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Heart Murmurs in Young Dogs and Cats: Differentials, Tips and Additional Testing

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Heart Murmurs in Young Dogs and Cats: Differentials, Tips and Additional Testing SMALL ANIMAL I CONTINUING EDUCATION Heart murmurs in young dogs and cats: differentials, tips and additional testing Ilaria Spalla DVM PhD MRCVS MVetMed DACVIM, veterinary cardiology specialist, Ospedale Veterinario San Francesco (Milan, Italy) provides a comprehensive overview of heart murmurs in young dogs and cats Heart murmurs can occasionally be auscultated in young dogs (S1-S2) from diastole (S2-S1). A quiet environment and a and cats; their discovery can be in conjunction with other relaxed patient provide the best clinical condition to detect signs of cardiac disease or it may be an incidental finding. abnormalities; however, this sometimes may not happen in The identification of heart murmurs can cause apprehension everyday practice. Strategies to reduce environmental noise for owners, and depending on the location, intensity and levels and calm the patient, as well as repeated auscultation characteristics, the veterinary professional can perform a list can be attempted to increase e icacy or confirm the initial of di erentials and suggest the best diagnostic approach. suspicion. The patient should be standing, and palpation of the chest walls should be performed prior to applying the CARDIAC AUSCULTATION stethoscope to identify the precordium and look for thrills, if The first stethoscope was invented in 1816 by René Laennec present (Smith et al, 2006). in Paris (Rishniw, 2018) and it has been, since then, a very Inching (moving the stethoscope between the cardiac apex powerful instrument to aid clinicians in their everyday cardiac and base) helps in identifying any abnormal heart sound and evaluation. Auscultation takes time and practice, but it can its point of maximal intensity (PMI). Traditionally, three areas help in stratifying the risk associated with the identification of are heard on the left hemithorax (pulmonary, aortic and mitral an abnormal finding. It is very important that the stethoscope [PAM] from a more cranial to caudal position) and one on the is in good condition too. right (tricuspid valve [T] [Smith et al, 2006]). Some murmurs may be well localised, whereas some others irradiate to the other hemithorax. Auscultation of the thoracic inlet may aid in identifying particular murmur irradiation (ie. aortic stenosis). Heart murmurs are the result of turbulent blood flow. The Reynolds number gives the probability of a flow to be laminar (low) or turbulent (high). The Reynolds number has no practical use but is helpful in explaining which conditions can increase the chances of a flow to become turbulent, and therefore to cause a heart murmur (Sisson DD and Ettinger SJ, 1999). These include increased blood velocity, decreased blood viscosity (such as in anaemic patients), changes in vessel/valve radius (such as stenosis, which is generally associated with increased velocity) or changes in blood density. Heart murmurs can either be associated with heart disease (pathological murmur) or may occur in an otherwise normal heart (non-pathological, normal, innocent, functional or physiological murmur). A slight di erence in Figure 1: Anatomy of a stethoscope. The stethoscope is composed of earpiece meaning can be given when using the words ‘functional’ or tips, binaural headpiece, tubing and chest piece. The latter is composed of bell ‘innocent’ murmur. Functional murmurs can be defined as and diaphragm. The bell held lightly against the chest transmits both low and high frequency (which is generally preferred for auscultating both lung and low heart murmurs in the absence of structural heart disease, frequencies heart sounds), whereas the diaphragm allows for a more fi ltered but a plausible explanation for the murmur can be identified auscultation of high frequencies (cardiac auscultation). Most stethoscopes allow (ie. anaemia), whereas an innocent murmur defines a the locking of one of the two components (either bell or diaphragm) to permit better alignment with the tubes and increase quality of sound (image courtesy of heart murmur in the absence of structural heart disease Jarould, 2017 under Creative Commons Licence, https://commons.wikimedia. without any obvious causative explanation (Coté et al, 2015). org/wiki/File:Stethoscope.svg). Non-pathological murmurs may also come with peculiar auscultatory characteristics that can aid in their recognition In dogs and cats, normal auscultation is characterised by two (see Table 1). audible heart sounds (S1 and S2), which separate systole 376 Veterinary Ireland Journal I Volume 9 Number 7 Vet July.indd 376 02/07/2019 13:36 CONTINUING EDUCATION I SMALL ANIMAL Table 1: Heart murmur characteristics that are more likely associated with a More recently, a simplified grading scheme in dogs with mitral non-pathological heart murmur in dogs. valve disease seemed to provide enough clinical information Characteristics when only four grading categories were applied (soft – grade I+II/VI; moderate – grade III; loud – grade IV; and thrilling – Softer murmur at rest or even absent, grade V+VI/VI [Ljungvall et al, 2014]). In dogs with pulmonic Change with rest/exercise increased intensity after exercise stenosis and subaortic stenosis, an even simpler classification Murmur intensity Grade 1 to 3/6; can be variable was considered to be already informative in discriminating mild disease from moderate/severe disease, the latter of Early/mid-systolic or late systolic Timing (does not last the entire systole) which would require further workup (anything louder than soft murmurs; ie. murmur grades greater than III/VI [Caivano Murmur localisation Left heart base, no murmur irradiation et al, 2018]). Other auscultation abnormalities Absent Non-pathological heart murmurs have been identified in young puppies (Szatamari et al, 2015), boxer dogs (Höglund et al, 2004), retired racing hounds (Fabrizio et al, 2006) and whippets (Bavegem et al, 2011), but they can also be Thoracic auscultated in animals with systemic disease (ie. anaemia, Inlet L base PDA, PDA Tricuspid SAS Aorta fever).The most common murmur grading scheme proposed Pulmonary VSD VSD in veterinary medicine comes from Ettinger and Suter, a L apex Mitral six-level scheme adapted from the Detweiler’s first veterinary grading scheme (see Table 3). Table 2: Heart murmur grading scales. Descrip- 6-level tive murmur Description 4-level Description grading murmur grading Nearly imperceptible, Softer than heart may be heard with very sounds. Both heart I/VI careful auscultation in Soft sounds can be easily a quiet environment; (I-II/VI) heard and are louder always focal than the murmur Equal to heart sounds. Heard readily but very Moderate Heart sounds can be II/VI soft; always focal (III/VI) easily heard and are Figure 2: Cardiac aus- equal to the murmur in cultation. On the left intensity hemithorax murmurs at Louder than heart the pulmonary and aor- Heard readily, moderate sounds. One or both tic valve are heard at intensity; usually heart sounds often the heart base, whereas III/VI regional (can be heard Loud obliterated by the murmurs affecting in several auscultatory (IV/VI) murmur or distinctly the mitral valve are regions of the heart) softer than the located more toward murmur the cardiac apex. At the thoracic inlet some Heard readily, loud, and murmurs can still be usually radiates widely Has a palpable auscultated, and on the IV/VI (can be heard in most or Palpable thrill, regardless of right hemithorax mur- all auscultatory regions (V-VI/VI) auscultated intensity murs at the tricuspid of the heart), but without valve are heard. Note a palpable thrill that to fully auscultate Heard readily, loud, the characteristic con- and associated with a tinuous water hammer precordial thrill, but the murmur typical of pat- V/VI murmur is not heard ent ductus arteriosus, with the stethoscope the stethoscope needs lifted off the surface of to be further cranial the thorax in the left hemithorax; ventricular septal Heard readily, loud, asso- defects murmurs are ciated with a precordial loudest on the right thrill, and the murmur hemithorax but can VI/VI remains audible with the also be auscultated stethoscope lifted 1cm on the left hemithorax off the surface of the between the heart base thorax and apex. Veterinary Ireland Journal I Volume 9 Number 7 377 Vet July.indd 377 02/07/2019 13:36 SMALL ANIMAL I CONTINUING EDUCATION Table 3: Differentials and associated clinical signs in puppies with a murmur Possible associated clinical signs/physical Murmur Location Differentials examination findings Systolic murmur Left heart base Stunted growth, exercise intolerance, syncope, Pulmonic stenosis (true or relative) ascites arrhythmias Stunted growth, exercise intolerance, syncope, Subaortic stenosis respiratory distress, arrhythmias. Weak pulses ('pulsus parvus et tardus') Non-pathologic murmur No clinical signs Systolic murmur Left apex Mitral valve dysplasia Syncope, respiratory distress Mitral regurgitation due to mitral annular dilation (juvenile dilated cardiomyopathy, arrhythmia- Exercise intolerance, respiratory distress, induced cardiomyopathy, patent ductus arrhythmias. Regular alternation of femoral pulse arteriosus) amplitude ('pulsus alternans') Systolic murmur Right hemithorax Ventricular septal defect (murmur heard also between L heart base and L apex, loudest on R Respiratory distress hemithorax) Tricuspid valve dysplasia Ascites. Jugular distension Continuous murmur Left heart base Stunted growth, exercise intolerance, respiratory Patent ductus arteriosus distress. Bounding femoral pulses Diastolic murmurs Left cardiac base
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