Pugapalooza Alberta
Health Problems For Pugs
To Help Prevent Most of these Health problems or slow them down . If your Pug does have any of these please go see your vet today!
4-12 months of age
• Gene test for Degenerative Myelopathy
• X-rays of head, neck & spine for Upper Airway Syndrome and Hemi-Vertebra
• Surgical repair - for Upper Airway Suyndrome and Fold Dermatitis (if needed)
1 year of age
• Eye exam for Distichiasis, Entropion, Cataracts & Exposure Eye Keratopathy - repeat yearly
• Skin exam for Demodectic Mange
2 years of age
• Teeth Cleaning - repeat every 2-3 years
• Skin exam for skin allergy evaluation for Atopy and Demodectic Mange
• Eye exam for Distichiasis, Entropion, Cataracts & Exposure Eye Keratopathy
Fold Dermatitis
DEMODECTIC MANGE
Demodex in the dog is a common infestation of the dog’s skin with tiny, cigar-shaped, eight-legged mites. Also referred to as demodectic mange, the mites reside and feed in the hair follicle and oil glands of the skin.
Demodex is generally less severe than Sarcoptic mites (often called scabies) and in most cases is self-limiting -- that is, the animal is able to arrest the reproduction and growth of the mites and eventually repair the damage they do.
Once eliminated, most dogs do not acquire another infestation; the dog’s immune defenses are primed to eliminate any new demodex mites. However, there are certain dogs that, because of genetic programming, do not produce the specific immune factors that will target the mites for destruction. That specific lack of adequate immune defense against the mites is a hereditary aspect of the disease that can predispose an infested dog to a severe, unresponsive case of demodex.
Many veterinarians believe that all dogs have small numbers of demodex mites residing in the skin and that having a few mites is normal and common. It is when immune related -- or nutritional or environmental -- stresses impact the dog that visible skin lesions from mite infestations become noticeable.
Skin Fold Dermatitis is often initiated by abnormal rubbing in the area coupled with retained moisture in an area of the body where it’s warm and there is poor exposure to air. Extra rolls of skin in obese dogs can also be a favorable place for an infection to set in. These conditions are favorable for the growth and proliferation of normal skin flora such as bacteria and fungi (yeast) leading to an inflammatory skin condition known as dermatitis. One of the most common complications of dermatitis is a skin infection called pyoderma.
Obesity and skin allergies in dog breeds prone to developing Skin Fold Dermatitis can often make the condition worse.
Skin fold dermatitis is often suspected when alopecic (hairless) areas are visible and accompanied by inflamed and stinky skin fold interiors particularly in brachycephalic dogs. In most cases the infected folds become more pronounced when pophyrin pigments in the tears stain the face.
Distichiasis
Brachycephalic Airway Syndrome
Brachycephalic (meaning to having a short, broad head) breed may experience partial obstruction of the upper airway due to physical characteristics such as narrowed nostrils, an overly long soft palate, or collapse of the voice box (also known as thelarynx). Breathing difficulties may also occur because of an abnormally small windpipe (or trachea), another characteristic common to brachycephalic breeds. Some of the more common brachycephalic breeds are the pug, bulldog, boxer, chihuahua, andshih tzu.
Symptoms of an obstructed upper airway may include snoring, rapid breathing (ortachypnea), noisy breathing when inhaling, frequent panting, difficulty eating or swallowing, coughing and gagging, inability to perform physical activity, especially in warm, humid weather, and occasionally physical collapse. A physical examination may reveal further indications, such as stenotic nares (narrowed nasal passages), abnormally high body temperature (or hyperthermia), and increased respiratory effort evident by open-mouth breathing and constant panting.
Brachycephalic airway syndrome stems from the dog's unique head shape, which is inherited at birth. Most dogs are diagnosed as young adults, generally by age three. A characteristic reported in nearly 100 percent of cases of dogs with brachycephalic airway syndrome is an elongated soft palate. Narrowed nasal passages is also reported in about about 50 percent of all cases of dogs suffering from brachycephalic airway syndrome.
Factors that may increase the risk and further complicate the condition further includeobesity, allergies, over-excitement, and exercise, which may cause rapid breathing that the obstructed airway can not manage. These problems worsen in warm, humid weather, which can lead to excessive panting.
Distichiasis is quite common in dogs. Distichiasis is a condition in which extra hairs grow out of the eyelash area. It happens when there are two or more hairs growing out of a Meibomian gland opening. (Meibomian glands are located along the margin of the eyelid.) These hairs are not supposed to be there. In some cases, these extra hairs can be long and stiff and irritate the eye, resulting in a corneal ulcer. The severity of the problem depends on how stiff the hairs are, how long they are, where they’re located, and how many extra hairs there are.
Distichiasis is different from entropion. Distichiasis involves extra eyelashes; entropion is an inward roll of the eyelid that causes eye irritation from normal eyelashes or hair.
Untreated distichiasis can cause corneal ulcers, chronic eye and eyelid pain, and excessive tearing. It is quite uncomfortable and/or painful for the animal, depending on the amount irritation. If the excessive hair causes any clinical signs at all, the hair should be permanently removed.
Signs include increased blinking, lots of extra tears that often look like a tear streak, and squinting. Dogs don’t typically paw at the eye. The more severe cases are the most easily diagnosed, as the milder cases often involve small softer hairs that can easily be missed.
It’s seen most often in puppies or young adults and is typically diagnosed before a dog is three years old. Any dog can have it, but it’s considered to be one of the most commonly inherited diseases in dogs, and considered by some to be the most common congenital eye problem. Breeds that seem to be predisposed to distichiasis include:
• Cocker spaniel
• Cocker Spaniel, American
• English bulldog
• Flat-coated Retriever
• Golden retriever
• Lhasa apso
• Miniature Longhaired Dachshund
• Miniature poodle
• Pekingese
• Poodle
• Pug
• Shetland sheepdog
• Shih tzu
• Toy poodle
• Yorkshire terrier
Hemivertebrae
the Pug, often possess a tail that is curled like a cork screw. Nature may have dictated that this cork screw appearance of the tail provide a balance to a Pug’s short, pushed in face, but it may also indicate an abnormality in the formation and development of the dog’s spine known as Hemivertebrae.
Aside from the Pug, other breeds of dogs that are likely to possess a hemivertebrae at the tail include Boston Terriers, French Bulldogs, and English Bulldogs. When the condition affects the bones of the tail, it is not really a major problem because there is no spinal cord tissue present in this part of the vertebral column. However, a cork-screw tail may be prone to skin-fold infections.
Aside from the tail, Hemivertebrae can also occur in other parts of the vertebral column. These types of Hemivertebrae can occur in the middle of the backbone thus resulting in the arching of the back. This can create areas in the spine which can be susceptible to injury. A dog suffering from this form of hemivertebrae often suffers from pain even with the slightest movement.
The deviation of the spine will mainly depend on the degree by which the bones which are involved have developed. Symptoms associated with hemivertebrae usually plateau at about 9 months of age when the bones of the vertebral column stops growing.
Legg-Calvé-Perthes Disease
Legg-Calvé-Perthes Disease involves spontaneous degeneration of the head on the femur bone, located in the dog's hind leg. This results in disintegration of the hip joint (coxofemoral) and bone and joint inflammation (osteoarthritis).
The exact cause of the condition is unknown, though blood supply issues to the femoral head are usually seen in dogs suffering from Legg-Calvé-Perthes Disease. It is commonly seen in miniature, toy, and small-breed dogs, and has a genetic basis inManchester terriers. Moreover, most dogs affected with Legg-Calvé-Perthes Disease are five to eight months in age.
Symptom and Types
Lameness (gradual onset over two to three months)
Carrying of affected limb(s)
Pain when moving hip joint
Wasting of thigh muscles on affected limb(s)
Causes
The exact cause for Legg-Calvé-Perthes Disease is unknown, though some researchers suggest it is related to blood supply issues to the head of the femur bone.
Pug Encephalitis
Pug dog encephalitis, or PDE, is a brain disease that affects pug dogs. Vets think that this condition is genetic, since it often strikes dogs who are closely related to one another. The illness progresses quickly, and cannot be cured.
Vets don't really understand what causes pug dog encephalitis, an inflammation of the brain that typically strikes pug dogs between two and three years of age. Only pug dogs get this disease, and vets think it must be genetic, because it often occurs in litter mates and closely related animals. Recent research suggest that pug dog encephalitis may be autoimmune in nature.
Female pugs are more likely than males to succumb to this disease. Most pugs who come down with pug down encephalitis are two to three years of age, though it has been reported in dogs as young as six months of age, and in middle-aged animals as well.
Pug dog encephalitis is always fatal. Once symptoms appear, dogs with this disease have only months left.
Symptoms of Pug Dog Encephalitis
The primary symptom of pug dog encephalitis is seizures. Seizures may occur every few days or weeks, or more frequently, depending on the rate at which the disease is progressing.
In between episodes of seizure, the dog will exhibit other symptoms of the disease, including:
depression
disorientation
lack of coordination
confusion
Pug dogs with encephalitis may also stagger, appear to be blind, have trouble walking, walk in circles, or press their heads against furniture, walls, or other solid surfaces.
Pug dog encephalitis can strike rapidly, and may often kill the dog when it does.
Diagnosing Pug Dog Encephalitis
Your vet will need a complete medical history and physical exam to diagnose pug dog encephalitis. If you happen to know that other dogs in your pug's immediate family have succumbed to this disease, tell your vet.
MRIs and spinal taps can help your vet make a diagnosis. Because so little is known about this disease, your vet may ask you to donate your dog's remains to veterinary science after he has died. You can help further the cause of veterinary research into this disease by allowing your vet to take CAT scans and MRIs while your dog is still alive.
Eyelid Entropion
Entropion is an abnormality of the eyelids in which the eyelid "rolls" inward. This inward rolling often causes the hair on the surface of the eyelid to rub against the cornea (outer part of the eyeball) resulting in pain, corneal ulcers or corneal erosions. This corneal damage can also result in corneal scarring, that can interfere with vision.
Most dogs will squint, hold the eye shut and tear excessively (epiphora). Interestingly, many flat-faced dogs with medial entropion (involving the corner of the eyes near the nose) exhibit no obvious signs of discomfort. In most cases, both eyes are affected.
Cataracts
Cataract is an opacity in the lens of a dog’s eye, causing him to have blurry vision. If the cataract is small, it won’t likely disturb the dog’s vision too much, but cataracts must be monitored because the thicker and denser they become, the more likely it is they will lead to blindness.What Causes Cataracts?Cataracts can develop from disease, old age and trauma to the eye, but inherited conditions are the most common cause. Cataracts may be present at birth or develop when a dog is very young-between one and three years of age. A high-incidence of cataracts is also often attributed to diabetes.How Can I Tell if My Dog Is Developing Cataracts?If your dog’s eyes look cloudy or bluish-gray, you should take him to the vet for an exam. Be aware, though, that it’s natural for a dog’s lens to become cloudy, or gray, with age. This condition, called nuclear sclerosis, doesn’t put a dog’s vision in as much danger as cataracts might, and treatment isn’t usually recommended. However, any cloudiness at all in your pet’s eye is a sign for you to take him to the vet.What Happens When a Cataract Goes Untreated?An untreated cataract may “luxate” or slip from the tissue that holds it in place, freeing it to float around in the eye where it may settle and block natural fluid drainage. This can lead to glaucoma, which can cause permanent blindness. Cataracts may also begin to dissolve after some time, causing deep, painful inflammation in the eye.
Atopic Dermatitis
Eye Exposure Keratopathy Syndrome
Keratitis is a condition in which the eye's cornea, the front part of the eye, becomesinflamed. The condition is often marked by moderate to intense pain and usually involves impaired eyesight. It may cause feelings of itchiness each time the individual blinks.
Periodontal Disease
Periodontal disease is the inflammation of the tissues surrounding a tooth (essentially, the tooth's support system). It can affect as little as one or two teeth or as much as a dog's whole mouth. Left untreated, periodontal disease can lead to severe oral pain, loss of teeth, other dental diseases and a wide array of complications throughout the body. Proper dental care can prevent periodontal disease and is an important aspect of keeping your dog healthy.
Causes of Periodontal Disease in Dogs:
The development of periodontal disease is a gradual process that begins with the formation of plaque on the teeth. Bacteria in the mouth form plaque, a bacterial film that adheres to the teeth. Next, minerals in saliva harden the plaque into dental tartar (calculus), which becomes firmly attached to teeth. The plaque and tartar, both of which contain bacteria, spread under gum line. The bacteria secrete toxins and cause damage to the supporting tissues around the tooth, creating a pocket around the tooth.
Certain dogs seem to have a genetic predisposition to periodontal disease. This often relates to the dog's breed. Many small breed dogs, such asDachshunds and Chihuahuas are especially prone to periodontal disease.
Signs of Periodontal Disease in Dogs:
The signs of periodontal disease depend upon the severity of the disease. They may also vary from dog to dog. The first thing most people will notice ishalitosis. Contrary to what many people believe, dogs are not supposed to have bad breath. This is a sign of dental disease that should be addressed right away. Dogs with advanced periodontal disease tend to have especially foul breath.
As periodontal disease progresses, so does oral pain. Dogs may become reluctant or unable to chew food and treats. They may also lose interest in chew toys. Often, dogs will begin to salivate more than usual. The saliva may even be blood-tinged. Upon closer inspection of the teeth, you or your vet will notice gingivitis (inflammation/reddening of the gums) at the very least. As periodontal disease advances, teeth will eventually become loose.
Periodontal disease is diagnosed and numbered from one to four (based on severity). Grade I is the earliest form of the disease, when only gingivitis is present. Periodontitis (loss of bone and soft tissue around teeth) is present in grades II, III and IV. Grade IV is the most advanced stage, when loss of more than half of the tooth's supportive structures is noted.
Risks of Periodontal Disease in Dogs:
In the mouth, periodontal disease causes damage to gum tissue and bone around the teeth, leading to loss of these tissues. In addition, periodontal disease can also cause the following problems to occur in the mouth:
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Development of a hole (fistula) from the oral cavity into the nasal passages causing nasal discharge
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Weakening of the jaw bone that can lead to fractures
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Bone infection
However, it is important to understand that periodontal disease can lead to other major health problems throughout the body, including the following:
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Heart Disease
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Kidney Dz
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Liver Disease
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Diabetes
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Various infections
Treatment of Periodontal Disease in Dogs:
Gingivitis can be cured with a professional dental cleaning and home care. However, there is no cure for periodontitis. Once bone loss occurs, it cannot be undone. Fortunately, it can be treated to slow the progression of the periodontal disease.
No matter the grade of periodontal disease, the first treatment step is a professional dental cleaning. This procedure must be done under general anesthesia. Veterinarians and technicians can get a better look at the teeth and accurately assess the stage of the disease. Many vet office are now performing dental x-rays, which are extremely valuable when it comes to making an accurate diagnosis and treating accordingly. A thorough cleaning of the teeth can be done, including the subgingival surfaces of the teeth (under the gum). Be wary of places offering "anesthesia-free dentistry." A thorough dental cleaning and periodontal treatment is not something that cannot be done if the pet is awake, no matter how well-behaved that pet may be.
Once your dog's teeth are clean, your job begins. Home dental care is an essential for all dogs, but is even more important for dogs with existing periodontal disease. The gold standard is daily brushing with an enzymatic toothpaste made especially for pets. However, this may not be a realistic option for you. As an alternative to daily brushing, you can try simply applying toothpaste to the dogs teeth daily. If daily care is still not an option, there are various topical gels that can be applied periodically (usually once a week). In addition, the are food and water additives on the market that change the chemistry of the dog's mouth, slowing the buildup of plaque and tartar. Be aware that not all dog dental products are created equal! Talk to your vet about products that have been proven effective and safe.you can also check out the Veterinary Oral Health Council for a list of approved products. The VOHC is similar to the American Dental Association, but for pets.
The best time to start a dental home care routine for your dog is the minute you bring him into your life. This will get your dog used to the process so it's not a struggle. It will also help prevent periodontal disease from starting in the first place. As with most diseases, prevention is key.
Keratoconjunctivitis sicca
Sometimes called dry eye syndrome, Keratoconjunctivitis sicca (KCS) is characterized by a deficiency of aqueous tear film over the surface of the eye and in the lining of the lids. The result is severe drying and inflammation of the cornea (the transparent front part of the eye) and conjunctiva (the clear membrane that covers the sclera -- the white part of the eye).
This condition is relatively common in dogs, particularly cocker spaniels, bulldogs, West Highland white terriers, Lhasa apsos, and shih-tzus. In addition, there is some suspicion that females may be more predisposed to KCS than males.
Symptoms and Types
Excessive blinking
Swollen conjunctival blood vessels
Chemosis (swelling of the tissue that lines the eyelids and surface of the eye)
Prominent nictitans (third eyelid)
Discharge of mucus or pus from the eye
Corneal changes (chronic disease) in the blood cells, with pigmentation and ulceration
Severe disease can lead to impaired or complete loss of vision
Causes
Immune-mediated adenitis (inflammation of a gland that is brought about by abnormal activity of the body's immune system) is most common, and is often associated with other immune-mediated diseases
Congenital in pugs and Yorkshire terriers, sporadically in other breeds
Neurogenic - disease of the central nervous system is occasionally seen after traumatic proptosis (eyes displaced from their sockets) or after a neurologic disease that interrupts the nerves of the tear gland
Often a dry nose on the same side as the dry eyes
Drug induced - general anesthesia and atropine cause transient dry eye syndrome
Drug toxicity - some sulfa-containing drugs or etodolac (an NSAID) may cause transient or permanent condition
Physician induced - removal of the third eyelid may lead to this condition, especially in at-risk breeds
X-Ray induced – can occur in response to the eye coming into close contact with a primary beam from a radiology device
Systemic disease - canine distemper virus
Chlamydia conjunctivitis - bacterial
Chronic blepharoconjunctivitis – long term inflammation of the conjunctiva (lining of the eyeball and lids) and eyelids
Breed-related predisposition
Diagnosis
Your veterinarian will perform a thorough physical and ophthalmological exam on your dog, taking into account the background history of symptoms and possible incidents that might have led to this condition. A Schirmer tear test can be used to measure tear values and the amount of wetness on the eye; that is, the amount of tear production that is taking place in the tear ducts and the amount available for the eye. A low value would be indicative of keratoconjunctivitis sicca. A fluorescein stain, a non-invasive dye that shows details of the eye under blue light, can be used to examine your dog's eye for abrasions/ulcerations. Your doctor may also take a sample of the aqueous fluid for culture, in order to determine how severe bacterial growth is in the eye and whether there is an infection that is underlying the KCS
Atopic dermatitis is an inflammatory, chronic skin disease associated with allergies. In fact, this is the second most common allergic skin disease in dogs. These allergic reactions can be brought on by normally harmless substances like grass, mold spores, house dust mites, and other environmental allergens.
Dogs normally show signs of the disease between 3 months and 6 years of age, though atopic dermatitis can be so mild the first year that it does not become clinically apparent before the third year.
Despite the fact dogs are more prone to atopic dermatitis than cats, it does occur in felines.
Symptoms and Types
Often symptoms associated with atopic dermatitis progressively worsen with time, though they become more apparent during certain seasons. The most commonly affected areas in dogs include the:
Ears
Wrists
Ankles
Muzzle
Underarms
Groin
Around the eyes
In between the toes
The signs associated with atopic dermatitis, meanwhile, consist of itching, scratching, rubbing, and licking, especially around the face, paws, and underarms.
Causes
Early onset is often associated with a family history of skin allergies. This may lead the dog to become more susceptible to allergens such as:
Animal danders
Airborne pollens (grasses, weeds, trees, etc.)
Mold spores (indoor and outdoor)
House dust mite
Diagnosis
Your veterinarian will want a complete medical history to determine the underlying cause of the skin allergies, including a physical examination of the dog.
Serologic allergy testing may be performed, but it does not always have reliable results. The quality of this kind of testing often depends on the laboratory which analyzes the results. Intradermal testing, whereby small amounts of test allergens are injected in the skin and wheal (a red bump) response is measured, may also used to identify the cause of your pet's allergic reaction.
Degenerative myelopathy
Degenerative myelopathy of dogs is a slowly progressive, non-inflammatory degeneration of the white matter of the spinal cord. It is most common in German Shepherd Dogs and Welsh Corgis, but is occasionally recognized in other breeds. The cause is unknown, although genetic factors are suspected.
Affected dogs are usually greater than 5-years-old and develop non-painful weakness of the hind legs that causes an unsteady gait. Early cases may be confused with orthopedic injuries; however, proprioceptive deficits (inability to sense where the limbs are in space) are an early feature of degenerative myelopathy and are not seen in orthopedic disease. Signs slowly progress to paralysis of the back end of the body over 6-36 months, although severity of signs may fluctuate. An MRI or CSF analysis is performed to rule out other causes of spinal cord dysfunction.
How is degenerative myelopathy treated?
Treatment with aminocaproic acid, vitamin supplements, and exercise has been recommended, but the safety and efficacy of these treatments has not been documented. Physical therapy, acupuncture, or supportive casts/braces may also be beneficial.
What symptoms can present as degenerative myelopathy progresses?
Early Stages
Progressive weakness of the hind limbs
Worn nails
Difficulty rising
Stumbling
Knuckling of the toes
Scuffing hind feet
Wearing of the inner digits of the rear paws
Loss of muscle in the rear legs
Tremors of the rear legs
Late Stages
Persistent early stages
Urinary and fecal incontinence
Eventual front leg weakness from compensatory strain
Mental stress and anxiety
Pressure sores on boney prominences
Inability to rise
Muscle atrophy
Poor hygiene - soiled appearance
Pneumonia
Depression
Infection/sepsis
Constipation
Organ failure
Crisis — Immediate veterinary assistance needed regardless of the disease
Difficulty breathing
Prolonged seizures
Uncontrollable vomiting/diarrhea
Sudden collapse
Profuse bleeding — internal or external
Crying/whining from pain*
* It should be noted that most animals will instinctually hide their pain. Vocalization of any sort that is out of the ordinary for your pet may indicate that their pain and anxiety has become too much for them to bear. If your pet vocalizes due to pain or anxiety, please consult with your tending veterinarian immediately.
What is the prognosis for degenerative myelopathy?
The long-term prognosis is poor and most animals are euthanized within 6 months to 3 years of diagnosis as the disease progresses. When the patient can no longer walk, and mobility carts are not an option, long-term hospice care or euthanasia should be considered.
A personalized treatment plan is important to slow the progression of degenerative myelopathy and maintain quality of life. Talk to your veterinarian regarding the best treatment protocol for your pet.
Sick Sinus Syndrome
The sinoatrial node (SA Node, or SAN), also called the sinus node, is the initiator of electrical impulses within the heart, triggering the heart to beat, or contract, by firing off electrical surges. Sick sinus syndrome (SSS) is a disorder of the heart’s electricalimpulse formation within the sinus node. It is also a disorder of the conduction of the electrical impulse out of the sinus node. Sick sinus syndrome will also affect subsidiary (backup) pacemakers and the specialized conduction system of the heart. Pacemaker refers to the generation of electrical impulses within the muscle tissue, which set the pace for the heart's rhythm.
On an electrocardiogram (ECG), the irregular contraction of the heart (arrhythmia) will be visible. Tachycardia-bradycardia syndrome, in which the heart beats too slowly, and then too quickly, is a variant of sick sinus syndrome. Clinical signs of sick sinus syndrome in animals will become apparent when organs begin to dysfunction because they are not receiving a normal amount of blood supply.
This syndrome can affect both dogs and cats.
Symptoms and Types
Some dogs will not show any symptoms of sick sinus syndrome, especially if they tend to be fairly inactive under normal circumstances. Generally, the symptoms that will present are:
Weakness
Fainting
Fatigue
Collapse
Seizure
Abnormally fast, or abnormally slow heart rate
Pauses in the heart rate
Rarely, sudden death
Causes
The causes for this condition are mostly unknown. Some of the suspected relationships to SSS are genetic, since some breeds, like the miniature schnauzer, appear to be predisposed; another cause is heart disease that is cutting off the blood supply to or from the heart and disrupting normal heart function, including the electrical functionality; and, cancer in the thoracic or pulmonary (both refer to the chest) region may also lead to SSS.
Diagnosis
Your veterinarian will perform a complete physical exam, including a blood chemical profile, a complete blood count, a urinalysis, and an electrolyte panel to verify proper organ function. You will need to give your doctor a thorough history of your dog's health, including a background history and onset of symptoms, and possible incidents or recent health conditions that might have precipitated this condition. The history you provide may give your veterinarian clues as to which organs are being affected secondarily.
A provocative atropine response test may be done to assess sinus node function. This test uses the drug atropine to stimulate the firing action (sending electrical impulses out) of the SA Node. Dogs with SSS generally will have no response, or will have an incomplete response to the atropine.
An ECG may be indicated in certain breeds which are predisposed to SSS, as these same breeds are often predisposed to other diseases of the heart valves (the valves that separate the four chambers of the heart). Hence, if there is a heart murmur, disease of any of the heart’s valves should first be ruled out.