Syncope in Cavalier King Charles Spaniels
Cavalier King Charles spaniels with mitral valve murmurs from Grade 3 through Grade 6 and enlarged atrial chambers may lose consciousness or display episodic weakness, especially of the hindquarters, ataxia (an inability to coordinate muscular movements), or collapse. This disorder, when loss of consciousness occurs, is called syncope; absent the loss of consciousness, it is called presyncope.
Technically, syncope is the temporary loss of consciousness, or fainting, due to a sudden decline in blood flow to the brain. It is not unique to dogs with heart disorders and generally may be referred to as canine syncope syndrome.
In cavaliers, syncope and presyncope are associated with Mitral Valve Disease because in mid- to late stages of MVD, when the affected dog experiences excessive excitement, stress, or sudden shock, the heart and blood vessels are prompted to constrict, with the heart rate increasing suddenly, depleting the blood volume from the left ventricle and in the blood vessels to the brain. Syncope associated with the heart's reaction to MVD is called vasodepressor syncope. An episode may occur while an MVD-affected dog is having a coughing fit, in which is known as "cough-drop" syndrome.
Common factors which may precipitate vasodepressor syncope in cavaliers with mid- to late stage MVD are excessive exercise, running, stress, coughing, barking, urination, defecation, or pain. Even grooming or bathing, if stressful to the dog, could prompt syncope.
Diagnosing whether loss of consciousness is due to syncope, as opposed to a seizure or weakness or fainting or trauma, can be challenging. Examining veterinarians often rely upon medical histories, as well as blood tests, urine analysis, electrocardiography (ECG), echocardiography, and Holter monitor.
Among the blood tests, a December 2016 report recommended obtaining serum cardiac troponin I (cTnI) analysis to confirm that cardiac issues are the cause. In that report, UK researchers studied cTnI in 79 dogs diagnosed with syncope collapse, including 9 cavalier King Charles spaniels. They found that serum cTnI diagnosed cardiogenic syncope with a sensitivity of 75% and specificity of 80%, but that the overlap in troponin concentrations reduces the discriminatory power of the test in an individual dog. Therefore, they recommend using troponin assays but not as stand-alone tests.
Treatment for syncope involves treating the underlying disorder, which in the case of cavaliers suffering from MVD would be treatment of that disease, including adjustment of the medication. Also, cavaliers in the advanced stages of MVD should avoid stress, excitement, and coughing, and excessive exercise.
December 2016: Study finds that cavaliers' cardiac-caused syncope collapses have increased troponin concentrations. In a December 2016 article, a team of UK researchers (Emily Dutton (right), J. Dukes-McEwan, P.J. Cripps) studied the cardio-marker "serum cardiac troponin I" (cTnI) in 79 dogs diaganosed with syncope collapse, including 9 cavalier King Charles spaniels. They divided the dogs into 5 categories: generalized epileptic seizures (2 CKCSs out of 30), cardiogenic syncope (1 CKCS out of 20), dogs with both epileptic seizures and cardiac disease (4 CKCSs out of 9), vasovagal syncope (no CKCSs) or unclassified (2 CKCSs out of 13). They found that serum cTnI diagnosed cardiogenic syncope with a sensitivity of 75% and specificity of 80%, but that the overlap in troponin concentrations reduces the discriminatory power of the test in an individual dog. Therefore, they recommend using troponin assays but not as stand-alone tests, and instead in combination with other diagnostic investigations, such as ECG and echocardiography.
January 2014: Holter monitoring shows MVD dogs with syncope had less sinus arrhythmia, and decreased overall heart rate variability. In an international study published in January 2014, of 43 dogs with advanced MVD, which included 21 dogs (6 cavaliers) with syncope and 22 dogs (10 CKCSs) without syncope, cardiologists found that:
"Compared with dogs without a history of syncope, dogs with advanced MMVD and a history of syncope did not have a higher occurrence of arrhythmias, but had less sinus arrhythmia, and had changes in HRV variables representing decreased overall HRV, decreased parasympathetic, and increased sympathetic modulation of heart rate."
Clinical usefulness of cardiac event recording in dogs and cats examined because of syncope, episodic collapse, or intermittent weakness: 60 cases (1997-1999). Bright JM, Cali JV. J Am Vet Med Assoc. April 2000; 216:1110-1114. Quote: "Objectives: Cardiac arrhythmias as a cause of syncope, collapse, or intermittent weakness can be challenging to diagnose. The purpose of this paper is to retrospectively review the diagnosis and outcome of 23 cases of syncope or collapse in dogs that had a Reveal® Plus ILR recorder placed as part of the diagnostic evaluation. Animals, materials and methods: Medical records of 23 client-owned dogs [including a cavalier King Charles spaniel] that were presented for evaluation of syncope, collapse, or intermittent weakness were retrospectively reviewed. Results: Recurrent syncope occurred in 13/23 (57%) and a positive diagnosis of the cause of the event was made in 11/13 (48% of all dogs). Diagnoses: included 6/11 with prolonged periods of sinus arrest with slow ventricular escape rate and one each of sub-optimal fixed heart rate by endocardial pacing, high grade second degree atrioventricular block, supraventricular tachycardia, normal ECG during multiple episodes, and high grade second degree atrioventricular block or sinus arrest. Conclusions: The Reveal® Plus ILR device was successful in diagnosing a high percentage of cases of syncope or collapse in which signs recurred and implantation had a low complication rate. The Reveal® Plus ILR device is a useful tool to diagnose the etiology of recurrent syncope, collapse, or intermittent weakness in the dog."
Chronic valvular heart disease in dogs. Rush J.E.. In: Proceedings of the 26th Annual Waltham Diets; OSU Symposium for the Treatment of Small Animal Cardiology, pp. 1-7, 2002.
Syncope in Small Breed Dogs. Marc S. Kraus, Anna R.M. Gelzer. Clinicians Brief. April 2004. Quote: "Syncope, or episodic weakness, is common in elderly small-breed dogs with myxomatous mitral valve disease. Affected dogs may lose consciousness or have ataxia, weakness, or collapse. The history probably reveals that the collapsing episode is associated with excitement. The physical examination is usually unremarkable except for a prominent left-sided systolic apical (5th intercostal space) heart murmur. Results of the complete blood count and serum chemistry are also unremarkable. Echocardiography reveals a markedly enlarged left atrium and ventricle."
Mitral valve prolapse in Cavalier King Charles Spaniel: A review and case study. Hyun C. J. Vet. Sci. 2005 Mar;6(1):67-73. Quote: "A 5 year-old spayed female Cavalier King Charles Spaniel was presented after a 3- to 5-day onset of severe respiratory distress. The dog also had a history of several episodes of syncope prior to presentation. A comprehensive diagnostic investigation revealed a midsystolic click sound on cardiac auscultation, signs of left sided cardiac enlargement in ECG and thoracic radiography, mitral valvular leaflet protrusion into left the atrium, decreased E-point-to septal separation (EPSS) and mitral regurgitated flow in echocardiography, all of which are characteristic signs of mitral valvular prolapse. After intensive care with antidiuretics and a vasodilator with oxygen supplement, the condition of the dog was stabilized. The dog was then released and is being medicated with angiotensin converting enzyme (ACE) inhibitor with regular followup."
Differential diagnosis of collapse in the dog 3. Cardiovascular and miscellaneous causes. Wray,J, In Practice, 31 Mar 2005;27(3): 128-135(8).
Recurrent syncope: only the heart was considered. Peter Stiefelhagen. MMW Fortschr Med. 2006 Sep 28;148 (39):21.
A retrospective study of 153 cases of undiagnosed collapse, syncope or exercise intolerance: the outcomes. L. Barnett, M. W. S. Martin, J. Todd, S. Smith, and M. Cobb. J.Sm.Anim.Prac. (Jan 2011) 52(1):26–31. Quote: "Objectives: To retrospectively assess the long-term outcome for dogs that were presented with collapse, syncope or exercise intolerance for which an underlying cause is not identified. ... Results: One hundred and fifty-three cases were successfully followed up. Clinical signs had resolved in 64 cases (42%), 35 dogs (23%) were continuing to exhibit clinical signs, although 22 of these had improved without medical intervention. In 17 cases (11%), a diagnosis had subsequently been made or treatment was being administered and 37 dogs (24%) had died. Of the deaths, 18 (12%) were considered to be related to the original presentation. The overall prevalence of death and deterioration related to the problems investigated was 16·2% of cases. Death in boxers was significantly more common than in other breeds (36%). ... Age at death ranged from 8 months in a cavalier King Charles spaniel to 17 years 3 months in a border collie. ... A total of 21 of the 37 dogs which had died (56·8%) were over the age of 10 at death. Of the 16 dogs that died before 10 years of age, ... two were cavalier King Charles spaniels ... . Clinical Significance: Death and deterioration are uncommon outcomes for dogs other than boxers presenting with collapse, syncope and exercise intolerance for which a definitive diagnosis cannot be made."
Holter Monitoring of Small Breed Dogs with Advanced Myxomatous Mitral Valve Disease with and without a History of Syncope. C.E. Rasmussen, T. Falk, A. Domanjko Petrič, M. Schaldemose, N.E. Zois, S.G. Moesgaard, B. Åblad, H.Y. Nilsen, I. Ljungvall, K. Höglund, J. Häggström, H.D. Pedersen, J.M. Bland and L.H. Olsen. J.Vet.Int.Med. Jan. 2014. Quote: "Background: Syncope is a transient loss of consciousness occasionally occurring in dogs with advanced myxomatous mitral valve disease (MMVD). Objective: (1) To study ECG changes during syncopal episodes in dogs with advanced MMVD and (2) to compare the occurrence of arrhythmias and changes in heart rate variability (HRV) between dogs with advanced MMVD with and without a history of syncope. Animals: Forty-three privately owned dogs (<15 kg) with advanced MMVD: 21 with [including 6 cavalier King Charles spaniels] and 22 without a history of syncope [including 10 CKCSs]. Methods: Prospective study with dogs recruited for an evaluation including history, physical examination, echocardiography, and arrhythmia and HRV analysis performed on 24-hour Holter recordings. Results: A syncopal episode was observed during Holter monitoring in 4 dogs: 3 dogs had sinus rhythm and 1 dog had sinus arrest followed by escape rhythm. An arrhythmia variable representing sinus arrhythmia was significantly lower in dogs with a history of syncope than in those without (P = .008). Eight of 26 HRV variables were significantly different between dogs with and without a history of syncope. Conclusions and Clinical Importance: Compared with dogs without a history of syncope, dogs with advanced MMVD and a history of syncope did not have a higher occurrence of arrhythmias, but had less sinus arrhythmia, and had changes in HRV variables representing decreased overall HRV, decreased parasympathetic, and increased sympathetic modulation of heart rate."
Serum cardiac troponin I in canine syncope and seizures. E. Dutton, J. Dukes-McEwan, P.J. Cripps. J. Vet. Cardiol. December 2016. Quote: Objective: To determine if serum cardiac troponin I (cTnI) concentration distinguishes between cardiogenic syncope and collapsing dogs presenting with either generalized epileptic seizures (both with and without cardiac disease) or vasovagal syncope. Animals: Seventy-nine prospectively recruited dogs [including nine cavalier King Charles spaniels], grouped according to aetiology of collapse: generalized epileptic seizures (group E)[two cavaliers out of 30], cardiogenic syncope (group C)[one cavalier out of 20], dogs with both epileptic seizures and cardiac disease (group B)[four cavaliers out of 9], vasovagal syncope (group V) or unclassified (group U)[two cavaliers out of 13]. Methods: Most patients had ECG (n = 78), echocardiography (n = 78) and BP measurement (n = 74) performed. Dogs with a history of intoxications, trauma, evidence of metabolic disorders or renal insufficiency (based on serum creatinine concentrations >150 μmol/L and urine specific gravity <1.030) were excluded. Serum cTnI concentrations were measured and compared between groups using non-parametric statistical methods. Multivariable regression analysis investigated factors associated with cTnI. Receiver operator characteristic curve analysis examined whether cTnI could identify cardiogenic syncope. Results: Median cTnI concentrations were higher in group C than E (cTnI: 0.165 [0.02–27.41] vs. 0.03 [0.01–1.92] ng/mL; p<0.05). Regression analysis found that serum cTnI concentrations decreased with increasing time from collapse (p=0.015) and increased with increasing creatinine concentration (p=0.028). Serum cTnI diagnosed cardiogenic syncope with a sensitivity of 75% and specificity of 80%. Conclusions: Patients collapsing with a cardiac cause have significantly increased troponin concentrations compared with epileptic or vasovagal patients; however, the overlap in troponin concentrations reduces the discriminatory power of the test in an individual dog. Therefore, troponin assays should not be used as stand-alone tests, but in combination with other diagnostic investigations, such as ECG and echocardiography. Future large prospective studies investigating the possible prognostic value of cTnI in syncopal dogs are warranted.