It is a sinus rhythm as there is a P wave for every QRS apart from one single, wide and bizarre looking QRS that occurs near the start.

    Liz Bode
    Keymaster
    14:55 10/11/21

    Love these!!

    Liz Bode
    Keymaster
    14:55 10/11/21

    Love these!!

    Liz Bode
    Keymaster
    21:13 25/10/21

    Hi Lesley,

    Sorry I missed this post! Such a sad case.

    I have looked at the radiographs and I can’t see anything obvious in terms of the thorax. The heart is a normal size and shape. The airways look normal. There is mediastinal shift on the DV, but this is likely due to atelectasis from the dog being in lateral recumbency (I would imagine).

    My thoughts on the case:
    Given the forelimb signs and pain, I wonder if she had a cervical disc lesion. This would explain those signs. Also, if it got acutely worse then this could explain the collapse, bradycardia and respiratory arrest as all the nerves controlling these physiological processes arise in the cervical spine?

    Scott may have more to add though 🙂

    Liz

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