Difference between revisions of "Heart Failure, Diagnosis"

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A number of diagnostic procedures need to be taken into account when diagnosing heart failure.
 
  
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== History & Clinical Signs ==
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==History & Clinical Signs==
  
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Coughing, dyspnea, tachypnea, orthopnea, exercise intolerance, syncope, lethargy, peripheral oedma, ascites, mucous membrane colour and weight loss are all clinical signs that may be caused by heart disease, but may also have other causes. There may also be a capillary refill time of less than 3 seconds, which is normal. Over 3 seconds is abnormal. Pale mucous membranes suggest poor peripheral circulation due to vasoconstriction, decreased hemoglobin in the blood ([[anaemia]]), or [[shock]]. Cyanosis suggests adequate hemoglobin, but inadequate oxygenation. This can be seen with pleural effusion/pulmonary oedema - right to left shunt within the circulation causing deoxygenated blood to mix with oxygenated blood.
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-Cough
  
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Signs of heart failure are directly related to [[Heart Failure - Pathophysiology|which side is affected]]. The above signs are characteristic of cardiac problems, but can also be the signs of other diseases involving different body systems therefore a good physical exam including signalment, history, observation, palpation, percussion, and auscultation are necessary to identify true cardiac problems.
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-Dyspnea
  
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== Physical Exam  ==
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-Tachypnea
  
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Felines often present acutely with no history of heart disease.  They commonly throw blood clots to the aorta which lodge in the bifurcation just before entering the rear limbs. The presence of no palpable femoral pulses and cold limbs along with pulmonary edema and/or pleural effusion is strongly supportive of heart failure.
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-Orthopnea
  
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-Exercise Intolerance
  
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=== Observation  ===
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-Syncope
  
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Clinical signs as described above.
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-Lethargy
  
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=== Palpation  ===
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-Ascites
  
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'''Precordium:''' (Left side of the chest behind the elbow where heart contractions are easily palpated and auscultated). Heart rate, rhythm, character, apex beat and palpable thrill can all be detected here. 
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-Peripheral Edema
  
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'''Pulse:''' (rate, rhythm, character). Dog: Femoral pulse; palpate heart, Horse: External maxillary/ facial artery; transverse facial artery; median artery; digital artery; metatarsal artery, Cattle: external maxillary/ facial artery; middle coccygeal artery; median artery. 
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-Weight Loss
  
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'''Pulse Deficits '''(seen with arrhythmias)
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-Capillary Refill Time: under 3 seconds is normal; over 3 seconds is abnormal
  
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Jugular pulses and/or jugular venous distension and/or enlarged ventral abdominal veins (indicates high venous pressure).
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-Mucous Membrane Color:
  
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Abdomen: pitting oedema, ascites, splenomegaly, hepatomegaly and fluid thrill (fluid movement causes a palpable vibration).
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Pallor=pale skin/mucus membrane; suggests poor peripheral circulation due to vasoconstriction, decreased hemoglobin in the blood (anemia), or shock
  
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==== Percussion  ====
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Cyanosis=blue skin/mucus membrane discoloration; Suggests adequate hemoglobin, but inadequate oxygenation; Seen with Pleural effusion/pulmonary edema, right to left shunt within the circulation causing deoxygenated blood to mix with oxygenated blood
  
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A method of diagnosis performed by flicking a body part with fingers and the resulting sound helps determine size, position, and density of the underlying structures. The thorax will have a lack of resonance if the lung has solidified and you will be able to detect a fluid line. The abdomen will show a fluid thrill on percussion.
 
  
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==== Auscultation  ====
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*Signs of heart failure are directly related to which side is affected.
  
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A method of diagnosis performed by listening to sounds inside the body. Auscultation can be performed with or without a stethoscope. Abdominal, cardiac, pulmonary, and thoracic auscultation can all be performed. Cardiac auscultation is used to listen to heart sounds and [[Heart Murmurs|heart murmurs]].
 
  
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'''Heart Sounds: '''
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*The above signs are characteristic of cardiac problems, but can also be the signs of other diseases involving different body systems.  
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:These differ with different species. In the '''dog''' and '''cat''' normal heart sounds are S1 (closure of atrioventricular valves; heard best at left heart apex) and S2 (closure of semilunar valves; heard best at left heart base); Lub-Dup sound. Abnormal Heart Sounds: S3 & S4 occur during diastole and should not be audible in dogs and cats. If either one is present, this is called a GALLOP RHYTHM and suggests poor ventricular filling. Du-Lub-Dup sound.
 
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:In the '''horse''' normal heart sounds are S1 & S2, S3 & S4; S3 is audible in many horses and marks the end of ventricular filling.
 
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:In the '''bovid''', normal heart sounds are S1 & S2, S4; Healthy farm animals do not have an audible S3 as in the horse.
 
  
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'''Heart Murmurs '''are abnormal heart sounds due to turbulent blood flow. Heart murmurs are characterized based on their timing, location, intensity, radiation, pitch, and shape.
 
  
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'''Pulmonary edema''' will have crackles present in the lungs.  
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*A good physical exam including signalment, history, observation, palpation, percussion, and auscultation are necessary to identify true cardiac problems.  
  
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'''Pleural effusion''' will have dull lungs songs, more so ventrally.
 
  
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=== Electrocardiography (ECG)  ===
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===Physical Exam===
  
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This can be used to recognise conduction problems or arrhythmias but is not needed in the diagnosis of heart failure.
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====1. Observation====
  
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=== Radiology  ===
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-Clinical signs: (listed above)
  
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Will show cardiac enlargement +/- '''[[Heart Failure, Right-Sided|right-sided heart failure]] '''signs, which are ascites, hepatomegaly and pleural effusion and [[Heart Failure, Left-Sided|'''left sided heart failure ''']]signs which are pulmonary oedema and pulmonary venous distension.
 
  
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=== Echocardiography  ===
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====2. Palpation====
  
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Can be used to determine the cause of heart failure, such as structural deformities etc.  Right parasternal short axis view (mushroom view) can provide quick insight into general volume status as well as ventricle thickness and ratio giving even a novice observer some idea as to cardiac vs non cardiac disease. 
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-Precordium:(Left side of the chest behind the elbow where heart contractions are easily palpated and auscultated)
  
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'''Pericardial effusion''' can also be ruled out
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Heart Rate, Rhythm, Character
  
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'''Blood clots''' can be seen in the left atrium sometimes.
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Apex Beat
  
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=== Ultrasound ===
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Palpable Thrill
  
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[[TFAST]] and [[VetBLUE]] can be used to quickly determine if edema is present in the lungs or effusion is present in the pleural cavity, thus differentiating it from "dry" lung diseases such as asthma.  Presence of nodules is indicative of fungal or neoplastic disease. If the lungs are dry, there is no left sided congestive heart failure present by definition. 
 
  
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The vena cava can be evaluated as it crosses the diaphragm.  Distension is diagnostic for volume overload or right sided heart failure.
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-Pulse: (Rate, Rhythm, Character)
  
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=== Cardiac Markers ===
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Dog: Femoral Pulse; Palpate heart
  
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NT-pro BNP levels can be measured in house or sent out to lab to measure heart muscle stretch.  This cane be applied as a screening test for at risk breeds or as a diagnostic tool in emergencies or when other tests do not provide a clear answer.
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Horse: External Maxillary/Facial Artery; Transverse Facial Artery; Median Artery; Digital Artery; Metatarsal Artery
  
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{{Chapter}}
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Cattle: External Maxillary/Facial Artery; Middle Coccygeal Artery; Median Artery
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{{Mansonchapter
 
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|chapterlink = http://www.mansonpublishing.co.uk/book-images/9781840761856_sample.pdf
 
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|chaptername = Congestive Heart Failure in the Dog (part of Congestive Heart Failure in the Cat)
 
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|book = Small Animal Emergency and Critical Care Medicine
 
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|author = Elizabeth Rozanski, John Rush
 
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|isbn = 9781840761856
 
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}}
 
  
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== References ==
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Pulse Deficits (Seen with Arrhythmias)
  
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Andrews, A.H, Blowey, R.W, Boyd, H and Eddy, R.G. (2004) '''Bovine Medicine '''(Second edition), ''Blackwell Publishing''
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Jugular Pulses and/or Jugular Venous Distension and/or Enlarged Ventral Abdominal Veins (Indicates High Venous Pressure)
  
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Blood, D.C. and Studdert, V. P. (1999) '''Saunders Comprehensive Veterinary Dictionary '''(2nd Edition) ''Elsevier Science ''
 
  
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Ettinger, S.J. and Feldman, E. C. (2000) '''Textbook of Veterinary Internal Medicine Diseases of the Dog and Cat''' Volume 2 (Fifth Edition) ''W.B. Saunders Company''
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-Abdomen:
  
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Ettinger, S.J, Feldman, E.C. (2005) '''Textbook of Veterinary Internal Medicine '''(6th edition, volume 2) ''W.B. Saunders Company''
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Pitting Edema
  
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Fossum, T. W. et. al. (2007)''' Small Animal Surgery''' (Third Edition) ''Mosby Elsevier''
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Ascites
  
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Merck & Co (2008)''' The Merck Veterinary Manual '''(Eighth Edition)'' Merial''
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Splenomegaly
  
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Nelson, R.W. and Couto, C.G. (2009) '''Small Animal Internal Medicine '''(Fourth Edition)'' Mosby Elsevier''
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Hepatomegaly
  
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Radostits, O.M, Arundel, J.H, and Gay, C.C. (2000) '''Veterinary Medicine: a textbook of the diseases of cattle, sheep, pigs, goats and horses '''''Elsevier Health Sciences''
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Fluid Thrill (Fluid movement causes a palpable vibration)
  
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Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine '''(Third Edition), ''Saunders''
 
  
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====3. Percussion====
  
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{{review}}
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A method of diagnosis performed by flicking a body part with fingers and the resulting sound helps determine size, position, and density of the underlying structures.
  
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{{OpenPages}}
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-Thorax: Lack of resonance if the lung has solidified; Detection of fluid line
  
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[[Category:Heart_Failure]] [[Category:Expert_Review]]
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-Abdomen: Detection of fluid thrill
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[[Category:Cardiology Section]]
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 +
 
 +
====4. Auscultation====
 +
 
 +
A method of diagnosis performed by listening to sounds inside the body. Auscultation can be performed with or without a stethoscope. Abdominal, cardiac, pulmonary, and thoracic auscultation can all be performed.
 +
 
 +
Cardiac auscultation is used to listen to heart sounds & heart murmurs.
 +
 
 +
'''Heart Sounds'''
 +
 
 +
Cardiac Auscultation Species Differences:
 +
 
 +
'''Dog & Cat'''
 +
 
 +
Normal Heart Sounds: S1 (closure of atrioventricular valves; heard best at left heart apex) & S2(closure of semilunar valves; heard best at left heart base); Lub-Dup sound
 +
 
 +
Abnormal Heart Sounds: S3 & S4 occur during diastole and should not be audible in dogs and cats. If either one is present, this is called a GALLOP RHYTHM and suggests poor ventricular filling. Du-Lub-Dup sound.
 +
 
 +
'''Horse'''
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Normal Heart Sounds: S1 & S2, S3 & S4; S3 is audible in many horses and marks the end of ventricular filling.
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 +
'''Ox'''
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Normal Heart Sounds: S1 & S2, S4; Healthy farm animals do not have an audible S3 as in the horse.
 +
 
 +
 
 +
'''Heart Murmurs'''
 +
 
 +
-Heart Murmurs=abnormal heart sounds due to turbulent blood flow. Heart murmurs are characterized based on their timing, location, intensity, radiation, pitch, and shape.
 +
 
 +
 
 +
===Electrocardiography (ECG)===
 +
 
 +
-Not needed in the diagnosis of heart failure
 +
 
 +
-Can be used to recognize arrhythmias or conduction problems
 +
 
 +
 
 +
===Radiology===
 +
 
 +
-Cardiac enlargement +/-
 +
 
 +
'''Right-Sided Heart Failure:'''
 +
 
 +
-Ascites
 +
 
 +
-Hepatomegaly
 +
 
 +
-Pleural Effusion
 +
 
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'''Left-Sided Heart Failure:'''
 +
 
 +
-Pulmonary edema
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-Pulmonary venous distension
 +
 
 +
 
 +
===Echocardiography===
 +
 
 +
-Used to determine the cause of heart failure
 +
[[Category:Heart_Failure]][[Category:To_Do_-_Cardiovascular]]

Revision as of 12:07, 3 July 2010

History & Clinical Signs

-Cough

-Dyspnea

-Tachypnea

-Orthopnea

-Exercise Intolerance

-Syncope

-Lethargy

-Ascites

-Peripheral Edema

-Weight Loss

-Capillary Refill Time: under 3 seconds is normal; over 3 seconds is abnormal

-Mucous Membrane Color:

Pallor=pale skin/mucus membrane; suggests poor peripheral circulation due to vasoconstriction, decreased hemoglobin in the blood (anemia), or shock

Cyanosis=blue skin/mucus membrane discoloration; Suggests adequate hemoglobin, but inadequate oxygenation; Seen with Pleural effusion/pulmonary edema, right to left shunt within the circulation causing deoxygenated blood to mix with oxygenated blood


  • Signs of heart failure are directly related to which side is affected.


  • The above signs are characteristic of cardiac problems, but can also be the signs of other diseases involving different body systems.


  • A good physical exam including signalment, history, observation, palpation, percussion, and auscultation are necessary to identify true cardiac problems.


Physical Exam

1. Observation

-Clinical signs: (listed above)


2. Palpation

-Precordium:(Left side of the chest behind the elbow where heart contractions are easily palpated and auscultated)

Heart Rate, Rhythm, Character

Apex Beat

Palpable Thrill


-Pulse: (Rate, Rhythm, Character)

Dog: Femoral Pulse; Palpate heart

Horse: External Maxillary/Facial Artery; Transverse Facial Artery; Median Artery; Digital Artery; Metatarsal Artery

Cattle: External Maxillary/Facial Artery; Middle Coccygeal Artery; Median Artery

Pulse Deficits (Seen with Arrhythmias)

Jugular Pulses and/or Jugular Venous Distension and/or Enlarged Ventral Abdominal Veins (Indicates High Venous Pressure)


-Abdomen:

Pitting Edema

Ascites

Splenomegaly

Hepatomegaly

Fluid Thrill (Fluid movement causes a palpable vibration)


3. Percussion

A method of diagnosis performed by flicking a body part with fingers and the resulting sound helps determine size, position, and density of the underlying structures.

-Thorax: Lack of resonance if the lung has solidified; Detection of fluid line

-Abdomen: Detection of fluid thrill


4. Auscultation

A method of diagnosis performed by listening to sounds inside the body. Auscultation can be performed with or without a stethoscope. Abdominal, cardiac, pulmonary, and thoracic auscultation can all be performed.

Cardiac auscultation is used to listen to heart sounds & heart murmurs.

Heart Sounds

Cardiac Auscultation Species Differences:

Dog & Cat

Normal Heart Sounds: S1 (closure of atrioventricular valves; heard best at left heart apex) & S2(closure of semilunar valves; heard best at left heart base); Lub-Dup sound

Abnormal Heart Sounds: S3 & S4 occur during diastole and should not be audible in dogs and cats. If either one is present, this is called a GALLOP RHYTHM and suggests poor ventricular filling. Du-Lub-Dup sound.

Horse

Normal Heart Sounds: S1 & S2, S3 & S4; S3 is audible in many horses and marks the end of ventricular filling.

Ox

Normal Heart Sounds: S1 & S2, S4; Healthy farm animals do not have an audible S3 as in the horse.


Heart Murmurs

-Heart Murmurs=abnormal heart sounds due to turbulent blood flow. Heart murmurs are characterized based on their timing, location, intensity, radiation, pitch, and shape.


Electrocardiography (ECG)

-Not needed in the diagnosis of heart failure

-Can be used to recognize arrhythmias or conduction problems


Radiology

-Cardiac enlargement +/-

Right-Sided Heart Failure:

-Ascites

-Hepatomegaly

-Pleural Effusion

Left-Sided Heart Failure:

-Pulmonary edema

-Pulmonary venous distension


Echocardiography

-Used to determine the cause of heart failure

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