Under pressure: A survey of Canadian veterinarians in the diagnosis and treatment of feline hypertension

Abstract

Objectives

The objectives of this study were to explore feline hypertension diagnostics and treatment practices among Canadian veterinarians and to identify barriers to recommending blood pressure monitoring in senior (> 7 y) feline wellness patients.

Procedure

An online survey was developed and circulated by CommuniVET using email and social media.

Results

A total of 114 Canadian veterinarians completed the survey. Most respondents indicated that they either do not recommend (n = 45; 39.5%) or occasionally recommend (n = 47; 41.2%) blood pressure monitoring in senior (> 7 y) feline wellness examinations. The most frequently reported barriers to recommending a blood pressure evaluation were the difficulty in interpreting results in stressed patients (n = 87; 76.3%), time involved in obtaining blood pressure (n = 73; 64.0%), and cost to the owner (n = 54; 47.4%). When faced with a patient diagnosed with a comorbidity commonly associated with hypertension, most respondents indicated that they always recommend (n = 38; 33.3%) or frequently recommend (n = 27; 23.7%) blood pressure monitoring. Most veterinarians’ first line treatment for hypertension was amlodipine for primary (n = 81; 71.1%) and secondary (n = 39; 34.2%) hypertension.

Conclusion

Most veterinarians did not routinely recommend blood pressure evaluation during senior feline wellness examinations. Although the frequency of recommendation for blood pressure monitoring appeared to be better in patients diagnosed with a comorbidity associated with hypertension, there was a substantial shortfall.

Clinical relevance

This study identified the most common barriers to recommending blood pressure monitoring in senior feline wellness examinations. Normalizing blood pressure monitoring as part of a routine examination in senior feline patients may lead to increased intervention for hypertension and improved outcomes.

Introduction

Hypertension, or systemic arterial hypertension, is commonly referred to as the “silent killer.” Sustained elevations in blood pressure can lead to devastating and often irreversible target organ damage (TOD) affecting the eyes, heart, brain, and kidneys. In many cases, unless a patient is demonstrating clinical signs consistent with TOD, there are no pathognomonic clinical signs of hypertension or they are often attributed to aging (1). Once a patient is diagnosed with hypertension, it can be categorized into 1 of 3 types. Idiopathic hypertension typically occurs in the absence of other disease, pathology, or therapeutic agents associated with blood pressure variations. Secondary hypertension is associated with a disease that increases systolic blood pressure, most commonly chronic kidney disease (CKD) or hyperthyroidism. Situational hypertension is a temporary elevation in blood pressure due to environmental or situational stressors in a patient that is otherwise normotensive (1).

A recent publication by Sparkes et al (2) evaluated data from single blood pressure assessments in 8884 feline patients > 7 y old, as reported by primary veterinarians internationally. Results indicated that 35.1% of surveyed patients with no reported disease, 45.9% of patients with CKD and 50.4% of patients with hyperthyroidism were in American College of Veterinary Internal Medicine (ACVIM) categories of hypertensive or severely hypertensive, necessitating additional evaluation. In another study, 13% of 141 hypertensive client-owned cats (> 9 y) enrolled in a study evaluating effects of blood pressure control in patient survival were non-azotemic and euthyroid (3). In feline patients diagnosed with CKD, study prevalence of hypertensive patients ranged from 29.1 to 61% (4,5). Finally, some studies reported that 10% of newly diagnosed feline hyperthyroid patients were hypertensive, and an additional 23% of previously normotensive feline patients developed hypertension after treatment for hyperthyroidism (6,7). Age appears to be an important predisposing factor for development of systemic hypertension in feline patients (8).

It is widely recommended that screening for hypertension be done on a regular basis to prevent or minimize TOD. The International Society of Feline Medicine (ISFM) and the ACVIM have recently published readily available consensus statements and guidelines on the diagnosis and treatment of feline hypertension (1,9). Most recently, the American Association of Feline Practitioners (AAFP) developed a readily available toolkit for veterinarians in the diagnosis and management of patients with feline hypertension (10).

Feline hypertension is theorized to be vastly underdiagnosed. In a study by Conroy et al (11) of cats attending 244 United Kingdom primary care practices, only 2.8% of hypertensive patients were diagnosed at their geriatric health examinations. Unpublished results of the Conroy et al (11) study also reported that based on review of the electronic records, only 2% of cats have their blood pressure measured during routine veterinary consultations. In a recent survey by Navarro et al (12), of 733 first-opinion small animal veterinarians who see cats in their practice and have access to at least one non-invasive blood pressure device, 49.5% of respondents made recommendations to an owner that blood pressure be measured at least once weekly, 32.1% at least once a month, and 16.4% once every few months. The survey respondents also indicated that most (92.0%) made the recommendation to measure blood pressure in cats with a disease that predisposes them to hypertension, whereas 27.0% recommended it for healthy cats > 7 y of age. Otherwise, literature regarding veterinarian recommendations concerning screening for and treating feline hypertension remains sparse.

The objectives of this study were to explore Canadian veterinarians’ feline hypertension diagnostics and treatment practices in comparison to recommended guidelines and consensus statements, in addition to identifying barriers to recommending blood pressure monitoring in senior feline wellness patients.

Materials and methods

Study population

The target study population was veterinarians practicing in Canada who treat feline patients. To target Canadian veterinarians, a collaborative effort was undertaken with CommuniVET to distribute the electronic survey (13). The survey was available in both French and English.

Survey design and distribution

The survey was comprised of 16 questions divided into the following sections:

1. demographic information;

2. hypertension diagnostics; and

3. hypertension treatment.

All questions were multiple choice, with some having the option for multiple responses. On several questions, respondents had the opportunity to further clarify when selecting ‘other’ or ‘it depends.’ For this survey, respondents were informed that senior feline patients were considered those > 7 y of age. The survey is available as supplementary material (online from www.canadianveterinarians.net).

The survey was open from August 5 to 20, 2021 and was distributed by email to CommuniVET members and through social media. Email reminders to CommuniVET members were sent on August 10th and 17th, 2021. Participants were able to withdraw at any point. Ten, $50 gift cards were offered as an incentive for participation, with winners randomly chosen by ballot.

Statistical analyses

Survey data were automatically generated as a table in Excel (Microsoft Office 365 ProPlus, Toronto, Ontario, Canada) from the SurveyMonkey (SurveyMonkey, USA) report. An independent observer from CommuniVET manually double-checked the data from SurveyMonkey results. Respondents who selected that they did not practice in Canada were excluded from all analyses. Chi square/Fisher’s Exact test and Kruskal-Wallis were used to assess the presence of statistically significant associations among variables. Independent variables evaluated include the numbers of years in practice, the type of practice, being in feline-exclusive practice, access to tools to measure blood pressure in the examination room or treatment area outside of general anesthesia, and the type of tool used to routinely measure systolic blood pressure. Dependent variables evaluated included each individual potential barrier identified to recommending blood pressure evaluation in senior feline wellness examinations, and the recommendation to evaluate blood pressure monitoring in feline patients with comorbidities associated with hypertension. One variable, the recommendation of blood pressure evaluation in senior feline wellness examinations, was evaluated as both a predictor and an outcome variable. Statistical analyses were performed using SAS (Version 9.2; SAS Institute, Cary, North Carolina, USA). For all statistical tests, P < 0.05 was considered significant.

Results

A total of 121 respondents fully completed the survey. Seven respondents indicated that they did not practice in Canada and were excluded, resulting in 114 qualified respondents.

Respondent demographics

Respondent demographic information is presented in Table 1. Most survey respondents selected that they worked as general practitioners, with a large portion living in Ontario. Other types of practices identified by respondents that did not fall into one of the answer categories included teaching hospitals and mixed animal practice.

Table 1.

Demographic characteristics of Canadian veterinarians (N = 114) responding to a survey on feline hypertension diagnostics and treatment.

Characteristic	Choice	Number of respondents (%)
Current province of practice	Alberta	15 (13.2)
	British Columbia	14 (12.3)
	Manitoba	1 (0.9)
	New Brunswick	3 (2.6)
	Newfoundland and Labrador	5 (4.4)
	Northwest Territories	0 (0)
	Nova Scotia	7 (6.1)
	Nunavut	0 (0)
	Ontario	47 (41.2)
	Prince Edward Island	3 (2.6)
	Quebec	17 (14.9)
	Saskatchewan	2 (1.8)
	Yukon	0 (0)
Years in practice	< 1	0 (0)
	1 to 5	14 (12.3)
	6 to 10	17 (14.9)
	> 10	83 (72.8)
Type of practice	General medicine	94 (82.5)
	Emergency medicine	9 (7.9)
	Referral practice	3 (2.6)
	Other	8 (7.0)
Feline-exclusive practice	Yes	8 (7.0)
	No	106 (93.0)

Hypertension diagnostics

The majority, or 88.6% (n = 101) of respondents indicated that they have access to a tool to measure arterial systolic blood pressure outside of general anesthesia monitoring. Among respondents, 50.9% (n = 58) reported that their clinic used oscillometric techniques to obtain routine measurements of feline patient’s blood pressure, whereas 40.4% (n = 46) reported using Doppler ultrasound. The remainder, or 8.8% (n = 10) of respondents selected that they did not know.

When asked who routinely measures blood pressures in the clinic, most survey respondents (84.2%, n = 96) selected a registered veterinary technician. Otherwise, 10.5% (n = 12) of respondents reported that it was performed by veterinarians, and 5.3% (n = 6) selected ‘other.’ Some of the clarifications provided by respondents who selected ‘other’ noted that the clinic uses veterinary assistants or trains owners to do their own pet’s blood pressure at home.

When respondents were asked approximately what percentage of the time they recommend blood pressure evaluation during annual or wellness examinations in feline patients > 7 y of age, 39.5% (n = 45) of veterinarians responded that they never recommend it, and another 41.2% (n = 47) recommended it approximately 25% of the time (Figure 1).

Figure 1.

Survey respondents’ reported approximate frequency of recommending systolic blood pressure in feline patients in senior (> 7 y) feline wellness examinations, and when diagnosing a co-morbidity associated with hypertension.

Respondent veterinarians were also surveyed as to what are the barriers to recommending blood pressure monitoring during wellness examinations in feline patients > 7 y of age. Respondents could select more than 1 option. The most frequently selected barriers included the difficulty of interpreting results in stressed patients (76.3%, n = 87), the time involved in obtaining blood pressure measurements (64.0%, n = 73), and cost to the owner (47.4%, n = 54). Full results are presented in Figure 2. Out of all survey respondents, 8.8% (n = 10) respondents selected “other” and provided additional barriers such as resistance of staff to do it, and lack of a consistent and easy to use piece of equipment on the market to obtain blood pressure readings. Multiple statistically significant associations were identified between predictor and outcome (Table 2). Only predictor variables with statistically significant associations are in the table. Of note, veterinarians who identified as practicing in referral practices were less likely to select cost to the owner (P = 0.04) or time involved (P = 0.03) as barriers to recommending blood pressure monitoring in senior feline wellness examinations. Respondents who selected that they are in feline-exclusive practices were less likely to respond that difficulty to interpret results in stressed cats as a barrier (P < 0.001). Veterinarians that did not recommend blood pressure evaluation in senior feline wellness exams were more likely to report the time involved as a potential barrier (P < 0.001).

Figure 2.

Survey respondents’ frequencies to potential barriers in measuring blood pressure frequencies in senior (> 7 y) feline wellness examinations.

Table 2.

Associations between variables of Canadian veterinarians (N = 114) responding to a survey on the diagnosis and treatment of feline hypertension.

Independent variable	Dependent variable	P-value
Type of practice	Recommend evaluation of blood pressure in senior feline wellness examinations	0.06
	Cost to the ownera	0.04
	Time involveda	0.03
	Not necessarya	0.75
	Causes too much stress for patientsa	0.87
	Difficult to interpret in stressed patientsa	0.47
	Lack of staff traininga	0.27
	Lack of equipmenta	0.22
	Recommend evaluation of blood pressure in feline patients with comorbidities associated with hypertension	0.10
Feline-exclusive practice	Recommend evaluation of blood pressure in senior feline wellness examinations	0.16
	Cost to the ownera	1
	Time involveda	0.46
	Not necessarya	0.41
	Causes too much stress for feline patientsa	1
	Difficult to interpret in stressed feline patientsa	< 0.001
	Lack of staff traininga	1
	Lack of equipmenta	0.60
	Recommend evaluation of blood pressure in feline patients with comorbidities associated with hypertension	0.37
Access to tool to measure systolic blood pressure outside of general anesthesia	Recommend evaluation of blood pressure in senior feline wellness examinations	0.09
	Cost to the ownera	0.02
	Time involveda	0.22
	Not necessarya	0.58
	Causes too much stress for patientsa	1
	Difficult to interpret in stressed patientsa	1
	Lack of staff traininga	0.04
	Lack of equipmenta	< 0.001
	Recommend evaluation of blood pressure in feline patients with comorbidities associated with hypertension	0.001
Recommend evaluation of blood pressure in senior feline wellness examinations	Cost to the ownera	0.28
	Time involveda	< 0.001
	Not necessarya	0.81
	Causes too much stress for patientsa	0.57
	Difficult to interpret in stressed patientsa	0.37
	Lack of staff traininga	0.78
	Lack of equipmenta	0.36
	Recommend evaluation of blood pressure in feline patients with comorbidities associated with hypertension	< 0.001

Significance declared at P < 0.05.

^aBarriers to measuring blood pressure during senior (> 7 y) feline wellness examinations.

Respondents were asked approximately what percentage of the time they recommended blood pressure evaluation in a feline patient diagnosed with a comorbidity that is associated with hypertension, such as CKD or hyperthyroidism. Results are presented in Figure 1. In this case, 33.3% (38/114) indicated that they recommend blood pressure evaluation 100% of the time.

Surveyed veterinarians were asked to rank various patient, client, and clinic factors in their importance when considering recommending blood pressure monitoring in feline patients. Respondents could rate each factor from 1 (very important) to 10 (not important) (Table 3).

Table 3.

Median and interquartile range (IQR) of each factor in the decision to recommend blood pressure monitoring, ranging from 1 (very important) to 10 (not important) in cats.

Factor	Median (IQR)
Presence of proteinuria	2 (1 to 4)
Target organ damage (retinal detachment, cardiac changes, neurological clinical signs)	1 (1 to 1)
Presence of co-morbidity typically associated with hypertension (e.g., CKD, hyperthyroidism)	2 (1 to 3)
Age of the cat	4 (3 to 6)
Ease of performing the procedure on the patient	3 (2 to 5)
Availability of trained staff	3 (1 to 5)
Ability of the cat owner to administer the treatment	3 (2 to 5)
Cost of procedure	5 (3 to 7)
Cost of treatment	5 (3 to 7)
Cost of subsequent monitoring	5 (3 to 7)

Hypertension treatment

In treatment of primary hypertension, most survey respondents selected amlodipine as a first line of treatment (71%, n = 81), distantly followed by angiotensin-converting enzyme (ACE) inhibitors (14.0%, n = 16; Figure 3). Other options provided by respondents included that the first line of treatment selected was the cheapest option available, or that it was based on the severity of the hypertension. When practitioners were faced with a hypertensive feline patient diagnosed with secondary hypertension (with or without proteinuria), responses varied widely. In the survey, 34.2% (n = 39) of respondents selected amlodipine, followed by 28.9% (33/114) of respondents selecting telmisartan (see Figure 3). Many respondents (20.9%, 23/114) selected ‘other’ or ‘it depends.’ The clarifications for this selection included: initial treatment selection depends on the co-morbidity diagnosed; patients are referred to internal medicine for a treatment plan; wait to treat with amlodipine to see if treating the comorbidity decreases the blood pressure; depending on presence or absence of proteinuria; depends on the cost; and ability of the owner to medicate with tablets or liquid.

Figure 3.

Survey respondents’ frequencies to first line of treatment when diagnosing a feline patient with primary hypertension, or secondary hypertension, with or without proteinuria.

In determining a treatment plan for feline hypertension, most (66.7%, n = 76) of the respondents selected International Renal Interest Society guidelines. This was followed by 12.3% (n = 14) of respondents selecting ACVIM consensus guidelines, 12.3% (n = 14) selecting ‘none,’ and 3.5% (n = 4) selecting ISFM guidelines. In addition, 5.3% (n = 6) of respondents selected ‘other,’ which included AAFP guidelines, textbooks, and the Veterinary Information Network.

When treating feline hypertension, most respondents (65.8%, n = 75) indicated that they never initiate antihypertensive therapy without a blood pressure measurement. Furthermore, 34.2% (n = 39) of respondents have started antihypertensive therapy without a blood pressure measurement in varying frequencies, with 5.3% (n = 6) doing so 100% of the time.

Once a feline hypertension patient is treated and becomes normotensive, 45.6% (n = 52) advise rechecking blood pressure every 6 mo, 38.6% (n = 44) recommend every 3 mo, and 10.5% (n = 12) recommend it annually. A further 2.6% (n = 3) of respondents do not recommend rechecking blood pressure once a patient has become normotensive. In addition, 2.6% of patients selected ‘other’ and clarified that the frequency advised was based on the underlying condition.

Discussion

Based on this study’s results, it appeared that Canadian veterinarians are likely to recommend blood pressure monitoring in feline patients diagnosed with co-morbidities associated with hypertension. Unfortunately, most respondents are not recommending blood pressure monitoring in an increasingly recognized susceptible segment of the population, namely senior feline patients. This finding reinforced the notion that feline hypertension is a commonly underdiagnosed pathology.

Most Canadian veterinarian respondents indicated that they had access to a tool to measure blood pressure in the examination room, or treatment room, outside of general anesthesia monitoring for ease of use, yet this was not associated with an increase in recommending blood pressure evaluation in senior feline patients. A little over half of respondents indicated that oscillometric devices were used to measure feline blood pressure, followed by Doppler ultrasound. These results were somewhat similar to a report that 48.5% of blood pressure measurements were obtained using oscillometric devices and 47.4% were done using Doppler ultrasound (2). Collectively, these results appeared to indicate that use of either category of devices is common with an almost equal distribution.

Similar to Navarro et al (12), our survey respondents identified that veterinary technicians were the most common individuals to perform blood pressure measurements, followed by veterinarians. This was not surprising, given that veterinary technicians are often the veterinary staff member to perform many diagnostic tests while veterinarians are attending to other patients or working on other tasks such as interpreting diagnostics or defining treatment plans. One respondent clarified that they train clients to assess their pet’s blood pressure at home. Although this might initially raise concern for reliability of readings, it may be an alternative to overcome the common concern for situational hypertension in the clinic setting. Unpublished studies using small sample sizes have preliminarily evaluated the results of at-home blood pressure measurements by owners compared to those taken in-clinic, with potentially promising results (14–16).

Current guidelines and consensus statements recommend instituting annual screening of healthy senior feline patients for hypertension (> 7 to 9 y of age) (1,9,10). Unfortunately, only 6.1% of our survey respondents selected that they recommend blood pressure screening 100% of the time in senior feline wellness examinations. Similarly, Navarro et al (12) reported that only 27% of their survey respondents routinely measured blood pressure in these cats; however, it is uncertain what the frequency was for “routine” recommendation. To better understand this discrepancy, our survey enquired about potential barriers to recommending blood pressure monitoring in senior feline wellness examinations. Not surprisingly, the most selected barrier was the difficulty in interpreting results in stressed patients. This was attributed to the concern of falsely diagnosing hypertension in a cat with situational hypertension. This objection was also the most selected barrier in Navarro et al (12). There has been a recent focus on the importance of reducing fear, anxiety, and stress in veterinary patients, and how it can impact the quality of care performed. Veterinarians are now very aware of this phenomenon. This highlights the importance of obtaining multiple blood pressure measurements, at separate visits, while using techniques to reduce situational hypertension, as discussed in the feline hypertension toolkits (9,10). Other barriers selected included the time involved and the cost to the owner. This survey was distributed in the height of a pandemic during which many veterinary clinics were doing curbside appointments. Curbside service is less efficient, and many veterinarians likely shifted their focus away from preventative medicine due to a lack of time. The cost to the owner is an ongoing concern in veterinary medicine. Combined with the recommended annual or semi-annual wellness bloodwork and urinalysis in senior patients, the added cost of blood pressure monitoring may not be financially feasible for some. This is where wellness plans and incorporating blood pressure monitoring as a routine vital and part of every appointment, such as in human medicine, may be of great benefit.

When respondents were surveyed about how often they recommend blood pressure monitoring in patients diagnosed with a comorbidity associated with hypertension, a different trend emerged than during senior wellness appointments, with more veterinarians recommending it. This was more in line with consensus and guideline recommendations. However, 24.6% of survey respondents only recommended blood pressure monitoring 25% of the time, and 1.8% indicated that they do not recommend it. This was similar to the Navarro et al (12) study in which 92% of responders made recommendations based on their feline patient having a disease that predisposes them to hypertension. Although it is encouraging that veterinarians appear to recommend blood pressure monitoring more frequently when associated comorbidities are diagnosed, with the high prevalence of hypertension in feline patients with CKD and hyperthyroidism, we are still missing many patients in whom early intervention could improve their quality of life. The most important considerations in the decision to recommend blood pressure monitoring in this survey were similar to those in Navarro et al (12); the presence of TOD and co-morbidities associated with hypertension. This is likely why our survey identified that more veterinarians selected they recommend blood pressure measurement when associated comorbidities are diagnosed. In our survey, proteinuria was an important consideration in recommending blood pressure monitoring. The presence of proteinuria is an important risk factor for the progression of CKD and is associated with a decrease in survival time (3,17–19). Furthermore, in cats with CKD, proteinuria occurs more often in hypertensive cats than those that are normotensive (17). Survey respondents appeared knowledgeable regarding the importance of hypertension in the presence of proteinuria.

For treatment of feline hypertension, survey respondents indicated that amlodipine was usually the first-line treatment for primary or secondary hypertension. This was in agreement with the ACVIM consensus statement and ISFM consensus guideline’s recommendations (1,9). In the treatment of primary hypertension, the second most selected option (far behind amlodipine) were ACE inhibitors. This was interesting, as ACE inhibitors are not recommended as a first-line antihypertensive treatment in cats (1,9). For secondary hypertension, the second most selected first-line treatment was telmisartan; this may have been frequently selected as there is a veterinary-labelled telmisartan for controlling systemic hypertension in cats in the United States. A few respondents selected that the first-line treatment option for secondary hypertension depended on the presence of proteinuria, using amlodipine if not present, and either telmisartan or ACE inhibitors if present. Although it is not an on-label indication in Canada, amlodipine has been shown to decrease proteinuria when used in the treatment of hypertension in feline patients with CKD (3). A few respondents indicated that they first treat the comorbidity, before rechecking blood pressure and treating if still hypertensive. Although treating the comorbidity may decrease systemic blood pressure, most cases fail to become normotensive and due to the continued risk of development of TOD, it is recommended that the hypertension be treated at diagnosis instead of waiting until the underlying condition has been controlled (1).

Approximately 1/3 of respondents indicated that they have started antihypertensive therapy without a blood pressure measurement. This is of concern for several reasons. Firstly, not having a baseline blood pressure leads to difficulty in monitoring response to therapy. Secondly, all therapies have potential adverse effects. Therefore, subjecting a patient to a treatment or medication that is not necessary exposes the patient to potential adverse effects while also adding to the cost of treatment for the owners.

Most survey respondents indicated that once blood pressure is controlled after the treatment of feline hypertension, recommendations are made to monitor blood pressure every 3 to 6 mo, in line with current recommendations. The ISFM guidelines advise rechecking blood pressure at least every 3 mo, whereas the ACVIM consensus statements recommend rechecking at 4 to 6 mo intervals (1,9). These blood pressure rechecks should be done in conjunction with monitoring the improvement or progression of TOD by performing an ophthalmic examination, neurological assessment, and cardiac auscultation, in addition to appropriate laboratory testing.

Interestingly, the respondents’ years in practice and type of blood pressure tool used were not associated with a difference in the likelihood of recommending blood pressure evaluation in senior feline wellness examinations, when diagnosing comorbidities associated with hypertension, or in identifying barriers to recommending blood pressure evaluation during senior wellness examinations. Not surprisingly, respondents that identified as practicing in a referral center were less likely to identify cost to the owner, and the time involved as barriers to recommending blood pressure monitoring during senior feline wellness examinations. Depending on the service, referral centers may have longer scheduled appointment times, more support staff to perform these diagnostic procedures, and clients often expect or are aware that they will be paying more for their services. Veterinarians who identified as being in feline-exclusive practice were less likely to identify the difficulty of interpreting results in a stressed patient as a barrier to recommending blood pressure monitoring in senior feline wellness examinations. Feline-exclusive veterinarians may be more comfortable handling fearful or anxious feline patients and may have more strategies to reduce the risk of situational hypertension. Not surprisingly, lack of a tool to measure blood pressure outside of general anesthesia was associated with a lower likelihood of recommending blood pressure monitoring when diagnosing a comorbidity and in senior feline wellness examinations (although not statistically significant). If a practice only has tools in the surgery suites or only available for general anesthesia, there may be times during which a patient’s blood pressure cannot be obtained due to surgeries being performed. This would result in the patient having to wait or return on a different date to get their blood pressure reading, which may discourage veterinarians from recommending it. Most importantly, there was a strong statistically significant association between veterinarians who recommended blood pressure monitoring during senior feline wellness examinations, and those who recommended blood pressure evaluation in feline patients with comorbidities associated with hypertension. This may be due to veterinarians being more aware or the concerns associated with untreated hypertension or being more comfortable recommending it and performing it due to having done it more routinely.

There are several limitations regarding extrapolating results from this survey. First, results should be interpreted cautiously due to the limited power of analysis with our relatively small sample size. In addition, although our survey respondent’s current province of practice (Table 1) appeared somewhat well-distributed according to the general population of veterinarians, there is potential for the survey sample population to not be representative of the general population due to self-selection bias, and the inability to calculate a response rate (20). It is believed that the self-selection bias may be limited based on the overall response and the fact that many survey respondents indicated that they do not recommend blood pressure evaluation in senior wellness examinations. Survey respondents were not questioned on the type of oscillometric device primarily used for routine blood pressure monitoring in cats. These data would have facilitated additional comparisons with other manuscripts. Finally, the survey was sponsored by Ceva Animal Health, a manufacturer of a veterinary-licensed feline hypertension treatment. It is noteworthy that the survey was distributed and completed before there was any knowledge in the market or the veterinary population that this drug would be available to the Canadian population in the future.

In conclusion, a survey of Canadian veterinarians identified that there remain significant barriers to recommending blood pressure monitoring in senior feline wellness examinations, as recommended by multiple veterinary organizations and expert consensus. Potential implications of this finding include missed opportunities for early intervention of feline hypertension, the potential for development of irreversible TOD affecting patient quality of life, and costs associated with the treatment of certain TOD. The most often identified barriers to making this recommendation were the difficulty in interpreting results in stressed patients and the time involved. These 2 barriers need to be the area of focus for future continuing education opportunities and veterinarians should be made aware of readily available resources. The AAFP’s Hypertension Educational Toolkit and ISFM Hypertension Toolkit are resources to help become comfortable in performing this procedure, while also learning how to create an optimal environment to reduce the risk of situational hypertension (10,21). More research is needed in the accuracy of at home monitoring of blood pressure by pet owners as a potential alternative to in-clinic monitoring which could help alleviate the 2 most often identified barriers in this survey. Surveyed veterinarians were more likely to recommend blood pressure evaluation when patients were diagnosed with a comorbidity associated with hypertension; however, it is recommended to be done at every diagnosis; antihypertensive therapy should not be started without a proper diagnosis of hypertension. Most veterinarians followed consensus and guideline recommendations in selection of antihypertensive treatment and follow-up monitoring (1,9,10).