Interview with Frane Ivasovic, specialist in small animal cardiology Res.ECVIM-CA (Board Eligible)

Diplovets: How do you see telemedicine by specialists helping practising veterinarians?

Frane Ivasovic: A great advantage of working in a team with many people with different professional backgrounds (e.g., a university hospital) is that everyone can interpret a case with his own view; and I find that telemedicine is a way to bring that positive "teamwork" feeling to the treating veterinarian and offer a new perspective to the case in question.

Diplovets: What do you believe are the advantages of telemedicine in the field of small animal cardiology?

Frane Ivasovic: A major advantage is that you can access the expertise of a specialist from the comfort of your own clinic.

For example, in the case of an unstable patient with dyspnea, you can record videos using simple ultrasound techniques such as a "focused cardiac ultrasound (FCU) " 1,2, "focused assessment with sonography for trauma" (FAST) 3 or "lung ultrasound" (LUS)" 4, initiate initial treatment and then ask the specialist via telemedicine for advice on how to continue the therapy. This feedback is not only useful for the case in question, but also allows the treating veterinarian to expand his or her knowledge.

Personally, I have received echocardiographic images from several colleagues, which often helped me to answer questions about the presence of possible serious cardiac problems and to initiate further cardiological clarification if necessary.
For example, an ECG performed correctly in the office (the position of the patient is also important!5,6), can have the same diagnostic value as an ECG performed by a specialist!

Diplovets: What do you need in order to make a sound diagnosis?

Frane Ivasovic: A clear medical history and complete clinical examination (presence or absence of an intense cardiac murmur; adequate heart rate? regular or irregular?) are essential.

For example, a dog with dyspnea that is elderly and small in stature, and also has an intense left cardiac murmur, may have pulmonary edema due to mitral endocardiosis. However, if the murmur is not present (and therefore mitral regurgitation is usually not severe), pulmonary edema due to a mitral valve problem is less likely.
In the case of ECG evaluation, ECGs should be accurate, of adequate quality, and possibly multiple leads (some artifacts can easily be misinterpreted as arrhythmias, and the use of multiple leads allows them to be better identified).

On the other hand, if echocardiographic evaluation is required, try to follow one of the protocols mentioned above. Personally, I find it easier when longer loops are sent (often an inexperienced hand cannot provide a perfect examination, but useful information for the specialist can result from the transition from one projection to another!).

Diplovets: Do you have a final advice?

Frane Ivasovic: In my experience, with a good clinical exam, medical history, and initial testing (radiographs and a rapid emergency ultrasound), many emergency cardiac patients can be pointed in the right direction with telemedicine, avoiding further stress when transporting the patient.

A tip for when you have a cat with dyspnea and are unsure of the initial results: an elevated NTproBNP is suspicious for a cardiac problem!7,8,9

And in the material obtained during a thoracentesis, you can also measure this biomarker without stressing the cat and drawing additional blood!10

Similarly, in a patient with cardiac arrhythmias, a good ECG already allows possible interpretations.

And another tip: In stable patients, in whom the own examinations have not revealed any clear abnormalities, an echocardiographic examination by a specialist can always be advantageous.

Referent sources:

1. DeFrancesco TC, Ward JL. Focused Canine Cardiac Ultrasound. Vet Clin North Am Small Animal Pract. 2021;51(6):1203–16.

2. Loughran KA, Rush JE, Rozanski EA, Oyama MA, Larouche-Lebel É, Kraus MS. The use of focused cardiac ultrasound to screen for occult heart disease in asymptomatic cats. J Vet Intern Med [Internet]. 2019 Jul 17;33(5):1892–901.

3. Boysen SR, Lisciandro GR. The Use of Ultrasound for Dogs and Cats in the Emergency Room AFAST and TFAST. Vet Clin North Am Small Animal Pract. 2013 Jul 1;43(4):773–97.

4. Ward JL, Lisciandro GR, Keene BW, Tou SP, DeFrancesco TC. Accuracy of point-of-care lung ultrasonography for the diagnosis of cardiogenic pulmonary edema in dogs and cats with acute dyspnea. Journal of the American Veterinary Medical Association. 2017 Mar 15;250(6):666–75.

5. Coleman MG, Robson MC. Evaluation of six-lead electrocardiograms obtained from dogs in a sitting position or sternal recumbency. Am J Vet Res. 2005;66(2):233–7.

6. Harvey AM, Faena M, Darke PGG, Ferasin L. Effect of Body Position on Feline Electrocardiographic Recordings. J Vet Intern Med. 2005 Jul;19(4):533–6.

7. Connolly DJ, Magalhaes RJS, Fuentes VL, Boswood A, Cole G, Boag A, et al. Assessment of the diagnostic accuracy of circulating natriuretic peptide concentrations to distinguish between cats with cardiac and non-cardiac causes of respiratory distress. J Vet Cardiol. 2009 May 1;11:S41–50.

8. Fox PR, Oyama MA, Reynolds C, Rush JE, DeFrancesco TC, Keene BW, et al. Utility of plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) to distinguish between congestive heart failure and non-cardiac causes of acute dyspnea in cats. J Vet Cardiol. 2009 May 1;11:S51–61.

9. Ward JL, Lisciandro GR, Ware WA, Viall AK, Aona BD, Kurtz KA, et al. Evaluation of point-of-care thoracic ultrasound and NT-proBNP for the diagnosis of congestive heart failure in cats with respiratory distress. J Vet Intern Med. 2018 Sep 14;32(5):1530–40.

10. Humm K, Hezzell M, Sargent J, Connolly DJ, Boswood A. Differentiating between feline pleural effusions of cardiac and non-cardiac origin using pleural fluid NT-proBNP concentrations. J Small Anim Pract. 2013 Nov 7;54(12):656–61.

Thank you for your time and the interesting interview, Frane Ivasovic!

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