The Modern
Equine Vet www.modernequinevet.com
Vol 11 Issue 12 2021
Can Chiropractic Care Affect Limb Lameness? Recognizing Important Murmurs Test May Help ID Clotting Problems in Horses with GI Ailments
NEWS FROM THE 67TH ANNUAL AAEP CONVENTION
TABLE OF CONTENTS
COVER STORY
4 Can Chiropractic Care Reduced Pain and Stiffness in Limb Lameness? Cover: Shutterstock/Annabell Gsoedl
CARDIOLOGY
Is This an Important Leak? Tips on Recognizing and Evaluating Murmurs in the Horse............................................................8 GASTROENTEROLOGY
Tests May Help Identify Clotting Problems in Horses with Gastrointestinal Ailments...................................................14 NEWS NOTES
Topical Steroids May Not Be Enough for Some Uveitis................................3 Dr. Emma Read Takes Reins as AAEP's President........................................16 ADVERTISERS Shanks Veterinary Equipment..........................................................................3 Arenus Animal Health/Assure Gold.................................................................5 American Regent/Adequan...............................................................................7 Arenus Animal Health/Aleira............................................................................9
American Regent/BetaVet ..............................................................................11 Arenus Animal Health/Releira........................................................................15 Arenus Animal Health/Assure Gold...............................................................17
The Modern
Equine Vet SALES: Matthew Todd • Matthew Gerald EDITOR: Marie Rosenthal ART DIRECTOR: Jennifer Barlow CONTRIBUTING WRITERS: Paul Basilio • Adam Marcus COPY EDITOR: Patty Wall Published by PO Box 935 • Morrisville, PA 19067 Marie Rosenthal and Jennifer Barlow, Publishers PERCYBO media publishing
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NEWS NOTES
Topical Steroids May Not Be Enough for Some Uveitis Although equine ophthalmic inflammatory diseases are often treated with topical anti-inflammatory drugs, they might not be good choices for acute equine recurrent uveitis (ERU). Researchers from Utrecht University, in The Netherlands, found that concentrations of topical dexamethasone (DEX) and prednisolone (PRED) in the vitreous were negligible. In addition, systemic absorption was minimal. Therefore, just treating with topical products might not be sufficient for horses with posterior uveitis. ERU is a common ophthalmic condition in horses throughout the world. In the United States, for example, the prevalence can be as high as 25%, and in Europe, the prevalence is estimated to be between 7% to 10%. The condition is often debilitating, and despite intensive medical and surgical treatment, ERU eventually leads to blindness in most horses, according to the researchers. However, treatment typically depends on empiric data and extrapolation of data about treatment in other species because comparative pharmacokinetic data about these topical treatments in horses are limited. They wanted to know how these products worked for horses, so they did a prospective, randomized experimental pharmacokinetic study to look at the penetration and local concentrations of topically applied dexamethasone and prednisolone. They monitored the equine ocular fluids and serum in 21 Shetland ponies while receiving topical doses of dexamethasone and prednisolone. The horses did not have ophthalmic disease and were slated for euthanasia for another reason. The horses received topical steroids every 2 hours for 24 hours, which would mimic the type of aggressive treatment a veterinarian would prescribe if the horse had an acute ERU. One eye received 0.15 dexamethasone disodium phosphate (0.1%) and the other eye received 1.5 mg prednisolone acetate. Which eye received which product was chosen randomly. The researchers took serum samples prior to induction of general anesthesia. Aqueous and vitreous humor samples were taken during euthanasia at various times after administration of the last dose (5 min, 15 min, 30 min, 60 min, 90 min, 120 min and 180 min). Each pony was randomly assigned to 1 time and 3 ponies were sampled per time point. The mean standard deviation (SD) of dexamethasone concentration in aqueous humor was 32.4 ± 10.9 ng/mL and the mean ± SD prednisolone concentration was 321.6 ± 96.0 ng/mL. The vitreous and serum concentrations of both corticosteroids were below the limit of detection
(LOD 2.5 ng/mL), the researchers said. “According to current literature, prednisolone acetate has a better ocular penetration than dexamethasone phosphate solutions,” the researchers wrote. “This was not supported by the results of our study. In our study, the penetration of DEX and PRED were not statistically different.” Administering medication by oral or subconjunctival routes might be better if the horse has recurrent uveitis, they said. MeV
For more information: Hermans H., van den Berg EMH, Slenter IJM, et al. Penetraion of topically administered dexamethasone disodium phosphate and prednisolone acetate into the normal equine ocular fluids. Equine Vet J. 2021 Oct 27. https://doi.org/10.1111/evj.13526 https://beva.onlinelibrary.wiley.com/doi/10.1111/evj.13526
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CHIROPRACTIC CARE
CAN CHIROPRACTIC CARE REDUCE Pain and Stiffness in Limb Lameness?
B y
M a r i e
Shutterstock/risphotos
Although a new study found no significant
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changes in lameness scores after chiropractic care, there were significant changes in the severity of pain. Some locations also saw less muscle stiffness and hypertonicity. “Therefore, we concluded that chiropractic care may be beneficial for addressing compensatory pain that results from a primary lameness,” explained Samantha Parkinson, DVM, a veterinary resident at Colorado State University, College of Veterinary Medicine, who presented the data at the American Association of Equine Practitioners Annual Convention & Trade Show, which ran from Dec. 4–8, in Nashville, Tenn. Interest in chiropractic care for horses has been increasing. One of its advantages is that it “is affordable to the majority of our veterinary clients,” she said, but should it be recommended for lameness involving the limbs? Dr. Parkinson and her colleagues did a study to evaluate the effects of chiropractic care on limb lameness and concurrent axial skeleton pain and dysfunction. The interactions between the axial and appendicu-
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R o s e n t h a l ,
M S
lar skeleton are important to consider when trying to intervene in a horse with lameness. “When one leg is lame, there's altered weight-bearing to increase the weight on the other 3 limbs as the horse attempts to unload the painful leg,” she said, which results in changes throughout the axial and appendicular regions. Previous studies found that horses with primary limb lameness have back pain in 23% to 32% of cases; and horses with primary back pain have a concurrent limb lameness in 68% to 85% of cases. “This highlights the importance and the significance of these interactions and our need to be able to address them,” she said. “While we have evidence supporting the use of chiropractic for axial skeleton pain, we haven't to date looked at its effect on lameness,” she said. The goal of their study was to evaluate the efficacy of chiropractic care in reducing limb lameness and concurrent axial skeleton pain and disfunction. “We hypothesized that chiropractic treatment would improve measures of lameness, as well as our axial skeleton pain and dysfunction,” she said.
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CHIROPRACTIC CARE
Significant changes were noted in the severity of pain in the treated group of horses.
Twenty polo horses with grade 1-to-3 lameness on the AAEP lameness scale were enrolled in the blinded randomized controlled clinical trial. Ten horses were in each group. Some horses had multilimb lameness. Horses with grade 4 or 5 lameness were excluded from the study because the researchers felt they needed more work-up. They were evaluated at day 0, day 14 and day 28 by a single, blinded examiner. A different blinded examiner, trained in chiropractic care and boarded in sports medicine rehabilitation, provided chiropractic treatment for 10 horses on day 0, 7, 14 and 21. Both the axial and appendicular skeletons were evaluated and restrictions—the chiropractic term for pain, stiffness and restricted motion—were addressed individually. The control horses were asked to stand for an equivocal amount of time. They used both subjective and objective methods for assessing the success of the treatments. For the subjective lameness exam, a single examiner watched the horse trot in a straight line on asphalt and scored each
CHIROPRACTIC CARE
Shutterstock/risphotos
Chiropractic care is a form of manual therapy that affects the musculoskeletal and nervous systems by using a high velocity low amplitude (HVLA) thrust during motion palpation of the horse. Individual joints and articulations are evaluated for pain, stiffness and range of motion. When alterations in these parameters are identified—also referred to as a restriction—a specific articulation is moved into the paraphysiologic space. An HVLA thrust stimulates stretch receptors within the muscle to induce the muscle to relax.
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limb 1 through 5. The scores were added for a cumulative score. The objective lameness score used the Equinosis lameness locator with 2 inertial sensors, which evaluate asymmetry, and 3 measurements were taken with a gyroscope along the spine. They then checked spinal reflexes, and the horses’ range of motion and stretching. The spinal examination palpated the neck in the thoracolumbar and gluteal regions for pain, stiffness and muscle ethnicity. “Finally, we evaluated spinal flexibility using 5 different baited carrot stretches to assess the flexibility throughout the cervical spine, as well as the thoracolumbar regions,” she explained. “Using carrots, we asked the horse to flex by holding the treat at the level of the withers for an upper cervical stretch. Next, we moved the treat to the level of the girth, asking the horse to bend the middle cervical region. And finally, we moved the treat to the level carpus asking for a caudal cervical flex. “The last 2 stretches involved, both combined cervical and thoracolumbar stretches,” she said. There was no change in measures of lameness, nor in mechanical nociceptive thresholds between the treated and untreated horses, she said. However, “there were significant changes noted in the severity of the pain in our treatment group,” she said, both in spinal pain severity and affected cervical vertebral levels. They also saw a decrease in muscle hypertonicity and spinal stiffness in a number of locations in favor of the treated group. Dr. Parkinson said the study had several limitations. They did not localize the origin of the lameness, and the lameness was not addressed nor treated because they wanted to evaluate the effects of chiropractic care alone. In addition, the animals were second-career polo ponies, with bilateral multilimb lameness. Since the lameness locator is looking for asymmetries, they might be less prominent in a horse with bilateral lameness. “Additionally, the majority of them had chronic lameness. When we have chronic lameness, we increase our risk of central sensitization or the development of neuropathic pain, which may not be amenable to chiropractic care,” Dr. Parkinson said. More study is needed “to determine where chiropractic may be the most beneficial and where it will have the largest effect,” she said. MeV
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www.adequan.com 1 Data on file. 2 Adequan® i.m. Package Insert, Rev 1/19. 3 Burba DJ, Collier MA, DeBault LE, Hanson-Painton O, Thompson HC, Holder CL: In vivo kinetic study on uptake and distribution of intramuscular tritium-labeled polysulfated glycosaminoglycan in equine body fluid compartments and articular cartilage in an osteochondral defect model. J Equine Vet Sci 1993; 13: 696-703. 4 Kim DY, Taylor HW, Moore RM, Paulsen DB, Cho DY. Articular chondrocyte apoptosis in equine osteoarthritis. The Veterinary Journal 2003; 166: 52-57. 5 McIlwraith CW, Frisbie DD, Kawcak CE, van Weeren PR. Joint Disease in the Horse.St. Louis, MO: Elsevier, 2016; 33-48. All trademarks are the property of American Regent, Inc. © 2021, American Regent, Inc. PP-AI-US-0629 05/2021
CARDIOLOGY
Is This an Important Leak?
Tips on Recognizing and Evaluating Murmurs in the Horse B y
P a u l
B a s i l i o
The equine heart has a great capacity to compen-
sate. Even in the face of considerable cardiovascular disease the horse will find a way to keep plugging away. While that is physiologically impressive, it does pose quite a challenge for a cardiovascular examination in a horse presenting with a murmur and a slight decrease in performance. To help clinicians interpret cardiac findings, Katharyn Jean Mitchell, BVSc, DVCS, DVM, PhD, DAVCIM (LAIM), recently offered helpful tips at the 67th AAEP Conference in Nashville.
“Our physical exam really tells us what's leaking,” said Dr. Mitchell, an assistant professor of large animal medicine at the Cornell University College of Medicine. “We don't need the ultrasound to know what's leaking. We need the ultrasound to tell us the consequences of that leak.” 8
Issue 12/2021 | ModernEquineVet.com
Shutterstock/ SciePro
The initial exam
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CARDIOLOGY
Courtesy of Dr. Katharyn Jean Mitchell
For the physical exam, Dr. Mitchell explained that veterinarians need good equipment, a quiet environment, and to take a quick walk around to the right side of the horse. “Always go around to the right side and have a listen to both sides of the thorax,” she said. “You’d be surprised how many horses have complex heart disease that is missed because nobody walked around to the right side.” Instead of just a quick listen to the heart rate, it is also important to take note of the heart sounds and the rhythm. The pulse is also a vital part of the exam, especially if a murmur is present. “If you feel the pulse and hear the noise at the same time, that’s systole,” she said. “If you feel the pulse and then hear the noise, that’s diastole.”
Courtesy of Dr. Katharyn Jean Mitchell
Color flow mapping image of the mitral valve and left atrium, showing severe mitral regurgitation and left atrial enlargement with atrial fibrillation.
Color flow mapping image of the left ventricular outflow tract showing severe aortic regurgitation.
Luckily, a good history, including signalment, offers some clues. “If I’m examining an Arabian or Friesian horse, I have loud bells going off in my head if I hear a murmur,” she said. “If I hear a murmur in a Standardbred or a Thoroughbred, the bells might be a little quieter.” To start narrowing down potential pathology, she emphasized the need for a proper history to put the murmur into perspective. What is the horse’s job, and how has it changed recently? Is there a general lack of energy, or does the horse need an extended rest period after exercise? When was the horse last acting “normal”? 10
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Mitral valve regurgitation
In the case of mitral valve regurgitation, the murmur is less important than the associated heart remodeling. “We rarely see acute mitral regurgitation,” Dr. Mitchell said. “Sometimes we’ll see it in a racehorse that ruptures a chordae acutely or develops a flail leaflet, or with some sort of ischemic disease. Acute dysfunction of the papillary muscles is rare.” Chronic mitral regurgitation, in which the left atrium gets larger, is much more common. Over time, the pressure increases a small amount, but the overall volume of the atrium increases to a great extent, causing it to enlarge. “A big atrium is a substrate for arrhythmias,” she explained. “Most of the consequences of heart disease that we worry about are the arrhythmias that are caused by the heart disease, not the heart disease itself.” ACVIM consensus recommendations suggest that a grade 3/6 or louder left-side systolic murmur should be evaluated on echocardiography. Dr. Mitchell said that she also considers further evaluation in any horse with a high resting heart rate, a prolonged recovery after exercise, or any horse that develops any kind of arrhythmia. If a murmur and an arrhythmia are both present, that is much more concerning.
Aortic regurgitation
The left ventricle is the area of concern with aortic regurgitation. Like mitral regurgitation, chronic aortic regurgitation is most common in horses as they get older. “The left ventricle gets bigger with time, it compensates, it remodels, and it develops eccentric hypertrophy, where the chamber gets bigger and the wall gets
The only dual ingredient injectable corticosteroid approved by the FDA for use in horses
The link between RAPID ONSET and LONG-ACTING RELIEF of pain & inflammation 1
BetaVet® (betamethasone sodium phosphate and betamethasone acetate injectable suspension) is indicated for the control of pain and inflammation associated with osteoarthritis in horses. Learn more at www.betavetequine.com or call 1-800-458-0163. Please see Brief Summary of Full Prescribing Information on the following page. INDICATION BetaVet® (betamethasone sodium phosphate and betamethasone acetate injectable suspension) is indicated for the control of pain and inflammation associated with osteoarthritis in horses. IMPORTANT SAFETY INFORMATION For Intra-articular (I.A.) use in Horses. CONTRAINDICATIONS BetaVet® is contraindicated in horses with hypersensitivity to betamethasone. Intra-articular injection of corticosteroids for local effect is contraindicated in the presence of septic arthritis. WARNINGS: Do not use in horses intended for human consumption. Clinical and experimental data have demonstrated that corticosteroids administered orally or parenterally to animals may induce the first stage of parturition when administered during the last trimester of pregnancy and may precipitate premature parturition followed by dystocia, fetal death, retained placenta, and metritis. Additionally, corticosteroids administered to dogs, rabbits and rodents during pregnancy have resulted in congenital anomalies. Before use of corticosteroids in pregnant animals, the possible benefits should be weighed against potential hazards. Human Warnings: Not for use in humans. Keep this and all medications out of the reach of children. PRECAUTIONS: Corticosteroids, including BetaVet,® administered intra-articularly are systemically absorbed. Do not use in horses with acute infections. Acute moderate to severe exacerbation of pain, further loss of joint motion, fever, or malaise within several days following intra-articular injection may indicate a septic process. Because of the anti-inflammatory action of corticosteroids, signs of infection in the treated joint may be masked. Due to the potential for exacerbation of clinical signs of laminitis, glucocorticoids should be used with caution in horses with a history of laminitis, or horses
otherwise at a higher risk for laminitis. Use with caution in horses with chronic nephritis, equine pituitary pars intermedia dysfunction (PPID), and congestive heart failure. Concurrent use of other anti-inflammatory drugs, should be approached with caution. Consider appropriate wash out times prior to administering additional NSAIDs or corticosteroids. ADVERSE REACTIONS: Adverse reactions reported during a field study of 239 horses of various breeds which had been administered either BetaVet® (n=119) or a saline control (n=120) at five percent (5%) and above were: acute joint effusion and/ or local injection site swelling (within 2 days of injection), 15% BetaVet® and 13% saline control; increased lameness (within the first 5 days), 6.7% BetaVet® and 8.3% saline control; loose stool, 5.9% BetaVet® and 8.3% saline control; increased heat in joint, 2.5% BetaVet® and 5% saline control; and depression, 5.9% BetaVet® and 1.6% saline control. SHAKE WELL IMMEDIATELY BEFORE USE. For additional safety information, please see full prescribing information. CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian. References: 1. Trotter GW. Intra-articular corticosteroids. In: McIlwraith CW, Trotter GW, eds. Joint Disease in the Horse. Philadelphia: W.B. Saunders; 1996; 237–256.
All trademarks are the property of American Regent, Inc. © 2021 American Regent, Inc. PP-BV-US-0035 (v2.0) 09/2021
BRIEF SUMMARY OF PRESCRIBING INFORMATION (Betamethasone Sodium Phosphate and Betamethasone Acetate Injectable Suspension) 6 mg betamethasone per mL For Intra-Articular (I.A.) Use in Horses CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian. INDICATION: BetaVet® is indicated for the control of pain and inflammation associated with osteoarthritis in horses. DOSAGE AND ADMINISTRATION: Shake well immediately before use. CONTRAINDICATIONS: BetaVet® is contraindicated in horses with hypersensitivity to betamethasone. Intra-articular injection of corticosteroids for local effect is contraindicated in the presence of septic arthritis. WARNINGS: Do not use in horses intended for human consumption. Clinical and experimental data have demonstrated that corticosteroids administered orally or parenterally to animals may induce the first stage of parturition when administered during the last trimester of pregnancy and may precipitate premature parturition followed by dystocia, fetal death, retained placenta, and metritis. Additionally, corticosteroids administered to dogs, rabbits and rodents during pregnancy have resulted in cleft palate in offspring. Corticosteroids administered to dogs during pregnancy have also resulted in other congenital anomalies including deformed forelegs, phocomelia and anasarca. Therefore, before use of corticosteroids in pregnant animals, the possible benefits to the pregnant animal should be weighed against potential hazards to its developing embryo or fetus. Human Warnings: Not for use in humans. For use in animals only. Keep this and all medications out of the reach of children. Consult a physician in the case of accidental human exposure. PRECAUTIONS: Corticosteroids, including BetaVet®, administered intra-articularly are systemically absorbed. Do not use in horses with acute infections. Acute moderate to severe exacerbation of pain, further loss of joint motion, fever, or malaise within several days following intra-articular injection may indicate a septic process. Because of the anti-inflammatory action of corticosteroids, signs of infection in the treated joint may be masked. Appropriate examination of joint fluid is necessary to exclude a septic process. If a bacterial infection is present, appropriate antibacterial therapy should be instituted immediately. Additional doses of corticosteroids should not be administered until joint sepsis has been definitively ruled out. Due to the potential for exacerbation of clinical signs of laminitis, glucocorticoids should be used with caution in horses with a history of laminitis, or horses otherwise at a higher risk for laminitis. Use with caution in horses with chronic nephritis, equine pituitary pars intermedia dysfunction (PPID), and congestive heart failure. Concurrent use of other anti-inflammatory drugs, such as NSAIDs or other corticosteroids, should be approached with caution. Due to the potential for systemic exposure, concomitant use of NSAIDs and corticosteroids may increase the risk of gastrointestinal, renal, and other toxicity. Consider appropriate wash out times prior to administering additional NSAIDs or corticosteroids. ADVERSE REACTIONS: Adverse reactions reported during a field study of 239 horses of various breeds which had been administered either BetaVet® (n=119) or a saline control (n=120) were: acute joint effusion and/or local injection site swelling (within 2 days of injection), 15% BetaVet® and 13% saline control; increased lameness (within the first 5 days), 6.7% BetaVet® and 8.3% saline control; loose stool, 5.9% BetaVet® and 8.3% saline control; increased heat in joint, 2.5% BetaVet® and 5% saline control; depression, 5.9% BetaVet® and 1.6% saline control; agitation/anxiety, 4.2% BetaVet® and 2.5% saline control; delayed swelling of treated joint (5 or more days after injection), 2.5% BetaVet® and 3.3% saline control; inappetance, 3.4% BetaVet® and 2.5% saline control; dry stool, 1.7% BetaVet® and 0% saline control; excessive sweating, 0.8% BetaVet® and 0% saline control; acute non-weight bearing lameness, 0.8% BetaVet®and 0% saline control; and laminitis, 0.8% BetaVet® and 0% saline control.
CLINICAL PHARMACOLOGY: Betamethasone is a potent glucocorticoid steroid with anti-inflammatory and immunosuppressive properties. Depending upon their physico-chemical properties, drugs administered intra-articularly may enter the general circulation because the synovial joint cavity is in direct equilibrium with the surrounding blood supply. After the intra-articular administration of 9 mg BetaVet® in horses, there were quantifiable concentrations of betamethasone (above 1.0 ng/mL) in the plasma. EFFECTIVENESS: A negative control, randomized, masked field study provided data to evaluate the effectiveness of BetaVet® administered at 1.5 mL (9 mg betamethasone) once intra-articularly for the control of pain and inflammation associated with osteoarthritis in horses. Clinical success was defined as improvement in one lameness grade according to the AAEP lameness scoring system on Day 5 following treatment. The success rate for horses in the BetaVet® group was statistically significantly different (p=0.0061) than that in the saline group, with success rates of 75.73% and 52.52%, respectively (back-transformed from the logistic regression). ANIMAL SAFETY: A 3-week target animal safety (TAS) study was conducted to evaluate the safety of BetaVet® in mature, healthy horses. Treatment groups included a control (isotonic saline at a volume equivalent to the 4x group); 1X (0.0225 mg betamethasone per pound bodyweight; BetaVet®); 2X (0.045 mg betamethasone per pound bodyweight; BetaVet®) and 4X (0.09 mg betamethasone per pound bodyweight; BetaVet®). Treatments were administered by intra-articular injection into the left middle carpal joint once every 5-days for 3 treatments. Injection site reactions were the most common observations in all treatment groups. Injection site reactions were observed within 1 hour of dosing and included swelling at the injection site, lameness/stiffness of the left front limb, and flexing the left front knee at rest. The injection site reactions ranged from slight swelling (in many horses on multiple days in all treatment groups) to excessive fluid with swelling, pain, and lameness (4x group only). Injection site reactions were observed most commonly on treatment days, and generally decreased in number and severity over subsequent days. The incidence of injection site reactions increased after the second and third injection (number of abnormalities noted on day 10 > day 5 > day 0). In the BetaVet® treated groups the number and severity of the injection site reactions were dose dependent. The 4X BetaVet® group had the highest overall incidence of and severity of injection site reactions, which included heat, swelling, pain, bleeding, and holding the limb up at rest. The control group and 4X group (which received similar injection volumes) had a similar incidence of injection site reactions; however, the severity of reactions was greater in the 4X group. Absolute neutrophils were statistically significantly higher in the BetaVet® treated groups as compared to the control group. Trends toward a decrease in lymphocytes and eosinophils, and an increase in monocytes were identified in the BetaVet® treated groups after the initial dose of BetaVet®. Individual animal values for white blood cells generally remained within the reference range. BetaVet® treated horses also had a trend toward increased blood glucose after the initial dose. Some individual animals showed mild increases in blood glucose above the reference range. SHAKE WELL BEFORE USING NADA 141-418, Approved by FDA For For customer customer care care or or to to obtain obtain product product information information visit visit www.betavetequine.com www.betavetequine.com or or call call 1-800-458-0163. 1-800-458-0163. To report an adverse event please contact American Regent Animal Health at at 1-888-354-4857 or email pv@americanregent.com. (800) 734-9236 or email pv@americanregent.com.
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thicker,” she explained. “That is an amazing substrate for an arrhythmia, and that’s where our concerns are for these horses.” If a horse develops an important arrhythmia during exercise, the horse could collapse or even have sudden cardiac death. In a healthy horse, pulse pressure—the difference between systolic pressure and diastolic pressure—is typically around 40 mmHg. In horses with severe regurgitation, the aortic valve is leaking, so the diastolic pressure is falling. That leads to a bigger ventricle with a larger stroke volume that’s pushing the larger amount of blood through the same size aorta. This causes systolic pressure to go up. “You end up with a bigger difference between systolic pressure and diastolic pressure, and we can feel that in a bounding pulse, also called a water hammer pulse,” Dr. Mitchell said. “If you feel that means the horse has important aortic regurgitation and that left ventricle is big, that is something you need to worry about.” ACVIM consensus guidelines recommend echocardiography in horses that have grade 3 or louder diastolic murmurs, but Dr. Mitchell also recommends performing a scan in horses with a grade 2 murmur plus a strong pulse. “I’ve seen many horses that have had a quiet diastolic murmur that was missed,” she said. “But if they have a strong pulse, they have an important amount of regurgitation. So, add that to your exam.” She also recommends further evaluation in horses with a history of decreased performance, collapse, weakness, exercise intolerance, or one that requires long recovery time after exercise.
Tricuspid regurgitation
Depending on the population of horses you see, tricuspid regurgitation either happens a lot or not often at all. Outcomes depend on the type of horse. Race-
Courtesy of Dr. Katharyn Jean Mitchell
CARDIOLOGY
Color flow mapping image of the right ventricular outflow tract, showing severe tricuspid regurgitation.
horses often have tricuspid regurgitation but tolerate it well, but the condition may be more important in pleasure horses or low-level performance horses. “I am particularly worried about horses that have evidence of respiratory disease and tricuspid regurgitation,” Dr. Mitchell said. History and owner expectations often come into play in determining her concern for the horse and the risk tolerance she is willing to accept. Depending on what the horse’s job is, the experience of the rider, and its lifestyle and environment, the risk assessment may change. “I’m also going to look at what kind of disease is present,” she said. “Are there atrial consequences, or are we talking about ventricular consequences? I will be more risk averse if something dangerous has happened with the horse in the past. If the horse has a history of being ‘wobbly’ or the horse is weak after exercise, I am more averse to risk in those cases.” MeV
BREAKING DOWN THE MURMURS If a murmur is soft, early systolic and localized cranially over the great vessels on the left side, it’s more likely to be physiological and not worrisome. According to the ACVIM consensus guidelines for equine athletes with cardiovascular abnormalities, important murmurs tend to be grade 3/6 or louder. “When we talk about causes of the murmurs, we are lucky because it’s simple in the horse compared with small animals and humans,” Dr. Katharyn Jean Mitchell said. “If you hear a systolic murmur loudest on the left side, that is mitral regurgitation. If you hear a systolic murmur loudest on the right, it’s either going to be tricuspid regurgitation or potentially a ventricular septal defect.” Diastolic murmurs are even easier. Regardless of the side of the murmur, a diastolic murmur is almost always going to be aortic valve regurgitation. An aortic cardiac fistula is possible with a right-sided diastolic murmur, but those are more likely to be combined systolic/diastolic murmurs.
ModernEquineVet.com | Issue 12/2021
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GASTROENTEROLOGY
Tests May Help Identify Clotting Problems in Horses With Gastrointestinal Ailments By Adam Marcus A pair of sophisticated tests for clotting can accurately identify clotting problems in horses experiencing gastrointestinal illness, researchers in Denmark found. In a pilot study, the researchers showed that the calibrated automated thrombogram (CAT) and plasma-thromboelastography (TEG), which assess the coagulability of blood, can differentiate animals with severe versus mild or no GI problems. The CAT and TEG are considered more accurate ways to measure clotting anomalies than conventional hemostatic markers, such as platelet count, fibrinogen, D-dimer concentration and other commonly used tests. However, CAT in particular had not previously been assessed in horses, according to the researchers. “Critically ill horses often suffer from hemostatic changes. In equine medicine the conventional static hemostatic markers are still the most commonly used,” said Marie Louise Honoré, a doctoral student at the Department of Veterinary Clinical Sciences at the University of Copenhagen, who led the study. “Global hemostatic tests on the other hand are dynamic and show the entire hemostatic process. There has however only been moderate progression in the use of these more advanced hemostatic tests in equine medicine. Hence, there was a need for further exploring the use of these global hemostatic tests in horses.” For the study, Ms. Honoré and her colleagues sought to determine if plasma-TEG, which has been investigated in humans, dogs and pigs, was applicable on equine citrated platelet poor plasma (PPP) as an alternative to whole blood-TEG. If so, that would make the assay more widely available, given its reduced time sensitivity, she told Modern Equine Vet. “In addition, we wanted to demonstrate that the CAT assay, which has been applied in humans, dogs and cats, would be applicable on equine citrated PPP with a high degree of validity and reliability,” she said. Finally, the researchers hoped to show that both the CAT and plasma-TEG could differentiate clot-
ting anomalies in horses with GI conditions (15 severe, 9 mild) compared with 10 healthy animals. The severely ill horses were suffering from a variety of GI ailments, including peritonitis, acute colitis and ruptured intestines. Using CAT, the researchers observed statistically significant differences in peak (P=0.04) and time to peak (P=0.01) among the 3 groups of horses. They also found that CAT revealed a significantly higher peak in horses with severe GI disease than those with mild ailments (P=0.04), as well as a significantly lower time to peak for horses with severe GI disease compared with healthy animals (P=0.008). Using plasma-TEG revealed statistically significant differences in angle (P=0.016), maximum amplitude (P=0.023) and shear elastic force (P=0.022) among the 3 groups of horses. The plasma-TEG test showed a significantly higher angle (P=0.032), maximum amplitude (P=0.017) and shear elastic force (P=0.017) in horses with severe GI disease compared with healthy animals, according to the researchers. “The CAT assay performed well in horses with intra- and inter-assay coefficients of variation below the accepted limits and are thus reliable,” the authors reported. “Additionally, the heparin dilution curve showed that the CAT assay is valid in horses. The CAT assay and plasma-TEG were applicable for use in equine citrated PPP and both assays showed hemostatic aberrations in horses with GI disease. Except for time to peak in the CAT assay, the assays could not distinguish mild from severe GI disease.” Ms. Honoré added that for the moment, the 2 tests generally are performed in teaching hospitals or larger veterinary clinics rather than in smaller facilities. “They require trained personnel to operate them, and they are fairly expensive. However, our hope with this study was to make both tests more accessible since the use of plasma makes it possible to store the samples for longer and transport them to facilities where the relevant machines and tests are available,” she said. MeV
For more information: Honoré ML, et al. A pilot study evaluating the calibrated automated thrombogram assay and application of plasma-thromboelastography for detection of hemostatic aberrations in horses with gastrointestinal disease. BMC Vet Res. 2021 Nov 8;17(1):346. doi: 10.1186/s12917-021-03058-7. https://bmcvetres.biomedcentral.com/articles/10.1186/s12917-021-03058-7#Sec2
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Issue 12/2021 | ModernEquineVet.com
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NEWS NOTES
Dr. Emma Read Takes Reins as AAEP's 2022 President
Courtesy of AAEP
Emma Read, DVM, MVSc, DACVS, associate dean for professional programs at The Ohio State University College of Veterinary Medicine, became the president of the American Association of Equine Practitioners during the 67th Annual Convention in Nashville, Tenn. Dr. Read joined Ohio State in 2018 after 11 years on the veterinary faculty at the University of Calgary, which included stints as chair of the Clinical Skills Program, associate dean academic and interim dean. She also taught at the Ontario Veterinary College and worked for a private specialty referral practice in Alberta. While in Calgary, Dr. Read worked with national and international equine athletes and riders as part of the treatment team at Spruce Meadows show jumping
“Bill” Moyer, DVM, received the Distinguished Life Member Award for his leadership and service to the association during his 51 years of membership. Dr. Moyer retired from Texas A&M University College of Veterinary Medicine & Biomedical Sciences in 2015 but continues to serve as a professor emeritus. Throughout his career, Dr. Moyer has been an enthusiastic advocate of the AAEP and a leading voice for its educational programs. Those efforts have been instrumental in recruiting academic leaders to become more involved with the association. Dr. Moyer’s 2 terms on the AAEP board of directors culminated in his role as president in 2011. Since 1981, he has served on numerous councils, committees and task forces, including as chair of the Nominating and Equine Insurance committees, and member of the Farrier Liaison, Professional Conduct & Ethics, Public Policy and Racing committees. Dr. Moyer remains active within The Foundation for the Horse, specifically assisting in the area of disaster medicine. He served as lead author of the AAEP’s Disaster Medicine Guidelines published in May 2021. “Dr. Moyer has served our association in many and varied capacities for over 40 years,” said nominator Harry Werner, VMD. Immediate Past President Dr. Scott Hay (left) welcomes incoming President Dr. William "Bill" Moyer (left) accepts the DistinDr. Emma Reed. guished Life Member Award from Dr. Scott Hay. “Chairing or sitting on multiple committees, forums and task forces facility. She also helped develop and validate several as well as serving on our board of directors and as our simulator models that were later commercialized by president, Dr. Moyer has helped shape the vision and Veterinary Simulator Industries. achieve the goals of the AAEP throughout his career.” Dr. Read said that retaining graduates will be a goal He received his veterinary degree from Colorado for her presidency. “I look at our current issues with State University in 1970 and completed his surgical resretaining new graduates and really want to help that idency at the University of Pennsylvania’s New Bolton situation so others have the opportunity to make the Center in 1973. In 1993, he joined Texas A&M Univermost of a career in this field and feel like they belong in sity following 13 years on faculty at New Bolton Center. a welcoming, inclusive profession with a bright future.” Jackie Christakos, DVM, associate veterinarian at Dr. Read earned her veterinary degree from the Littleton Equine Medical Center in Colorado, joined Western College of Veterinary Medicine in 1998 and the AAEP's board of directors. Upon receiving her became board certified in veterinary surgery in 2004. veterinary degree from Colorado State University in She has served on various boards and committees at the 2012, Dr. Christakos completed an internship at LitAAEP, including on the board of directors from 2011tleton Equine, where she became an assistant veteri2013. Dr. Read also serves on the Competency Based narian to Terry Swanson, DVM, before becoming a Veterinary Education working group and the Council full-time associate in 2015. Her primary areas of focus for International Veterinary Medical Education for the are lameness/sports medicine and musculoskeletal ulAssociation of American Veterinary Medical Colleges. trasound, but she also enjoys general practice/wellness In related news, AAEP Past President William care, emergency field work and acupuncture. MeV 16
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