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How I Approach... A Young Puppy with a Heart Murmur
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Hannah Hodgkiss-Geere
BVM&S, MSc, PhD, Dip. ECVIM-CA (Cardiology), MRCVS
Dr Hodgkiss-Geere graduated from the Royal (Dick) School of Veterinary Science, Edinburgh in 2006 and pursued a career in both mixed and small animal practice before returning to academia. She has dual clinical and research interests, having undertaken an MSc in virology and a PhD in canine stem cells, and a residency in small animal cardiology at Edinburgh. She is a European Recognized Specialist in small animal cardiology and is currently a lecturer at Liverpool Vet School, where her interests center on cardiac disease, in particular pericardial disease and stem cell research.
Key Points
- Puppy murmurs are often found, but can vary greatly in their significance.
- Understanding cardiac anatomy and physiology will assist with localization and timing of murmurs.
- Assessment and accurate description of the murmur will enable creation of a differential diagnosis list.
- Early identification and management of many congenital cardiac abnormalities result in a better long-term outcome for the patient.
- Referral to a cardiologist is warranted with any cardiac murmur to allow for accurate diagnosis using echocardiography.
Introduction
Puppy murmurs are a common clinical finding for many practitioners. They are typically detected during routine primary vaccination appointments and are therefore found as “incidental” murmurs, although occasionally some will be found after clinical signs of heart disease are identified. Owners can be very distressed by the diagnosis of a puppy murmur, and the guidance and reassurance of their veterinarian is essential. Knowledge of the differential diagnosis, and the significance and approach for each type of murmur, is needed to help better guide appropriate management in each case. Referral to a cardiologist should always be considered and offered to the owner if a clinically significant murmur is identified.
What is a murmur?
Murmurs are sound waves created by vibrations caused by turbulent or regurgitant blood flow in the heart or nearby vasculature (the chamber walls, valves and walls of blood vessels). Blood must move at high velocity to produce turbulence or a regurgitation which creates a murmur loud enough to detect. The key is the difference in pressure across two chambers; for example, a mitral regurgitation forces blood into the low pressure left atrium (approximately 10 mmHg) from the high pressure left ventricle (approximately 120 mmHg) in systole, therefore moving blood with an overall pressure difference of 110 mmHg and causing local tissue vibrations which translate into a detectable sound.
It is important to note that shunting of blood through defects may not always cause a murmur. Movement of blood between two low pressure systems will not create a murmur loud enough to hear, for example with an atrial septal defect. Furthermore, some shunts will originate left to right, with the high-pressure differential between the systemic and pulmonary circulations. However, over time chronic overload of the right side can increase right-sided pressures until they equate and then surpass left-sided pressures, resulting in a right to left shunt; this may translate into a dramatic worsening of clinical signs but with loss or significant reduction in the murmur. [...]
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