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CARDIOLOGY

Daniel F. Hogan, DVM, Diplomate ACVIM (Cardiology), Purdue University

Cardiac Examination & History

n todays world of high-tech cardiology
diagnostic techniques, such as echocardiography, the physical examination
and historical clinical information may
seem obsolete. However, this could not
be further from the truth. In fact, an accurate cardiac diagnosis (or at least short
differential list) is usually made while the
clinician is still in the examining room,
based on the results of the physical
examination of the patient and questioning of the owner.

In addition, high-tech equipment is often

not available in all practices, or access to
specialists trained in the use of such
equipment is limited. Furthermore, an
accurate physical examination and clinical
history allow a clinician to focus the diagnostic workup so that superfluous diagnostic tests can be avoided. This reduces
the amount of potentially distracting test
results as well as financial burden on the
client.

STEP BY STEP CARDIAC EXAMINATION & HISTORY

Interviewing

Pertinent History

There are a few key points to a

good clinical history, including
body language and listening skills. Closed
body language (such as crossed arms) and
lack of eye contact can immediately put off
clients and will negatively affect the history
they can provide. Active listening lets clients
know you feel what they are saying is important. Asking questions generated from their
previous answer is a very good way to
demonstrate active listening. It is also very
important to introduce yourself to your
patient.

There are no unique aspects to history for cardiovascular disease

compared with other diseases. As for any dis-

ease, you should determine why the client

brought the animal to see you, whether the
problem has gotten better or worse, what
treatment (if any) has been used, and
whether any clinical response (better or
worse) to that treatment has occurred.
Because many of these animals receive multiple medications, it is strongly suggested to
list each medication, the dose, and the frequency of administration (Table 1). This information is important if new medications will
be added or doses changed. Additional
questions that may be related to the cardiovascular system include the presence and
frequency of coughing, difficulty breathing,
and abdominal distension. A history of collapse, especially exercise-induced, could be
very important but is uncommonly reported.
c o n t i n u e s

Table 1. Drug History

Drug Name:___________________________________________________________
Dose of Drug:__________________________________________________________
Dosing Frequency: ______________________________________________________
Improvement

No Change

Worsening

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Physical Examination

The physical examination should

be done systematically so that the
process is consistent between patients and
important clinical variables are not overlooked.
The initial physical exam can be accomplished
while acquiring the history and includes
observing the animal with respect to
demeanor, respiratory effort, and overall condition. Once the history has been taken, the
hands on physical exam can begin.

Arterial Pulses
A good first step is palpation of the femoral
arterial pulse for strength, symmetry, and synchrony to the apical heartbeat. The strength of
the arterial pulse is an indication of left ventricular function. Common causes of reduced
pulse strength (quality) include reduced cardiac output from systolic dysfunction (ie, dilated cardiomyopathy), reduced left ventricular
filling (ie, pericardial effusion), or delayed left
ventricular emptying (ie, subaortic stenosis).
The figure shows pressure tracings of arterial
blood pressure demonstrating normal pulses
(A), bounding arterial pulses (B) (patent ductus arteriosus, aortic insufficiency), weak arterial pulses (C) (dilated ventricular chamber,
pericardial tamponade), and bigeminal pulses
(D) (alternating pulse deficits) seen with cardiac arrhythmias.
Very strong (bounding) arterial pulses are usually associated with reduced diastolic arterial
pulse pressure (ie, patent ductus arteriosus,
aortic insufficiency, or arteriovenous fistulae).
Peripheral arterial disease is not common in
small animal species, but asymmetric femoral
arterial pulse quality (in which the pulse is

stronger on one side than the other) may be

associated with thrombotic disease (as in Cavalier King Charles spaniels) or embolic disease
(eg, arterial thromboembolism). Pulse deficits
(apical beat with absent or greatly reduced
arterial pulse) arise from reduced stroke volume and indicate cardiac arrhythmias. The
exact type of arrhythmia must be determined
from a surface electrocardiogram.
Assessment of pulse quality can be affected by
such things as patient obesity or the practitioners inexperience with evaluating pulse quality.
It is important to remember that the physical
examination focuses on acquiring information
that is supportive of a diagnosis and helps
guide additional diagnostic tests. If a practitioner is not confident about interpreting pulse
quality, then a concerted effort should be made
to increase his or her experience through repetitive evaluation in multiple animals or through
continuing education wet labs.

PROCEDURE PEARL
Pulmonic stenosis and subaortic stenosis, common congenital abnormalities in the boxer
dog, result in similar heart murmurs. However, accurate evaluation of femoral arterial pulse
quality can usually differentiate these 2 conditions. With pulmonic stenosis, the femoral
arterial pulses are of normal strength; with subaortic stenosis, the pulses are usually weak.

PDA = patent ductus arteriosus; PVC = premature ventricular contraction

Thoracic Auscultation

Thoracic auscultation allows the

examiner to determine whether
normal heart sounds are present, muffled, or
absent; the presence of abnormal heart
sounds; and the presence of normal or abnormal lung sounds. Cardiac auscultation should
focus on all cardiac regions; specifically
anatomic areas along the thoracic wall that
correspond to locations of the cardiac valves
(Figures A and B). The mitral valve region
(M) is over the area where the apical cardiac
beat is palpated. From this location, the pulmonic (P ) and aortic (A ) areas can be determined. The tricuspid region (T ) is located
where the apical beat is palpated on the right
hemithorax. Abnormal blood flow associated
with one of these valves is most commonly
heard over the associated areas on the thoracic wall.
It should be emphasized again that all areas
of the thorax should be ausculted as important information may be missed if this is not
done. An excellent example is the situation
with some PDAs: If examiners auscult only
the M region, they may hear only a systolic
murmur and diagnose mitral regurgitation.
However, if they had listened to the left heart
base (A and P regions) after listening to the
M region, they would have noted the continuous murmur and, when combined with the
finding of bounding arterial pulses, would
have made the correct diagnosis of PDA.
The normal heart sounds (S1 and S2), along
with most pathologic murmurs, are high-frequency heart sounds and are heard best with
the diaphragm of the stethoscope. The abnormal gallop sounds are low-frequency
sounds, and their detection is accentuated
with the bell of the stethoscope. The most
common type of murmur by far is that occurring during systole; continuous murmurs
(those occurring during both systole and diastole) are a distant second (Figure C). Isolated
diastolic murmurs are relatively rare. Cats
often present with soft systolic murmurs along
the parasternal region. These murmurs can be
very focal and quite dynamic; the intensity (or

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A
M

T
V

A
loudness) of the murmur can vary considerably or even be absent at times (intermittent
murmur).

(and occurs during late diastole). The presence

of an S3 or S4 is always considered abnormal
in the dog and cat.

When the timing of the murmur is combined

with the anatomic location where the murmur
is loudest, the cause of the murmur can be
accurately diagnosed (Table 2). The gallop
sounds can be heard with abnormal ventricular filling. The third heart sound (S3) is due to
the rapid cessation of ventricular filling associated with a dilated ventricular chamber and
occurs in early diastole. The fourth heart
sound (S4) occurs when atrial contraction
pushes blood into an already stiff ventricle

Gallops can be difficult to hear in any species

and are probably harder to hear in cats given
their rapid heart rate. Cats usually develop S4
gallops where dogs usually develop S3 gallops. Systolic clicks should never be confused
with a gallop as they occur during systole
(gallops are diastolic sounds) and clicks are
sharp, high-frequency, and short sounds as
compared to the low-frequency, dull, and
more prolonged sounds of gallops

Table 2. Common Cardiac Diseases & Their Murmurs

Mitral regurgitation

Systolic murmur
Left apex (M region)

Patent ductus arteriosus

Continuous murmur
Left heart base (A region)

Subaortic stenosis

Systolic murmur
Left heart base (A region)

Pulmonic stenosis

Systolic murmur
Left heart base (P region)

Ventricular septal defect

Systolic murmur
Right cranial sternal border (V region)

Aortic insufficiency

Diastolic murmur
Left heart base (A region)

c o n t i n u e s

Systolic Regurgitant Murmur

Mitral Regurgitation

Systolic Ejection Murmur

Subaortic Stenosis

Continuous Murmur
PDA

Diastolic Murmur
Aortic Insufficiency

S3 and S4 Gallop Sounds

41

2 3

Phonocardiograms illustrating murmurs and gallop

sounds of common cardiac diseases

PROCEDURE PEARL
The most common cardiac disease
encountered in small animal general
practice is mitral regurgitation due to
endocardiosis. This is usually seen in
older animals and most commonly in
small breeds. Therefore, it is extremely
uncommon to encounter congestive heart
failure in an older, small-breed dog when
a cardiac murmur is not present.

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CONTINUED

Mucous Membranes

Examination of the mucous membranes allows estimation of tissue

perfusion due to the membranes rich capillary
network. Certain changes can indicate alterations to the circulatory system.
Pale mucous membranes often indicate
reduced or poor perfusion, which can be
caused by many conditions including poor
cardiac output (eg, dilated ventricular
chamber, hemodynamically significant cardiac arrhythmias) or intense peripheral
vasoconstriction (eg, shock, pain). Pale
mucous membranes are also associated
with clinically significant anemia.
Dark red or brick red mucous membranes indicate that the capillary beds are
dramatically vasodilated; this is more commonly associated with excessive heat or
certain types of shock, such as septic
shock.
Mucous membranes can appear bluish,
which is also known as cyanosis. Cyanosis
can be further defined as peripheral or
central. Peripheral cyanosis is probably the
most common clinically recognized form of
cyanosis; with this type there is local
reduced perfusion of tissues combined
with continued or increased oxygen uptake
from the blood by the tissue. Good clinical
examples of this include slight bluish discoloration of the tongue of obese animals,
infracted nail beds or footpads in cats with
cardiogenic embolism (Figure A), and the

bluish appearance of the distal aspect of

human fingers in very cold weather.
Central cyanosis occurs when the circulating
blood has more than 5 g/dL of hemoglobin
desaturated of oxygen. This can be seen in
animals with clinically significant pulmonary
disease and hypoxemia or with right-to-left
cardiovascular shunts, such as a reverse
patent ductus arteriosus and tetralogy of Fallot (Figure B). This right ventricular angiogram
demonstrates blood flow from the right ventricle into the aorta (Ao ) and pulmonary artery
(PA ) in a cat with tetralogy of Fallot.

With right-to-left cardiovascular shunts, the

mucous membranes can change dramatically
and rapidly on the basis of underlying hemodynamic status. As a result, the cyanosis may
be present at rest but nearly always worsens
with exercise; in fact, it may be noted only
when the animal is exercising.
Finally, with reverse patent ductus arteriosus,
only the caudal mucous membranes will be
cyanotic because the brachycephalic trunk and
left subclavian, which supply blood to the
head and thoracic limbs, arise proximal to the
site of right-sided blood entry (Figure C). This
right ventricular angiogram demonstrates
blood flow from the right ventricle (RV ) crossing the patent ductus arteriosus (*) and into
the distal aorta (Ao ) in a dog with reverse
patent ductus arteriosus. Note that the venous
blood from the right ventricle enters the
descending thoracic aorta after the origins of
the brachycephalic trunk and left subclavian
arteries.

PA
Ao

B
Ao

RV

PROCEDURE PEARL
A dog with reverse PDA can present with relatively pink oral mucous membranes but cyanotic caudal mucous membranes (especially with exercise). When evaluating the mucous
membranes, be sure to evaluate both the cranial (oral) and caudal (preputial, vulvar)
aspects of the body.

PDA = patent ductus arteriosus

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Jugular Veins

The final step in the physical examination, and the one most often
overlooked, is evaluation of the jugular veins.
This allows assessment of right ventricular filling. The animal must be standing (or sitting)
with the head in a normal elevated position to
allow for accurate assessment.
The most common alteration seen is distension of the jugular vein, which indicates
increased right ventricular filling pressures.
The latter is most commonly seen with rightsided heart failure from pericardial disease,
tricuspid regurgitation, dilated ventricular
chamber, heartworm disease, or tricuspid
valve stenosis. A distended jugular vein
(arrowheads ) can also indicate obstruction
of flow of the cranial vena cava (ie, cranial
caval syndrome) from such things as mediastinal or heart-based masses, thrombi, or vascular stenoses. Abnormal jugular pulsations can
also be detected, but these findings are more
subtle and can be altered by a bounding
carotid pulse underlying the jugular vein.
However, a jugular pulse that extends past the
thoracic inlet in a dog or cat is considered
abnormal and could suggest increased right

Differentiating
Congestive Heart
Failure

There are some additional physical exam findings that may help support, or suggest
against, congestive heart failure as the cause
of respiratory distress. A consistent hallmark
of congestive heart failure is elevated sympathetic tone, which often results in a loss of
sinus arrhythmia (very common in dogs) and
sinus tachycardia. Therefore, an animal presenting with respiratory distress that has
prominent sinus arrhythmia or bradycardia is
most often not exhibiting congestive heart
failure. Some animals, however, will have concurrent respiratory disease, which can con-

ventricular filling, severe tricuspid regurgitation, or cardiac arrhythmia.

Cranial caval syndrome is also usually associated with subcutaneous edema in the ventral
neck and pectoral region. If the jugular veins
are not distended but right-sided heart failure
is suspected, a provocative test (hepatojugular

found the diagnosis. In addition, while uncommon, some animals with severe cardiogenic
edema will present with bradycardia, presumably due to hypoxemia.
It should also be mentioned that the most
common canine patient with cardiac disease
is older and often has multiple concurrent
problems. One of the most common is tracheal or lower airway collapse, which can
often present with very similar clinical signs to
congestive heart failure. The combination of
collapsing airways with mitral regurgitation
and left atrial enlargement can magnify the
clinical signs and make differentiating which
condition is most responsible very difficult
indeed.

reflux) can be used to identify elevated right

ventricular filling pressures. The jugular veins
are examined while pressure is applied to the
cranial abdomen, increasing the amount of
blood return to the right heart from the liver.
A positive response is distension of the jugular vein while pressure is applied.

Procedure Pearl
A positive response to furosemide therapy does not always differentiate congestive heart failure from chronic pulmonary
disease as the cause of cough. In some
dogs furosemide dries up the secretions
associated with underlying pulmonary
disease, thereby reducing the stimulus
for cough. Your suspicion of cardiac
disease as the cause of cough should
increase in the presence of heart murmur
or cardiomegaly with pulmonary venous
congestion on thoracic radiography.

See Aids & Resources, back page, for

references, contacts, and appendices.
Article archived on www.cliniciansbrief.com

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