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Cardiovascular
Disease in Small
Animal Medicine
WENDY A WARE
DVM MS Diplomate ACVIM (Cardiology)
Departments of Veterinary Clinical Sciences and
Biomedical Sciences
College of Veterinary Medicine
Iowa State University
Ames, Iowa, USA

MANSON PUBLISHING/THE VETERINARY PRESS

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CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742
2011 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Version Date: 20130709
International Standard Book Number-13: 978-1-84076-622-6 (eBook - PDF)
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable
data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be
made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal
to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use
by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professionals own judgement, their
knowledge of the patients medical history, relevant manufacturers instructions and the appropriate best practice guidelines. Because of the rapid
advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly
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Contents
Preface

Abbreviations

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Section 1
1

Introduction and normal

reference information

Section 2
9

The normal cardiovascular system

The heart
The circulation
References

10
11
20
24

The cardiovascular examination

General considerations
The cardiovascular examination
References

26
26
27
33

Overview of cardiac radiography

General principles
Evaluation of the heart
Evaluation of intrathoracic
blood vessels
Evaluation of pulmonary
parenchyma
Evaluation of the pleural space
References

34
34
34

Transesophageal echocardiography
Three-dimensional echocardiography
References

Overview of electrocardiography
General principles
Cardiac rhythym assessment
Mean electrical axis
Cardiac chamber enlargement
Other ECG abnormalities and
considerations
Ambulatory ECG
References

47
47
51
60
61
62
66
67

Murmurs and abnormal heart sounds

92
Overview
92
Cardiac murmurs
92
Abnormal transient sounds
95
Approach to the patient with a murmur or
abnormal heart sounds
96
References
97

Cardiomegaly
Overview
Pathophysiology
Approach to the patient with
cardiomegaly
References

99
100

Cough
Overview
Pathophysiology
Approach to the coughing patient
References

101
101
101
102
105

Respiratory difficulty
Overview
Pathophysiology
Approach to the patient with
respiratory difficulty
References

106
106
107

Overview of echocardiography
General principles
The echocardiographic examination
Two-dimensional echocardiography
M-mode echocardiography
Doppler echocardiography

68
68
69
70
77
82

10
5

Clinical manifestations and

management of cardiovascular
problems
91

40
43
44
46

87
87
88

Jugular vein distension or

pulsations
Overview
Pathophysiology
Approach to the patient with jugular
vein distension/pulsations
References

98
98
98

112
115
117
117
118
119
120

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CARDIOVASCULAR DISEASE IN SMALL ANIMAL MEDICINE

11

12

13

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14

15

16

17

Abdominal distension
Overview
Pathophysiology
Approach to the patient with
abdominal distension
References

121
121
121

Subcutaneous edema
Overview
Pathophysiology
Approach to the patient with
subcutaneous edema
References

127
127
127

Abnormal heart rate or rhythm

Overview
Pathophysiology
Approach to the patient with
abnormal heart rate or rhythm
References

131
131
132

Syncope or intermittent collapse

Overview
Pathophysiology
Approach to the patient with
syncope or intermittent collapse
References

139
139
139

Thromboembolic disease
Overview
Pathophysiology
Approach to the patient with
thromboembolic disease
Thromboembolic disease prophylaxis
References

145
145
147

Management of heart failure

Overview
Pathophysiology
Clinical manifestations of congestive
heart failure
Management of acute decompensated
congestive heart failure
Management of chronic heart failure
References

164
164
164

Management of arrhythmias
Overview
Pathophysiology
General arrhythmia management
considerations
Management of supraventricular
tachyarrhythmias
Management of ventricular
tachyarrhythmias

194
194
194

124
126

Management of bradyarrhythmias
Overview of antiarrhythmic drugs

206

227

Acquired valve diseases

Degenerative valve disease
Infective endocarditis
References

263
263
272
277

20

Myocardial diseases of the dog

Dilated cardiomyopathy

280
280

Arrhythmogenic right ventricular

cardiomyopathy
Secondary myocardial diseases

289
290

Hypertrophic cardiomyopathy
Infective myocarditis
Noninfective myocarditis
References

292
293
295
296

Myocardial diseases of the cat

Hypertrophic cardiomyopathy
Secondary hypertrophic myocardial
disease
Restrictive cardiomyopathy
Dilated cardiomyopathy
Arrhythmogenic right ventricular
cardiomyopathy
Corticosteroid-associated congestive
heart failure
Myocarditis
References

300
300

168

202

Cardiovascular
diseases

19

142
144

196

221

250
255
256
258
258
259

135
138

170
176
188

219

References

Congenital cardiovascular
diseases
Overview
Subaortic stenosis
Pulmonic stenosis
Patent ductus arteriosus
Ventricular septal defect
Atrial septal defect
Mitral dysplasia
Tricuspid dysplasia
Tetralogy of Fallot
Pulmonary hypertension with shunt
reversal
Vascular ring anomalies
Cor triatriatum
Other vascular anomalies
Endocardial fibroelastosis
References

129
130

152
160
161

Overview of pacing therapy

Section 3
18

209
211

21

228
228
229
234
238
241
243
244
246
247

309
310
312
316
316
316
317

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23

Pericardial diseases and cardiac

tumors
Acquired pericardial effusions
Constrictive pericardial disease
Congenital pericardial malformations
Cardiac tumors
References

320
320
329
330
332
337

Pulmonary hypertension
Overview
Pathophysiology
Clinical features
References

340
340
340
342
348

24

Heartworm disease
Dirofilaria immitis
Angiostrongylus vasorum
References

351
351
368
369

25

Systemic hypertension
Overview
Clinical features
References

372
372
374
381

Index

385

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Preface
The extensive use of visual images is a core feature of
this book. Over 570 figures and 65 summary tables
are used to illustrate various cardiovascular disease
conditions and key concepts. The opportunity to
write such a richly illustrated book is what drew me
to this project. Over twenty years of teaching
veterinary students and interacting with veterinary
practitioners has convinced me of the importance of
visual learning. Most of the images were collected in
the course of my practice at the University Veterinary
Teaching Hospital. Others are reproduced here with
the kind permission of my colleagues and various
publishers. I have included multiple graphical
examples for a number of important disease
conditions in order to reflect some of the variability in
clinical appearance that occurs.
My goal was to create a practical clinical
reference that would also provide a broad overview of
small animal cardiovascular medicine. In writing the
text, I have tried to summarize concisely important
information about various cardiovascular diseases,
the clinical tools used to assess the cardiovascular
system, and approaches to disease management. This
book was written primarily for veterinary general
practitioners and students, although veterinary
technicians and others should find it useful as well.
The book is organized into three sections. The
initial chapters (15) review the normal
cardiovascular system and common methods used for
cardiac evaluation. Chapters 617 contain overviews
of common clinical problems, approaches to
differentiating these clinical manifestations of disease,
and management of heart failure and arrhythmias.
Finally, more detailed information about specific
cardiovascular diseases is organized anatomically in
chapters 1825. The danger in this organizational
structure is the potential for excessive repetition. I
have tried to minimize redundancy by crossreferencing among the various chapters. As a
consequence, it may be necessary to turn to a different

page for the desired information. I hope the reader

will forgive such inconvenience in the interest of
keeping the book to a more concise length. The
chapter reference lists are not exhaustive, but include
important and representative resources. Readers who
wish for more detailed information, especially related
to certain procedures or diseases, are urged to refer
directly to individual references.
No one stands alone. What anyone is able to
accomplish is intertwined with the work, support,
and influence of others. I wish to acknowledge my
gratitude to the many colleagues, students, clients,
and animals who, over the years and in a multitude
of ways, have made it possible for me to write this
book. To all my mentors and teachers who helped
prepare me for my journey into the world of
veterinary clinician/educator, and especially to Drs.
John Bonagura and Bob Hamlin, I thank you for
sharing your extensive knowledge, dedication, and
creativity, and for your high expectations. I am
grateful to Mr. Michael Manson and Ms. Jill
Northcott of Manson Publishing for asking me to
write this book, and for their patience throughout the
lengthy process. Thanks are due to Mr. Peter Beynon,
Ms. Julie Bennett, and the other members of the
Manson Publishing team for all their help and
suggestions, as well as to Ms. Kathy Hedges and also
Ms. Lori Moran for extensive assistance in preparing
the clinical graphics. Most importantly, I wish to
express my love and deepest gratitude to my family
thank you for your continued love and support
(except for all the times you said just get the book
done).
Finally, to you the reader, it is my hope that you
find this book easy to use and truly helpful in your
study and practice.

Wendy A. Ware
Iowa State University

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Abbreviations
Ab antibody
ABT aortic body tumor(s)
ACE angiotensin-converting enzyme
Ach acetylcholine
ADH antidiuretic hormone
ADPase adenosine diphosphatase
AF atrial fibrillation
Ag antigen
AHA/ACC American Heart Association and
American College of Cardiology
ALD aldosterone
ALT alanine aminotransferase
ANP atrial natriuretic peptide
aPTT activated partial thromboplastin time
AR aortic regurgitation
ARVC arrhythmogenic right ventricular
cardiomyopathy
ASD atrial septal defect
AST aspartate aminotransferase
AT angiotensin
ATP adenosine triphosphate
A-V arterio-venous
AV atrioventricular
AVP arginine vasopressin
BNP brain natriuretic peptide
BP blood pressure
BUN blood urea nitrogen
Ca calcium
cAMP cyclic adenosine monophosphate
CaVC caudal vena cava
CBC complete blood count
CF color flow (mapping)
cGMP cyclic guanylate monophosphate
CHF congestive heart failure
CK creatine kinase
CK-MB (cardiac-specific) isoenzyme of CK
CNS central nervous system
CO cardiac output
CO2 carbon dioxide
CRI constant rate infusion
CRT capillary refill time
CTD cor triatriatum dexter
CrVC cranial vena cava
CT computed tomography
cTn cardiac troponin
cTnI cardiac troponin protein I

cTnT cardiac troponin protein T

CV cardiovascular
CVP central venous pressure
CW continuous wave (Doppler)
D5W 5% dextrose in water
DADs delayed afterdepolarizations
DC direct current (conversion)
DCM dilated cardiomyopathy
DEC diethylcarbamazine
DHA docosahexaenoic acid
DIC disseminated intravascular coagulation
DLH domestic longhair (cat)
DSH domestic shorthair (cat)
DTI Doppler tissue imaging
DV dorsoventral
EADs early afterdepolarizations
ECG electrocardiogram
EDVI end-diastolic volume index
EF ejection fraction
ELISA enzyme-linked immunosorbent assay
EPA eicosapentaenoic acid
Epi epinephrine
EPSS E point to septal separation
ESVC European Society of Veterinary Cardiology
ESVI end-systolic volume index
ET endothelin
Fab antigen-binding fragments
FDPs fibrinogen/fibrin degradation products
FIO2 fraction of inspired oxygen
FS fractional shortening
GFR glomerular filtration rate
GI gastrointestinal
gp glycoprotein
HCM hypertrophic cardiomyopathy
Hct hematocrit
HOCM hypertrophic obstructive cardiomyopathy
HPRF high pulse repetition frequency
HR heart rate
HRV heart rate variability
HSA hemangiosarcoma
HWD heartworm disease
HWs heartworms
ICD implantable cardioverter defibrillator
ICS intercostal space(s)
IL interleukin
IM intramuscular

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IMHA immune-mediated hemolytic anemia

ISACHC International Small Animal Cardiac
Health Council
IV intravenous
IVRT isovolumic relaxation time
IVS interventricular septum/septal
K potassium
kVp kilovoltage peak
LA left atrium/atrial
LBBB left bundle branch block
L-CHF left-sided congestive heart failure
LMWH low-molecular-weight heparin (products)
LRS lactated Ringers solution
LV left ventricle/ventricular
LVET left ventricular ejection time
MAP mean arterial pressure
mAs milliamperes x seconds
Mdys mitral valve dysplasia
MEA mean electrical axis
Mg magnesium
MR mitral (valve) regurgitation
mV millivolts
Na sodium
NE norepinephrine
NH neurohormonal
NO nitric oxide
NOS NO synthetase
NT-proANP/BNP N-terminal fragments
(ANP and BNP)
NYHA New York Heart Association
O2 oxygen
PA pulmonary artery/pulmonary arterial
PAI-1 plasminogen activator inhibitor type 1
PaO2 partial pressure of oxygen in arterial blood
PAO2 partial pressure of oxygen in the alveolus
PCR polymer chain reaction
PCV packed cell volume
PDA patent ductus arteriosus
PDE phosphodiesterase
PEP pre-ejection period
PEP:ET pre-ejection period:ejection time (ratio)
PH pulmonary hypertension
PISA proximal isovelocity surface area
PMI point of maximal intensity
PNS parasympathetic (cholinergic) nervous
system
PPDH peritoneopericardial diaphragmatic hernia
PR pulmonary (valve) regurgitation
PRAA persistent right aortic arch
PRF pulse repetition frequency
PRN pro re nata (according to circumstances)

PS pulmonic stenosis
PTE pulmonary thromboembolism
PvO2 venous partial pressure of oxygen
PVR pulmonary vascular resistance
PVT paroxysm of ventricular tachycardia
PW pulsed wave (Doppler)
RA right atrium/atrial
RAP right atrial pressure
RAAS renin-angiotensin-aldosterone system
RBBB right bundle branch block
RBC red blood cell
R-CHF right-sided congestive heart failure
RCM restrictive cardiomyopathy
RIA radioimmunoassay
RMP resting membrane potential
rt-PA recombinant tissue plasminogen activator
RV right ventricle/ventricular
SA sinoatrial
SAECG signal averaged electrocardiography
SAM systolic anterior motion
SAS subaortic stenosis
SC subcutaneous
SNS sympathetic (adrenergic) nervous system
sPAP systolic pulmonary artery pressure
SR sarcoplasmic reticulum
SSS sick sinus syndrome
STIs systolic time intervals
SV stroke volume
SVT supraventricular tachycardia
TdP torsades de pointes
Tdys triscupid valve dysplasia
TE thromboembolic/thromboembolism
TEE transesophageal echocardiography
TFPI tissue factor pathway inhibitor
TICM tachycardia induced cardiomyopathy
TNF tumor necrosis factor
TNF tumor necrosis factor alpha
T of F Tetralogy of Fallot
t-PA tissue plasminogen activator
TR tricuspid (valve) regurgitation
US United States
V/Q pulmonary ventilation/perfusion
VD ventrodorsal
VF ventricular fibrillation
VHS vertebral heart score
VPCs ventricular premature
complexes/contractions
VSD ventricular septal defect
VT ventricular tachycardia
WPW WolffParkinsonWhite (type/syndrome)