FELINECARDIOLOGYBACKTOTHEBASICS
[Link],BSN,MS,DVM,DACVIM(Cardiology&InternalMedicine)
FortCollins,Colorado
INTRODUCTION
Diagnosisandtreatmentofcardiovasculardiseaseisparticularlychallengingincats
becauseoftheirsmallbodyandheartsize,theirrapidheartrate,theiroftenuncooperative
nature,andthefrequentlyabruptonsetoftheirclinicalsigns,Inaddition,therearenumerous
[Link]
felinecardiologyandbasicfelinecardiologyarereviewedinthisarticlewithemphasisplacedon
differencesbetweencatsanddogs.
CARDIOVASCULAREXAMINATION
Dogswithheartdiseaseoftenhaveclinicalsignsthatareinsidiousinonsetandslowly
[Link],catswithcardiaclesionscharacteristicallyremainasymptomaticuntil
[Link]
example,catsareoftenasymptomaticuntilthesuddenonsetofseveredyspneafrom
congestiveheartfailure(CHF)oruntilperacutedevelopmentofhindlimbparalysisdueto
[Link]
signsyetdiesuddenlyfromhypertrophiccardiomyopathy.
Commonclinicalsignsofheartdiseaseincatsinclude1)respiratorydistress(tachypnea
&dyspnea),2)peracuteparalysisorparesis(usuallyhindlimborrightforelimb),3)syncope,and
4)anorexia,lethargy,[Link]
heartdisease,itisextremelyrareforcatswithheartdisease,evensevereheartdisease,to
cough.1
Astethoscopewithapediatricorneonatalsizechestpieceisrecommendedfor
[Link],thethyroidglands
[Link]
rightsidedCHFisrarelymassiveasindogsandisusuallyaccompaniedbyhepatomegalyand
jugulardistentionifduetoheartdisease.1Extradiastolicsounds(gallops)duetoanaudible
S3orS4arecommonincatswithheartdisease,andtheseabnormalsoundsareeasilymissedif
[Link]
[Link],coughingandwheezingincatsarenearly
[Link]
thatmostcatswithheartfailurewillhavesometypeofauscultablecardiacabnormality
(murmur,gallop,and/orarrhythmia).Finally,itshouldbepointedoutthatfunctionalmurmurs
(e.g.,murmursduetofever,anemia,volumeoverload,andadministrationoftranquilizing
drugs)arecommonincats.
SURVEYRADIOGRAPHY
NormalRadiographicFindings
Theoverallsizeofthecardiacsilhouetteisrelativelysmallerincatsthanindogs,and,
therefore,catshaverelativelymorelungtissueonthoracicradiographsthandogs.2Incatsthe
heartisfartherfromthechestwallandfromthediaphragmthanindogs,andthenormalfeline
heartdoesnotcontactthediaphragmontheventrodorsal(VD)ordorsoventral(DV)views.
Unlikeindogs,themainpulmonaryartery(MPA)doesnotprojectbeyondtheedgeofthe
cardiacsilhouetteincatsontheventrodorsal(ordorsoventral)thoracicradiograph.3Therefore,
[Link]
(LV)formsthecardiacapexwhichisnormallyslightlyleftofmidline;however,itmaybetothe
rightofmidlineontheradiographinsomenormalcats,especiallyifaDVviewistaken.1The
craniocaudalventriculardiameterofthecardiacsilhouetteonthelateralviewisnormally
between22.5intercostalspaces(4th6thintercostalspaces),2andthenormalvertebralheart
sumincatsis7.5.4
Therearesomeuniqueagingchangesthatoccurnormallyinthefelinecardiovascular
system,[Link],ascats
age,theheartbecomesmorehorizontallypositionedwithinthethoraxandtheaorticrootmay
enlarge.5Consequently,ingeriatriccatsthecardiacsilhouetteonthelateralviewistypically
morehorizontallypositionedthaninyoungcats(thesternalangleismoreacute).Enlargement
[Link]
oftennotedasanormalagingchangeincats;however,anenlargedaorticrootmayalso
indicatesystemichypertension.
RadiographicCriteriaforCardiacEnlargementinCats
Cardiomegalymayresultinwidening,elongation,alteredposition,oralteredcontourof
[Link]
[Link]
sumexceeding8.0isindicativeofcardiomegaly,itisdifficulttodeterminethissumincatswith
[Link]
[Link]
enlargementthecardiacapexisoftenshiftedtowardthemidlineproducingavalentine
shapedcardiacsilhouetteontheDVorVDview.1Thisradiographicchangeisoften
[Link]
easilyidentifiedonthelateralradiographindogs,thiscardiacchamberissituatedmore
craniallyincats,andenlargementisnotalwayseasytoappreciateonthisview.6Cardiogenic
pulmonaryedemaindogsistypicallydorsalandperihilar,butincatstheedemamayalsobe
patchyorventralindistribution.
ECHOCARDIOGRAPHY&DOPPLERECHOCARDIOGRAPHY
Itisbesttoavoidsedatingfelinepatientswithketamineor2agonistswhendoing
[Link]
measurements,theymaynotbewelltoleratedbycatswithcardiovasculardiseases.
Mmodeechocardiographyisthebestultrasoundmodalitytouseformeasuring
[Link],patientvalues
[Link]
diastolicthicknessoftheleftventricularwallareusedtodeterminepresenceorabsenceofleft
[Link],however,toclearlydistinguishnormalfrom
abnormalincatswithslightlyincreasedwalland/orseptalthicknessbasedsolelyonthese
[Link]
lesions,regional(focal)hypertrophy,[Link]
diastolicfunction,bloodflowpatterns,[Link]
[Link],tissueDopplerhasbeen
showntoidentifyhumanandfelinepatientswithhypertrophiccardiomyopathypriortothe
developmentofleftventricularhypertrophy.7
ELECTROCARDIOGRAPHY
AlthoughrightlateralrecumbencyisthestandardpositionforECGrecording,somecats
[Link]
beused,butitisimportanttorealizethatthePandRwavesareslightlytallerandfrontalplane
axiswiderinthisposition.8Becauseoftherapidheartratesofcats,ECGinterpretationis
facilitatedbyusingarecordingspeedof50mm/[Link]
[Link],infact,[Link]
bestnottousemusclefilterswhenobtainingafelineECGbecausethesefilterscausesignificant
alterationsinthewaveformamplitudes.9
AleftanteriorfascicularblockECGpatterniscommonlyassociatedwithprimaryor
secondaryfelinemyocardialdiseases,andthepresenceofthisECGabnormalityshouldalertthe
[Link]:
upright(positive)QRScomplexesinleadsI&AVL(i.e.,aqLorLpatternintheseleads);
abnormallydeepSwavesinleadsII,III,andAVF;andaleftaxisdeviationinthefrontalplane
(meanelectricalaxis0to90).Tachycardiasandprematurebeatsarealsocommoninall
[Link]
incatswithrestrictivecardiomyopathy.10
CONGESTIVEHEARTFAILURE(CHF)INCATS
Cats,unlikedogs,oftenhaveanacuteorperacuteonsetofclinicalsignsofheartfailure.
ManifestationsofleftsidedCHFincatsmayresultfromreducedcardiacoutputsuchas
weakness,exerciseintolerance,syncope,lethargy,hypothermia,orperipheralvasoconstriction
(palemucousmembranes&prolongedcapillaryrefilltime).Morecommonly,however,left
[Link],
clinicalsignsofleftsidedCHFincatsincludetachypnea,dyspnea,cyanosis,andincreasedlarge
[Link]
catsmaydeveloppleuraleffusionaswellaspulmonaryedemafromincreasedleftsidedfilling
pressures.1Appropriatemanagementofdyspneaduetoleftsidedheartdiseasemayinclude
[Link]
leftsidedheartfailurerarelycausescoughingincatsasitfrequentlydoesindogs.
Catsarerelativelysusceptibletodevelopmentofpulmonaryhypertension(with
subsequentsignsofrightsidedfailure)[Link]
uncommon,therefore,forcatstoshowsignsofbiventricularfailure.
ClinicalmanifestationsofrightsidedCHFincatsmayincludethesignsofreduced
[Link],however,catswithRV
failureusuallyhavesignsofincreasedrightsidedfillingpressuresincludingjugularvenous
distentionandpulsation,hepatojugularreflux,hepatomegaly,ascites,pleuraleffusion
(modifiedtransudateorchylous),andpericardialeffusion.
DiagnosisofCHFisaclinicaldiagnosisbasedonhistory,physicalexamination,
radiography,echocardiography,and,rarely,[Link]
CHFwillhaveeitherasystolicmurmurordiastolicgallop.
CONGENITALHEARTDISEASE(CHD)
Althoughcongenitalheartdiseaseismuchlesscommonthanacquiredheartdiseasein
cats,congenitallesionsoccurwithaprevalenceof0.020.2%.11Congenitalheartdefectsin
catsarereportedlymorecommoninmalesthaninfemales,andcomplexcongenitalheart
disease(morethanasingleanomalyinapatient)occursmorecommonlyincatscomparedto
[Link],ventricularseptal
defects,atrioventricularseptaldefects(endocardialcushiondefects),tetralogyofFallot,patent
ductusarteriosis,andsubaorticstenosis.11,12Nearlyallfelinecongenitalcardiacanomalies
producesystolicmurmurs,and,therefore,timingofthemurmurisnotashelpfuldiagnostically
[Link]
dysplasia,ventricularseptaldefects,andatrioventricularseptaldefects,andbecauseECG
changesarenottypicalofanyoftheselesions,theECGisusuallyoflittlehelpindetermining
[Link],anormalECGdoesnotruleoutaseriouscongenital
[Link]
manifestishighlyvariableincats,andallcatswithmurmurspresentsincebirtharesuspectfor
CHD,[Link],allkittenswithmurmurs>2/6shouldbe
suspectedofCHDevenifasymptomatic.
FELINEMYOCARDIALDISEASES(FELINECARDIOMYOPATHIES)
Felinemyocardialdiseasescompriseaheterogeneousgroupofdisorderscharacterized
[Link]
usuallyacquired,heritableformswhicharenotpresentatbirthmaydevelopataveryyoung
[Link],likecaninemyocardialdisease,maybeprimary(defectwithin
themyocardium)orsecondarytoanextracardiacdisorderornonmyocardialcardiaclesion.
Whenamodifyingterm(hypertensivecardiomyopathy,ischemiccardiomyopathy,etc.)isnot
[Link](WHO)updatedits
classificationformyocardialdiseasesinpeople1996.13Thisclassification,basedon
morphologicandpathophysiologicfeatures,isapplicabletothefelinemyocardialdiseasesas
[Link],hypertrophiccardiomyopathy,
restrictivecardiomyopathy,andarrhythmogenicrightventriculardysplasia.
DilatedCardiomyopathy(DCM)
FelineDCMischaracterizedprimarilybymyocardialsystolicfailure(decreasedinotropic
state).Althoughallfourcardiacchambersareusuallydilated,thisdilationoccurssecondaryto
thedecreasedmyocardialcontractility.Ithasbeenrecognizedsincethe1980sthatfelineDCM
mayresultfromreduceddietarytaurineintakeofdecreasedtaurineabsorption.14Primary
felineDCMisrare.
HypertrophicCardiomyopathy(HCM)
Hypertrophiccardiomyopathyischaracterizedprimarilybyimpairedmyocardial
relaxation,reducedLVdiastolicvolume,[Link]
isknowntobeheritableinsomebreeds(Mainecoon,Persian,ragdoll,andseverallinesof
Americanshorthair).AlthoughHCMmaycauseleftsidedCHF,biventricularCHF,andsudden
death,[Link]
presenceofseptalorLVfreewallthickness>[Link],itisimportanttopointoutthat
incats,asinpeople,hypertrophymaybepresentonlyinfocalareasoftheventricleandmaybe
[Link]
indicatethatsystolicanddiastolicfunctionalabnormalitiesmayberecognizedinpeoplewith
HCMpriortothepresenceofrecognizablehypertrophy.7PrimaryHCMmustbedifferentiated
fromsecondaryformsofHCM,butincatsthisdistinctioncannotbereliablymadewithECGor
[Link]
cardiomyopathyinsomeanimals.15,16
RestrictiveCardiomyopathy(RCM)
Restrictivecardiomyopathyischaracterizedbyreducedmyocardialcompliance,normal
LVdiastolicvolume,[Link]
causedbypreviousHCMinsomecats15,16andtopreviousinflammatorydiseaseinothers17,18,
[Link]
[Link].
ArrhythmogenicRightVentricularDysplasia
Arrhythmogenicrightventricular(RV)dysplasiaismuchlesscommonthanHCMand
[Link];orasRV
[Link]
theRVmyocardiumandprofoundRVfailure.19Itisoftenmisdiagnosedastricuspidvalve
dysplasia.
SYSTEMICARTERIALTHROMBOEMBOLISM(ATE)
Systemicarterialembolismisacommonandseriouscomplicationofanyformoffeline
heartdisease!Althoughthisproblemismoreprevalentincatswithsevereleftatrial
enlargement,itisoccasionallyseenincatswithanormalappearingatrium.20Thrombusforms
[Link]
[Link]
visceralembolismmayalsooccur.
ThepathogenesisoffelineATEinvolvesstasisofbloodflow(duetounderlyingcardiac
disease),activationofplateletsand/orclottingfactors,andischemicdamageofdistaltissues
whichismediatedbyplateletderivedvasoactivefactors.21Diagnosisisusuallystraightforward
basedonclinicalexamination,[Link]
creatinekinase,[Link]
approachisdebated,thisconditionisgenerallyconsideredamedical,ratherthanasurgical
[Link],ifpresent,mustbetreated,andcardiacfunctionoptimizedtoreduce
[Link]
tissueplasminogenactivator(probablythetreatmentofchoiceforanacuteembolism(i.e.,
thrombus<8hrs)andanticoagulationwithunfractionatedorlowmolecularweightheparin.
PrognosisforcatswithATEisguardedatbestbecauseitisdifficulttopredicthowmuch
[Link]
2448hoursoriftheybecomeedematous,recoveryisunlikely,andgangrenousnecrosismay
[Link]
[Link],longtermanticoagulationshouldbe
considered.
REFERENCES
1
Bonagura,[Link],2ndEdition,pp819946(1994).2RushJ,[Link]
theRadiographicDiagnosisofHeartDiseaseinSmallAnimals,pp849(1996).3Suter,PF.
ThoracicRadiography:AtextAtleasofThoracicDiseasesoftheDogandCat.1984.4LitsterAL,
etal.JAVMA2000;216:210.5Moon,[Link][Link].6Kittleson,
[Link],p63(1998).7Nagueh,SFetal.Circ2001;104:128.
8
Gompf,REetal.AmJVetRes1979;40:1483.9Schrope,DPetal.AmJVetRes1995;56:1534.
10
Martin,[Link],pp550576(2002).11Bolton,[Link]
NorthAmSmallAnimPract1977;7:341.12Hunt,[Link][Link].
13
Richardson,Petal.Circ1996;93:841.14Pion,PDetal.Science1987;237:764.15Kittleson,MD
[Link][Link].16Baty,CJetal.JVetInternMed2001;15:595.17Stalis,
IHetal.VetPathol1995;32:122.18Meurs,KMetal.JVetInternMed1998;12:201.19Fox,PRet
al.Circ1998:98(Suppl):297(Abstr).20Laste,NJetal.JAmAnimHospAssoc1995;31:492.
21
Kittlesom,[Link],pp540551(1998).
TPAaccelerated(frontloaded)doseprotocol(feline)
0.75mgIVbolus
2.5mgIVover30minutes
1.75mgIVoverIhour
5mgtotal
(Monitorcloselyforsignsofreperfusioninjurysuchashyperkalemiaandacidosis.)
Table1:NormalMmodeEchoValuesandDopplerValuesforAdultCats
MEASUREDVARIABLE
NORMALRANGE
LVdimension(diastole)
1118mm*
LVdimension(systole)
510mm
IVS(diastole)
2.55.5mm*
IVS(systole)
59mm
LVwall(diastole)
2.55.5mm
LVwall(systole)
59mm
Leftatrium
815mm
Aorta
6.512mm
LA/aorta
0.81.6
LVfractionalshortening
3565%
PeakLVOTvelocity
0.81.4m/s
PeakRVOTvelocity
0.81.7m/s
IVRT
4555ms**
PeakEwavevelocity
0.70.9m/s**
PeakAwavevelocity
0.20.4m/s**
E/A
1.02.0**
E/E
<7cm/s
Abbreviations:LV=leftventricle;IVS=interventricularseptum;LA=leftatrium;LVOT=leftventricular
outflowtract;RVOT=rightventricularoutflowtract;IVRT=isovolumicrelaxationtime
*Diastolicvaluesof>5.5mmarecompatiblewithleftventricularhypertrophyinmostadultcats.
**Affectedbyageandloadingconditions.
Table2:NormalElectrocardiographic(ECG)ValuesforAdultCats
VARIABLE
Heartrate
Rhythm
Pwave
PRinterval
NORMAL
140240/min <140/min=bradycardia;>240/min=tachycardia
regularsinus
<2.5mV;<0.04sdamplitudeordurationmayindicateatrialenlargement
QRSduration
QRSamplitude
1)
2)
3)
4)
5)
6)
7)
Sinusarrhythmiaisuncommonandusuallyabnormal
0.050.09s
ProlongationindicatesAVnodal,infranodal,orbundlebranch
conductiondelay;shorteningsuggestspreexcitation
<0.04s
Wideningindicatesventricularenlargement,
intraventricularconductiondelay,oraventricularorigin
rhythm
Rwave<0.9mVdamplitudesuggestsventricularenlargement,
conductionblock,oraventricularoriginrhythm
Q+R+S<1.3mV
QRSfrontalplaneaxis 0160
QTinterval
Twaveamplitude
CHAMBERENLARGEMENTORCONDUCTIONABNORMALITY
0.160.22s
Abnormalaxissuggestsventricularenlargement,
conductionblock,oraventricularoriginrhythm
Variesinverselywithheartrate
<0.3mV
Table3:ManagementofFelineAorticThromboembolism
Monitor&recordvascularandneuromuscularstatus
ObtainstatserumBUN,K+,andECG
Preventfurtherhypothermiawithsubsequentvasoconstriction(providewarm
environment)
Treatcongestiveheartfailure,ifpresent(furosemideandnitroglycerinointment)
Treatmetabolicacidosisifsevere
Obtainthoracicradiographs&echocardiogramifpatientsrespiratorystatusisstable
Determinetreatmentplan:
a)
8)
refertocriticalcaresettingforthrombolytictherapyandrequisite
monitoring(assoonasheartfailurehasbeenstabilized)or
b)
conservativetherapy
1. analgesics:butorphanol0.20.4mg/kgq612hPRN
2. maintainhydrationandurinaryoutputwithcautiousfluidtherapy
(0.45%NaClin2.5%dextrosesolution,3040ml/kgq24hIV
3. Sodiumheparin200IU/kgIV,followedby200IU/kgSCq68hto
increaseAPTT1.5xbaselinefor4872hours
Considerlongtermanticoagulationwithwarfarinorlowmolecular weightheparin
