Assessment of hypertension in 40 cats with left ventricular hypertrophy by Doppler-shift sphygmomanometry

Increased insulin-like growth factor 1 concentrations in a retrospective population of non-diabetic cats diagnosed with hypertrophic cardiomyopathy

OBJECTIVES

The aim of the study was to document whether a proportion of non-diabetic cats with left ventricular hypertrophy (LVH) previously diagnosed with hypertrophic cardiomyopathy (HCM) have elevated circulating insulin-like growth factor 1 (IGF-1) concentrations.

METHODS

A retrospective analysis of residual blood samples obtained at the time of echocardiographic diagnosis of HCM from a population of 60 non-diabetic cats were analysed for circulating IGF-1 concentrations using a validated radioimmunoassay and compared with a control group of 16 apparently healthy cats without LVH. Clinical and echocardiographic data for cats with an IGF-1 level >1000 ng/ml were compared with those with an IGF-1 level <800 ng/ml.

RESULTS

In total, 6.7% (95% confidence interval 1.8-16.2%) of cats with HCM had an IGF-1 level >1000 ng/ml. The prevalence of an IGF-1 level >1000 ng/ml in the control group was zero.

CONCLUSIONS AND RELEVANCE

A small proportion of non-diabetic cats previously diagnosed with HCM had an IGF-1 concentration at a level that has been associated with feline hypersomatotropism (fHS) in the diabetic cat population. Further prospective research is required to confirm or refute the presence of fHS in non-diabetic cats with LVH and increased IGF-1.

Hypertension: Why Is It Critical?

Hypertension is a common problem, particularly in older cats. Hypertension secondary to a concurrent disease is the most common form of hypertension in cats, particularly in association with chronic kidney disease or hyperthyroidism. However, idiopathic hypertension may account for up to 24% of cases. Any form of persistent hypertension risks target organ damage (TOD), therefore measurement of blood pressure is vital in at-risk cats to identify occult hypertension before TOD occurs. This article addresses when and how to perform blood pressure measurement in cats, TOD that has been documented in this species, and our evidence basis for treating hypertension.

ACVIM consensus statement: Guidelines for the identification, evaluation, and management of systemic hypertension in dogs and cats

An update to the 2007 American College of Veterinary Internal Medicine (ACVIM) consensus statement on the identification, evaluation, and management of systemic hypertension in dogs and cats was presented at the 2017 ACVIM Forum in National Harbor, MD. The updated consensus statement is presented here. The consensus statement aims to provide guidance on appropriate diagnosis and treatment of hypertension in dogs and cats.

ISFM Consensus Guidelines on the Diagnosis and Management of Hypertension in Cats

Practical relevance:

Feline hypertension is a common disease in older cats that is frequently diagnosed in association with other diseases such as chronic kidney disease and hyperthyroidism (so-called secondary hypertension), although some cases of apparent primary hypertension are also reported. The clinical consequences of hypertension can be severe, related to ‘target organ damage’ (eye, heart and vasculature, brain and kidneys), and early diagnosis followed by appropriate therapeutic management should help reduce the morbidity associated with this condition.

Clinical challenges:

Despite being a common disease, routine blood pressure (BP) monitoring is generally performed infrequently, probably leading to underdiagnosis of feline hypertension in clinical practice. There is a need to: (i) ensure BP is measured as accurately as possible with a reproducible technique; (ii) identify and monitor patients at risk of developing hypertension; (iii) establish appropriate criteria for therapeutic intervention; and (iv) establish appropriate therapeutic targets. Based on current data, amlodipine besylate is the treatment of choice to manage feline hypertension and is effective in the majority of cats, but the dose needed to successfully manage hypertension varies between individuals. Some cats require long-term adjuvant therapy and, occasionally, additional therapy is necessary for emergency management of hypertensive crises.

Evidence base:

These Guidelines from the International Society of Feline Medicine (ISFM) are based on a comprehensive review of the currently available literature, and are aimed at providing practical recommendations to address the challenges of feline hypertension for veterinarians. There are many areas where more data is required which, in the future, will serve to confirm or modify some of the recommendations in these Guidelines.

Hypertrophic cardiomyopathy. Clinical and pathologic correlates

Hypertrophic cardiomyopathy is a primary myocardial disease with a wide range of clinical and morphologic characteristics. It is characterized by increased cardiac mass associated with a non-dilated, hypertrophied left ventricle. Phenotypic variability is substantial and includes both diffuse and segmental forms of left ventricular hypertrophy. Histopathologic features consist of myofiber disorganization, intramural arteriosclerosis, and pathologic fibrosis and matrix connective tissue. Associated functional derangements include dynamic obstruction to left and right ventricular outflow and diastolic dysfunction, including heart failure.

Spectrum of M-mode echocardiographic abnormalities in 75 cats with systemic hypertension

A retrospective study was performed in 75 hypertensive cats to determine the spectrum and frequency of M-mode echocardiographic abnormalities. Results indicated that 21.3% of the cats had M-mode measurements within normal reference ranges. For cats with echocardiographic abnormalities, changes were variable. Thirty-nine percent of hypertensive cats had hypertrophy of the interventricular septum in diastole, and 41.3% had hypertrophy of the left ventricular (LV) posterior wall in diastole. One cat in five had a dilated left atrium, while fractional shortening and LV internal dimension in diastole were normal in 82.7% and 86.7% of the cats, respectively. The marked variability of echocardiographic findings in hypertensive cats made echocardiography an unreliable screening test for hypertension.

Systolic Blood Pressure of Clinically Normal and Conscious Cats Determined by an Indirect Doppler Method in a Clinical Setting

The purposes of the present study were to determine the systolic blood pressure (SBP) of clinically normal and conscious cats, and to set up reference values of feline SBP for subsequent clinical application. SBPs were measured in 53 healthy cats using an ultrasonic Doppler device. The mean SBP was 133.6 +/- 16.0 mmHg (range, 110.0-180.0 mmHg). The distribution of SBP values was not significantly affected by factors such as breed, body condition score, or age (P>0.05), but SBP values of female cats were significantly lower and more variable than those of males (t test, P=0.004; F test, P<0.001). Feline SBP between 114.3 mmHg and 149.5 mmHg was considered indicative of normotension. SBP values higher than 159.3 mmHg were defined as hypertension, and those less than 104.5 mmHg were determined as hypotension.

How to obtain a blood pressure measurement

Noninvasive blood pressure measurement is now a standard diagnostic test in small animal practice. Factors such as patient selection, environment, technical support staff, and necessary equipment and supplies will be discussed. Step by step techniques for obtaining reliable blood pressure measurements in both cats and dogs are presented.

Evaluation of a technique of inducing hypertensive renal insufficiency in cats

OBJECTIVE

To compare 2 techniques of inducing combined renal insufficiency and systemic hypertension in cats.

ANIMALS

22 cats 6 to 12 months of age.

PROCEDURES

Cats were randomly assigned to 1 of 3 groups. Control (C) group cats had 2 intact kidneys, remnant kidney (RK) group cats underwent unilateral partial renal infarction and contralateral nephrectomy, and remnant-wrap (W) group cats underwent unilateral partial renal infarction and partial abtation and wrapping of the contralateral kidney. Systemic arterial blood pressure (BP) was measured continuously by use of implanted radiotelemetric devices. Renal function was assessed via determination of glomerular filtration rate, measurement of serum creatinine and BUN concentrations, and determination of urine protein-to-creatinine ratio (UP/C). Serum aldosterone concentration and plasma renin activity were measured on day 75.

RESULTS

Systolic BP was significantly higher in groups RK and W than in group C, and systolic BP was significantly higher in group W than in group RK. Serum aldosterone concentration and plasma renin activity were significantly higher in group W, compared with groups C and RK. Glomerular filtration rate was significantly lower in groups RK and W, compared with group C. Histologic indices of renal injury and UP/C were significantly higher in group W, compared with groups C and RK.

CONCLUSIONS AND CLINICAL RELEVANCE

Hypertensive renal insufficiency in group W was characterized by marked sustained systemic hypertension, decreased renal function, proteinuria, activation of the renin-angiotensin-aldosterone axis, and renal structural injury. Results support the hypothesis that marked systemic hypertension, activation of the renin-angiotensin-aldosterone axis, and proteinuria may damage the kidney of cats with preexisting renal insufficiency.

Stimulation of the renin-angiotensin system in cats with hypertrophic cardiomyopathy

Feline hypertrophic cardiomyopathy (HCM) is a disease of the ventricular myocardium, which may cause sudden death in cats, but neither the aetiology nor the effect on the circulation are well understood. Fourteen cats of either sex with naturally occurring HCM were studied post mortem. Their ages ranged from 9 months to 10 years with an average age of 4.9 years. Heart weights and heart weight expressed as a percentage of body weight were elevated (27.9 g and 0.65%, respectively) as compared with normal values obtained in previous studies. Myocardial disarray was evident in nine of the 14 cats and moderate to severe fibrosis was present in six animals. To evaluate the renal renin-angiotensin system, semiquantitative morphometric data were obtained by means of renin immunohistochemistry and compared with results from an earlier study of 10 healthy cats by the author. The juxtaglomerular index was 36.8% in the cats with HCM as compared with 30.6% in healthy cats. The renin-positive portion of the afferent arteriole was increased in cats affected by HCM to 86.0 microm as compared with 49.9 microm in normal cats. The increase in kidney renin values in cats with HCM may have been due to decreased blood pressure and reduced renal perfusion resulting from impaired cardiac output.

Effects of the angiotensin converting enzyme inhibitor benazepril in cats with induced renal insufficiency

OBJECTIVE

To determine effects of the angiotensin converting enzyme inhibitor benazepril in cats with induced renal insufficiency.

ANIMALS

32 cats.

PROCEDURE

Renal mass was surgically reduced, and cats were assigned to 1 of 4 eight-cat groups. Group 1 received placebo, whereas groups 2, 3, and 4 received benazepril hydrochloride orally once daily for approximately 6.5 months at the following doses: group 2, 0.25 to 0.50 mg/kg of body weight; group 3, 0.50 to 1.00 mg/kg; and group 4, 1.00 to 2.00 mg/kg. Arterial blood pressures, glomerular filtration rate (GFR), and renal plasma flow were determined before treatment and during the treatment period. Other determinants of renal hemodynamics were measured by use of micropuncture techniques. Renal biopsy specimens were examined microscopically.

RESULTS

Compared with cats that received placebo, mean systolic arterial blood pressure was significantly less and GFR significantly greater in cats that received benazepril. Glomerular capillary pressure and the ratio of efferent to afferent arteriolar vascular resistance were also significantly less in treated cats. However, histologic differences in renal specimens were not detected.

CONCLUSIONS AND CLINICAL RELEVANCE

Treatment with benazepril sustained single nephron GFR in remnant nephrons of cats with induced renal insufficiency. Administration of benazepril was also associated with a small but significant reduction in degree of systemic hypertension and an increase in whole kidney GFR. Benazepril may be an effective treatment to slow the rate of progression of renal failure in cats with renal disease.

Ocular lesions associated with systemic hypertension in cats: 69 cases (1985-1998)

OBJECTIVE

To characterize clinical and clinicopathologic findings, response to treatment, and causes of systemic hypertension in cats with hypertensive retinopathy.

DESIGN

Retrospective study.

ANIMALS

69 cats with hypertensive retinopathy.

PROCEDURE

Medical records from cats with systemic hypertension and hypertensive retinopathy were reviewed.

RESULTS

Most cats (68.1%) were referred because of vision loss; retinal detachment, hemorrhage, edema, and degeneration were common findings. Cardiac abnormalities were detected in 37 cats, and neurologic signs were detected in 20 cats. Hypertension was diagnosed concurrently with chronic renal failure (n = 22), hyperthyroidism (5), diabetes mellitus (2), and hyperaldosteronism (1). A clearly identifiable cause for hypertension was not detected in 38 cats; 26 of these cats had mild azotemia, and 12 did not have renal abnormalities. Amlodipine decreased blood pressure in 31 of 32 cats and improved ocular signs in 18 of 26 cats.

CONCLUSIONS AND CLINICAL RELEVANCE

Retinal lesions, caused predominantly by choroidal injury, are common in cats with hypertension. Primary hypertension in cats may be more common than currently recognized. Hypertension should be considered in older cats with acute onset of blindness; retinal edema, hemorrhage, or detachment; cardiac disease; or neurologic abnormalities. Cats with hypertension-induced ocular disease should be evaluated for renal failure, hyperthyroidism, diabetes mellitus, and cardiac abnormalities. Blood pressure measurements and funduscopic evaluations should be performed routinely in cats at risk for hypertension (preexisting renal disease, hyperthyroidism, and age > 10 years). Amlodipine is an effective antihypertensive agent in cats.

Non-invasive blood pressure measurements in cats: clinical significance of hypertension associated with chronic renal failure

The systolic, mean and diastolic pressures as well as the heart rate were measured using the oscillometric method, on a total of 104 cats (60 cats in the normal group, and 44 in the renal disease group) which were brought into Azabu University Animal Hospital. The blood pressure in the normal group was systolic: 115.4 +/- 10.1 mmHg, mean: 96.2 +/- 12.2 mmHg, and diastolic: 73.7 +/- 10.7 mmHg. Although no difference in heart rate, the renal disease group showed significantly (p < 0.05) higher values for systolic, mean, and diastolic pressure when compared with the normal group. Moreover, when plasma renin activity, angiotensin I and II, and aldosterone concentrations were measured in other cats (11 normal and seven with chronic renal failure), all cats with chronic renal failure showed significantly (p < 0.05) higher values than the normal group. It is, therefore, indicated that hypertension due to stimulating renin-angiotensin-aldosterone system may have manifested in cats with renal dysfunction.

Amlodipine: a randomized, blinded clinical trial in 9 cats with systemic hypertension

The efficacy of amlodipine (AML) was tested in hypertensive cats in a placebo-controlled, randomized, blinded clinical trial. Five cats were randomized to receive 0.625 mg AML once daily and 4 cats to receive placebo (PLA) once daily. The average systolic blood pressure (SBP) recorded by the Doppler method on day 0 was 212 +/- 21 mm Hg in the AML group and 216 +/- 32 mm Hg in the PLA group. On day 7, the cats receiving AML had a significantly lower average daily SBP (160 +/- 30 mm Hg) but SBP in the PLA group was unchanged (207 +/- 31 mm Hg). On day 7, all cats receiving PLA and one cat receiving AML were crossed over to the other group because of inadequate response. Blood pressure did not decrease adequately in 3 cats by day 14 (7 days of PLA and 7 days AML) and the treatment code was broken. Each of these cats was subsequently administered 1.25 mg AML daily. Cats requiring 1.25 mg AML once daily (6.1 kg +/- 0.7 kg) weighed significantly more than cats that responded to 0.625 mg AML once daily (4.1 +/- 0.7 kg). The average daily SBP recorded in the 6 cats that completed the study was significantly lower after 16 weeks of treatment (152 +/- 14 mm Hg) compared to day 0 (221 +/- 24 mm Hg). Three cats were euthanized before completion of the study. All 3 cats were responders to AML on day 7. SBPs measured 24 hours after AML administration were similar to the average daily SBP, suggesting that AML effectively controlled SBP for a 24-hour period. AML was shown to be an effective once-daily antihypertensive agent when administered to cats at a dosage of 0.18 +/- 0.03 mg/kg sid.

Systemic hypertension and its management

The pathophysiology of hypertension in dogs and cats, the methods available to monitor blood pressure, and the signs and treatment of hypertension are reviewed. Clinical signs of hypertension are usually referable to target organ damage, most notably in ophthalmic, renal, and cardiovascular tissues, which have a rich arteriolar supply. Blood pressure should be measured in any animal with renal disease, hyperthyroidism, hyperadrenocorticism, retinal detachment or hemorrhage, hyphema, or echocardiographically determined cardiac hypertrophy. All cats with acquired cardiac murmur should also be evaluated for hypertension. Antihypertensive medication should be administered if the indirect blood pressure in cats is consistently over 170/100 mmHg, or if the indirect blood pressure in dogs is greater than 180/100 mmHg.

The renin-angiotensin system in cats with chronic renal failure

The kidneys of eight male and two female cats with subacute (clinical illness 1-3 months) to chronic (clinical illness > 3 months) renal failure were examined histopathologically, electron microscopically and immunohistochemically. Semiquantitative morphometric data, obtained by measurement of the reninpositive portion of the afferent arteriole (RPP) and evaluation of the juxtaglomerular index (JGI), were compared with data from three healthy control cats. On the basis of the morphometric data, the animals with renal failure could be classified in three groups showing either a stimulated (group A), an unaltered (group B) or an inhibited (group C) renin-angiotensin system. In the three group A cats the JGI and RPP were increased (45.5 +/- 3.5%; 130 microns); in the four group B cats these values were comparable with those of the controls; in the three group C animals the JGI was decreased but the RPP was unaltered (11.7% +/- 3.2%; 56 microns). The increase in kidney renin in animals affected by chronic renal failure (CRF) may have been due to a volume depletion. Prolonged CRF seemed to result in increasing hypertrophy of renal blood vessels, leading to renal hypoxia and increasing preglomerular resistance. Reduced kidney renin status may have been caused by inhibition of renin synthesis in prolonged CRF as a result of renal ischaemia.

Doppler ultrasonographic, oscillometric sphygmomanometric, and photoplethysmographic techniques for noninvasive blood pressure measurement in anesthetized cats

Blood pressure (BP) measurements obtained using 3 indirect BP measuring instruments, a Doppler ultrasonic flowmeter, an oscillometric device, and a photoplethysmograph, were compared with direct arterial pressure measurements in 11 anesthetized cats. The standard deviation of the differences (SDD) between direct and indirect pressure measurements were not significantly different from each other (P < .01), and ranged from 10.82 to 24.32 mm Hg. The high SDD values indicate that indirect BP estimates obtained with all these devices must be interpreted cautiously in individual patients. The mean errors (calculated as the sum of the differences between direct and indirect pressure measurements divided by the number of observations) of the 3 indirect devices were significantly different for systolic (SAP), diastolic (DAP), and mean (MAP) arterial pressures (P < .05). The Doppler and photoplethysmographic devices had the highest overall accuracy, as indicated by mean error values of less than 10 mm Hg. Correlation coefficients varied from .88 to .96 for the Doppler flowmeter, and from .85 to .94 for the photoplethysmograph; for both devices, the regression line slopes were close to unity. The Doppler flowmeter detected a pulse under all experimental conditions. The photoplethysmograph was also efficient in obtaining BP measurements, obtaining over 90% of SAP, DAP, and MAP readings attempted. The oscillometric device was the least accurate, with mean error values varying from 10 to 22 mm Hg. Correlation coefficients were high (.90 to .94) for this device, but the slopes of the regression lines were 0.7 to 0.8, indicating a trend for increased error at higher BP. The oscillometric device tended to underestimate BP by increasing amounts as the BP increased. The oscillometric device was the least efficient device for obtaining BP measurements (P < .01).

Effects of thyroid hormone and thyroid dysfunction on the cardiovascular system

Thyroid disease is common in veterinary practice. The heart, especially the myocardium, is sensitive to thyroid hormone, and deficiencies or excesses can alter cardiovascular function. Observed changes result from direct effects upon the myocardium and indirect effects that result from effects upon the vasculature and peripheral tissues. Clinically significant cardiovascular abnormalities related to hypothyroidism are rare. If present, they are primarily manifest as reduced left ventricular pump function, as apparent echocardiographically, or arrhythmias. Hyperthyroidism is common in the cat and infrequently encountered in dogs. Clinically significant cardiovascular manifestations are common and often dramatic. Hyperdynamic systolic function and mild myocardial hypertrophy are common manifestations which may lead to overt congestive and high output heart failure. If signs of congestive heart failure or significant arrhythmias are not evident, specific therapy need only be directed toward restoration of the euthyroid state. In most cases the cardiovascular changes associated with thyroid dysfunction are completely reversible.