Serum cardiac troponin I concentrations in dogs with systemic inflammatory response syndrome

Effect of early stepwise cardiopulmonary rehabilitation on function and quality of life in sepsis patients

BACKGROUND

Sepsis, as a non-limiting host infection disease, can be accompanied by serious complications such as organ failure, which seriously threatens patient quality of life.

AIM

To investigate the effect of early stepwise cardiopulmonary rehabilitation on cardiopulmonary function and quality of life in patients evacuated from mechanical ventilation with sepsis.

METHODS

A total of 80 patients with sepsis who were hospitalized in our hospital from January 2021 to January 2022 were selected and divided into the observation group (n = 40) and the control group (n = 40) according to the random number table method. The observation group was treated with early stepwise cardiopulmonary rehabilitation, and the control group was treated with a conventional treatment regimen. Cardiac function indexes (central venous pressure, cardiac troponin I, B-type brain natriuretic peptide), lung function indicators (diaphragmatic mobility, changes in central venous oxygen saturation, oxygenation index), and quality of life (Quality of Life Evaluation Scale) were compared between the two groups after treatment.

RESULTS

After treatment, the central venous pressure, diaphragm mobility, central venous oxygen saturation, oxygenation index, and Quality of Life Evaluation Scale scores in the observation group were higher than those in the control group, and the differences were statistically significant (P < 0.05). The observation group was less than that of the control group for other parameters, and the differences were statistically significant (P < 0.05).

CONCLUSION

Early stepwise cardiopulmonary rehabilitation can effectively enhance cardiac and pulmonary function and improve the quality of life in patients evacuated from mechanical ventilation with sepsis.

Cardiac Troponin I and Electrocardiographic Evaluation in Hospitalized Cats with Systemic Inflammatory Response Syndrome

Several studies conducted on humans demonstrate the increase in cardiac troponins and the onset of arrhythmias in the course of systemic inflammatory response syndrome (SIRS). The aim of the current study was to assess the blood concentration of cardiac troponin I (cTnI) and electrocardiographic findings in SIRS-affected cats. Seventeen shorthair cats hospitalized with SIRS were enrolled (Group 1). SIRS diagnosis was performed based on the detection of at least two of the four criteria such as abnormal body temperature, abnormal heart rate (i.e., tachycardia or bradycardia), abnormal respiratory rate (i.e., tachypnea or bradypnea), and alterations of white blood cell number (i.e., leukocytes or band neutrophils). Ten cats screened for elective surgery such as neutering or dental procedures were evaluated as a control population (Group 2). They were considered healthy based on history, physical examination, hematological and biochemical profile, urinalysis, coprological exam, thyroxine assay, blood pressure measurement, and echocardiography. A physical examination, complete blood cell count, biochemistry test (including an electrolyte panel), electrocardiographic examination, and cTnI assay were carried out in each cat enrolled. Traumatic events, gastrointestinal, neoplastic, respiratory, and neurological disorders were identified as causes of SIRS in Group 1. In Group 1, a significantly higher concentration of cTnI than that in Group 2 was recorded (p = 0.004). In 37.5% of cats with SIRS, ventricular premature complexes occurring in couplets with multiform configuration were detected. Similarly, to humans, data herein reported would indicate possible cardiac damage present in cats with SIRS diagnosis.

Analytical validation, sample stability, and clinical evaluation of a new high-sensitivity cardiac troponin I immunoassay for use in dogs, with comparison to a previous ultrasensitive assay

Cardiac troponin I (cTnI) is considered the gold standard biomarker for myocardial injury and shows a high degree of homology between humans and dogs. The ADVIA Centaur XP High-Sensitivity Troponin I (AC-cTnI-HS) assay has been validated for use in humans but not dogs. The study objectives were to analytically validate the AC-cTnI-HS assay in dogs, to assess correlation between the AC-cTnI-HS and a previous ADVIA Centaur TnI-Ultra (AC-cTnI-U) assay, to assess cTnI sample storage stability, and to clinically evaluate the AC-cTnI-HS assay in healthy dogs and dogs with cardiac disease. Canine serum samples were used for analytical validation. Intra- and inter-assay variability, dilutional parallelism, and spiking recovery were assessed. Samples from 196 client-owned dogs were evaluated (healthy dogs (n = 39) or dogs with congenital heart disease (n = 54), myxomatous mitral valve disease (n = 68), dilated cardiomyopathy (n = 15), or myocarditis (n = 20)). Inter- and intra-assay coefficient of variation (%CV) was between 2.8-41.4% and 3.8-30.2%, respectively, with pools with concentrations >20 pg/mL all having %CVs <10%. The observed to expected ratios for dilutional parallelism and spiking recovery experiments ranged between 92.3 and 266.7.0% and 84.3 and 108%, respectively. A strong correlation between the AC-cTnI-HS and AC-cTnI-U assays was observed (Spearman's ρ = 0.927), though a proportional bias existed, with AC-cTnI-HS assay concentrations being proportionally lower than AC-cTnI-U assay concentrations. Serum samples stored at -80°C had stable cTnI measurements for up to 2.7 years and after a single freeze-thaw cycle. Healthy dogs and dogs with congenital heart disease had significantly lower cTnI concentrations than dogs in the other three groups. The AC-cTnI-HS assay precisely, reproducibly, and accurately measures cTnI concentrations in dog serum with cTnI concentrations >20 pg/mL.

Serial measurement of cardiac troponin I in hospitalised dogs with canine parvoviral enteritis: Association with outcome and canine pancreas-specific lipase concentration

The aim of this study was to serially evaluate serum cardiac troponin I (cTnI) concentrations in dogs with parvoviral enteritis (CPVE), and investigate the association with outcome and serum pancreas-specific lipase (Spec cPL) concentrations. Dogs with CPVE that were hospitalised for at least 5 days were included. cTnI and Spec cPL concentrations were measured on days 1, 3 and 5 of hospitalisation. Twenty-nine dogs (20 survivors, 9 non-survivors) were included. Spec cPL was indicative of pancreatitis (>400 μg/L) on at least one day in 10/29 (34.5%) dogs. Serum median (range) cTnI concentration was higher (P = 0.021) in non-survivors on day 5 [0.032 (0.001-0.395) ng/mL] compared to day 1 [0.012 (0.003-0.196) ng/mL]. Non-survivors had higher (P = 0.014) cTnI concentrations on day 5 [0.032 (0.001-0.395) ng/mL] compared to survivors [0.001 (0.001-0.042) ng/mL], but not at admission or on day 3 (P > 0.05). Serum cTnI concentrations were not significantly different (P = 0.465) between the three Spec cPL groups [group 1 (Spec cPL ≤ 200 μg/L): 0.007 (0.001-0.527) ng/mL; group 2 (Spec cPL: 201-399 μg/L): 0.0045 (0.001-0.196) ng/mL; group 3 (Spec cPL ≥ 400 μg/L): 0.011 (0.001-0.278) ng/mL]. cTnI and Spec cPL concentrations were not significantly correlated (rho = -0.043, P = 0.703). Serial measurement of cTnI had prognostic value in the examined cohort. However, cTnI was not correlated with spec cPL.

Evaluation of cardiac troponin I as a predictor of death in critically ill cats

BACKGROUND

Abnormally high serum cardiac troponin I (cTnI) concentration, reflecting leakage from or necrosis of cardiomyocytes, is a negative prognosticator for death in dogs.

OBJECTIVES

To investigate in critically ill cats whether serum cTnI concentration is abnormally high, identify conditions associated with abnormally high cTnI concentrations, and evaluate cTnI as an independent prognosticator for death and a potential coprognosticator to the acute patient physiologic and laboratory evaluation (APPLE) score in cats.

ANIMALS

One hundred nineteen cats admitted to intensive care units (ICU) and 13 healthy cats at 2 university teaching hospitals.

METHODS

Prospective study. Clinical examinations were performed, APPLE scores calculated, and serum cTnI and serum amyloid A (SAA) measured within 24 hours after admission. Outcome was defined as death/euthanasia or survival to discharge, 28 and 90 days after ICU-admission. Prognostic capacity of cTnI, APPLE scores and models combining cTnI and scores were evaluated by receiver-operator-characteristic analyses.

RESULTS

Median (IQR) serum cTnI concentration was higher in ill (0.63 [0.18-2.65] ng/mL) compared to healthy (0.015 [0.005-0.041] ng/mL) cats (P < .001) and higher in subgroups with structural cardiac disease (2.05 [0.54-16.59] ng/mL; P < .001) or SAA >5 mg/L (0.84 [0.23-2.81] ng/mL; P = .009) than in cats without these characteristics (0.45 [0.12-1.70] and 0.35 [0.015-0.96] ng/mL). The in-hospital case fatality rate was 29%. Neither serum cTnI concentration for all critically ill cats (area-under-the-curve 0.567 [95% CI 0.454-0.680], n = 119) or subgroups (0.625 [0.387-0.863], n = 27; 0.506 [0.360-0.652], n = 86), nor APPLE scores (fast 0.568 [0.453-0.682], full 0.585 [0.470-0.699], n = 100), were significant prognosticators for death.

CONCLUSIONS AND CLINICAL IMPORTANCE

Abnormally high serum cTnI concentration was common in critically ill cats. Unlike in dogs, cTnI did not confer prognostic information regarding death.

Autochthonous Babesia canis infections in 49 dogs in Germany

BACKGROUND

Vector-borne diseases are of increasing importance in Germany. Since 2015, autochthonous cases have been increasingly documented in Berlin/Brandenburg.

OBJECTIVES

Describe autochthonous Babesia canis infection in the Berlin/Brandenburg region.

ANIMALS

Forty-nine dogs with autochthonous B. canis infection.

METHODS

Evaluation of history, clinical signs, laboratory abnormalities, treatment, and outcome.

RESULTS

Dogs were presented between March and August (9) and September and January (40) in the years 2015-2021. Historical and clinical findings were lethargy (100%), pale mucous membranes (63%), fever (50%), and pigmenturia (52%). Common clinicopathological findings were thrombocytopenia (100%), anemia (85%), intravascular hemolysis (52%), pancytopenia (41%), and systemic inflammatory response syndrome (SIRS; 37%). Babesia detection was based on blood smear evaluation (n = 40) and PCR targeting the 18S rRNA gene of piroplasms (n = 49). Sequencing indicated 99.47% to 100% identity to B. canis sequences from GenBank. All dogs were treated with imidocarb (2.4-6.3 mg/kg; median, 5 mg/kg); 8 dogs received 1, 35 received 2, and 1 dog each received 3, 4, or 5 injections, respectively. Continued PCR-positive results were detected in 7 dogs after the 1st, in 5 after the 2nd, in 2 after the 3rd, and in 1 28 days after the 4th injection. Four dogs were euthanized and 3 dogs died.

CONCLUSIONS AND CLINICAL IMPORTANCE

Autochthonous B. canis infections in Berlin/Brandenburg were associated with severe clinicopathological changes, SIRS, and multiorgan involvement. Testing by PCR during and after treatment is advisable to monitor treatment success. Screening of blood donors in high-risk areas and year-round tick protection is strongly recommended.

Apolipoprotein A1 and serum amyloid A in dogs with sepsis and septic shock

Introduction

Apolipoprotein-A1 (Apo-A1) acts as a negative acute phase protein (APP) during inflammatory states, and has a potential prognostic value in people and dogs with sepsis. The aim of this retrospective study was to investigate the association of serum Apo-A1 concentration with disease severity, multiorgan dysfunction syndrome (MODS) and outcome in a population of dogs with sepsis, and to assess its correlation with major canine APPs.

Methods

Ninety-nine dogs with uncomplicated sepsis (n = 78) or septic shock (n = 21) were included. The serum concentration of Apo-A1, C-reactive protein (CRP) and serum amyloid A (SAA) were recorded, alongside the canine acute patient physiologic and laboratory evaluation fast (APPLE_fast) score and the presence of MODS.

Results

Dogs with septic shock had significantly lower serum Apo-A1 concentrations (106.3 ± 22.7 mg/dl; reference interval: 123.0-142.3 mg/dl), higher APPLE_fast score (30, 13-38) and greater frequency of MODS (67%) compared to those with uncomplicated sepsis (117.9 ± 19.3 mg/dl; 25, 6-33 and 8%, respectively) (P = 0.0201; P = 0.0005; P < 0.0001, respectively). Similarly, dogs with MODS had significantly lower serum Apo-A1 concentrations (104.1 ± 4.6 mg/dl) and higher APPLE_fast score values (31, 13-38) compared to those without MODS (118.32 ± 2.1 mg/dl and 26, 6-33, respectively) (P = 0.0050 and P = 0.0038, respectively). Conversely, neither CRP nor SAA were different between these groups. No difference in serum APPs concentrations was detected between survivors and non-survivors. Significant negative correlations were detected between serum Apo-A1 and SAA (P = 0.0056, r = -0.277), and between serum Apo-A1 and the APPLE_fast score (P = 0.0027, r = -0.3). In this population, higher values of the APPLE_fast score and the presence of MODS were independently associated with a higher risk of death.

Discussion

Our study shows that Apo-A1 is a useful biomarker of sepsis severity in dogs, since it is decreased in those with septic shock and MODS. Further prospective investigations are deemed to evaluate the applicability of Apo-A1 to predict sepsis course and response to treatment in septic dogs.

Electrocardiographic Findings and Cardiac Troponin I Assay in Dogs with SIRS Diagnosis

Several studies performed in humans have demonstrated that the onset of systemic inflammatory response syndrome (SIRS) represents a high risk condition to develop myocardial damage and arrhythmias. Therefore, we also hypothesized cardiac involment for dogs affected by SIRS. To assess this hypothesis, 24 dogs with a diagnosis of SIRS (13 entire males, 7 entire females, and 4 spayed females) with an age ranging from 4 to 11 years (mean 5.6 years) and an average weight of 24 kg (range from 5 to 47 kg) were enrolled. The dogs were divided into two groups according to their prognosis: Survivors (G1) and not survivors (G2), composed by 13 and 11 dogs, respectively. Moreover, healthy dogs were included as the control group (CTR). All the dogs with a history of cardiac or renal disease were excluded. At the inclusion, each patient underwent a physical examination and a complete cell count, and a biochemistry panel (including electrolyte profile) was performed; moreover, the blood cardiac Troponin I (cTnI) was measured. For each clinical variable indicative of SIRS, a score between 0 (absence) and 1 (presence) was applied. Furthermore, an electrocardiographic examination was recorded. Seventeen out of 24 (70.8%) dogs with SIRS showed arrhythmias, of which n. 6 belonged to the G1, while n. 11 belonged to the G2. Most represented findings were sinus tachycardia (7/17; 41.1%), followed by monomorphic premature ventricular beats (6/17; 35.3%), less common were first-degree atrioventricular block (2/17; 11.7%) and sinus bradycardia 1/17; 5.8%). Notably, in G1 dogs, only sinus tachycardia and premature ventricular beats were observed. G2 dogs presented a number of total and banded leukocytes significantly higher than those of G1 (p = 0.002 and 0.049), in the same manner, the clinical score suggestive of SIRS (3 vs. 2.1) was significantly higher in G2 than in G1 dogs (p = 0.01). Moreover, a significantly higher value of cTnI was observed in the G2 group compared to the G1 group (p = 0.006). Data presented here suggested a cardiac involvement in dogs with SIRS, analogously to humans, that may significantly influence the patient's prognosis.

The Future of Biomarkers in Veterinary Medicine: Emerging Approaches and Associated Challenges

Simple Summary

In this review we seek to outline the role of new technologies in biomarker discovery, particularly within the veterinary field and with an emphasis on ‘omics’, as well as to examine why many biomarkers-despite much excitement-have not yet made it to clinical practice. Further we emphasise the critical need for close collaboration between clinicians, researchers and funding bodies and the need to set clear goals for biomarker requirements and realistic application in the clinical setting, ensuring that biomarker type, method of detection and clinical utility are compatible, and adequate funding, time and sample size are available for all phases of development.

Abstract

New biomarkers promise to transform veterinary practice through rapid diagnosis of diseases, effective monitoring of animal health and improved welfare and production efficiency. However, the road from biomarker discovery to translation is not always straightforward. This review focuses on molecular biomarkers under development in the veterinary field, introduces the emerging technological approaches transforming this space and the role of ‘omics platforms in novel biomarker discovery. The vast majority of veterinary biomarkers are at preliminary stages of development and not yet ready to be deployed into clinical translation. Hence, we examine the major challenges encountered in the process of biomarker development from discovery, through validation and translation to clinical practice, including the hurdles specific to veterinary practice and to each of the ‘omics platforms–transcriptomics, proteomics, lipidomics and metabolomics. Finally, recommendations are made for the planning and execution of biomarker studies with a view to assisting the success of novel biomarkers in reaching their full potential.

Short-term effects of Whole-Body Vibration on clinical, cardiac, and ambulatory electrocardiographic (Holter) parameters of healthy younger and older adult male non-athletic crossbreed dogs

ABSTRACT This study investigated the effects of WBV in clinical, cardiac, and ambulatory electrocardiographic (Holter) parameters of healthy young and aged male non-athletic dogs. Fourteen dogs were divided into two groups of seven animals: Group I (GI) - young dogs (12.0 and 84.0 months old); Group II (GII) - aged dogs (above 84.0 months old). Dogs were submitted to a single session of WBV (frequencies of 30 and 50 Hz), for 15-min. Variations were identified in the thickness of the interventricular septum and thickness of the left ventricle-free wall values: GI < GII at 5-min before the session. The diameter of the left atrium values showed a difference: GI < GII at 5-min before and 1-min after the session; and a decrease in GII between 5-min before and 1 min after the WBV. Several ambulatory electrocardiography (Holter) parameters demonstrated significant differences between both groups and time-points. A single session of WBV at frequencies of 30 and 50 Hz during 15-min by using a vibrating platform that delivered a vortex wave circulation did not induce significant changes in clinical, cardiac, and ambulatory electrocardiographic (Holter) parameters in healthy young and aged dogs.

Screening for dilated cardiomyopathy in dogs

BACKGROUND

Dilated cardiomyopathy (DCM) is the most common cardiac disease in large breed dogs. The disease can start with arrhythmias or with systolic dysfunction of the myocardium.

OBJECTIVE

To describe screening methods for DCM in various breeds and provide a new, modified staging system.

RECOMMENDATIONS

Screening for occult DCM should start at three years of age and use Holter monitoring in Boxers and Dobermans and might be useful also in other breeds. Single ventricular premature complexes (VPCs) can be detected in many healthy dogs, but healthy animals typically have <50 VPCs in 24 h and demonstrate minimal complexity most often occurring only as single ectopic beats. In general, >100 VPCs in 24 h was recommended as the cut-off value for establishing a diagnosis of DCM. However, there are breed-specific recommendations related to Holter recording diagnosis of DCM in Dobermans and Boxers. Yearly screening over the life of a dog is recommended, as a one-time screening is not sufficient to rule out the future development of DCM. Several echocardiographic methods such as M-mode derived measurements, the measurement of the left ventricular (LV) volume by Simpson's method of discs (SMOD), and E-point to septal separation (EPSS) are recommended for screening purposes. The value of additional tests such as cardiac biomarkers (troponin I and N-terminal pro-B-type natriuretic peptide) as well as a 5-min resting electrocardiogram (ECG) or newer echocardiographic methods such as strain measurements is discussed.

CONCLUSION

This review suggests some guidelines for screening for DCM in various breeds.

Biochemical, electrolytic, and cardiovascular evaluations in cats with urethral obstruction

Background and Aim:

Urethral obstruction (UO) is a common condition in feline medicine. Severe acid-base and electrolyte disorders promote relevant electrocardiographic changes in these animals. Cardiac biomarkers such as cardiac troponin I have been shown to be useful in identifying cats with myocardial disease, but it has not been investigated whether UO leads to myocardial damages. This study aimed to evaluate biochemical changes, electrocardiographic findings, troponin I measurements, and electrolyte disturbances for 7 days in cats with UO.

Materials and Methods:

This follow-up prospective study included 33 cats diagnosed with UO for 7 days. For all cats, clinical examination, serum biochemistry, electrolyte analyses, blood pressure, and electrocardiography were performed. Cardiac troponin I was measured in the serum in 16 cats at 3 different times.

Results:

The mean age of the feline population was 1.83±1.58 years (mean±standard deviation). Creatinine, urea, blood urea nitrogen, glucose, phosphorus, base excess, bicarbonate, and serum potassium decreased significantly (p≤0.05), while ionic calcium and blood pH increased significantly (p≤0.05) at different times. Electrocardiographic abnormalities were observed in 21/33 (63.63%) of the felines on admission day. The electrocardiographic abnormalities were no longer observed on the subsequent days. Only one feline showed changes in troponin I cardiac concentrations.

Conclusion:

This study suggests the sum and severity of electrolyte abnormalities aggravate the clinical and cardiovascular status of these patients. However, cTnI, blood pressure, and heart rate within the reference range do not exclude the presence of major cardiovascular and metabolic abnormalities. The hyperglycemia in felines with UO appears to be associated with decreased renal clearance, which may reflect the severity of hyperkalemia and azotemia. The metabolic and cardiovascular changes of these felines are minimized by the establishment of appropriate intensive care; however, cardiac and blood gas monitoring is essential to assess the severity of the disease.

Evaluation of atrial natriuretic peptide and cardiac troponin I concentrations for assessment of disease severity in dogs with naturally occurring mitral valve disease

OBJECTIVE

To evaluate and compare the clinical usefulness of plasma atrial natriuretic peptide (ANP) and cardiac troponin-I (cTnI) concentrations for assessment of disease severity in dogs with naturally occurring mitral valve disease (MVD).

ANIMALS

316 dogs with MVD and 40 healthy control dogs.

PROCEDURES

Each dog underwent a physical examination and echocardiographic and thoracic radiographic assessments. Blood samples were obtained and processed for measurement of plasma ANP and cTnI concentrations. Dogs with MVD were categorized into 3 groups (stages B1 [no clinical signs or evidence of cardiac enlargement], B2 [no clinical signs with evidence of cardiac enlargement], and C [history of congestive heart failure and pulmonary edema]) on the basis of American College of Veterinary Internal Medicine guidelines. Receiver operating characteristic curve analysis was used to evaluate the accuracy of plasma ANP and cTnI concentrations for assessment of MVD severity.

RESULTS

Plasma ANP and cTnI concentrations increased as disease severity increased. Median plasma ANP concentrations for all 3 MVD groups and median plasma cTnI concentrations for the stage B2 and C groups were significantly greater than the corresponding concentrations for the control group. Plasma ANP concentration, but not cTnI concentration, appeared to be useful for detection of dogs with subclinical (stages B1 and B2) MVD, whereas both concentrations appeared useful for detection of dogs with stage C MVD.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that plasma ANP and cTnI concentrations should not be used independently to diagnose MVD but can be used to assess MVD severity and supplement echocardiographic findings.

Ambulatory electrocardiography and serum cardiac troponin I measurement in 21 dogs envenomated by the European adder (Vipera berus)

BACKGROUND

Envenomation by the European adder (Vipera berus) is common in dogs in Europe. Cardiac arrhythmias occur but clinical studies of envenomated dogs are limited.

OBJECTIVES

To describe arrhythmias in dogs within 48 hours of envenomation, and investigate associations between arrhythmia grade, serum troponin I (cTnI), and snakebite severity score (SS score).

ANIMALS

Twenty-one client-owned dogs bitten by V berus.

METHODS

Prospective cohort study of envenomated dogs. Ambulatory electrocardiograms were recorded from presentation to 48 hours after snakebite, and arrhythmias graded 0 to 3 based on frequency and severity. Serum cTnI was measured at presentation, 12 hours, 24 hours, 36 hours, and 14 days after bite. An SS score of 1 to 3 was recorded at admission and based on clinical examination.

RESULTS

All dogs survived. Twelve dogs (57%) developed arrhythmias, all of which were ventricular in origin. Severe complex ventricular arrhythmias (VAs) were observed in 6 dogs (29%). Eighty-one percent of dogs (n = 17) had increased cTnI concentrations at 1 or more time points. Dogs that developed arrhythmias had significantly higher concentrations of cTnI at 12 hours (1.67 [0.04-32.68] versus 0.03 [0.01-0.052]; P = .002), 24 hours (1.88 [0.2-14.23] versus 0.06 [0.01-2.06]; P = .009), and 36 hours (3.7 [0.02-16.62] versus 0.06 [0.01-1.33]; P = .006) after bite compared to those that did not. Contingency table analysis showed that SS score was not significantly associated with arrhythmia grade (P = .9).

CONCLUSIONS AND CLINICAL IMPORTANCE

Myocardial cell injury, reflected by increased cTnI concentrations and VAs, is common after V berus envenomation in dogs. Prolonged electrocardiography monitoring is advised, particularly where cTnI is increased.

Diagnostic methods for the canine idiopathic dilated cardiomyopathy: A narrative evidence-based rapid review

Idiopathic dilated cardiomyopathy (DCM) is an important etiology of mortality and morbidity in dogs and its diagnosis relies on systolic dysfunction, chambers dilation, electrical instability and congestion. During the last decades veterinary cardiologists have been joining efforts to obtain diagnostic resources to correctly identify canine DCM in the preclinical stage. Unfortunately, most diagnostic resources have been used with the support of research with weak evidence, without high quality methodologies such as systematic reviews or meta-analysis. Therefore, the support of evidence-based medicine is tailored by empiricism and diagnostic criteria lose'out the ability to properly classify dogs suffering DCM. The presentation of the evidence in medicine is established by multiple sources and the most reliable source has been the presentation of evidence-based medicine from systematic reviews and meta-analysis. Rapid reviews can be interpreted as a pragmatic approach to systematic reviews and although a rapid review follows most of the critical steps of a systematic review to provide timely evidence, some components of a systematic review process are either simplified or omitted. The objective of this narrative evidence-based rapid review is twofold. First: To recognize and to stratify the level of evidence offered by rigorous selected papers about the diagnosis of DCM. Second: To classify the degree of clinical recommendation of the diagnostic resources available.

Long-term management of high-grade atrioventricular block using cilostazol in a cat

Case summary

A 12-year-old neutered female domestic shorthair cat was admitted for syncope. Clinical signs and electrocardiography revealed high-grade atrioventricular (AV) block. Treatment with cilostazol ameliorated the clinical signs and arrhythmia. However, the high-grade AV block recurred on several occasions. After 640 days, the cat presented again with clinical deterioration owing to reoccurrence of the arrhythmia and it died 11 days later. Histopathological examination revealed a loss of conduction cells within the His bundle.

Relevance and novel information

To our knowledge, this is the first report of high-grade AV block treated with cilostazol in a cat. Treatment with cilostazol prolonged survival for 650 days without pacemaker implantation. Histological findings suggested that the AV block was related to fibrosis of the impulse conduction system.

The Causes of Canine Myocarditis and Myocardial Fibrosis Are Elusive by Targeted Molecular Testing: Retrospective Analysis and Literature Review

Myocarditis can cause death or permanent heart damage. As epidemiologic and etiopathologic data for canine myocarditis are lacking, we performed a retrospective study using nucleic acid extracted from archived (2007 to 2015) tissues from myocarditis cases and control dogs without myocardial lesions. Heart tissue from pediatric/juvenile and adult dogs was tested with a comprehensive panel of conventional and real-time polymerase chain reaction (PCR) assays targeting recognized agents of canine myocarditis based on a literature review and informed by the comparative epidemiology of human myocarditis. The PCR screen, which included canine parvovirus 2 (CPV-2), canine distemper virus, canine herpesvirus, Borrelia spp, West Nile virus, adenovirus, parainfluenza virus, pneumovirus, respiratory coronavirus, influenza virus, Bartonella spp, Rickettsia spp, Mycoplasma spp, and Neospora caninum, did not detect agents in 35 of 66 cases (53%; 95% confidence interval [CI], 41%-65%) and was frequently negative in adults (21/26); by comparison, agents were not detected in 27 of 57 controls (47%; 95% CI, 35%-60%). Canine distemper virus, herpesvirus, adenovirus, coronavirus, parainfluenza virus, Mycoplasma haemocanis, and N. caninum were occasionally detected in both cases and controls; thus, PCR detection was not considered to indicate causation. We previously reported that CPV-2 continues to be associated with myocarditis in young dogs despite widespread vaccination; in adults, CPV-2 was detected in 2 of 26 cases and 4 of 22 controls. As several agents were similarly detected in cases and controls, it is unclear if these are cardiopathogenic, incidental, or latent. West Nile virus was detected at the analytic limit in 1 adult case. We did not detect Borrelia spp, Bartonella spp, Rickettsia spp, or influenza A virus in the myocarditis cases. These data demonstrate the limitations of current targeted diagnostic tests and the need for additional research to identify unknown agents and develop testing strategies for canine myocarditis.

Evaluation of cardiac troponin I in serum and myocardium of rabbits with experimentally induced polymicrobial sepsis

Sepsis is a potentially life-threatening condition, and it is frequently complicated by myocardial damage. Data on myocardial damage in rabbit caecal ligation and puncture (CLP) models are limited, although numerous animal models have been used to study sepsis-associated myocardial damage. This study aimed to investigate the effect of CLP on cardiac muscle by measuring serum cardiac troponin I (cTnI) concentrations and by detecting both histopathological changes and cTnI immunoreactivity in cardiomyocytes in rabbits. After CLP was performed in rabbits, blood samples were taken from the jugular vein at 0, 4, 8, and 12 h for haematological and biochemical analyses. At the end of the experiment, all of the rabbits were euthanised to examine the histopathological changes and the cTnI immunoreactivity in cardiac muscle tissue. No changes in serum cTnI concentration were observed in the experimental group (EG) or control group (CG) at 0 and 4 h. In EG, the mean serum cTnI concentrations were 0.230 ± 0.209 and 1.177 ± 0.971 ng/ml at 8 and 12 h, respectively. In CG, the mean serum cTnI concentrations were 0.032 ± 0.014 and 0.031 ± 0.021 ng/ml at 8 and 12 h, respectively. Moreover, cytoplasmic cTnI immunoreactivity decreased in EG compared with that in CG (P<0.01). The results demonstrated that CLP induced a systemic inflammatory response and caused myocardial damage in rabbits.

Analytical quality assessment and method comparison of two immunoassays for the measurement of serum cardiac Troponin I in dogs and cats

BACKGROUND

Cardiac troponin I (cTnI) is a sensitive and specific biomarker for myocardial injury. Validation of point-of-care (POC) analyzers for cTnI measurement is valuable to the critical care setting, in which rapid results can facilitate prompt diagnoses. An immunoassay for detecting cTnI is available for the POC AIA-360 analyzer (Tosoh Bioscience), but this has not been validated using canine and feline serum.

OBJECTIVES

The objectives were (a) to determine precision, accuracy, and linearity of cTnI measurement using the AIA-360 immunoassay in pooled canine and feline samples, and (b) to compare results for individual canine and feline samples with those obtained using a reference chemiluminescence method (Immulite 1000, Siemens).

METHODS

Intra- and inter-assay repeatability was determined using pooled canine and feline samples, and the coefficient of variation (CV) was calculated for each. Pooled samples were also serially diluted to assess linearity. A modified spike and recovery analysis was performed by mixing pooled samples with different concentrations. Bland-Altman and Deming regression analyses were used to determine bias for individual samples, and the total observed error (TE_obs ) was calculated.

RESULTS

Coefficient of variation values were well within the required maximum of 20%. Linearity was demonstrated over the range of samples tested, and the recovery study showed minimal proportional inaccuracies. Although the correlation between the analyzers was excellent, there was a large mean bias due to relative proportional bias. Total observed error consequently exceeded the total allowable error (TE_A ).

CONCLUSION

Although, in most respects, the analyzer demonstrated adequate performance, pronounced bias contributed to the large TE_obs , indicating a requirement for analyzer-specific reference intervals.

Cardiovascular biomarkers in dogs with systemic inflammatory response syndrome

OBJECTIVE

To measure plasma N-terminal fragments of pro-B-type natriuretic peptides (NT-proBNP) and cardiac troponin T (cTnT) concentration in hospitalized dogs and relate these markers to underlying conditions and evaluate their potential as prognostic markers in dogs with systemic inflammatory response syndrome (SIRS).

DESIGN

Prospective, observational, clinical study.

SETTING

Emergency department of a university teaching hospital.

ANIMALS

Sixty-nine dogs with SIRS examined in the emergency department were prospectively studied. Patient age ranged from 5 months to 15 years, and weight ranged from 5.5 to 75 kg.

MEASUREMENTS AND MAIN RESULTS

Blood samples were obtained at presentation, during hospitalization until discharge or death, and at a "control" visit (T1m) at least 1 month after hospital discharge. NT-proBNP was assayed with a commercially available canine ELISA, while cTnT was measured with an automated immunoassay previously used in dogs. A correlation procedure, mixed procedure on a linear model, and a logistic procedure were performed. Forty-four patients survived, 19 of which had control visits. cTnT concentrations were significantly higher than T0 and T1m at T12, T24, and T72. In 28 dogs, cTnT was detected during hospitalization, but cTnT was not detected in any dog at the control visits. Higher concentrations of cTnT were negatively associated with survival, irrespective of disease category. NT-proBNP concentrations were significantly higher than T0, T6, T12, and T1m at T24, T72, and T120, but were not associated with survival.

CONCLUSIONS

NT-proBNP and cTnT increased significantly in dogs with SIRS, regardless of the underlying disease process. Nonsurvivors displayed significantly higher cTnT concentrations during hospitalization.

Evaluation of a high-sensitivity cardiac troponin I assay compared to a first-generation cardiac troponin I assay in Doberman Pinschers with and without dilated cardiomyopathy

BACKGROUND

Echocardiography and 24-hour ECG are the gold standard tests to diagnose dilated cardiomyopathy (DCM) in Doberman Pinschers (DP), but myocardial damage might be detected earlier using a high-sensitivity cardiac troponin I (hs-cTnI) assay.

OBJECTIVE

To evaluate and compare an hs-cTnI assay (Advia Centaur TnI-Ultra assay) with a conventional cTnI assay in DP with different stages of DCM and in healthy DP.

ANIMALS

Three hundred forty-five examinations from 162 DP with and 179 DP without DCM.

METHODS

Prospective longitudinal study. Dogs were allocated into 6 groups based on echocardiographic and 24-hour ECG criteria: (1) healthy group (179 dogs), (2) last-normal group (29 dogs), which included dogs that were considered to be healthy at the time of their examination but were assigned to the last-normal group retrospectively when DCM was diagnosed at their next examination within 1.5 years, (3) only arrhythmias (45 dogs, 119 examinations), (4) only echocardiographic changes (24 dogs, 61 examinations), (5) echocardiographic changes with ventricular premature complexes (41 dogs, 100 examinations), and (6) decompensated (23 dogs, 36 examinations). Hs-cTnI and conventional cTnI concentration measurements were performed and compared.

RESULTS

A cutoff value of hs-cTnI concentration >0.113 ng/mL had a sensitivity of 81.2% and a specificity of 73.2% to identify the presence of DCM. The conventional cTnI assay showed a similar test performance, but the hs-cTnI assay identified more dogs (21/29 dogs, 72%) in the last-normal group compared to the conventional cTnI test (18/29 dogs, 62%).

CONCLUSIONS AND CLINICAL IMPORTANCE

The hs-cTnI is an additional test with good potential to identify early DCM.

Diagnostic utility of cardiac troponin I in cats with hypertrophic cardiomyopathy

Background

Cardiac troponin I (cTnI) is useful for assessing hypertrophic cardiomyopathy (HCM) in cats.

Objective

To measure plasma cTnI concentrations in healthy cats and evaluate the clinical utility of cTnI in determining the severity of HCM.

Animals

Clinically healthy cats (n = 88) and cats with HCM (n = 93).

Methods

Multicenter prospective study. Cats with HCM, including hypertrophic obstructive cardiomyopathy at various stages, were diagnosed using echocardiography. Plasma cTnI concentrations were analyzed by a commercial laboratory. Receiver‐operating characteristic curve analysis was used to evaluate the accuracy of plasma cTnI concentrations to detect HCM.

Results

The median cTnI concentration was 0.027 ng/mL (interquartile range, 0.012‐0.048 ng/mL) in healthy cats. Concentrations were significantly higher in diseased cats than in healthy controls, and concentrations were significantly higher in cats with heart failure than in asymptomatic cats. A plasma cTnI concentration of 0.163 ng/mL had a sensitivity of 62.0% and specificity of 100% when used to distinguish normal cats from asymptomatic HCM cats without left atrial dilatation. A cutoff of 0.234 ng/mL had high sensitivity (95.0%) and specificity (77.8%) for assessing heart failure. The areas under the receiver‐operating characteristic curves were 0.85 and 0.93, respectively.

Conclusions and Clinical Importance

Increased cTnI concentrations reflect the severity of HCM. If other causes of cardiac injury are ruled out, plasma cTnI concentration may be useful for predicting the severity of HCM in cats.

Plasma procalcitonin concentrations predict organ dysfunction and outcome in dogs with sepsis

Background

Procalcitonin (PCT) is a valuable prognostic biomarker in human sepsis that is predictive of organ dysfunction, septic shock and mortality. Data on PCT in dogs is limited. This study aimed to investigate the prognostic value of baseline and serial PCT measurements in dogs with sepsis and to determine the association between PCT and sepsis severity and the presence of organ dysfunction. PCT concentrations were measured in citrated plasma samples collected from 53 dogs with sepsis at the time of admission (T0, n = 53) and at 24 h (T1, n = 35) and 48 h (T2, n = 30) post-admission using a commercial ELISA. Dogs were classified by sepsis severity (sepsis without organ dysfunction; severe sepsis; septic shock) and outcome (survivors; non-survivors). Organ dysfunctions were recorded at T0 and during hospitalization, and the APPLE_fast score calculated at T0. Healthy dogs (n = 12) were used as controls.

Results

There were 18 septic dogs without organ dysfunction, 24 dogs with severe sepsis and 11 with septic shock. Baseline PCT concentrations were significantly greater in dogs with sepsis compared to healthy controls (P < 0.0001), and in dogs with septic shock compared to dogs without cardiovascular compromise (P = 0.01). Baseline PCT was significantly correlated with organ dysfunction (P = 0.003). Declining PCT concentrations were documented in survivors at T1 and T2 compared to PCT at T0 (P = 0.0006), and PCT clearance at 24 h was significantly higher in survivors (n = 38) compared to non-survivors (n = 15) (P = 0.037). Canine APPLE_fast score was not predictive of sepsis severity, the development of MODS or outcome.

Conclusion

In dogs with sepsis, PCT concentrations at hospital admissions are predictive of organ dysfunction and septic shock. Serial procalcitonin monitoring may offer valuable prognostic information in canine sepsis, wherein early decreases in PCT concentrations are associated with survival.

Electronic supplementary material

The online version of this article (10.1186/s12917-018-1427-y) contains supplementary material, which is available to authorized users.

European Society of Veterinary Cardiology screening guidelines for dilated cardiomyopathy in Doberman Pinschers

BACKGROUND

Dilated cardiomyopathy (DCM) is the most common cardiac disease in large breed dogs and is inherited in Doberman Pinschers with a high prevalence (58%).

OBJECTIVE

The European Society for Veterinary Cardiology convened a task force to formulate screening guidelines for DCM in Dobermans.

RECOMMENDATIONS

Screening for occult DCM in Dobermans should start at three years of age and use both Holter monitoring and echocardiography. Yearly screening over the life of the dog is recommended, as a one-time screening is not sufficient to rule out future development of DCM. The preferred echocardiographic method is the measurement of the left ventricular volume by Simpson's method of discs (SMOD). Less than 50 single ventricular premature complexes (VPCs) in 24 h are considered to be normal in Dobermans, although detection of any number of VPCs is cause for concern. Greater than 300 VPCs in 24 h or two subsequent recordings within a year showing between 50 and 300 VPCs in 24 h is considered diagnostic of occult DCM in Dobermans regardless of the concurrent echocardiographic findings. The guidelines also provide recommendations concerning ancillary tests, that are not included in the standard screening protocol, but which may have some utility when recommended tests are not available or financially untenable on an annual basis. These tests include assay of cardiac biomarkers (Troponin I and N-Terminal pro-B-type Natriuretic Peptide) as well as a 5-min resting electrocardiogram (ECG).

CONCLUSION

The current guidelines should help to establish an early diagnosis of DCM in Dobermans.

Follow-up of troponin I concentration in dogs with atrioventricular block and dual-chamber pacing in a case-matched study

BACKGROUND

Increased cardiac troponin I (cTnI) concentration has been reported in dogs with atrioventricular (AV) block before and shortly following pacemaker implantation. The role of AV dyssynchrony, age, or concurrent cardiac disease on cTnI concentration remains unknown.

OBJECTIVES

To investigate change in cTnI concentration following dual-chamber pacemaker implantation on short- and long-term follow-up and to compare cTnI values to a case-matched control group.

ANIMALS

Thirty-eight client-owned dogs with permanent AV block and 38 matched control dogs.

METHODS

Retrospective review of medical records. Pacemaker group consisted of dogs with AV block and dual-chamber pacing. Control group matched the study population in age and cardiac disease. cTnI was compared between pacemaker and control group on short- and long-term follow-up. Different lead types and influence of arrhythmia on cTnI were tested.

RESULTS

cTnI was high at presentation (median 0.66 ng/ml; range 0.03-18.6) and showed a significant reduction over time after pacemaker implantation (p < 0.0001). Median cTnI values were significantly different between pacemaker and control group on short-term (p = 0.0004; 0.11 ng/ml, range 0.03-1.36 versus 0.06 ng/ml, range 0.03-0.46), but not on long-term follow-up (p = 0.0547; 0.14 ng/ml, range 0.03-0.73 versus 0.07 ng/ml, range 0.03-0.46). Lead type and severity of arrhythmia did not show a significant correlation to cTnI concentration.

CONCLUSIONS

On long-term follow-up, cTnI remained mildly elevated in some of the pacemaker dogs but was not significantly different to the matched control group.

Cardiac Troponin I and Amino-Terminal Pro B-Type Natriuretic Peptide in Dogs With Stable Chronic Kidney Disease

Background

Increased concentrations of N‐terminal pro B‐type natriuretic peptide (NT‐proBNP) and cardiac troponin I (cTnI) in dogs with azotemia have been documented. Knowledge of mechanisms behind increased concentrations of cardiac biomarkers in dogs with azotemia is warranted for correct interpretation of test results.

Objectives

The aim of the article was to investigate possible associations between plasma concentrations of cTnI and NT‐proBNP, respectively, and patient characteristics, glomerular filtration rate (GFR), a plasma volume factor (PVF) derived from scintigraphic examination (PVf), systolic blood pressure (SBP), selected hematologic and biochemical variables, and echocardiographic measurements in dogs with stable chronic kidney disease (CKD) and in healthy dogs.

Animals

Fifty student‐, staff‐, and client‐owned dogs were included. Twenty‐three of the dogs were healthy and 27 were diagnosed with CKD.

Methods

In this cross‐sectional observational study, dogs with a previous diagnosis of CKD and healthy control dogs were included. At inclusion, all dogs were characterized by physical examination, repeated blood pressure measurements, complete urinalysis, hematology and biochemistry panel, echocardiography, abdominal ultrasound examination of the entire urinary tract, and scintigraphic examination for measurement of GFR.

Results

Plasma volume factor and PCV were independently associated with NT‐proBNP (Radj2 = 0.42; P < .0001). Age, body weight (BW), and SBP were independently associated with cTnI (Radj2 = 0.50; P < .0001).

Conclusions and Clinical Importance

Neither NT‐proBNP nor cTnI concentrations were independently associated with measured GFR. Thus, findings were not suggestive of passive accumulation of either marker, suggesting that increased circulating concentrations of cTnI and NT‐proBNP can be interpreted similarly in dogs with stable CKD as in dogs without CKD.

Usefulness of serum cardiac troponin I concentration as a marker of survival of harbor seal (Phoca vitulina) pups during rehabilitation

OBJECTIVE To measure serum cardiac troponin I (cTnI) concentrations in orphaned harbor seal (Phoca vitulina) pups at various points during rehabilitation in a seal rescue center and determine whether cTnI concentration was associated with survival during rehabilitation and duration of rehabilitation. DESIGN Serial cross-sectional study. ANIMALS Fifty-five 2- to 9-day-old harbor seal pups. PROCEDURES Blood samples for serum cTnI concentration measurement, CBC, and serum biochemical analysis were obtained from seal pups at admission into a seal rescue center, after 2 weeks of rehabilitation at the center, and prior to release. Serum cTnI concentrations were compared between seals that did or did not survive rehabilitation. RESULTS Median serum cTnI concentration was highest at admission (0.03 ng/mL). After 2 weeks, the median value was 0.01 ng/mL; prior to release, it was 0.01 ng/mL. Seal pups that were found to have died during or after rehabilitation (n = 7) had a significantly higher median serum cTnI concentration at admission (0.06 ng/mL) than did seal pups that survived rehabilitation (and for which the postrelease fate was unknown; 48; 0.03 ng/mL). No correlation was identified between serum cTnI concentration and duration of rehabilitation. CONCLUSIONS AND CLINICAL RELEVANCE The results of this study suggested some degree of myocardial injury was present in most of the orphaned seal pups admitted for rehabilitation. Measurement of serum cTnI concentration in seal pups at admission might provide prognostic information about their likelihood of survival during or after rehabilitation.

Júnior A, L. Neto M, Oliveira M. Troponina I como biomarcador de lesão cardíaca em cães com sepse

RESUMO Avaliou-se a troponina I como biomarcador de lesão cardíaca na sepse, além de outros parâmetros hematológicos, em cadelas com piometra. Os grupos avaliados não diferiram estatisticamente na avaliação da concentração sérica da troponina I cardíaca. A quantidade total de leucócitos (mm3) e a porcentagem de bastonetes foram significativamente maiores no grupo sepse (23.221,74±16.848,80mm3 e 5,91±10,18%) quando comparado ao grupo não sepse (14.492,86±6.828,26mm3 e 1,93±1,64%) e ao grupo controle (10.320,00±3.999,02mm3 e 1,65±2,05%). Houve diferença significativa nas concentrações séricas da proteína C reativa (mg/dL) no grupo sepse (19,57±41,69md/dL) se comparado ao grupo não sepse (10,29±12,02mg/dL) e ao grupo controle (3,60±3,53mg/dL). Na avaliação da concentração sérica do lactato, houve diferença significativa entre cães com piometra e cães saudáveis, porém não houve diferença significativa entre os grupos sepse e não sepse. Os resultados do presente estudo indicam que a troponina I cardíaca não pôde ser considerada um biomarcador precoce para injúria miocárdica nos casos de cadela com piometra, pois os resultados das mensurações foram semelhantes entre os grupos, o que indica que pode não ter ocorrido lesão dos cardiomiócitos nessa fase. Já a proteína C reativa e o lactato são possíveis marcadores para inflamação sistêmica, uma vez que demonstraram concentrações séricas significativamente maiores em cadelas com piometra.

Evaluation of cardiac troponin I in dogs presenting to the emergency room using a point-of-care assay

We used a point-of-care assay to evaluate cardiac troponin I (cTnI) in clinically normal dogs and a heterogeneous population of dogs presenting to the emergency room (ER) and to determine whether cTnI has prognostic capabilities in an ER population. Fourteen clinically normal dogs and 129 dogs presented to the ER were evaluated. Of the study group, 88 dogs had normal cTnI (< 0.1 ng/mL), 29 had elevated cTnI (0.1 to 1.0 ng/mL), and 12 had high cTnI (> 1.0 ng/mL). Dogs with elevated cTnI had 8 times the odds of mortality compared to dogs with normal cTnI [odds ratio (OR): 8.2, 95% confidence interval (CI): 3.0, 22.3]. Dogs with high cTnI had 17 times higher odds of mortality compared to dogs with normal cTnI (OR: 17.6, 95% CI: 4.4, 70.1). We conclude that cTnI shows promise as a prognostic indicator for dogs presenting to the ER and can be easily evaluated using a point-of-care assay.

Cardiac Troponins in Dogs and Cats

Cardiac troponins are sensitive and specific markers of myocardial injury. The troponin concentration can be thought of as a quantitative measure of the degree of injury sustained by the heart, however, it provides no information on the cause of injury or the mechanism of troponin release. Conventionally, the cardiac troponins have been used for diagnosis of acute myocardial infarction in humans and have become the gold standard biomarkers for this indication. They have become increasingly recognized as an objective measure of cardiomyocyte status in both cardiac and noncardiac disease, supplying additional information to that provided by echocardiography and ECG. Injury to cardiomyocytes can occur through a variety of mechanisms with subsequent release of troponins. Independent of the underlying disease or the mechanism of troponin release, the presence of myocardial injury is associated with an increased risk of death. As increasingly sensitive assays are introduced, the frequent occurrence of myocardial injury is becoming apparent, and our understanding of its causes and importance is constantly evolving. Presently troponins are valuable for detecting a subgroup of patients with higher risk of death. Future research is needed to clarify whether troponins can serve as monitoring tools guiding treatment, whether administering more aggressive treatment to patients with evidence of myocardial injury is beneficial, and whether normalizing of troponin concentrations in patients presenting with evidence of myocardial injury is associated with reduced risk of death.

Perioperative Monitoring of Heart Rate and Rhythm

Perioperative disorders of heart rate and rhythm are common and can contribute to patient morbidity and mortality. Management of perioperative arrhythmias is facilitated by understanding the basic mechanisms of arrhythmia formation and the role of transient imbalances. The decisions of when and how to treat perioperative arrhythmias are based on whether or not hemodynamic signs are present and the assumed risk of sudden arrhythmic death. Perioperative arrhythmias warrant careful monitoring and consideration of potential complications associated with antiarrhythmic therapy.