INTERACTIVE CASE STUDIES

 
 

HaileyCase Background

 
Name Hailey
Age 7 years
Sex Female, spayed
Breed Cavalier King Charles Spaniel
Weight 26.4 pounds (12 kg)
Reason for Visit Hailey was presented for her yearly physical examination. The family has reported no clinical signs other than bad breath. There has been no cough, respiratory distress, weakness, decreased exercise tolerance or change in appetite
Medications Heartgard® Plus, no other chronic medications
     

Please review Hailey's clinical history.

 
Attitude/Demeanor Normal
Coughing No cough
Abnormal Respirations None
Exercise intolerance None
Sleep Patterns Unchanged
Weight Change (loss or gain) None
Appetite No change
Usual Diet Eukanuba™ Adult with some "people food"
Vomiting None
Diarrhea None
Syncope None
Change in urinary habits None
Change in drinking habits None
Other symptoms or signs None
 

Please review the results of Hailey's physical exam.

Body Condition Mildly obese - BCS 3.5/5
Attitude Alert, but calm
Mobility | Gait Normal gait upon inspection
Posture Laying in sternal recumbency, resting
Hydration Normal
Body Temperature 100.6 F
Arterial pulse - rate, regularity, intensity 120 bpm, regularly irregular, normal strength
Rate & Respiratory Effort 32 breaths per minute, normal
Mucous Membranes - Color & CRT Pink, <2sec
Jugular Venous Pulse & Pressure Normal
Abdominal Palpatation Normal, moderate size bladder
Lymph Nodes Normal
Oral Cavity Mild dental calculus
Other abnormalities Strong odor from mouth
 

Let's ascult Hailey's heart

Listen to Hailey's heart

What do you hear?

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Direct HR: 120 beats/min

Heart Rhythm: Suspect respiratory sinus arhythmia

Intensity of Heart Sound: Normal

Extra Sounds - Clicks or Gallops: None

Heart Murmur: Grade 3/6 holosystolic murmur, loudest over the mitral area and left apex. Barely audible on the right

Precordial Palpation: Normal precordial impulse, but no thrill

 

The following are potential diagnosis for you to consider at this time. Based on the history and the physical examination, please indicate the likelihood of each as:
  • High (could explain most or all of the signs)
  • Possible (less likely to explain most of the signs)
  • Unlikely

Degenerative Valve Disease

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Physiologic Flow Murmur

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Congenital Heart Disease

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Valvular Endocarditis

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The CEG considers the following differential diagnosis as most likely (and why):

A cardiac murmur in a patient of this breed and age, is highly likely to be degenerative valve disease, and the location and timing suggests mitral regurgitation. Physiologic flow murmurs typically occur at the left base, and in this breed would typically be associated with concurrent disease such as anemia or fever. The presence of a new heart murmur makes congenital heart disease less likely. Infectious valvular endocarditis is often suspected in patients with shifting leg lameness, fever, and inappetence, none of which were present in this patient. The incidence of endocarditis in small breed dogs is low.

BLOOD PRESSURE

Non-invasive blood pressure

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CLINICAL LABORATORY

CBC with platelet count

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Coagulation profile

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Serum biochemical profile (includes electrolytes)

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Urinalysis

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Serum Thyroxine (T4)

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Heartworm antigen test

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Heartworm antibody test

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Heartworm microfilaria test

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NT-proBNP

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Cardiac troponin-I

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Blood culture

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Thoracocentesis or abdominocentesis for diagnosis or therapy

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DIAGNOSTIC IMAGING (some may require a referral)

Thoracic radiographs

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Abdominal radiographs

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Echocardiogram doppler studies

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Abdominal ultrasound

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ELECTRODIAGNOSTICS (some may require a referral)

ECG rhythm strip or 6 lead ECG

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Ambulatory ECG - Holter ECG or event monitor

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  • You considered the following to be higher priority
    • You considered the following to be lower priority
      • You considered the following to be not indicated

        The CEG considers the following diagnostic tests as the highest priority: 

        A cardiac murmur in a patient of this breed and age is highly likely to be degenerative valve disease and the relative lack of symptoms suggests a stage B patient. However, further staging of the disease requires imaging of the heart. This can be accomplished by thoracic radiography or echocardiography.

        Systolic Blood Pressure: 135 mmHg
        Diastolic Blood Pressure: Not available for this case
        Mean Blood Pressure: Not available for this case
        Consensus Statements of the American College of Veterinary Internal Medicine (ACVIM) provides the veterinary community with up-to-date information on the pathophysiology, diagnosis, and treatment of clinically important animal diseases. In 2007, ACVIM published guidelines for the Identification, Evaluation, and Management of Systemic Hypertension in Dogs and Cats in the the Journal of Veterinary Internal Medicine.
        Click here to view and download a PDF of the ACVIM Consensus Statement, Guidelines for the Identification, Evaluation, and Management of Systemic Hypertension in Dogs and Cats.  

        Please review Hailey's thoracic radiographs.

        Click here for ventral dorsal view
        Click here for right lateral view

        What is the Vertebral Heart Score (VHS)?

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        10.6 is the correct answer
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        Is Hailey's heart significantly enlarged?

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        Hailey's heart shows little to no heart enlargement
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        Is pulmonary edema present?

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        There is no pulmonary edema present
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        Technical Quality: Good
        Pulmonary Venous Congestion: Normal pulmonary vasculature, no congestion noted.
        Pulmonary Infiltrated Distribution: None.
        Pulmonary Infiltrate Pattern: Mild bronchointerstitial pattern.
        Other Findings: n/a

           

         
        SERUM CHEMISTRIES
        BUN 19 mg/dL, Normal: <30 mg/dL
        Creatinine 1.1 mg/dL, Normal: <2.1 mg/dL
        Sodium 144 mEq/L, Normal:138 - 154 mEq/L
        Potassium 4.4 mEq/L, Normal: 3.6 - 5.2 mEq/L
        Chloride 113 mEq/L, Normal: 105 - 119 mEq/L
        ALT 40 IU/L, Normal: <75 IU/L
        ALP 56 IU/L, Normal: <100 IU/L
        HEARTWORM
        Heartworm Test Results Negative
        URINALYSIS
        Urinalysis - USG 1.024
        Urinalysis - Protein Negative
        Urinalysis - Biochemical Normal
        Urinalysis - Sediment Evaluation Normal

        Please review the results of Hailey's echo

        Subjective - lesions of valves, myocardium, pericardial space No pericardial effusion; normal systolic function of the left ventricle, thickened mitral leaflets with posterior leaflet mitral valve prolapse.
         LV chamber size and thickness Normal thickness but high normal to mildly increased chamber diameter.
         Left atrial size Mild dilation
         LVIDd & LVIDs Diastole (3.4 cm); systole (2.2 cm).
         LV shortening fraction Normal - 35%
         RA, RV and Pulmonary Artery Not remarkable (detailed images not shown).
         Effusions None.
         Doppler results Mitral regurgitation (MR); eccentric jet of MR is typical of primary valve disease; velocity of MR predicts normal systemic pressures; No tricuspid valve regurgitation (TR). Normal mitral inflow velocities.
           

        Click here to view ECG results
         
        Technical Quality, Leads, Paper Speed, Calibrations: Satisfactory recording; 6 frontal leads and lead 2 rhythm strip recorded; paper speed 50 mm/sec; calibration 10mm/mV.
        Artifacts: No significant
        Rhythm- regular or irregular/ patterns: Regularly irregular. Heart rate 110 bpm.
        Heart Rhythm Disturbances: Respiratory sinus arrhythmia; no premature complexes were detected.
        P Wave Abnormalities- morphology, amplitude, duration: Normal P wave height and width.
        QRS Abnormalities- axis, morphology, amplitude, duration: Normal frontal axis, no significant increase in height or width (insensitive measurement of chamber size).
        Abnormal Intervals- PR, QRS, QT: Normal intervals.
        Other: Slurred ST segments.

        You're ready to form a diagnosis and treatment plan for Hailey! Please select your answer to each question below.

        What is your diagnosis for Hailey?

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        Hailey is CKCS with structural heart disease without significant cardiac enlargement and she is exhibiting no clinical signs of heart failure.
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        Which stage of heart disease is Hailey in?

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        Hailey's clinical and exam findings lead to her classification as stage B1.
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        Click here to learn more about the stages of heart disease (ABCD Brochure)

        What treatment(s) would you recommend for Hailey?

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        THE CEG RECOMMENDS:

        The CEG recommends no treatment at this stage of heart disease. They also do not have isgnificant increase in cardiac anesthetic risk and are typically resilient to fluid administration. They also do not have a significant increase in cardiac anesthetic risk or iatrogenic fluid overload.

         ACTUAL TREATMENT
         Initial Therapy No medication indicated due to lack of significant cardiac enlargement and normal systemic blood pressure.

         Treatment Continue monthly preventative per referring veterinarian. There is no treatment recommended for Stage B1 valve disease in the absence of systemic hypertension. ACE inhibitors have not been shown to be beneficial at this stage and pimobendan may be harmful to these patients.
        Lifestyle Adjustments Avoid high sodium treats and foods, e.g. processed meats, hot dogs, cheese, some table scraps.
        Follow Up The rate of change in cardiac size may be indicative of progression of disease. Increases in cardiac size may be detected with radiographs, echocardiography or both - this repeat testing may be scheduled for 6-12 month intervals, or may be performed sooner if signs of congestive heart failure occur.