Abstract
The objectives of this study were to retrospectively compare blood pressure measurements obtained in clinic with those obtained at home from cats and dogs seen at our hospital and to investigate the potential for white-coat effect (WCE) and white-coat hypertension (WCH) in this population of 10 cats and 7 dogs. Medical records from Western College of Veterinary Medicine were searched to identify patients with paired home and in-clinic blood pressure measurements taken within 14 d. The results were compared with matched-pair analysis to determine the agreement and bias. Significantly higher systolic and diastolic blood pressures were measured in the clinic compared with those from home measurements. A mean difference of +27.7 mmHg [95% confidence interval (CI): 17.1 to 38.3 mmHg, P < 0.001] and +12.9 mmHg (95% CI: 6.4 to 19.5 mmHg, P = 0.0007) was found for systolic and diastolic pressure, respectively. The prevalence of WCH in this population was 41%. A total of 39% of home blood pressure measurements by owners were free of artefacts as evaluated by waveforms on high-definition oscillometry (HDO) devices. The results of this study showed that blood pressure measurements taken at home and at a clinic varied significantly, which was attributed to a high prevalence of white-coat effect and white-coat hypertension in this clinical population.
Résumé
Les objectifs de cette étude étaient de comparer rétrospectivement les mesures de pression sanguine obtenues en clinique avec celles obtenues à la maison pour des chats et des chiens vus en consultation à notre hôpital et d’examiner la possibilité d’hypertension réactionnelle (syndrome du sarrau blanc ou effet de la blouse blanche) dans cette population de dix chats et sept chiens. Les dossiers médicaux du Western College of Veterinary Medicine ont été consultés afin d’identifier des patients avec mesures pairées de la pression sanguine en clinique et à la maison prises dans un délai de 14 jours. Les résultats furent comparés par analyse par paires appariées pour déterminer l’accord et le biais. Des pressions sanguines systoliques et diastoliques significativement plus élevées ont été mesurées en clinique comparativement à celles mesurées à la maison. Une différence moyenne de + 27,7 mmHg [intervalle de confiance 95 % (CI) : 17,1 à 38,3 mmHg, P < 0,001] et + 12,9 mmHg (CI 95 % : 6,4 à 19,5 mmHg, P = 0,0007) a été trouvée pour la pression systolique et diastolique, respectivement. La prévalence de l’hypertension réactionnelle dans cette population était de 41 %. Un total de 39 % des mesures de pression sanguine à la maison par les propriétaires était exempt d’artéfact, tel qu’évalué par la forme des ondes sur des équipements d’oscillométrie à haute définition (HDO). Les résultats de cette étude ont montré que les mesures de pression sanguine prises à la maison et en clinique variaient de manière significative, ce qui a été attribué à une prévalence élevée de l’hypertension réactionnelle dans cette population clinique.
(Traduit par Docteur Serge Messier)
Introduction
Home blood pressure (HBP) measurement is commonly carried out in humans because of its ability to provide multiple measurements and to detect white-coat effect (WCE) and white-coat hypertension (WCH), as well as masked hypertension, which is defined as normal blood pressure in clinic, but elevated blood pressure at home (1). Measuring blood pressure at home has also been shown to better correlate with target organ damage (TOD), especially left ventricular hypertrophy and cardiovascular-related mortality, than office blood pressure (OBP) measurement (2).
These findings have led to the development of guidelines for clinical hypertension in humans that strongly recommend the use of out-of-office blood pressure measurement (via ambulatory blood pressure or home blood pressure) to confirm the diagnosis of hypertension and for titration of blood pressure-lowering medication and therapy (3). The American College of Veterinary Internal Medicine (ACVIM) acknowledges that physiological status, such as anxiety or excitement, may lead to an erroneous diagnosis of hypertension in veterinary patients with the use of OBP measurement (4,5).
To date, studies evaluating the clinical relevance and practicality of using HBP in dogs and cats have had the following clinical limitations. All these studies used apparently healthy animals, which is not the target population for HBP in practice (6–13). When HBP was used, it was almost always carried out by the investigators (6,7,9–13). To our knowledge, there is only one study in which results obtained with HBP carried out by investigators were compared with results carried out by owners in retired racing greyhounds to results obtained with OBP, and no statistical difference between the values was obtained (8). These studies all supported the presence of WCE and WCH when home measurements were taken, even in apparently healthy animals.
The main objective of this study was to retrospectively compare blood pressure (BP) measurements obtained in clinic with those obtained at home from cats and dogs seen at our hospital. The animals investigated were either diagnosed with hypertension in clinic and had underlying disease(s) thought to be associated with hypertension or they had evidence of hypertensive retinopathy, such as retinal hemorrhage, retinal detachments, and tortuous arteries on fundic examination. We hypothesized that HBP measurement would result in a clinically significant lower BP.
Another objective of this study was to report the prevalence of masked hypertension, WCE, and WCH in this population. The practicality of HBP measurement by owners was assessed using the number of successful attempts compared with the total number of attempts to measure blood pressure.
Materials and methods
Case enrollment
This study was a retrospective observational study. Medical records were reviewed of animals treated at Western College of Veterinary Medicine from January 2010 to January 2021. Cases were eligible for enrollment if a paired OBP and HBP were conducted within 14 d. Animals that had started or stopped BP-lowering medications or had dosage changes of these medications, e.g., angiotensin-converting enzyme-inhibitors, amlodipine, and angiotensin-receptor blockers, during the 14 d were excluded from the study. Animals with unpaired HBP measurements were included to evaluate the practicality of HBP measurement.
Blood pressure measurement
All the readings for OBP and HBP measurements were obtained using a high-definition oscillometry (HDO) blood pressure device (S+BmedVET, Babenhausen, Germany). This device allows the oscillometric waveforms being generated to be evaluated either in real-time or via data stored on the device that can be downloaded for evaluation. Visual inspection of the curve helps to eliminate tracings that are inaccurate because of artefact, low signal strength, or inadequate inflation parameters.
The oscillometric traces were reviewed using MDS Analyse software. Cuff sizes were selected according to the ACVIM consensus guideline, with the width of the cuff being 30 to 40% of the circumference of the extremity at the site of cuff placement (4,5). All in-clinic and at-home measurements were carried out with the same model of blood pressure monitoring device, cuff size, and site of cuff placement. All animals in the study had the cuffs placed at the base of the tail.
The animals were allowed to acclimate for 10 to 15 min in a quiet room with the owners before OBP measurement. The OBP was obtained by a single investigator (AC), with the owners present to minimize stress. No physical or chemical restraints were allowed during measurement. The oscillometric tracings were reviewed during the measurement in real time. Blood pressure measurements were carried out in succession while the animal appeared calm until readings with minimal artefact on oscillometric tracing were obtained. Only verified tracings were used to calculate blood pressure values; the rest of the readings were discarded.
For HBP measurements, owners were briefly instructed on how to use the device. It was verbally recommended that the owners obtain approximately 5 readings at 3 different BP sessions. The obtained readings were downloaded and saved for review by the investigator (AC) when the device was returned. Again, only the readings that showed minimal artefact were used for analysis in this study, with the rest considered unsuccessful attempts. For both OBP and HBP measurements, all successful readings were averaged to give a single measurement per individual.
Definitions and diagnostic threshold
White-coat hypertension (WCH) was defined as a systolic OBP of > 160 mmHg and a systolic HBP of < 160 mmHg. Masked hypertension was defined as a systolic HBP of > 160 mmHg and a systolic OBP of < 160 mmHg. A cutoff of 160 mmHg was selected as this is the threshold for intervention recommended by the ACVIM (4,5).
White-coat effect (WCE) is defined as any instances when OBP is greater than HBP. Since there are no established guidelines in veterinary medicine to define clinically significant WCE, a definition from human literature was referenced. A clinically significant WCE was defined as OBP > HBP by 20 mmHg systolic or 10 mmHg diastolic (14). It should be noted, however, that these criteria were established in human medicine with ambulatory blood pressure measurement as opposed to HBP measurement.
Statistical analysis
Statistical analyses were carried out using a commercial software (JMP Version 16; SAS Institute, Cary, North Carolina, USA) and included matched pair analysis of OBP and HBP as continuous variables via Bland-Altman plots.
Results
Animals
The dataset of 17 animals consisted of 10 cats and 7 dogs. Six of the cats were castrated males; the rest were spayed females. Two of the dogs were castrated males and the rest were spayed females. An additional 10 animals with unpaired HBP measurements were identified and included in the analysis of practicality of HBP measurements by owner only. The baseline information, including species, age, sex, and underlying disease associated with hypertension, are presented in the Supplementary Table.
Agreement between OBP and HBP measurements
Results of the OBP and HBP measurements are summarized in Table I. Matched pair analysis clearly shows that significantly higher systolic and diastolic values were measured in the clinic (Figures 1, 2). There was a mean difference of +27.7 mmHg (95% CI: 17.1 to 38.3 mmHg) and +12.9 mmHg (95% CI: 6.4 to 19.5 mmHg) for systolic and diastolic pressure, respectively. The null hypothesis of no difference between OBP and HBP is therefore rejected.
Table I.
Baseline characteristics (median and range) of blood pressure measurements.
| Variable | Median | Range |
|---|---|---|
| OBP (systolic) | 168 | 148 to 219 |
| OBP (diastolic) | 86 | 78 to 113 |
| HBP (systolic) | 149 | 119 to 191 |
| HBP (diastolic) | 85 | 60 to 107 |
OBP — Office blood pressure; HBP — Home blood pressure.
Note: All units in mmHg, millimeters of mercury.
Figure 1.
Matched pair analysis (Bland-Altman plots) comparing the difference between systolic office blood pressure (OBP) and home blood pressure (HBP). The dotted lines represent the 95% confidence levels of the differences, whereas the solid line represents the mean of the difference. The null hypothesis that there is no difference between systolic BP measurement at home or in the clinic was ruled out. (P < 0.0001).
Figure 2.
Matched pair analysis (Bland-Altman plots) comparing the difference between diastolic office blood pressure (OBP) and home blood pressure (HBP). The dotted lines represent the 95% confidence levels of the differences, whereas the solid line represents the mean of the difference. The null hypothesis that there is no difference between diastolic BP measurement at home or in the clinic was ruled out. (P = 0.0007).
Prevalence of white-coat hypertension, white-coat effect, and masked hypertension
A total of 7 animals (41% — 4 cats and 3 dogs) fit our definition of white-coat hypertension (WCH). No animal in the study population had the phenotype of masked hypertension. A clinically significant systolic white-coat effect (WCE) was identified in 11 of the patients, ranging from 23 to 61 mmHg, median 34 mmHg, and mean of 40 mmHg. Diastolic WCE was identified in 8 patients, ranging from 13 to 34 mmHg, median 28 mmHg, and mean of 24 mmHg.
Practicality of HBP measurement by owner
A total of 669 attempts to obtain HBP measurements by the owners was identified, with 261 (39%) of them considered to be successful. The median number of total attempts by an individual owner was 19 (range: 5 to 128). The median percentage of successful over unsuccessful attempts was 29% (range: 0% to 98%). Of the 27 owners who attempted to get HBP readings, 26 were successful in providing at least 1 reading with minimal artefact.
Post-hoc power analysis
Due to the small sample size used in this study, a post-hoc power analysis was carried out. Using the mean and standard deviation of the current dataset, with an alpha of 0.05, the current sample size would result in a power of 80.4%.
Discussion
The primary goal of this study was to analyze the presence of white-coat effect (WCE) and white coat hypertension (WCH) in a group of patients with either a disease known to be associated with hypertension and/or patients with signs of end-organ damage. These phenomena have been documented in small animals in a variety of studies.
With implanted telemetry in cats, the difference in blood pressure between a simulated office visit and a 24-hour average was 17.6 ± 1.5 mmHg; the WCE effect varied considerably, with results ranging from +75.3 to − 27.2 mmHg (15). Some of these studies had limitations that make them less applicable to patients that need accurate assessment of blood pressure status. As many of the studies were carried out on healthy animals, any hypertension diagnosed in clinic would most likely be a result of WCE/WCH (6–13).
In most of these studies, HBP was measured by an investigator (6,7,9–13). The predominant technology used in these studies was Doppler (6,7,9,10,12,13). It has been shown that, when this method is used, there are large differences in values attained based on the operator’s level of experience, which makes it not suited for HBP measurement by owners (16).
In the studies that used oscillometry (8,11), owners obtained the readings in addition to an investigator in only one (8). In healthy animals, there was no difference between results obtained at home, whether readings were taken by the owner or an investigator. A shortcoming of the studies that used oscillometry is that, with the equipment used, the oscillometric traces could not be verified to determine which readings were acceptable and which were erroneous because of machine settings or artefact.
Our data showed a statistically and clinically significant difference between OBP and HBP measurement. We detected WCE in 65% of our patients for systolic BP, with 41% of them meeting the definition of WCH. The white-coat effect was seen in 47% of our patients regarding diastolic blood pressure and WCH was present in 60% (3 of 5) of those patients diagnosed with diastolic hypertension. White-coat hypertension (WCH) is a common phenomenon in human patients, with a prevalence ranging from 10 to 20% (17). It is important to recognize WCH in order to avoid overestimating BP and unnecessarily prescribing medications (1,2).
Although initiating BP-lowering medications with WCH is not currently recommended in human guidelines, vigilant monitoring is recommended, as a large proportion of patients with WCH eventually develop sustained hypertension (2,18). It is not known at this point whether similar recommendations can be translated to veterinary medicine, as no studies have yet evaluated the long-term risk and clinical relevance of WCE/WCH in cats and dogs.
A proposed alternative to HBP measurement is to measure blood pressure repeatedly on multiple occasions so that the patient can acclimate to the procedure. The effect of repeating OBP measurements to eliminate the white-coat effect appeared to vary in canine patients, ranging from a gradual decrease and subsequent plateau after 14 d in a study with beagles, to a lack of change in retired racing greyhounds (8,19). In feline patients subjected to 5 simulated visits over a 6-week period, no apparent effect of repeating OBP on the magnitude of white-coat effect was identified (15).
Collectively, it appears that repeating OBP does not reliably eliminate white-coat effect in canine or feline patients and that HBP would be of more clinical value than repeating OBP. From a practical and financial standpoint, it could also be anticipated that HBP would have the additional benefits of reducing the professional time and labor required to carry out and repeat OBP on multiple occasions in busy clinical settings. It should be noted, however, that the time required to review the waveforms of HBP measurements would also contribute to the cost of such practice.
Another objective of our study was to look at the practicality of HBP and its success rate for owners who had limited training in obtaining blood pressure readings. As HBP techniques have to be easy for owners to master, oscillometric devices are preferred. We used the proportion of successful attempts to the number of overall attempts as a benchmark to evaluate the practicality of measuring HBP. The results were highly variable, ranging from 0 to 98% of attempts being successful. If the owner with a 0% success rate is considered an outlier, then the next data point with the lowest success rate would be 13%, which would translate to approximately every 8 attempts being successful. This should represent a relatively realistic goal for clients to measure their pet’s blood pressure at home. In fact, more than half (16 of 27) of the clients in the present study carried out more than the 15 HBP measurements that were verbally recommended to them. In our group of owners, HBP was successfully achieved in most of the patients. The data does show that many values obtained were erroneous, however, so it is unlikely that any useful clinical information would be obtained without the ability to verify the blood pressure trace.
One of the main drawbacks of HBP in humans is a tendency to become obsessive and take too many measurements, and reporting bias (20). This problem of obsession leading to multiple measurements was also present in our study population, with 27% of pet owners (7 out of 27) taking more than double (> 30) the recommended measurements and 1 owner registering a total of 128 attempts.
Although the clinical relevance of these findings should be minimal, it does indicate that some owners would repeat BP measurements much more than needed. Due to the retrospective nature of this study, it is also possible that this selected population of pet owners were highly motivated individuals, which subsequently contributed to the large number of measurements being taken at home. The problem of reporting bias can be eliminated with the use of a device with built-in memory, such as was used herein.
Potential limitations of using a high-definition oscillometry (HDO) blood pressure monitoring device in this study include the subjective interpretation of the tracing and its lack of validation in dogs. The first limitation could minimally affect the creditability of our results as they were interpreted by one investigator to eliminate possible inter-observer variation. The HDO monitor is the first and only noninvasive method for measuring blood pressure that is validated in cats according to the criteria defined by the ACVIM (21).
In a study that compared telemetry and HDO in purpose-bred beagles, a bias of 10.4 mmHg was reported for systolic BP measured by HDO compared with telemetry (22). This value was just above the cutoff of ± 10 mmHg required for validation, as recommended by the ACVIM. The authors noted that the variability between HDO and telemetric measurement may be partly attributed to the well-documented difference between central (telemetric) and peripheral (HDO) measurement (22). Although it is important to acknowledge these limitations, we believe that HDO measurement is the best available method for the purpose of our study due to its validation in cats, as well as its ability to provide a tracing for the investigator to review.
Other limitations of the present study include its small sample size, inherent retrospective design, and the use of convenient sampling, with the latter 2 limitations potentially leading to the capture of inaccurate data or missed data. Despite a post-hoc power analysis with a power of 80.4%, the small dataset did not allow potential differences in species to be detected. It was also not possible to verify protocols for HBP measurements, such as body position and cuff placement, that could contribute to the difference between HBP and OBP in the present study. Unlike the conventional practice of averaging multiple BP measurements to give a final reading, only a minimum of 1 verified reading, i.e., without artefact on tracing, was required for inclusion in this study.
We speculate that the common practice of repeating BP measurements in companion animals is heavily attributable to the limited availability of validated equipment and the observer’s lack of ability to determine whether a BP reading is subjected to artefacts. With repeated measurements, however, the observer has no objective way to judge whether the readings are indeed accurate. From an analytical standpoint, repeating measurements would only be expected to decrease the effect of random errors when the measurements were averaged out, but not when there is systematic error.
Further study is required to confirm whether having the ability to evaluate the oscillometric tracing with the use of HDO would eliminate the need for repetitive BP measurements. As a result, it should be noted that repeating BP measurements should still be recommended as a common practice until further studies provide more insight into our speculation. In addition, as the clients in this study were probably highly motivated pet owners, the perceived practicality of monitoring blood pressure at home may not necessarily apply to the general population of owners.
In conclusion, our results documented a clinically significant lack of agreement between OBP and HBP, which was attributed to a high prevalence of WCE/WCH in the study population. Home blood pressure (HBP) measurement is a practical method for measuring blood pressure and should be encouraged to reduce the likelihood of unwarranted diagnosis of hypertension and unnecessary medical interventions in the form of prescriptions for medications or diagnostics to lower blood pressure.
Supplementary Information
Supplementary table.
Baseline information including species, age, sex, and underlying disease associated with hypertension in the study population.
| Species (feline/canine) | Age at time of visit (y) | Sex (male castrated, MC/female spayed, FS) | Underlying disease associated with hypertension |
|---|---|---|---|
| Feline | 14 | MC | Chronic kidney disease |
| Feline | 8 | MC | Chronic kidney disease, hyperthyroidism |
| Feline | 12 | MC | Hyperthyroidism |
| Feline | 17 | MC | Chronic kidney disease |
| Feline | 12 | FS | Chronic kidney disease |
| Feline | 18 | FS | Chronic kidney disease, hyperthyroidism |
| Feline | 10 | MC | Hyperthyroidism |
| Feline | 11 | FS | Chronic kidney disease, hyperthyroidism |
| Feline | 16 | MC | Chronic kidney disease, hyperthyroidism |
| Feline | 25 | FS | Chronic kidney disease, hyperthyroidism |
| Canine | 9 | FS | Hyperadrenocorticism |
| Canine | 13 | MC | Chronic kidney disease |
| Canine | 11 | FS | Chronic kidney disease |
| Canine | 11 | FS | Chronic kidney disease |
| Canine | 12 | FS | Glomerulonephritis |
| Canine | 8 | FS | Chronic kidney disease |
| Canine | 11 | MC | Hyperadrenocorticism |
Acknowledgments
S+B MedVet donated some of the blood pressure units that were used in this study to Anthony Carr. Koo, Siu To declares that there is no resulting conflict of interest.
Footnotes
Part of the data from this work was presented in the form of Abstracts at the European College of Veterinary Internal Medicine Forum 2011 and the American College of Veterinary Internal Medicine Forum 2012.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary table.
Baseline information including species, age, sex, and underlying disease associated with hypertension in the study population.
| Species (feline/canine) | Age at time of visit (y) | Sex (male castrated, MC/female spayed, FS) | Underlying disease associated with hypertension |
|---|---|---|---|
| Feline | 14 | MC | Chronic kidney disease |
| Feline | 8 | MC | Chronic kidney disease, hyperthyroidism |
| Feline | 12 | MC | Hyperthyroidism |
| Feline | 17 | MC | Chronic kidney disease |
| Feline | 12 | FS | Chronic kidney disease |
| Feline | 18 | FS | Chronic kidney disease, hyperthyroidism |
| Feline | 10 | MC | Hyperthyroidism |
| Feline | 11 | FS | Chronic kidney disease, hyperthyroidism |
| Feline | 16 | MC | Chronic kidney disease, hyperthyroidism |
| Feline | 25 | FS | Chronic kidney disease, hyperthyroidism |
| Canine | 9 | FS | Hyperadrenocorticism |
| Canine | 13 | MC | Chronic kidney disease |
| Canine | 11 | FS | Chronic kidney disease |
| Canine | 11 | FS | Chronic kidney disease |
| Canine | 12 | FS | Glomerulonephritis |
| Canine | 8 | FS | Chronic kidney disease |
| Canine | 11 | MC | Hyperadrenocorticism |