Vol.19, No.
2 February 1997
Continuing Education Article
FOCAL POINT
★Chronic renal disease and
hyperthyroidism are most often
associated with hypertension in
cats.
KEY FACTS
■ Treatment with oral amlodipine
(0.625 mg/day) is advised if the
indirect systolic blood pressure is
consistently higher than 170 mm
Hg.
■ Elevation of the systolic blood
pressure, alone or in combination
with the diastolic pressure, is
most commonly recognized
in cats; isolated diastolic
hypertension is apparently rare.
■ Doppler systolic measurements
greater than 200 mm Hg
are unlikely to be artifactual
and warrant immediate
antihypertensive treatment.
■ An acquired murmur, retinal
detachment, and retinal
hemorrhage are indicators of
the presence of hypertension.
Diagnosis and
Treatment of Feline
Systemic Hypertension
University of Wisconsin
Rosemary A. Henik, DVM, MS
S
ystemic hypertension and its consequences are increasingly recognized in
feline practice. Caring for a growing population of geriatric patients in-
volves the recognition and treatment of multiple, simultaneously occur-
ring medical problems. One of these problems is often high blood pressure,
which is usually secondary to another disease process in cats.
This article explores the hypothesized pathophysiology of hypertension in
cats, the methods available for monitoring blood pressure, and the signs and
treatment of hypertension. This information will enable feline practitioners to
control more effectively systemic hypertension and its effects in cats.
DEFINITIONS AND CONTROL OF ARTERIAL BLOOD PRESSURE
The mean arterial pressure (MAP) is the pressure in the arteries averaged
over time, and the systolic and diastolic pressures are the upper and lower lim-
its of the periodic oscillations around the mean pressure.1 The pulse pressure is
the difference between systolic and diastolic pressures. Because systole is short,
the mean pressure is not midway between systolic and diastolic pressures but
closer to diastolic pressure. Mean pressure is approximated by the following
formula:
Mean pressure = Diastolic pressure + 1⁄3 pulse pressure
Because arterial blood pressure is the product of the cardiac output (CO)
and total peripheral resistance (TPR), conditions that affect cardiac output
or peripheral resistance will alter blood pressure. Cardiac output is the product
of heart rate (which is under autonomic control) and stroke volume (which is
determined by the inotropic state of the myocardium and the circulating
intravascular volume).
Total peripheral resistance is the sum of the resistances in all vascular beds of
the body. These resistances are not necessarily equal and do not always change
in the same direction.2
Other direct determinants of arterial pressure are aortic impedance (resis-
Small Animal
tance to flow) and diastolic arterial volume.2 These de-
terminants are influenced by factors that can be consid-
ered indirect determinants, including the activity of the
autonomic nervous system (primarily sympathetic), the
extracellular fluid volume, the renin–angiotensin sys-
tem, and salt-active steroids (e.g., aldosterone).2
The sympathetic nervous system modulates cardiac
output and TPR, the two determinants of blood pres-
sure.3 Sympathetic effects are mediated by epinephrine
(predominantly released from the adrenal medulla) and
norepinephrine (released into the synaptic cleft from
sympathetic nerve endings). Arterial and venous con-
striction occur via activation of postsynaptic α1 and α2
receptors, and cardiac output may be augmented in
response to sympathetic stimulation because of an
increased venous return and β-adrenergic receptor–
mediated direct inotropic and chronotropic effects.3
All of these systems are interrelated in the control of
blood pressure. For example, activity of the nervous
system influences renin release; the resultant angio-
tensin II controls aldosterone production, which in
turn affects fluid and electrolyte balance; angiotensin II
also has an independent effect on the renal excretion of
salt and water.2 Pharmacologic treatment of hyperten-
sion can be achieved by interfering with one or several
of these interrelated factors.
METHODS OF BLOOD
PRESSURE MEASUREMENT
Blood pressure should be measured in a quiet room,
away from other animals, humans, and background
noise. The owner should be present, if possible, to gen-
tly restrain and pet the cat. Blood pressure should be
measured before the physical examination but after the
cat has had enough time to acclimate to its surround-
ings.
Blood pressure can be measured by direct or indirect
methods. Direct blood pressure measurement, which is
considered to be the gold standard, usually involves
placing a 25-gauge needle or indwelling catheter into a
peripheral artery. The needle or catheter is attached to a
transducer, and pressure is displayed on a screen or
recording chart. This technique is technically difficult
in unsedated small patients and may be painful. Poten-
tial side effects include hematoma formation or infec-
tion, and falsely elevated blood pressure measurements
may occur secondary to catecholamine release associat-
ed with pain or restraint.
The indirect technique is more applicable in a clini-
cal setting because it requires less restraint and is less
painful to the patient. Like the direct technique, it re-
quires some operator practice; however, it is generally
faster and simpler than direct blood pressure measure-
DIASTOLIC ARTERIAL VOLUME ■ BLOOD PRESSURE CONTROL ■ DOPPLER TECHNIQUE
The Compendium February 1997
ment. Indirect methods of blood pressure measurement
include the auscultatory, Doppler, oscillometric, and
photoplethysmographic techniques.
The auscultatory technique is the most common
method of noninvasive blood pressure measurement in
humans. The technique involves a sphygmomanometer
(which consists of an inextensible cuff that contains an
inflatable bag), which is usually wrapped around the
arm in a human patient.1 The underlying artery is oc-
cluded via a rubber squeeze bulb to inflate the bag to a
pressure in excess of arterial systolic pressure. The pres-
sure in the bag is measured by means of a mercury or
aneroid manometer. In humans, a stethoscope is placed
over the brachial artery distal to the cuff; the listener
hears a tapping sound when the inflation pressure falls
below systolic pressure. As inflation pressure continues
to fall, more blood escapes under the cuff per beat.
Eventually the sounds disappear; this point represents
the diastolic pressure. In animals and children, the arte-
rial (Korotkoff ’s) sounds are low in amplitude and fre-
quency4; the auscultatory technique thus is not used in
cats. In addition, the size and irregular contour of feline
limbs make adequate placement of a stethoscope over a
peripheral artery difficult.
Machines that utilize the Doppler technique to mea-
sure blood pressure are inexpensive, efficient,5 easy to
operate, and widely used in veterinary operative and
outpatient settings. The Doppler flowmeter detects the
pulse signal in low-flow states more efficiently than do
newer, more automated devices.5 Doppler flowmeters
detect blood flow by emitting an ultrasonic signal and
then producing an auditory signal generated by the
change in the emitted versus returning frequencies (fre-
quency shift) reflected back to the transducer by under-
lying moving red blood cells.5,6 Blood pressure is read
by the operator from an aneroid manometer connected
to an occluding cuff placed proximal to the Doppler
transducer.5 Some Doppler machines detect arterial
wall motion (Doppler kinetoarteriography) associated
with reflow after the release of the occlusive cuff; these
machines are no longer manufactured.
Indirect blood pressure measurement studies in dogs
used a cuff width of 40% of the circumference of the
limb.4,7-9 Although this ratio has also been used in stud-
ies in cats,5,10 Grandy and coworkers suggested that a
cuff width of 30% of the circumference of the limb
may be more appropriate in this species.10 In studies in
which cuff width was 40% of the circumference of the
limb, a correction factor of 1410 to 14.75 mm Hg was
recommended to equate the lower indirect pressure
with the direct blood pressure. With a ratio of 30%,
most cats require a 2-cm (occasionally a 3-cm) cuff. If
the ideal cuff width is midway between two available
The Compendium February 1997 Small Animal

sizes, the larger cuff will the- Another problem associat-

oretically produce less error.8
An oversized cuff may pro-
vide erroneously low record-
ings.9,11
The cuff may be placed
around the brachial, medi-
an, cranial tibial, or medial
coccygeal artery. The cuff is
generally inflated to a pres-
sure 30 to 40 mm Hg high-
er than that required to
obliterate the pulse and is
then slowly deflated. The
first sound heard as blood Figure 1—A cuff wrapped around the foreleg of a cat oc-
begins to flow through the cludes blood flow in the median artery. The Doppler crys- oped device for measuring
artery is the systolic pres- tal is positioned over the median artery between the carpal blood pressure noninvasive-
sure; muffling or disappear- and metacarpal pads, distal to the occluding cuff.
ance of the sound of blood
flow represents the diastolic
pressure. Because blood pressure often falls with repeat-
ed measurements as the patient adjusts to the feel of the
cuff inflating and deflating, five to seven measurements
are advised during a 5- to 10-minute period.
At the School of Veterinary Medicine, University of
Wisconsin, arterial systolic pressure is easily moni-
tored in the examination room with the owner pre-
sent. A Doppler flowmeter is used, and a 2-cm pedi-
atric cuff is wrapped around the foreleg of the patient
(Figure 1). An excellent signal is usually obtained
from the median artery (between the carpal and
metacarpal pads) by wetting the hair with alcohol and
then applying coupling gel and the 10-MHz Doppler
probe. The major limitation of the Doppler technique
is the imprecise discrimination of the sounds that des-
ignate the diastolic pressure and thus the mean pres-
sure. In light of this fact, the Doppler method of
blood pressure measurement may be unreliable for
routine diagnosis and surveillance of patients with
5
diastolic hypertension.
The oscillometric technique detects pressure fluctua-
tions produced in an air bladder within the occluding
cuff resulting from the pressure pulse.12 Machines that
utilize oscillometric techniques display systolic, diastolic, a diastolic blood pressure greater than 100 mm Hg.21–23
and mean arterial pressures as well as pulse rate. In a
study comparing Doppler ultrasonographic, oscillomet-
ric sphygmomanometric, and photoplethysmographic
techniques for noninvasive blood pressure measurement
in anesthetized cats, the oscillometric device was deter-
mined to be the least accurate and least efficient device
for obtaining blood pressure measurements. This device
tended to underestimate blood pressure by increasing
amounts as the blood pressure increased.5
ed with the oscillometric de-
vice was the excessive time
required to obtain readings,
often more than several
minutes.5 The low efficiency
may have been related to the
fact that the small size of the
peripheral arteries in cats
does not allow generation
of sufficient pulse pressure
to produce detectable cuff
pressure oscillations in cer-
tain conditions.5
The most recently devel-
ly is the photoplethysmo-
graph, which measures arte-
rial volume by attenuation
of infrared radiation. The device is designed to be used
on the human finger.13 When evaluated in anesthetized
cats with low, normal, and elevated blood pressure, the
photoplethysmograph had less of a tendency to under-
estimate blood pressure at high pressures and over-
estimate blood pressure at low pressures than did the
Doppler and oscillometric devices.5 It may be more
useful than other indirect instruments for continuous
monitoring or when the blood pressure is changing.14
Disadvantages of the device are the cost, the need to
frequently reposition the cuff for optimum traces, and
the fact that use is limited to cats and dogs that weigh
less than 10 kg.5,15
NORMAL AND ABNORMAL BLOOD PRESSURE
By means of various indirect methods, normal arteri-
al blood pressure in unsedated cats has been reported as
less than 160/100 mm Hg,16 123/81.2 (mean of 96.8)
mm Hg,17 and 118.4/83.8 mm Hg.18,19 Hypertension is
defined as a sustained elevation of systolic or diastolic
pressure above the normal value for the species.20 In
cats, hypertension has been reported as an indirect sys-
tolic pressure greater than 16021,22 or 17023 mm Hg and
In cats, elevation of the systolic blood pressure alone or
in combination with the diastolic pressure is most com-
monly recognized; isolated diastolic hypertension is
apparently rare.18,19 Based on studies and evaluation
of cats at the School of Veterinary Medicine, University
of Wisconsin, antihypertensive treatment is advised if
the indirect systolic blood pressure is greater than 170
mm Hg or if the diastolic pressure is greater than 100
mm Hg.

CUFF WIDTH ■ OSCILLOMETRIC TECHNIQUE ■ DIASTOLIC HYPERTENSION

Small Animal The Compendium February 1997

In the absence of other clinical elevation results. The reported

signs of hypertension (e.g., retinal
hemorrhage or detachment), it is
advised that several readings be
taken (over several days, if possi-
ble) rather than basing treatment
on a single measurement. Even in
cats with ocular signs that suggest
hypertension, however, blood
pressure measurements may not
be elevated consistently at each
hospital visit.22 In my experience,
Doppler systolic readings of at
least 200 mm Hg are unlikely to
be artifactual and warrant imme-
diate antihypertensive treatment.
HYPERTENSION IN CATS
Causes
Although primary, or essential,
hypertension is present in most Figure 2—A cat presented blind with bilaterally sisted with a reduced-sodium
humans with hypertension, sys- dilated pupils and retinal detachment sec- diet.
temic hypertension in cats is usu- ondary to systemic hypertension. (Courtesy
ally secondary to chronic renal of Dr. Chris Murphy, School of Veterinary Signalment and History
disease or hyperthyroidism.18,23 El- Medicine, University of Wisconsin)
evation in systemic blood pressure
has been diagnosed in 61%18 to
65%22 of cats with chronic renal disease. The mecha-
nisms by which the kidneys trigger hypertension are
unknown, and even minimally azotemic cats may be
hypertensive. The following hypotheses have been pro-
posed for human hypertension with renal disease: fail-
ure to excrete a normal quantity of salt or fluid, stiffen-
ing of the venous capacitance system, alterations in
adrenergic activity, activation of the renin–angiotensin–
aldosterone axis with increased vascular resistance and
salt retention, stimulation of renopressor systems, sup-
pression of renodepressors or prostaglandins, and in-
creased cardiac output secondary to anemia.24,25
In cats with chronic renal disease and hypertension,
evaluation of the renin–angiotensin–aldosterone system
has demonstrated that plasma renin activity may be
low, normal, or elevated compared with that of normo-
26
tensive cats; plasma aldosterone is usually elevated.
The diagnosis of hypertension associated with chronic
renal disease necessitates lifelong antihypertensive treat-
ment.
Hyperthyroidism causes an increase in the number
and sensitivity of β receptors in the myocardium, re-
sulting in an increased response to circulating cat-
echolamines. A thyroid hormone–specific adenylate
cyclase–cyclic AMP system mediates an increased heart
rate, stroke volume, and cardiac output; blood pressure
prevalence of hypertension asso-
ciated with hyperthyroidism
ranges from 23%22 to 87%.18 Hy-
pertension resolved within 2 to 3
months after treatment of hyper-
thyroidism18; lifelong antihyper-
tensive therapy thus is usually
unnecessary unless another un-
derlying disease (e.g., chronic re-
nal failure) is present.
Less likely causes of systemic
hypertension in cats include
anemia,23 hyperadrenocorticism,
mineralocorticoid-secreting tu-
mor, pheochromocytoma, and
primary hypertension. Hyperten-
sion in a cat associated with a
high-salt diet has been reported27;
however, the hypertension per-
Cats with systemic hyperten-
sion are usually old, which is ex-
pected because hypertension is
secondary to other diseases that occur in older individ-
uals (e.g., chronic renal disease and hyperthyroidism).
The mean age of hypertensive cats has been reported as
15.1 ± 3.8,21 13.8 ± 4.8,18 and 13.4 ± 2.318 years; 71%
of affected individuals are at least 14 years of age.21
Fifty one18 to 63%21 of hypertensive cats reported in the
literature were males, but evaluation of the records of
32 hypertensive cats seen at the School of Veterinary
Medicine, University of Wisconsin demonstrated a
female:male ratio of 2.6:1.
Cats with hypertension may present with signs relat-
ed to the underlying disease (e.g., polyuria/polydipsia
or weight loss), signs related to hypertension (e.g., ocu-
lar hemorrhage), or no clinical signs. In one study, 83%
of hypertensive cats were presented with a history of
blindness21 (Figure 2). At the University of Wisconsin,
most hypertensive cats are first referred to the ophthal-
mology service for investigation of blindness, retinal
detachment, or hyphema. In advanced cases of hyper-
tension, clinical signs compatible with cerebral vascular
hemorrhage or stroke may be noted by the owner; these
signs include seizures, ataxia, and sudden collapse.21
Clinical signs related to heart failure are usually not as-
sociated with hypertension, although two cats in one
study were presented with labored breathing.21
Cats presenting with hypertension often have a histo-

PRIMARY HYPERTENSION ■ HYPERTHYROIDISM ■ ANEMIA

The Compendium February 1997 Small Animal

ry of steroid therapy. This ly small kidneys were pre-

may include oral or topical sent in 46% of the cats. Pro-
glucocorticoids, oral or in- teinuria and hyposthenuria,
jectable progestagens, or an- which may be caused by
abolic steroids. The sodium- pressure diuresis in hyper-
retaining properties of these tensive humans, are rare-
drugs may contribute to the ly noted in hypertensive
hypertensive state. cats. 18,21 Renal histologic
changes associated with
Clinical Signs and chronic hypertension in-
Consequences clude glomerulosclerosis,
Because old feline patients glomerular atrophy, prolifer-
may have multiple prob- ative glomerulitis, and fibri-
lems, the clinician must rec- noid necrosis with progres-
ognize abnormalities that Figure 3—Lateral radiograph of a cat with a murmur and sive parenchymal loss.
suggest the presence of sys- systemic hypertension.
temic hypertension. The Heart
clinical signs of hyperten- Systolic apical murmurs
sion are usually referable to and gallop rhythms are fre-
damage to target organs quently noted during ex-
with a rich arteriolar supply. amination of hypertensive
Affected regions include cats. 28 The presence of an
ophthalmic, renal, cardio- acquired murmur in a geri-
vascular, and cerebrovascular atric cat should prompt the
tissue. Autoregulatory arte- clinician to measure the
riolar vasospasm occurs in blood pressure. Because the
an effort to protect fragile heart is working against an
capillary beds from high ar- increased arterial pressure
terial pressure. Arteriolar (i.e., afterload), it is not sur-
changes can cause ischemia, prising that ventricular re-
infarcts, or alterations in modeling and hypertrophy
capillary permeability with occur, with secondary valvu-
subsequent hemorrhage or lar insufficiency.
leakage of plasma proteins The average heart rate in
into the surrounding tissue. one study of hypertensive
Histologic changes caused cats was 174.3 ± 30.2
by hypertension include beats/min 21; tachycardia is
arteriosclerosis and medial not commonly associated
hypertrophy. with hypertension unless
another disease (e.g., hyper-
Kidneys thyroidism) is present. Al-
Chronic renal disease may though it is impossible to
precipitate hypertension, estimate blood pressure via
and continued elevation of palpation of the peripheral
glomerular filtration pres- pulse,29 many cats with hy-
sure worsens existing renal pertension have a promi-
disease and contributes to Figure 4—Ventrodorsal radiograph of the patient in Figure nent apex beat and bound-
disease progression. In one 3. There is generalized cardiomegaly without evidence of ing femoral pulse.
study, only 17 of 23 hyper- pulmonary edema or pleural effusion. Radiography may demon-
tensive cats were azotemic; strate mild to moderate
however, all of the cats were generalized cardiomegaly
considered to have renal disease based on laboratory, (Figures 3 and 4) without evidence of congestive heart
physical examination, or histologic findings.21 Bilateral- failure (i.e., pleural effusion or pulmonary edema).28

ANABOLIC STEROIDS ■ GLOMERULAR FILTRATION PRESSURE ■ RADIOGRAPHY

Small Animal The Compendium February 1997

Dilation of the proximal Eyes

aorta or an undulating, tor- The eyes are the organs
tuous aorta is often not- most commonly reported to
ed. 21,23,28 Electrocardiogra- be affected by hypertension,
phy indicates left ventricular probably because ocular
enlargement23,28 or left cra- changes are easy to monitor.
nial fascicular block. In one study, 24 hyperten-
Systemic hypertension sive cats had bilateral retinal
was documented in 48% of detachment and/or hemor-
40 cats with echocardio- rhage; 20 of the cats were
graphically determined left blind at presentation.21 The
19
ventricular hypertrophy. In period between the diagno-
one study, 10 of 12 hyper- sis of hypertension and the
tensive cats examined by onset of retinopathy varies.22
echocardiography had evi- Figure 5—Retinal hemorrhage in a hypertensive cat. (Cour- Cats with retinal detach-
dence of cardiac hypertro- tesy of Dr. Chris Murphy, School of Veterinary Medicine, ment tend to have much
phy.21 Hypertension causes University of Wisconsin) higher systolic blood pres-
an increase in end-systolic sure than do those without
wall stress, which leads to detachment.a Cats with reti-
hypertrophy and normaliza- nal hemorrhage should be
tion of wall stress.30 In hu- considered to be hyperten-
mans, contractility is pre- sive until proven otherwise.
served or even increased in In one study of cats with
the early stages of hyperten- chronic renal disease, 80% of
sion, and asymmetric hyper- 15 hypertensive patients had
trophy of the left ventricle hypertensive retinopathy.22
30
may occur. In a study of The following findings are
cats with experimentally associated with hypertensive
induced chronic renal fail- retinopathy: hemorrhage of
ure and hypertension, left the retina (Figure 5), vitre-
ventricular mass was in- ous, or anterior chamber;
creased approximately 34% retinal detachment and atro-
compared with that of nor- Figure 6—The effect of localized vasoconstriction and vas- phy; retinal edema; perivas-
motensive controls. 31 A cular dilation in retinal vessels. (Courtesy of Dr. Paul culitis; retinal artery tortu-
diagnosis of hypertrophic Miller, School of Veterinary Medicine, University of Wis- osity; and glaucoma. 22,23
consin)
cardiomyopathy should not Precapillary vasoconstriction
be made unless other causes of retinal arterioles is a nor-
of hypertrophy (includ- mal autoregulatory response
ing hypertension or hyper- to hypertension, and sus-
thyroidism) have been ruled out. Left ventricular tained vasoconstriction can lead to ischemia and retinal
hypertrophy may regress with antihypertensive treat- degeneration.22 Eventually, endothelial cells and vascular
30
ment. smooth muscle break down; serum and red blood cells
Pleural effusion and systemic hypertension resulting leak into the surrounding retinal tissue. Vascular smooth
from subcutaneous fluid therapy may be evident in cats muscle necrosis and localized vascular dilation cause a so-
with underlying renal disease, probably because of an called boxcar (or sausaging) effect in the retinal vessels
inability of the diseased kidneys to handle even routine (Figure 6).
amounts of fluids. Pleural effusion resulting from In cats with hypertensive retinopathy associated with
overzealous fluid therapy may be difficult to differenti- chronic renal failure, diffuse retinal edema and foci of
ate from right-sided congestive heart failure. Histolo- intraretinal serous exudates were the most common ocu-
gically, cardiac changes associated with hypertension lar abnormalities noted.22 Six of the 12 cats with hyper-
include atherosclerosis; myointimal proliferation of ar- tensive retinopathy had hemorrhages; arterial tortuosity
teries and arterioles; and hypertrophy, hyperplasia, and was present in three cats (25%).22 Three cats also had ar-
necrosis of small arteries. eas of focal retinal degeneration of undetermined cause.

TORTUOUS AORTA ■ PLEURAL EFFUSION ■ SUSTAINED VASOCONSTRICTION

Small Animal
Common, early findings associated with hypertensive
retinopathy include retinal edema and foci of intrareti-
nal fluid accumulation as well as intraretinal hemor-
rhages, which are not usually associated with visual
deficits.22 Large intraretinal or preretinal hemorrhages
(including vitreous hemorrhage) and large areas of de-
tachment are found in patients with advanced hyper-
tensive retinopathy and are associated with serious visu-
al deficits.22 Ocular signs usually improve within 2 to 6
weeks of treatment,23 but retinal detachment associated
with hypertension warrants a poor prognosis for return
of vision. In one study, return of vision was noted in
one of four cats with hypertensive retinopathy.23
Brain
Although they are difficult to recognize in cats, ce-
rebrovascular changes may result from severe hyper-
tension. The central nervous system is susceptible to
hypertension-induced damage because of the abun-
dance of small arteries and arterioles. In humans,
seizures, cerebrovascular accidents, encephalopathy, or
dementia may result from intracerebral hemorrhage.
Signs that are consistent with cerebrovascular hemor-
rhage (e.g., head tilt, depression, and seizures) have
been clinically evident in cats with uncontrolled hyper-
tension and are associated with a poor prognosis.
Treatment
I consider antihypertensive treatment to be necessary
in any cat with a sustained indirect systolic blood pres-
sure greater than 170 mm Hg. Although systolic blood
pressure in cats averages approximately 120 mm
Hg,17–19 it is unnecessary and usually impossible to re-
store blood pressure to this value when treating a hy-
pertensive cat. The veterinarian’s goal should be to low-
er the systolic blood pressure to less than 170 mm Hg.
The chances of continued intraocular hemorrhage are
apparently decreased if the blood pressure is maintained
below this point.
Dietary
Although it is prudent to advise a low-sodium diet in
cats with hypertension, sodium restriction alone is not
sufficient to return blood pressure to reasonable and safe
levels.20 Part of the reason for prescribing such a diet is
to counteract the efforts of the kidneys to retain sodium
when influenced by antihypertensive therapy. It is more
important, however, to maintain caloric intake in cats
with chronic renal disease and hypertension than to
insist on a low-sodium diet. Because monitoring of
appetite and body weight is important in assessing
response to and tolerance of antihypertensive medica-
tion, it may be advisable to delay switching to a low-
RETINOPATHY ■ CEREBROVASCULAR CHANGES ■ SODIUM NITROPRUSSIDE
The Compendium February 1997
sodium diet until the cat is on stable antihypertensive
treatment.
Pharmacologic
Until recently, medical treatment of hypertension
in cats has been extrapolated from human protocols. Rec-
ommendations for medical therapy have involved diuret-
ics, β blockers, angiotensin-converting enzyme (ACE)
inhibitors, α-receptor antagonists, or calcium channel
blockers (Table I). Because hypokalemia associated with
renal dysfunction32–34 may worsen with diuretics (e.g.,
furosemide or thiazides), these agents are not usually
advised in treating hypertensive cats with renal disease.
Amlodipine besylate, a long-acting dihydropyridine
calcium antagonist, has been used successfully as a sin-
gle agent in hypertensive cats at an oral dosage of 0.625
mg every morning.35 Blood pressure decreased signifi-
cantly during amlodipine treatment, and significant ad-
verse effects (i.e., azotemia, hypokalemia, and weight
loss) were not identified.35 Because amlodipine has a
slow onset of action, such adverse effects as hypoten-
sion and loss of appetite are avoided. I consider it to be
the preferred drug for treating cats with systemic hyper-
tension. ACE inhibitors or β blockers can be combined
with amlodipine if therapy with amlodipine alone does
not restore normotension.36, 37
Hydralazine can be successful for chronic therapy if
all other treatments fail; however, direct-acting vaso-
dilators may have the adverse effect of activating the
renin–angiotensin system.28 As more fast-acting and
potent vasodilators are used, there is a greater chance of
acute renal failure resulting from a decrease in renal
blood flow.28
Emergency Management
Cats with neurologic signs or severe ocular manifesta-
tions of hypertension (e.g., retinal detachment) warrant
aggressive treatment. Sodium nitroprusside, an arterial
and venous vasodilator that acts as a donor of nitric ox-
ide in vascular smooth muscle cells, is advised in treat-
ing patients in hypertensive crisis.3 Because the drug
must be given by constant-rate infusion, it can only be
used if an infusion pump and continuous monitoring
are available. Sodium nitroprusside should be titrated
precisely according to the blood pressure response. The
agent usually does not cause reflex tachycardia.3
If constant-rate infusion and intensive monitoring
are not available in a veterinary hospital, hydralazine
and furosemide can be used in combination, with the
addition of a β blocker (propranolol or atenolol), when
blood pressure is not lowered within 12 hours.28 If loop
diuretics are administered to cats with renal disease,
potassium concentrations must be carefully monitored.
Small Animal The Compendium February 1997

TABLE I
Drugs Used to Treat Cats with Systemic Hypertension
Drug Mechanism of Action Dosage

Diuretics
Chlorothiazide Inhibits Na+ reabsorption in early DCT 20–40 mg/kg every 12 hours PO
Furosemide Inhibits Cl− reabsorption in the loop of Henle 1–2 mg/kg every 12–48 hours PO
Hydrochlorothiazide Inhibits Na+ reabsorption in early DCT 2–4 mg/kg every 12 hours PO
Spironolactone Acts as aldosterone antagonist in late DCT; 1–2 mg/kg every 12 hours PO
K+ sparing
Triamterene Inhibits Na+ reabsorption in late DCT; 1–2 mg/kg every 12 hours PO
K+ sparing

α blockers
Prazosin α1 receptor antagonist 0.5–2.0 mg/cat every 8–12 hours PO
Phenoxybenzamine α receptor antagonist 2.5 mg/cat every 12 hours PO initially,
then increase in 2.5-mg increments to a
maximum of 10 mg/cat every 12 hours PO

β blockers
Atenolol β1 receptor antagonist 6.25–12.5 mg/cat every 24 hours PO
Metoprolol β1 receptor antagonist 2–15 mg/cat every 8 hours PO
Propranolol β1 and β2 receptor antagonist 2.5–5.0 mg/cat (0.4–1.2 mg/kg) every
8–12 hours PO; 0.1 mg/cat IV slowly

Calcium channel blockers

Amlodipine Blocks entry of Ca++ into cell 0.625 mg/cat every 24 hours PO

Vasodilators
Benazepril ACE inhibitor 1.0 mg/kg every 24 hours PO
Capotopril ACE inhibitor 3.12–6.25 mg/cat every 8 hours PO
Enalapril ACE inhibitor 0.25–0.5 mg/kg every 12–24 hours PO
Lisinopril ACE inhibitor 0.25–0.5 mg/kg every 24 hours PO
Hydralazine Direct-acting arteriolar dilator 0.5 mg/kg (initial dose), titrated to
0.5–2.0 mg/kg every 12 hours PO
Sodium nitroprusside Arteriolar and venous dilator acting as 2.5–15 µg/kg/min IV CRI
nitric oxide donor

Na+ = sodium, DCT = distal convoluted tubule, Cl − = chloride, Ca ++ = calcium, K + = potassium, PO = orally, ACE = angiotensin-
converting enzyme, IV = intravenously, CRI = constant-rate infusion.

Follow-Up Care and Additional Medications single antihypertensive agent.

Long-term management of a hypertensive cat in-
volves monitoring blood pressure, evaluating the un-
derlying disease process (e.g., hyperthyroidism or
chronic renal disease), and evaluating the patient for
signs of drug toxicosis. The most common adverse
signs that owners may observe (and should report) are
lethargy, increased time spent sleeping, ataxia (caused
by intermittent or chronic hypotension), and anorexia.
Cats on multiple-drug regimens are more likely to
exhibit these adverse effects than are cats receiving a
If hypertension persists even though the cat is stable,
it should be evaluated by the veterinarian weekly and
the drug protocol should be adjusted until normoten-
sion is achieved. Once blood pressure is controlled, the
cat can be evaluated at 3-month intervals. If underlying
renal disease is present, body weight, the fundus of the
eye, blood pressure, electrolytes (especially potassium),
and creatinine should be closely monitored.
Other treatments for chronic renal disease should
accompany antihypertensive therapy as appropriate.

CHRONIC RENAL DISEASE ■ ATAXIA ■ ELECTROLYTES

The Compendium February 1997
Potassium supplementation is often necessary in cats
with chronic renal disease. Oral potassium chloride or
potassium gluconate can be dispensed. Veterinarians of-
ten administer recombinant erythropoietin to cats with
anemia secondary to chronic renal disease; however,
this agent may exacerbate hypertension. Uncontrolled
hypertension is a contraindication for erythropoietin
therapy.38 Prostaglandin inhibitors (including aspirin)
should be avoided if possible; they may adversely affect
renal prostaglandin activity.28 The use of topical, oral,
or parenteral corticosteroids should be limited or dis-
continued.11
Intravenous and subcutaneous parenteral fluids
should be used judiciously.11 I have seen pleural effu-
sion and hypertension caused by subcutaneous fluid
therapy in a cat with renal disease; the hypertension
and pleural effusion resolved when the fluids were dis-
continued. Fluids should not be given unless the pa-
tient is obviously dehydrated, an acute process has oc-
curred in the kidneys, systemic hypotension is present
(systolic pressure is less than 90 mm Hg), or the patient
requires additional fluids to maintain hydration and
appetite.
CONCLUSION
Hypertension frequently accompanies chronic renal
disease and hyperthyroidism in old cats. Blood pressure
should be measured in any cat with renal disease, hy-
perthyroidism, an acquired murmur, blindness, retinal
detachment, hyphema, or echocardiographically deter-
mined cardiac hypertrophy.
Antihypertensive medication should be administered
if the indirect systolic blood pressure is consistently
higher than 170 mm Hg. For control of chronic hyper-
tension, amlodipine (a calcium channel–blocking drug)
can be administered orally at a dosage of one fourth of
a 2.5-mg tablet (0.625 mg) once daily.
About the Author
Dr. Henik, who is a Diplomate of the American College of
Veterinary Internal Medicine, is affiliated with the Depart-
ment of Medical Sciences, School of Veterinary Medicine,
University of Wisconsin, Madison, Wisconsin.
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