Interview with Montse Rabanal, veterinary cardiology

“More than 18 years ago, my concern for cardiology began, with special interest and curiosity in electrocardiography. Since then more than 30000 ECG analyzed, together with their clinical histories and complementary tests such as radiographs in many of them …” This is how Montse Rabanal presents herself on the website of her clinic, ECGVeterinaria. She is the cardiologist specialist in charge of the studies that eKuore offers to veterinarians. In which patients should we pay more attention to evaluate cardiac processes? In puppies we must pay special attention to assess the presence of murmurs in auscultation since the most frequent congenital heart defects usually present, in most cases, a murmur on auscultation.
Tipo de pacientes

Types of patients

In large breeds, the most common heart disease is dilated cardiomyopathy that may initially present with fatigue but later with tachyarrhythmias and signs of CHF and low cardiac output. In small breeds, degenerative valvular disease is the most common pathology and appears in dogs from 8-9 years with a left apical systolic murmur. It has a slow but irreversible progression, so it is important to follow up to know when a therapy should be started that will try to delay the appearance of the most severe signs of CHF. In cats, things get complicated because in relation to heart disease, although they may present a murmur on auscultation, this is not always associated with heart disease. It is also important to pay special attention to some breeds predisposed to heart disease such as Boxer, Doberman, young German shepherds, English bulldog, schnauzer, cockers, etc., with more specific processes that must be known to be recognized. What elements do I have to diagnose heart disease? The clinical history and the patient’s own review already provide us with fundamental information to begin to direct a diagnosis and to decide the possibility of heart disease. The symptoms that it presents, its severity, the moments in which that sign is shown, what characteristics it has. The cough, the crisis of collapse, the tables of poor tolerance to exercise, of tachypnea / dyspnea, should be analyzed thoroughly with the owner. Exploration is fundamental, as is auscultation; The stethoscope is essential in the exploration of a possible patient with a cardio-respiratory process. A systematic auscultation should be done, both pulmonary (all fields) and cardiac (all points of maximum intensity of the different valves).
Exploración de paciente

Patient scan

In addition to the assessment of the location of the murmur, the intensity of the murmur and the type (systolic, diastolic or continuous) should be identified. The electronic stethoscopes also allow recording the phonocardiogram which can facilitate the identification task. It is very important to palpate the femoral pulse while evaluating the auscultation to relate the heartbeat to the strength and presence of the pulse. X-rays are a great help too. The electrocardiogram is a test easy to perform and very affordable test that provides information about heart rate and existing arrhythmias. No other test can give this type of data accurately
Electrocardiograma ECG

Electrocardiogram ECG

Doppler echocardiography is essential in certain heart diseases (congenital heart pathologies, feline cardiomyopathies, to differentiate a dilated cardiomyopathy from a pleural effusion, to evaluate neoplasms in the cardiac base, etc.) and, in any case, provides very useful information. It is necessary to evaluate the severity of existing cardiac dysfunction, to be able to choose the most appropriate treatment and be able to issue a more accurate prognosis. What is the use of having the recorded sound of an auscultation? The records of the auscultations can be very useful in different aspects: the visualization of the phonocardiogram can help us to identify the types of murmur (systolic, continuous, diastolic) or abnormal rhythms such as gallop rhythms, splitting of the S1 and S2 tones, appearance of extra sounds (S3 or S4), systolic clicks detection, etc., that help us relate them to different heart diseases or hemodynamic situations.
Auscultación con fonendoscopio ekuore

Auscultation with eKuore stethoscope

Keeping auscultation records can be helpful in making comparisons with new patient reviews, even as a comparison with other new cases of other patients. Sharing the recordings with other colleagues can help answer questions regarding auscultation. The use of sound software to, for example, slow down auscultation can facilitate the identification of cardiac sounds, especially in cats. Can early detection of heart disease be done? Clinical reviews, for example in pre-vaccination scans with careful auscultation, can provide data that indicate the onset of heart disease. In puppies (especially in breeds with special predisposition), the detection of a murmur is fundamental, even if they are asymptomatic, and Doppler echocardiography should always be recommended in these cases. In some predisposed races to heart disease, such as the Doberman with dilated cardiomyopathy, an echocardiogram could identify signs suggesting a subclinical phase of this pathology. What does a tele-diagnosis service in cardiology (remote diagnosis) provide? In those cases in which we decide to refer a patient because we believe that another colleague with more specific knowledge can be of help to give a good diagnostic service, we have two options: send it to another veterinary center in the area (when it exists, which is not always), proposing the displacement to the owner, or sending all the tests we have done to a tele-diagnosis service to have the advice in the clinic itself, via telephone, internet, etc. EKuore Phonocardiogram Ap This type of service offers several advantages: one of the main ones would be the comfort of the owner of not having to move outside his usual veterinary center. Thus, we do not depend on the existence of a veterinary center with a specialist in the area. The remote diagnosis allows the consultation of a specialist that can be many kilometers away, being able to choose the one that seems more competent. A final report is obtained that can be given to the owner as a summary of the assessment of the different tests performed, the conclusions, compatible diagnoses, recommendations of other additional or therapeutic tests, in addition to approximating a forecast and advising the following revisions. This means that the information collected during the visit and tests carried out by the general veterinarian (in their own center), ends up becoming a complete cardio-respiratory study with great added value that the owner will undoubtedly appreciate. The assessment of a remote diagnosis service is always much more affordable for the owner than sending the patient to another center where a specialist veterinarian will return to make the visit and, on occasion, may even ask to repeat the tests already performed. Unless directly, without doing any exploration, the general veterinarian refers the patient to the specialist veterinarian (very unusual and almost unthinkable), the general explorations will double and therefore the cost of the visits. The general veterinarian, in addition, will benefit from the invoicing in his center of the tests carried out in order to reach a diagnosis and the following follow-up visits. The most obvious disadvantages would arise in situations in which specific maneuvers are required for diagnosis or treatment and in which the general veterinarian is not highly trained, such as performing a pleurocentesis or pericardiocentesis. Other tests such as Doppler echocardiography, in addition to requiring the appropriate device, require a veterinarian who knows how to perform them correctly if the images are to be sent for evaluation. Also in cases in which the treatment requires surgery or intervention, it must always be the specialist who will perform the intervention, who will assess the case in detail. A disadvantage that could arise was the assessment of auscultation, which is a very important fact of the cardio-respiratory exploration, but with the use of an electronic stethoscope that allows to also refer the auscultation of the patient (especially when there are doubts of what has been auscultated), this problem is totally solved.