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Table of Website Contents

Canine Cardiology: A multimedia guide to


cardiac auscultation
Content and Layout by Dr Jonathan M. Naylor, Diplomate ACVIM, Dr Anthony P Carr,
Diplomate ACVIM, Mr Ryan E. Walker.
Funded in part by CONVINCE. This site is hosted by Vet Visions.
Other Learning Resources
Vet Visions also has complete audiovisual guides to auscultation in horses and cattle. We produce
a multimedia equine textbook, an interactive instructional CD on passing a nasogastric tube in
the horse which is proven to improve learning and equine welfare, books on techniques in equine
medicine and handling horses, and a series of equine case simulations. Our cattle books include
Cattle Claw Care and a series of Calf Case Simulations.
Canine Cardiology
Contents:
The Components of a Stethoscope How To Use a Stethoscope Correctly Anatomy The
Apex Beat
Cardiac Auscultation Basic Cardiac Function Audible Sounds Detected During Aucultation
The First and Second Heart Sounds The Third and Fourth Heart Sounds Other Normal
Sounds
Normal Resting Heart Rate Values for Canine Arrhythmias
Classification of Arrhythmias
Normal Sinus Impulse Formation
Normal Sinus Impulse Formation
Altered
Supraventricular Impulse Formation
Disrupted Impulse Conduction
Murmurs
Problems and Strategies for Murmur Localization
The Most Common Murmurs Afflicting Dogs and their Features
Tricuspid Regurgitation
Terminology
Diamond-Shaped Machinery Murmur
Stenosis
Information
The four basic principles required for successful auscultation are:
1. Correct use of the stethoscope.
2. Recognition of external landmarks that correspond to valve locations and that due to
acoustical effects within the heart, the locations where sounds are heard loudest do not

necessarily correspond to their anatomical source.


3. Correct differentiation, interpretation and understanding of normal versus abnormal sounds.
Studies have shown that both students and veterinary practitioners can correctly describe the
physical features of heart sounds, however, their ability to correctly interpret these sounds is
often lacking (Naylor et al., In Press). This finding may be because traditional teaching methods
rely on a verbal description of an audible anomaly rather than actual audio recordings. The
authors of this website hope that with the multimedia technologies used herein, specifically the
pairing of actual cardiac audio recordings with visual interpretation, individuals will improve
their diagnostic and interpretive skills. For further information on cardiology, you may consult
"Hearing Horse Hearts: An Interactive Guide to Equine Cardiac Auscultation" (Naylor, 2000).
4. The ability to convey your understanding and interpretation of what you heard to others using
standard veterinary terminology.
The Components of a Stethoscope Top
Most stethoscopes are designed with a bell and a diaphragm. The diaphragm is designed to pick
up high frequency sounds and should be held firmly against the skin. The bell is designed to
amplify lower frequency sounds when applied with light pressure. When using the bell, avoid
applying firm pressure because the skin beneath the bell will act as a diaphragm and negate the
amplification of low frequency sounds (Fox, 1988). The ear pieces should fit comfortably in your
ear canals. If the stethoscope comes with different sized ear pieces, select the ear pieces that form
the tightest seals in your ear canals. The tubing connecting the binaurals to the bell-diaphragm
may be single or double layered. Double layered tubing eliminates more background noise.

How To Use a Stethoscope Correctly Top


For auscultation to be effective, it should be performed in a quiet room with little extraneous
noise. The stethoscope is most effective if:

1. When placed in the ears, the binaurals follow the same direction as the ear canals (see diagram
below).
2. The ear pieces fit snugly in the ears forming a tight seal and the hand holding the stethoscope
is still, relaxed and placed against the animal with a constant amount of pressure.

Anatomy Top
The canine heart projects into both thoracic cavities, particularly the left, from the third to the
sixth intercostal space. The long axis of the heart is rotated cranially so that it lies at an angle
with the base more cranial than the apex. The base of the heart is fixed by the great veins and
arteries while the apex can move freely within the pericardial sac. The so-called right and left
sides of the heart are more correctly understood to be the dextro-cranial and levo-caudal sides
because the left ventricle lies behind and slightly left of the right ventricle. The left ventricle is
more conical and massive than the right ventricle which is more crescent shaped.
Landmarks
If the dog is standing square, much of the heart lies medial to the triceps mass. A horizontal line
drawn through the point of the shoulder lies slightly above the level of the heart valves. As
opposed to using features of the forelimbs (e.g. the point of the shoulder and position of the
olecranon) to locate heart valves, palpation of the apex beat is more accurate because its position
is independent of the dogs forelimbs.

Internal landmarks for the heart valves largely rely upon their positions relative to intercostal
spaces and costochondral junctions. The following guidelines (Tilley and Goodwin, 2001) may
be helpful for auscultation:

The Apex Beat Top


The apex beat is an impact vibration produced at the start of ventricular contraction as the heart
hits the chest wall. In the normal dog it is palpated on the left side, ventrally in about the fifth
intercostal space. The apex beat should be identified by palpation before the heart is listened to.
It is important in lesion localization because the mitral valve lies close by and S1 is loudest at
this point.
Palpation of the Apex Beat

Cardiac Auscultation Top


Cardiac auscultation should be performed in a quiet room free of excessive noise. Cardiac
auscultation should also be performed as soon as the animal enters the exam room or when the
dog is stressed since this increases the probability that a transient or subtle murmur will be
detected. The probability of detecting a murmur increases with stress because sympathetic
activation increases heart rate, cardiac contractility and cardiac output. Turbulent flow, which
gives rise to murmurs, is more likely at higher blood velocities.
Cardiac auscultation should proceed in a logical manner. The apex beat (mitral valve area)
should be palpated and the heart rate measured either by cardiac auscultation or palpation of the
femoral pulse. The femoral pulses should be palpated in each hindlimb and compared for
fullness, sharpness and regularity. Next the femoral pulse should be palpated simultaneously with
cardiac auscultation in order to detect pulse deficits due to arrhythmias. Each valve should be
ausculted in the order Mitral, Aortic, Pulmonic (acronym MAP). Some palpate the apex beat
(mitral valve area) and move cranially from there. However, if you wish to auscult in a particular
intercostal space it is easier if you start counting spaces from the last rib (13th) cranially.

Basic Cardiac Function Top


The cardiac cycle consists of two phases: Systole (ventricular contraction) and diastole
(ventricular relaxation). At rest, systole occupies one-third of the cardiac cycle while diastole
occupies two-thirds of the cardiac cycle. The normal rhythm (Poodle example) originates from
the sino-atrial node. When the rhythm is completely regular (the timing of the heart sounds
remain in a uniform, repeating cycle) it is called a normal rhythm. Sinus rhythm refers to the
normal rhythmic contractions of the heart initiated after the sino-atrial node discharges. It may be
completely regular or the interval between beats may wax and wane. This is referred to as sinus
arrhythmia and is normal in dogs. An ECG (electrocardiogram) is required to confirm the
presence of sinus rhythms or arrhythmias. In the following table the width of the columns
represent the duration of the audible characteristics of the cardiac cycle. All of the normal

characteristics of the cardiac cycle are represented in this movie (Normal Heart example)

Audible Sounds Detected During Aucultation Top


Research has revealed that there are four main sounds produced during the cardiac cycle of
which only the first and second are normally heard in canines. The third and fourth heart sounds
are pathological if ausculted.
Normal
S1 - The first heart sound (lub) is the result of the closure of the left and right atrioventricular
valves (mitral or bicuspid and tricuspid valves respectively).
S2 - The second heart sound (dup) is the result of the closure of the pulmonic and aortic
(semilunar) valves.
Pathological
S3 - The third heart sound is the result of the addition of more blood into a partially filled
ventricle thus creating turbulence and sound waves.
S4 - The fourth heart sound is the result of atrial contraction. Although S4 is labelled the fourth
heart sound; if present; it will be heard at the start of the cardiac contraction cycle.
The First and Second Heart Sounds Top
Listen to the recordings of isolated heart sounds and see if you can detect the differences in
duration, intensity and pitch. S1 (S1) is slightly longer in duration and of lower pitch than S2
(S2). More reliable clues are the timing of the sounds and that S1 is louder than S2 when you
listen at the apex beat (Left4).
A Comparison of S1 and S2

The Third and Fourth Heart Sounds Top


In canines, the third and fourth heart sounds (S3 and S4) are not heard in normal animals and
their presence is an indication of pathology. The presence of S3 is often associated with dilated
cardiomyopathy (DCM) or chronic volume overloads due to acquired mitral insufficiency while
S4 is associated with hypertrophic cardiomyopathy, pressure overloads (semilunar valvular
stenosis) or chronic hypertension (Fox, 1988). Since S3 and S4 are both low frequency sounds,
they are best heard with the stethoscope bell.
Qualities of S3 and S4

Other Normal Sounds Top


Other normal sounds include those sounds produced by the gastrointestinal tract and the
respiratory tract. Both gut and respiratory sounds are clearly distinguishable from cardiac sounds.

The gut sounds will be variable and irregular in timing while the respiratory sounds are
consistent and regular in timing.

Artifacts
During cardiac auscultation you can hear additional sounds produced by movement or the
environment. In order to eliminate these sounds the location where auscultation is being
performed should be free of excessive noise, the dog should be properly restrained and the vet
should take care in handling the stethoscope. To reduce the sound of hair rubbing against the
stethoscope, the dogs coat may be moistened with alcohol over the target area.

Normal Resting Heart Rate Values for Canines Top


The "normal" heart rate for canines varies with the age, physical size, breed, level of arousal and
physical condition of the animal (Tilley and Goodwin, 2001). Smaller dogs have faster heart
rates than larger ones. Compare the recordings from an adult Poodle with that from a Greyhound,
and use your watch to practice taking the heart rate. As a general rule, clinicians will take the
heart rate over a period of 10 or 15 seconds depending on how tachycardic the animal is. If you
have difficulty counting the faster rate try counting in tens and remembering every set of ten by

extending a finger. The answers are here.

Arrhythmias Top
An arrhythmia or dysrhythmia is a deviation from the regular rhythm. In dogs this may be
normal or abnormal and may result from abnormal cardiac impulse formation, conduction, rate
or regularity.
Regularity
Regularity refers to the predictability of an arrhythmia. Some arrhythmias occur in a predictable
fashion and are said to be regularly irregular. These rhythms may be normal (e.g. sinus
arrhythmia) or pathological. In others the onset of the next beat is completely unpredictable and
the rhythm is said to be irregularly irregular (e.g. atrial fibrillation). Irregularly irregular rhythms
are pathological in origin.
Classification of Arrhythmias Top
Tilley and Goodwin (2001) classify arrhythmias according to:
Origin
Supraventricular arrhythmias arise from the atria or AV node whereas ventricular arrhythmias
arise from the ventricles.
Rate
Arrhythmias with slow rates are bradyarrhythmias while those with fast rates are
tachyarrhythmias.
Regularity
Fibrillation is a rapid, irregular, chaotic rhythm while tachycardia is a rapid but regular rhythm.

Normal Sinus Impulse Formation Top


Sinus Arrhythmia
Sinus arrhythmia is a regularly irregular sinus rhythm which is a normal finding in most dogs
(especially brachycephalic breeds). SinusArrhythmia is characterized by slight variations in the
S1-S1 interval. These variations are related to changes in vagal tone to the heart and are often
associated with inspiration (negative pressure created in the thorax) or use of sedative or
anesthetic drugs. You can demonstrate sinus arrhythmia by palpating the radial artery on your
wrist. Once you feel your pulse take a big deep breath and you should feel your pulse quicken
and then slow down as you exhale.
Altered Sinus Impulse Formation Top
Sinus Bradycardia (Slow Heart Rate)
Sinus bradycardia has a regular rhythm and may result from systemic disease (renal failure),
toxicities, increased vagal tone, elevated intracranial pressure or compression of the eyeball,
hypothermia, hypothyroidism or drugs (tranquilizers, propranolol, morphine, various anesthetics)
(Fox, 1988). Sinus bradycardia is diagnosed when the heart rate is less than 65 beats / minute and
an ECG shows sinus rhythm.
Sinus Tachycardia (Increased Heart Rate)
Sinus tachycardia; often caused by stress; is the most common arrhythmia observed in dogs and
has a regular rhythm. Sinus tachycardia may result if there is increased metabolism and oxygen
demand or increased requirement for cardiac output (pain, fright, excitement), pathology (fever,
shock, anemia, hypoxia, hyperthyroidism) or pharmacological agents (atropine, epinephrine,
ketamine) (Fox, 1988). Sinus tachycardia is diagnosed when the heart rate is greater than 160
beats / minute for most dogs (>180 bpm for small / toy breeds or >220 bpm in puppies) and an
ECG shows sinus rhythm (Fox, 1988) .
Altered Supraventricular Impulse Formation Top
Atrial Fibrillation
Atrial fibrillation is a common pathological arrhythmia in dogs (atrial fibrillation example).
Auscultable characteristics of atrial fibrillation include a completely unpredictable rhythm,
sometimes called a "jungle-drums" rhythm. Listen for long diastolic pauses between some beats
and very short intervals between others. Sometimes the beats are so close together that S2 is not
generated and two S1 sounds follow each other. The other hallmark of atrial fibrillation is a pulse
deficit. Sometimes this can be detected because there is a large disparity between the heart rate
and the pulse rate. If the heart beat is slow it is more reliably detected by simultaneous
auscultation and palpation of the pulse. Normally every S1 heart sound is followed by a pulse
wave. Abscence of a wave is called a pulse deficit.

The most common causes of atrial fibrillation are chronic atrioventricular valvular insufficiency
in small breeds, dilated cardiomyopathy in large breeds, and congenital heart defects. Less
common causes include heartworm disease, cardiac trauma, digitalis toxicity and severe
metabolic disorders (Fox, 1988). Auscultable or palpable characteristics of atrial fibrillation
include inconsistently filled femoral pulses, detection of an S1 without an S2 and a pulse deficit.
Disrupted Impulse Conduction Top
Second Degree Atrioventricular (AV) Block
Second degree AV block may be of two types: Mobitz I, usually type A or Mobitz II, usually type
B. The two types of second degree AV block are best distinguished by ECG. Mobitz I is a normal
finding in dogs, especially in young animals and disappears with exercise. Mobitz II is
pathological in origin and will not disappear with exercise. Both types of second degree AV
block are manifested by a dropped beat detectable during auscultation. By exercising and
immediately ausculting the dog, you can determine if the AV block is a Mobitz I (the dropped
beats have disappeared) or Mobitz II (the dropped beats are still auscultable). Second degree AV
blocks can be associated with sinus arrhythmia, increased vagal tone, supraventricular
tachycardia, electrolyte imbalances or drugs (digitalis, intravenous atropine, xylazine) (Fox,
1988).
Murmurs Top
Murmurs are sounds produced by turbulent blood flow. Rapid flow, a wide vessel, low blood
viscosity and an uneven or constricted vessel wall all predispose to cardiac murmurs. They can
be physiological, for example high blood flow though the aortic outflow tract. Pathological
murmurs reflect heart disease, for example degeneration and roughening of a valve surface.
Veterinarians require a uniform method of describing murmurs to facilitate communication
between each other via a common understanding. Five parameters have been developed that
serve to describe all of the important aspects of a murmur. Of the five parameters, the most
important ones are position in the cardiac cycle, intensity, duration and pattern of intensity. The
point of maximal intensity (PMI) identifies the location where the murmur is heard loudest and is
often described using the valve location nearest (e.g. Mitral valve area). On the following page is
a table summarizing the parameters and their descriptions (Naylor, 2000). In dogs, systolic or
continuous murmurs are more common than diastolic murmurs (diastolic murmur example).
In describing the duration of murmurs, pan refers to a murmur that obliterates both heart sounds
either through systole or diastole but does not obliterate any heart sounds. Holo refers to a
murmur that lasts throughout stystole or diastole but does not obliterate any heart sounds. A
continuous or machinery murmur (example) lasts throughout most or all of systole and diastole
and may or may not obliterate heart sounds. Early- and late- describe murmurs that are
positioned closer to one heart sound than to another. Crescendo, decrescendo or diamond are
terms that describe the intensity profiles of murmurs as increasing, decreasing or increasing and

then decreasing in loudness. Musical and blowing and are terms used to describe the frequency
profile of a murmur. Grade refers to the absolute intensity of murmurs determined on a 6 point
scale where the higher the grade the more severe the murmur (Example: Grade 2 versus a grade
5 regurgitant murmur).

Research shows that most clinicians correctly describe the grade of a murmur. Localization of
the murmur to systole or diastole is less consistent. A clue is the timing of the heart sounds
(systolic murmurs occur in the short pause), however loud murmurs can be perceived as being of
longer duration than they really are (Naylor et al., In Press). Another useful method is to palpate
the pulse during auscultation. Pan- or holo-systolic murmurs should be heard coincident with the
pulse wave.
Problems and Strategies for Murmur Localization Top
On the left side, the pulmonic and aortic roots lie next to each other and it is difficult to separate
their respective valvular sounds. Both produce sounds that are best heard cranio-dorsally on the
left side of the thorax at the second or third intercostal spaces. Since the aortic valve is more
centrally located and produces louder sounds some aortic murmurs are also heard on the right

side. Mitral valve problems produce sounds that are heard more caudally centered on the fourth
or fifth intercostal space. On the right side, tricuspid and ventricular septal defects produce
murmurs that are heard ventrally around the fourth or fifth intercostal space. A problem with
localizing the origin of murmurs is that loud murmurs can radiate over a wide area and on both
sides of the thorax. Despite this, the point at which they are loudest is often close to the lesion.
Sometimes it may prove challenging to correctly identify the likely origin of a murmur.
Generally by following a logical process like the one outlined here, insight may be gained into
the type of murmur being dealt with. First of all the stethoscope should be moved around to all
the valve areas on each side of the thorax in order to ascertain where the PMI is located and
which; if any; valve is involved. With the location of the PMI known the murmur's intensity may
be accurately graded and the character and quality judged. Finally, by simultaneously ausculting
the PMI and palpating the femoral pulse an accurate indication of the position and duration of the
murmur within the cardiac cycle may be obtained. Additionally, note that by examining the
animal as soon as it enters the exam room or when it is stressed, the probability of detecting a
transient or subtle murmur increases because the intensity increases in accordance with the
sympathetic effects of stress.
The Most Common Murmurs Afflicting Dogs and their Features Top
In order of prevalence:
Mitral Regurgitation
Mitral Reguritation, the result of mitral insufficiency, allows backflow of blood into the left
atrium. Typical features of mitral regurgitation include a normal to increased arterial pulse, a
PMI located at the left apex, a plateau or decrescendo quality and systolic position in the cardiac
cycle (example) (Fox, 1988). Mitral regurgitation is most often the result of acquired valvular
disease (e.g. mitral valve endocardiosis) and is usually observed in older dogs.
Patent Ductus Arteriosus
Patent ductus arteriosus (listen to a PDA) results when the ductus arteriosus fails to close
properly (functional closure normally occurs by 72 hours after birth while anatomic closure is
complete within the first few weeks). PDA is therefore most commonly seen in young dogs with
a higher prevalence in purebreds and females (Fox, 1988). This murmur will feature an increased
arterial pulse, a normal to increased venous pulse, a PMI located at the left base and a machinery
or continuous quality as it is present throughout most or all of systole and diastole (Fox, 1988).

Tricuspid Regurgitation Top


Tricuspid regurgitation, the result of tricuspid insufficiency, allows backflow of blood into the

right atrium. Like mitral regurgitation, tricuspid regurgitation is most often caused by acquired
valvular disease and is usually observed in older animals. Features of a tricuspid regurgitant
murmur include an increased venous pulse, a PMI located at the right apex, a plateau or
decrescendo quality and a systolic position in the cardiac cycle (Fox, 1988).
The following two diagrams represent the locations where specific cardiac pathologies will be
auscultated best.

Terminology Top
Some of the common terms used in cardiology are:
Blowing
Blowing describes the frequency profile of a murmur in which there is no single predominant
frequency.
Continuous Murmurs
Continuous murmurs occur throughout both systole and diastole and are associated with patent
ductus arteriosus (PDA).
Crescendo
Crescendo describes an intensity pattern of a murmur that increases as it progresses towards
completion.

Crescendo-Decrescendo - See Diamond-Shaped


Decrescendo
Decrescendo describes an intensity pattern of a murmur that decreases as it progresses towards
completion.
Diamond-Shaped Top
Diamond-Shaped refers to an intensity pattern of a murmur that first increases and then decreases
towards completion.
Fibrillation
Fibrillation refers to the situation in which muscle tissue spontaneously enters a state of rapid,
irregular and completely random contractions.
Flutter
Flutter describes a state of rapid, regular and uniform muscular pulsations or contractions in the
range of 200-320 per minute.
HoloHolo- describes the duration of murmurs which last from the end of S1 to the beginning of S2 or
the end of S2 to the beginning of S1 and these murmurs do not obliterate S1 or S2.
Insufficiency
Insufficiency when related to any one of the four heart valves refers to the situation in which the
valve fails to close properly. Blood flows against its normal course producing turbulence and a
murmur.
Machinery Murmur Top
Machinery describes a murmur that occupies most of systole and diastole and may be used
interchangeably with continuous.
Musical
Musical describes the frequency profile of a murmur when there is a single prominent primary or
fundamental frequency with secondary harmonics.
PanPan- describes the duration of murmurs which last from the beginning of S1 to the end of S2 or
the beginning of S2 to the end of S1 and thus the murmur obliterates both of these heart sounds.
PDA (Patent Ductus Arteriosus)
PDA is a congenital condition characterized by the post-natal persistence of a lumen in the
ductus arteriosus between the aorta and the pulmonary artery. PDA is manifested by a continuous
murmur.

Plateau
Plateau describes an intensity pattern of a murmur that remains constant through to completion.
Stenosis Top
Stenosis when related to any one of the heart valves, chambers or great vessels refers to the
situation in which the valve fails to open properly or the chamber or vessel is abnormally narrow
and the normal flow of blood is hindered.
Thrill
Thrill is a vibration caused by turbulent fluid movement through an incompetent valve which is
palpable on the thoracic wall. Thrill is typically observed with grade 5 or 6 murmurs.
Regurgitation
Regurgitation results with valvular insufficiency and is characterized by blood flow against its
normal course. In canines mitral valve regurgitation is the most common regurgitant-type
murmur that will be encountered.
VSD (Ventricular Septal Defect)
VSD is a congenital condition characterized by the persistent patency of the ventricular septum
post-natally thus allowing blood to flow directly between the ventricles. Since the blood can
bypass the pulmonary circulation cyanosis may be present in addition to a grade 5/6 systolic
murmur.
Information Top
Other Learning Resources
Vet Visions also has complete audiovisual guides to auscultation in horses and cattle. We produce
a multimedia equine textbook, an interactive instructional CD on passing a nasogastric tube in
the horse which is proven to improve learning and equine welfare, books on techniques in equine
medicine and handling horses, and a series of equine case simulations. Our cattle books include
Cattle Claw Care and a series of Calf Case Simulations.
References
Fox, P.R. 1988. Canine and Feline Cardiology. Churchill Livingstone Inc. New York.
Naylor, J.M., Yadernuk, L.M., Pharr, J.W. and Ashburner, J.S. In press. An Assessment of the
Ability of Diplomates, Practitioners and Students to Describe and Interpret Heart Murmurs and
Arrhythmia. Journal of Veterinary Internal Medicine.
Naylor, J.M. 2000. Hearing Horse Hearts: An Interactive Guide to Equine Cardiac Auscultation.
Vet Visions Inc. Saskatoon.

Tilley, L. P. and Goodwin, J. K. 2001. Manual of Canine and Feline Cardiology 3rd Ed. W.B.
Saunders Company. Philadelphia.
Copyright
This web site is intended as a resource for veterinarians and students. You may link to the title
page and we would be grateful if you would let us know by E-mail when you do this. There is no
charge. If you link to a page other than the title page please acknowledge in the link that the page
is part of Canine Cardiology by J.M. Naylor, A.P. Carr and R.R.E. Wolker.
The content of this website, that is all text, graphics, tables, charts, audio and video are copyright
of Jonathan M Naylor and may not be downloaded in full or part without the author's written
permission.
Comments and suggestions:
Jon.Naylor@usask.ca
J. M. Naylor 2001, 2009
A complete range of Vet Visions multimedia books and case simulations is available below:
Equine:
The Art of Equine Medicine
Passing a Nasogastric Tube in the Horse
Techniques in Equine Medicine
Handling Horses
Equine Case Simulations
The Art of Equine Auscultation
Bovine:
Cattle Claw Care
The Art of Bovine Auscultation
Calf Case Simulations