Small Animal/Exotics 20TH ANNIVERSARY Compendium June 1999

Highlights and Horizons in

Cardiology
Philip R. Fox, DVM, MSc
Diplomate ACVIM (Cardiology), ECVIM (Cardiology), and ACVECC
The Animal Medical Center
New York, New York

P
erhaps few disciplines have witnessed
the rapid development, expansion of
knowledge, collective excitement, and
magic that are the hallmark of cardiology
over the past two decades. Advances in the field provide ongoing opportunities
to practice high-quality medicine and substantially improve animal health. To
understand how far cardiology has come and to gain a sense of future potential,
one needs only to compare the past 25 years with current clinical realities.
Just a quarter century ago, clinical evaluation of heart disease in companion
animals was largely confined to auscultation, electrocardiography, radiology, and
phonocardiography. The gold standard for anatomic diagnosis—cardiac cath-
eterization and angiography—was generally a province of universities and a few
referral institutions. Necropsy was available, of course, but represented a rather Philip R. Fox, DVM, MSc
draconian method to verify clinical diagnosis. Veterinary diagnostic ultrasound
had arrived on the scene but was in its infancy; only a few institutions had py required daily drug administration
echocardiography machines by 1980, and sufficient data had not yet been gener- and was tedious, and adulticidal thera-
ated to reliably distinguish between normal and disease states. py with thiacetarsamide sodium was as-
Resources were relatively limited 25 years ago for students or practitioners who sociated with high morbidity and sub-
wished to learn more about veterinary cardiology. A handful of veterinary journals optimal efficacy. Repair of congenital
were available and some textbooks (e.g., Current Veterinary Therapy) contained re- heart disease was greatly limited in
liable sections on cardiology, but only two books (Canine Cardiology and Hand- scope, and corrective procedures were
book of Canine Electrocardiography) dedicated solely to cardiology had been pub- the sole purview of veterinary surgeons.
lished by 1975. Most literature focused on heart disease in dogs. It was not until
the late 1970s that feline cardiology began to gain widespread recognition, aided Approaching the New Millennium
in part by the textbook Essentials of Canine and Feline Electrocardiography (pub- The past 25 years have produced ex-
lished in 1979) and by works published on cardiomyopathy by Liu and colleagues. citing and remarkable inroads to the
Until the late 1970s, medical therapy of heart failure often centered around rela- science and practice of cardiology. To-
tively few options. Barely a generation ago, therapeutic strategies were largely limited day’s clinical environment offers an
to a small number of drugs—most commonly furosemide, digitalis glycosides, and impressive array of diagnostic options,
some antiarrhythmics—and dietary sodium restriction. Heartworm preventive thera- technologic advances, and therapies.

ENDIU 1968 1974 1977 1978

MP 1980 1983
First clinical
implantation of a
American College of
Veterinary Internal
Diagnostic

1985
ultrasound becomes

19
First course in veterinary
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echocardiography

20th

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pacemaker in a dog Medicine (ACVIM) available is taught

1981
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Specialty of in veterinary

1 9 7

ANNIVERSARY
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9 9 9

1979 Cardiology is
established 1982
1984
medicine

19
 Compendium June 1999
Diagnostics
Although history, physical examina-
tion, and radiography continue to be
the foundation of cardiac evaluation,
new diagnostic methods have become
available and refinements in older
techniques have enhanced their value.
High-resolution, noninvasive imaging
has replaced angiocardiography as the
gold standard for morphologic diagno-
sis. Single-channel electrocardiograph
machines have developed into multi-
channel “page writers” that can pro-
vide computer analysis of P-QRS-T
complexes and even list diagnostic dif-
ferentials. Continuous heart rate assess-
ment and rhythm analysis are now
more easily obtained using smaller
Holter electrocardiogram monitors,
which capture data in digital format to
enhance diagnostic quality.
Perhaps the most stunning and
prominent technologic advances have
occurred in diagnostic ultrasound.
Echocardiography in all of its forms
now regularly assists clinicians in ob-
taining rapid, noninvasive, and safe di-
agnoses; evaluating cardiac structure
and function; and monitoring certain
therapies. New machines have made
high-quality and affordable two-dimen-
sional and color-flow Doppler echocar-
diography available in private practice
for the first time. In addition, a grow-
ing array of diagnostic businesses now
offer a variety of specialty consultation
services to private practitioners. Using
Internet and transtelephonic resources,
various diagnostic data, including elec-
trocardiograms, radiographs, echocar-
diograms, and pathology reports, can
be readily transmitted from practice to
consultant and interpreted; the results
can then be sent by transcription or dis-
cussed in real time via the Internet or
telephone.
98719901992 1979
1995
Feline cardiology
begins to gain widespread
1987
Taurine is used to
treat dilated
19911994 1998
recognition cardiomyopathy in cats
19891993 1997
First discussion
of the use of Holter
986 electrocardiograms
in dogs
20TH ANNIVERSARY
Continuing Education
The current learning environment
provides a wide range of multimedia
continuing education opportunities de-
signed to bridge the gap between clini-
cal cardiology and the empiric founda-
tion on which such practice should be
based. Today, individuals seeking to
learn more about cardiology can choose
from dozens of books, monographs,
journals, scientific proceedings, and re-
lated materials. Interactive CD-ROM
learning formats have arrived; national
scientific meetings regularly promote
cardiovascular defined-learning experi-
ences, laboratories, and topical sym-
posia; and the Internet offers online
courses ranging from diagnosis to case
management. Since the late 1970s, the
well-organized American College of
Veterinary Internal Medicine Specialty
of Cardiology has quadrupled its num-
ber of board-certified cardiologists,
most of whom participate in continu-
ing education forums.
Therapies and Management
of Cardiovascular Disease
A broad range of therapeutic op-
tions—including a plethora of new
drugs, nutraceuticals, and related
agents—are now available to treat
cardiovascular disease in companion
animals. To the old standbys of digi-
talis and furosemide have been added
drugs to modulate the neurohormon-
al system (i.e., angiotensin-converting
enzyme inhibitors); calcium-channel
blockers, which control supraventric-
ular tachycardias and arterial hyper-
tension and may benefit patients with
hypertrophic cardiomyopathy; sus-
tained-release preparations of β -
adrenergic blockers and other drugs;
and a number of antiarrhythmics.
New agents for chemoprophylaxis
1988
First comprehensive
book dedicated solely to
1990
Pacemaker bank
is established
canine and feline
cardiology is published
through the
ACVIM
Specialty of
Cardiology
Small Animal/Exotics
OWNERS’ OUTLOOK
The roles that pets play in the lives
of their owners are becoming more
recognized and socially acceptable:
■ Increasing numbers of pet owners
consider their pets to be members
of the family. According to the
Rimadyl® Dog Owner Survey
conducted for Pfizer Animal
Health by The Gallup
Organization in April 1998, 76%
of dog owners surveyed strongly
agreed with the statement “I
consider our dog(s) a member of
the family.”
■ Pet loss is now recognized as a
major life event. According to
information from the Animal
Medical Center in New York City,
the topic is covered in television
programs and newspaper articles. In
addition, numerous support groups
are available to help pet owners deal
with the grief associated with the
death of a pet, and there are even
greeting cards available that
specifically address pet loss.
(ivermectin and milbemycin oxime)
and adulticide chemotherapy (melar-
somine hydrochloride) have greatly
improved the management of heart-
worm disease. A large variety of addi-
tional drugs marketed for humans are
available but have not yet been fully
evaluated in veterinary medicine.
Certain canine arrhythmias are now
correctable by nonpharmacologic ap-
proaches, including ablation. Pace-
maker therapy has been simplified by
the use of transvenous approaches,
thereby avoiding the need for thora-
cotomies. Implantable electric defib-
rillators are being studied for canine
1995
Registered trials prove
angiotensin-converting
enzyme inhibitor therapy is
effective in small animals
1999
Compendium June 1999 20TH ANNIVERSARY
applications. Nonsurgical interventional techniques to cor-
rect certain congenital heart diseases were popularized in
the early 1990s and offer less-invasive, more-economic
methods to treat some diseases. Foremost among these
techniques are balloon valvuloplasty (to ameliorate con-
genital pulmonic or aortic stenosis) and coil occlusion
techniques (to close patent ductus arteriosus).
The Future
The new millennium will emphasize multicenter clinical
trials designed to determine and compare treatment effica-
cies as well as model management strategies based on evi-
dence-based medicine rather than subjective, individual bi-
ases. Advances in the understanding of nutrition and heart
Small Animal/Exotics
disease will grow in importance, as illustrated by the suc-
cessful elimination of feline taurine deficiency dilated car-
diomyopathy. Cardioactive drugs that have novel actions,
particularly those that target specific aspects of pathogenic
mechanisms of disease, will become available. Refinements
in noninvasive diagnostic imaging will continue to improve
the accuracy and acuity of morphologic diagnosis. Molecu-
lar screening for pathogens and genetic causes of heart dis-
eases is just around the corner in veterinary medicine and
will become as simple and commonplace as routine surveil-
lance for heartworm disease. Look toward the future to en-
hance educational opportunities, promote cardiovascular
health, and provide fulfilling avenues of practice.