Hi, my name is Aleka and today I'm going to talk to you about the diagnosis and treatment of hypertension in dogs and cats. So, briefly, let's start off with the summary of this lecture. We'll first talk about just the basics definition of hypertension, then we'll talk about the diseases associated with secondary hypertension.

We'll speak about target organ damage, selection of patients for blood pressure measurements. How do we actually measure blood pressure in a practise? Then we'll talk about diagnosis of hypertension and treatment of hypertension.

So I have preparing this lecture summarised the current available literature, but I have such as the core used the consensus of American College of Veterinary Internal Medicine about guidelines identification, evaluation, management of systemic hypertension in dogs and cats. I consulted the textbook for internal medicine, so Ettinger. And for the cats, I use the ISFM consensus guidelines of diagnosis and management of hypertension in cats and throughout this entire lecture also used several other papers, manuscripts that could help me prepare that or give you more information.

So let's start about the definition of hypertension. I think they all still a little bit remember that's him from the university, from other CPDs, but essentially what is comprises the minicul blood pressure is the multiplication of cardiac output and systemic vascular resistance. As you can see.

There's a little bit of everything involved in controlling the arterial pressure. We have sympathetic nervous system, breast activity. We have structural changes, and all of the diseases potentially or changes that could affect the vascular tone, as, as well as heart rate and stroke volume.

So we can see blood volumes, systolic diastolic cardiac function, and at the end of the previous plant, you have the main arterial pressure, which is a combination of cardiac outlook and systemic vascular resistance. The definition of the hypertension is that we have situational hypertension, we have idiopathic hypertension, and we have secondary hypertension. And we'll talk you through different concepts because we do see a lot of these differences in veterinary medicine.

It's kind of I can help you decide which patients actually we should be treating and which patients are, are not. Yeah, and I'm also apologising for my dog barking at the back. So, let's start with the situation of hypertension.

We tend to see quite a lot of that. It brings a lot of confusion in the measurements of blood pressure in our patients, because we know that with the white coat, or the animals being in an environment, a hospital environment exposed to handling of people that the animals don't know, nurses, vets, we can have . Quite high blood pressure as a result of that.

So, as you can see on the slide, there is a large fluctuation, blood pressure observed. We all know it's no need to explain that in people that this is the kind of a blood pressure that should not be treated, and this is the increase in blood pressure that's arising from the autonomic nervous system alteration because of excitement and anxiety. Interestingly, it's also saying that in people, the situation of hypertension has been associated with a long-term cardiovascular risk.

So here we go. Further, we have idiopathic hypertension. So idiopathic hypertension has been reported both in people, and it's been reported mostly in cats, and we see that it's reported in about 30 to 20% of cats.

We call it also essential or primary hypertension that's the kind of what you don't find any underlying cause for it. And in people, it's multi-factor can be a combination of or disorders involving genetic system, lifestyle and environmental factors. Now, as time previously, it is more common in cats as opposed to dogs, and it is a result of abnormalities of the renal and neurohormone laboratory mechanisms.

Now, what is diagnosis? The idiopathic hypertension, essentially, we diagnose once we exclude all the common causes that are associated with development with a secondary hypertension, which we will talk about in the next slide. And it is very important that there is one sort of a set of tests always run when you establish a hypertension in your patients, and we'll talk about that a little bit later about all the testing and the common diseases that we will need to rule out when we establish hypertension in our patients.

And essentially the idiopathic hypertension is gonna be the one that we diagnose as a sort of I'd say it's a diagnosis of exclusion. And once the all of the other, as I said, conditions are excluded. Coming further into secondary hypertension, which is the next slide, which is actually most common in dogs and cats, and it's usually associated with the underlying conditions, which in one way or another will affect the blood volume, will affect the vascular resistance, and, will affect the cardiac output as we discussed before, if you go to that initial diagram.

In cats, the most common condition associated with hypertension will be definitely chronic kidney disease, hyperthyroidism, hyperaldosterinism, even though the hyperaldosteroin is a very common cause in hypertension in, in cats, I mean, I'm not gonna say very common cause, it's known as to be associated with hypertension. It's fairly rarely diagnosed, so you are not going to see that many patients with this condition, just to give you a rough idea. In private ginary referral hospital in the last 10 years, we actually confirmed and treated only 4 patients with the primary hyperalosterism, just to give you a rough idea how uncommon this is.

Now, other less common conditions which you can see in this in both consensus as associated with hypertension will be diabetes, malls will be pheochromocytoma in cats, hyperadrenal cortices, and both very rare in cats. Now in dogs, similarly to cats, we'll see that kidney disease will be the primary cause for hypertension. So we have here chronic kidney disease, acute kidney injury, Cushing's disease.

And again, we have pheochromocytoma list as the diabetes mellitus. I think diabetes mellitus. I'd put it like this, we'll talk about this later.

Would that be a condition where we would routinely measure blood pressure? I would say no. And I would say that this is more extrapolated from the human, medicine.

And, as I said, it wouldn't be set out as a guideline that the diabetic patients need to have a regular measurement or measurement of the blood pressure as a part of establishment of their diagnosis. Now in dogs that are less common causes associated with hypertension will be obesity will be primary hyperonosteronism will be hyperthyroidism as well. This is one of those conditions if we review the consensuses.

Now, a little bit, let's touch base about how do these conditions, cause, the increase in blood pressure for specific diseases. Now, kidney diseases, I think there is, pretty much, I would say that the majority of you will know how the kidney disease could affect the blood pressure in any way. It will be the abnormalities or changes in the RAS system.

There will probably be a certain level of low sodium handling vegetables. There will be a constriction of sort of a glomeru arterulus, which will enhance the GFR, which will lead to intraglommeral hypertension, hyper perfusion, as well as proteinuria, and. So, as I said, some of these conditions are very well established.

Some of these conditions are extrapolated from human medicine but summarising again, the kidney diseases, we will have sodium and water retention, activation of the rest system and the sympathetic nervous system, and secondary structural changes of the real art to this, oxidative stress, and of course, genetics were the mechanisms described that cause hypertension in patients with kidney diseases. Now we have the hyperthyroidism. There is a very, very commonly we see hypertension in cats with hyperthyroidism, believe it or not, the aetiology of that is not very clear.

What there is a suspicion is that there is increased sensitivity of the heart muscle to circulating catecholamines and thyroid hormones and that to be the direct effect of cardiomys regarding resulting in an increased cardiac output. Then we have primary aldosterism, which is reported to cause hypertension in approximately 40 to 60% of cats diagnosed with this condition. It will be effectively increased all the sterile, which will lead to sodium retention, volume expansion, and consequently increased cardiac cat.

But we also see vascular remodelling and abnormal vascular tone in these patients. Hyperadrenal corticism, there are quite a few, I'm not gonna say quite a few, a few reasonal studies which have shown that the prevalence of systemic hypertension in patients with Cushing's disease is substantial. So we have from certain studies reporting 31%, up to 86% of patients with Cushing, and the Underlying cause for this would be the increased mineral cortico activity, decreased nitric oxide concentration, or increased renal vascular resistance.

Interestingly is that there is effectively no difference in the prevalence of systemic hypertension between dogs, with PDH, so pitu dependent hyperdroidocorticism and adreno-dependent hyperdrenal corticism. But if you look at the recent study, we can see that the prevalence of hypertension with the blood pressure systolic was increased about 150. Millimetres mercury was, you know, 82% of patients with hyperadrenal corticism, whereas severe systemic hypertension, which is where the blood pressure is increased to about 180 millimetre mercury, was reported 46% of Cushing patients.

So in our hospital, and I would advise that you also referring that I mean for the advice would be always monitor blood pressure in patients with hyperadrenal corticism. Now, a few bits and pieces about drugs, and how certain drugs could affect the blood pressure. So we have the glucocorticos here, routine use of glucocorticos, or the glucocortico use at a lower doses will not cause systemic hypertension.

It's much more common in the patients where we already cause the arogenic hyperadrenal cortices of patients where we literally cause them to become cushy we good at this way. Then we have mineral or cortico, so this oxycortisone peoplelateia, which is again uncommon to cause increased blood pressure that the beauty does, so you shouldn't be worried about your atisom and treated with DOC. Already opposite is dibopoietin, so erythropoietin treatment which has been reported to cause hypertension in 37% of cats and 96% of dogs.

And looking at a guideline of use of Dapoietin, the measurement of blood pressure in these patients is crucial. It's usually associated with increased perfusion and increased blood volume. Now we have the seric phosphate and it's a chemo drugs and hypertension would be documented in about 28% of previously normaltensive drugs, which are treated for various neoplastic diseases.

And then as the last one, if you look at the consensus, it was chronic high sodium intake which has been, you know, a concerning people, but effectively, effectively, in, in dogs and cats which are relatively salty insensitive, this would be, less common apologising for not moving, a slide forward. Now, . Next, we're gonna talk about the target organ damage.

Target organ damage is usually a consequence. So what effectively happened with increase and decrease of systemic blood pressure is that the small vessels, and these are small resistant vessels in organs, like kidney, brain. Retina and heart.

What they do is they constrict and dilate, not so much heart, I'm sorry, so constrict and dilate to regulate the flow to the vascular bands. So when you have a hypertensive damage with such, what happens is with, with the failing of these autoregulatory mechanisms, what happens is that you have hypertensive damage to the organs that are sort of associated with this vascular. Bats.

And what happens is that with the inadequate constrictions. So imagine, I usually say to my students, imagine these vessels as little balloons, and when they inflate sufficiently, you know, when they inflatesficiously, I would say when they are vascular such a regulatory mechanism, because what these vessels do is when you have an increased blood pressure, yeah, so they will constrict and with decrease the blood pressure, they will dilate and And with a certain extent when you have an increased blood flow to a certain organs, let's say glomeruli, these vessels imagine them like the balloons, and when they're over the stances, what you sort of what happens is that you have cracks in the endothelium. And then we'll talk about in a second what kind of changes do we see in the eyes or retina because of the increase or injury to this endothelium.

And the vascular bats, but essentially what happens is that we have either in the target social organs like eye, like brain, like kidneys, we have leakage of vasoactive substances as a consequence of damage to the vascular bats. We have decreased perfusion, and or we have, as I said, variable changes to the vascular walls which can lead progressively to the also the, the, if we speak about in the context of glomerular to progressive glomerular damage like glomerulosclerosis in this context. And now, .

The problem also, one of the biggest problems here that when we have target organ damage is that the vessels initially, when they vaso constricts to prevent, so to prevent the vascular bas from increased blood pressure is that the increased vaso constriction will lead to ischemia of the local tissue. Now, if you look at next, slide, we have, first of all, I think this is something that we see, I'd say among So to the target organ damages most frequently at at our hospital is the patients with the acute onset of blindness, yeah, or we see cats with the hyemas, yeah. And typically the ophthalmic changes will happen with the blood pressure, which can be as low as 168, so increases above 168, but substantial risk.

And those are the ones that I guess we will all see most frequently will be when the cystolic blood pressure will be about 180 millimetres mark. Now there are 3 types of damages that happens in the retina or in the eye. I'm not going to elaborate on this extensively because it's definitely not my area of expertise, but briefly, we have the hypertensive retinopathy.

It's where we have high pressure, sorry, transmitted to retinal retinal arterullis, so we have a vascular distention. And vascular distention remember I'm talking to you about the balloon causes the damage of the endothelial junctions, which then leads to retinal haemorrhage, which then develops later, in the course of the retinal changes, as I said, so I repeat again, high blood pressure is remitted to a retinal arterios, which caused the vascular distention and the damage of the endothelial junctions. Then we have hypertensive cordioopathy, which is a cause of leakage of vasoactive substances from the corrio capillaries.

For example, like angiotensin 2, and this will result in vasoconstriction and ischemia, which is followed by focal necrosis. And what happens is that exo from the capitalus leads to bus and then general retinal detachment. And then we have hypertensive optic neuropathy, where we have vasoconstricted substances which are released from the damaged vascular bas to compromise blood support, which causes an ischemia of the nerve head, edoema, and then loss of function of the optic nerves.

What do we see clinically? Clinically, you will all appreciate the retinal haemorrhage, multifocal retinal edoema, vassal osity, retinal periovascular edoema, papilledema. We will see viral haemorrhage, hyema, and then we can see secondary glaucoma and retinal degenerations.

We most commonly see these patients presented to our department because of an acute onset of blindness, and these patients are emergencies, so these are hypertensive emergencies. And no question that I have asked ophthalmology, the ophthalmologist or reviewing the literature from this, presentation is if I start treating them soon enough, can I guarantee the owner that the patient will be visual because that's all the answers would be the biggest question that the clients will have for you. Will my dog slash cat see again if we do this treatment?

Well, you cannot guarantee that. Yeah. We also cannot guarantee the clients that there will be a retinal reattachment, noted after treatment, but there is a high chance that if we start treatment sooner, that this patient actually can be visual and that we can see retinal reattachment.

As an overall, if I, Just report from my clinical experience is that the majority of these patients that presented with acute onset of blindness or patients that have retinal detachment or patients that have hype, that majority of them did have a massive improvement of their ophthalmic changes after treatment was started that these patients in our hospital typically will be hospitalised and treated quite aggressively over several days. Coming next will be, so these are some of the images. Hypertensive encephalopathy.

Well, this is an interesting one. This is, we see this, I'd say this bulk of patients is probably aside to hepatic shunts and some of metabolic, encephalopathies would be one of the largest percentage of what gets referred from our neurology departments. What we are called is these, these patients of these changes that are appreciated on MRI would be defined as vascular changes, and.

And the neurological signs reported in, in, in, as a cause of hypertension will be, reported in about 209-40% of cats with hypertension. They're fairly common in dogs, and they are the two types that you will see at the hospital, and this is what I usually say to my students and on my CPDs is that any sort of a vestibular or signs like head tilt and any stagus. Please measure blood pressure unless there is an obvious cause established already like an ear disease.

Vestibular signs will be one of the most common. Signs that we will see in these patients, and seizures very rarely, disorientation, alteredmentation also very rarely, but this is interesting. And sometimes, scanning patients with an MRI for let's say for variable causes or just very specific clinical signs, .

The vascular changes or the forebrain lesions associated with hypertension, I found purely incidentally. And I'll tell you why. It's because the forebrain lesions, mostly in dogs, are not well recognised by clients.

They're not so dramatic as having a patient suddenly develop a vestibular sins. But after starting of treatment, many of these patients, for example, will improve, let's say, so majority of forebrain changes that the clients will describe will be lethargy, will be, disorientation, which, as I said, the, the clients will appreciate disorientation, but the lethargy or sometimes mildly alteration will not always be absorbed by clients. And then we have an interesting change.

It's called in cats is he neuropathy, yeah, of the cranial cervical spine. And it's changes to the C2 which leads ambulatory Tresis or traplegia in cats. So what these cats present with with a significant cervical ventroflexus.

So when you put them on the table, examination type of these cats can sometimes do roll this poli, all right. So I repeat again, so hypertensive encephalopathy think about this when you have patients presenting with vestibular signs and With very nonspecific signs of a forebrain disease, the altermentation, lethargy unless the clinical signs of underlying causes already obvious. Now cardiac abnormalities tricky ones, especially in hypertensive cats because they're difficult to differentiate from HCM.

Usually, we will see 1 ventricular concentric hypertrophy, we will see gallop sounds, systolic heart murmur, but the cardiac failure is uncommon as a cause of systemic hypertension. And good news is that the hypertensive, anti-hypertensive therapy will Amelorate left ventricular hypertrophy. Now, renal abnormalities, the hypertension is associated with the worsening of proteinuria or development of proteinuria.

And it is a multifactorial, I said that multiple factors associated with how the hypertension will lead essentially to development of proteinuria. But effectively with the unopposed increased profusion of the glomerula, we will have the damage to the endothelium and we will have a leakage of variable vasoactive substances into the glomerulus and, and we will have as a secondary damage mealal cells. And, and meambile cells effectively and then proteinuria itself as we know, and it's not the part of this lecture effectively can then also on its own causes the progression of the kidney disease.

OK. Now, the most common changes that are histologic changes found in, in So a renal abnormalities, will be glomerulosclerosis and hyperplastic arteriosclerosis. And, hypertension, effectively, what's most important is that, and I cannot outline that more, is that the hypertension effectively will lead to then even further progressive damage to the kidneys.

Bear in mind that you have a kidney disease is effectively a result of . Loss of nephrons. So the remaining nephrons already on its own without the hypertension have to bear with the increased amount of perfusion because as I said, the remaining ones, but it is way the increased amount of perfusion or the increased amount of blood.

Towards the kidneys and now and we have to manage with that and at some point, as we talked about initially this compensatory mechanisms, so this up end of vessels that sort of a dilation and constriction which prevents these vascular bas like in glomerula will fail. And, at the, as I said, already increased blood flow to the remaining nephrons, all the single nephron units in, in kidneys adds the increased blood pressure to that, and then you will see that, that will additionally contribute to the progression of kidney disease. And as Ilined on this slide, it can be present at any stage of kidney disease and the creatinine value is not directly related to hypertension.

Now, here we go. We talked about the basics. We talked about the background, we talked about treating such about the target organ damages.

And now, how do you select the patients for screening? I think that every time, and I remember when I, when I see go to any CPT I, and I learn something new, I wanna apply it to all of my patients. But the hypotension, we all know that it can be quite some blood pressure.

We all know that it can be quite labour in a practise. That's why I'm glad that on this consensus, statement. Pretty much outlined that Routine screening of blood pressure in all dogs and cats is not necessary.

And that there is a very low prevalence of hypertension in, in practise in dogs and cats, some 0.5% to 30%, which means that the blood pressure measurement shouldn't be a part of every physical exam in the practise. No but the screening.

Really, screening is indicated, and I genuinely, as a referring clinician, I noticed that the vet still can't recognise well which patient needs screening. It should be with the diseases where hypertension is common. We talked about those diseases.

So long story short, I'll summarise it again. Please measure blood pressure with your kidney patients. Please measure blood pressure and hyperthalic cases.

Measure blood pressure obviously with pheochromocytoma, hyperalosteroidism, measure blood pressures with patients with vesiculars in which you can't find the obvious cause. Blood pressure in patients with cuing by all means measure blood pressure in patients with continuic kidney disease, right? So these are just the most common diseases.

So in those patients, this should be a part of your follow up and preparation of a treatment plan for these patients. Now, we also, what panellists advise is that blood pressure should be measured with ageing patients with subtle clinical signs like lethargy, altermentation, exercise intolerance, photophobia, I guess, remember, we talked about this for brain lesions incidentally documented on MRI which, which, after, you know, treatment is started and the clients do appreciate changes in the meanor of their patients. You know, if you, if you already correctly select these patients in your practise, you might actually prevent.

For the progression. Now, the panellists also advised, as I said, with 10 patients that this, they outline that these are patients older than 9 years old, and this should be done annually, so during the vaccination, regulatory vaccination, this can be done. But as I said, It's not always easy to measure blood pressure and it's, it's associated with costs.

So my personal advice would be measure blood pressure in patients with a subtle clinical signs, as outlined. My personal advice would be patients, obviously with clinical signs already associated with hypertension, so target organ damage, and patients where you know that hypertension will be a part of that disease. How is the blood pressure measured?

So, my advice for all the vets would be whatever device for blood measurement, HDO. Doppler and, use it, whatever, as I said, whatever you have in a practise, use it and use it well. We'll talk about that in a second.

I get a lot of questions asked is Doppler versus HTO. The truth is that none of these techniques has been evaluated, sufficiently to show the superiority of one versus another. There was a recent study conducted right where these techniques were compared.

The HDO versus Doppler and oscillometric techniques and the Doppler did show superior in cats, but the changes in some cats, I'd say comparing the different methods were significant. But, as an overall, because the Doppler technique can sometimes be quite laborious, can be challenging to do, my advice wouldn't be that don't measure blood pressure in cats because you don't have a perfect device. It means if you don't have a Doppler, use whatever you have in a practise to measure the blood pressure and then treat the hypertension accordingly, as we will discuss, later in this lecture.

Now, The cats, the biggest worry, as I said, was pyometric method in cats that they underestimate blood pressure at the higher values. A little photo here of variable, devices. Now, how do we measure blood pressure?

I'm gonna pause here a little bit because I, I'm gonna linger here on this bit slightly longer. My advice would be that You try and have a person available in your practise or you train multiple people, whatever is easier for you. To measure blood pressure, so I'll say because in our medicine department, all nurses are trained in this technique that I'm gonna talk to you about in a second, and that this technique of measurement of blood pressure is applied consistently.

Many times variability in blood pressure is not always associated with the disease itself or hypertension itself. They are associated with the different techniques used for measurement. So first of all, I noticed many times when I, I, speak to the vets is that for a start, That the blood pressure is measured away from the client, that the blood pressure is measured after the animals have been examined after the blood has been taken, which inevitably will result in, in a high blood pressure, as expected.

So the way we do this in our hospitals, so we follow the standards from ACDIM. So for animals that were coming, let's say for a follow-up of CKD or Cushing. Or proteinuria, we will have, we will admit the client, and we will allow the dog or the cat to settle in in a consult room, let's say for 5 to 10 minutes.

And before we will, so we won't do any physical exams, so usually the 1st 10 minutes, we will use to talk to the client. We will during this time not really interact with the animal. We won't touch, we won't examine the animal and the environment.

So we have the rooms which are isolated, quiet, and they're usually away from the other animals, which is specifically important for cats. Now, animals, typically, the blood pressure in our hospital will be measured with the presence of the client. The animals should be gently restrained.

They should be in a comfortable position with the, ventral, it can be ventrolateral recumbency, but what it's important is don't push the animals on the floor, don't, restrain animals in any sort of a position because this will inevitably result in animals getting stressed. But, what one needs to do is that the vertical distance from the heart to the base has to be minimal, yeah. Now, the cuff, which should be approximately 30 to 40% of the circumference of the c site, which you can measure straight away, and it's important that for this specific animal, the cuff that you use.

The leg that you use for measurement of the blood pressure should be noted on your system so that the next time you see an animal back, you use exactly the same technique. So what we do in the hospital, we note down the leg that was used, the size of the calf, and the position that the animal was during the measurement. Now, the, the measurements, as I said, is a consensus advises the patient should be calm and motionless.

But, no, that's not always achievable, so just try and do your best, would be my advice. We will measure the blood blood pressure on average will have 9 to 10 measurements, but the first few measurements should always be discarded. And so the first few measurements should be discarded and take 5 to 7 consecutive consistent values should be reported and we will calculate the average.

So this sort of, I think I covered sort of the basic of what needs to happen during blood pressure measurement. Vets will ask me, Elia, what about it that one leg works now and it doesn't work next time. My advice would be, you can varyate among different locations because unfortunately, in our profession, we will never achieve the perfection on the patient being completely still like in humans, put it this way.

So do your best with the advice, but I I think the biggest errors that I see in the vets or when I speak to the vets, is that they take animals away from the owners, that they perform entire physical exam and blood collection before they measure the blood pressure, and that the blood pressure monitoring is not always done in the same way, which I can appreciate, can be very challenging in a first-line hospital, and then perhaps the techniques for measurement are not always used correctly. So this is great. What's normal?

What's normal? Remember when we deal with this, you have a cat that is, is agitated. We have a dog that is agitated and your blood pressure goes to 180 and goes to 200 and you go like, oh my gosh, should I not treat you?

Is that real? And particularly if you have a patient with a kidney disease and you see this Huge and very high blood pressure, and of course, you would probably assume that treatment should be started, but again, you're worried that you might achieve quite the opposite cause the patient to be hypertensive. Yeah, I'm going to show you in a second an amazing table where different blood pressure measurements or values were obtained from various studies just to show you how high the variations can be in animals, mostly.

Due to stress, but as I told you, to minimise, because we, we know that in our profession, we will have variations due to stress, but if you improve your handling techniques, animal handling, if you measurement an operator experience is very good, you will be able to narrow down a little bit these variations from measurement to measurement. Now, sex, obesity, age, breed differences, they contribute minimally in the changes in blood pressure in animals, but in hound. We know that the blood pressure is greater than long.

I'm talking here about 10 to 20 millimetres mercury. Now, look at these studies. I thought this is very interesting.

If you look at the study, just some of those values that are measured, we have patients that present, for example, that's a very early study in 1968, but the blood pressure medium was 144 + minus 156 difference. So since it's quite insanely hypertensive patient already or you have 150 plus. 20, we have variations of plus minus 20, we have plus plus minus 50 plus 28, so you can see if your median blood pressure in the studies, let's say 146 and you have variation of 50, you're already reaching 1190 and 200, and these were just variations in a healthy conscious animal.

So do you see how difficult it is to give you, as I said, as a solid cookbook advice? Even in a conscious, healthy animals, this is the variation that you can see just due to stress and due to differences in day to day measurement. So how do we really then diagnosis?

Who do I treat? How do I really approach that? So these are some of the guidelines on how we split patients into, into the group.

So we have a normal intensive group where the blood pressure is systolic and they bear in mind therapeutic decisions are always made based on systolic blood pressure. OK. So, whether to treat or not depends on what your systolic blood pressure is, OK?

So, do not take mean anti-systolic blood pressure into a consideration when we're making the decisions whether to treat or not to treat. So here we go. So normal tensive patients will be patients with systolic blood pressure less than 140.

We will have pre-hypertensive patients with blood pressure between 104 and 159. We'll have hypertensive patients, usually 160, 179, and these are severely hypertensive patients, which will have systolic blood pressure above 180. And as you can see, the consensus has also added.

To this group, the levels of risk of target or the damage associated with the specific blood pressure. Now, what, how do I repeat this? It's a high blood pressure.

Do I treat you now? Do I repeat? So the general guidelines go like this.

If you have a patient that has got blood pressure in a sort of a pre-hypertensive patient, between 100 and 159, or the hypertension is a moderate risk of, of target organ damage, so between 100 and 179. So let's say from 100 and 100, 160, 100, 80. Repeat the blood pressure measurements.

Over 4 to 8 weeks. So it repeated in 1 to 2 months because, you know, as we spoken really at the beginning, at the beginning of the course the worst would be that you treat patients with situational hypertension. Yeah.

So, as I said, the consensus here applies in a group with minimal risk with the blood pressure not exceeding 180, you should repeat measurements, as I say, in over 4 to 8 weeks. Now, the patient that presents to you and has retinal changes. The patient that presents to you has got massive proteinuria patient that presents to you has got neurological changes.

You document severe hypertension above 180. You're very happy to start treating. And so those patients, I will be quite happy initiating treatment after a single measurement.

But in most of these cases, if you can, you can repeat the measurements over multiple occasions, and multiple occasions, sometimes in our hospital, would mean that in some Patients where I'd say where I have a significant proteinuria, I will, for example, measure it over several days in case they stay in the hospital. Some of them do. Yes, we have a luxury to have a patient in a hospital might measure the blood pressure within the same day or days and.

Now, if you have a patient with a more severe hypertension, yeah, but the patient doesn't have a target organ damage, then you must see that patient back for a second measurement sooner that's in, you know, 1 or 2 weeks. I'll repeat again. Happy to treat, you have target organ damage.

Happy to treat any document hypertension at the same time, specifically in retinal changes. If the patient is hypertensive but not at a moderate risk, take your time, 1 to 2 months, you can repeat the second measurement and if you are a patient who is hypertensive but doesn't have the target organ damage, you do need to repeat it, and usually takes smaller time frame 1 to 2 weeks. Now, how do we go once you document hypertension?

What do you do next, ma'am? First of all, if the patient has got severe hypertension, patient has got target organ damage, you treat while you look for an underlying cause. No doubt here, ma'am.

If you have a patients in pre-hypertensive groups or diseases that are associated with hypertension, They don't need to be treated. Instead, close monitor. What they advise is in the patients, for example, you have a Cushing patient.

This is a patient where it's predisposed to have a development of hypertension, but it doesn't have a hypertension. What we would be advised just to follow up every 6 months, OK? So a patient with kidney diseases, which you will see back if they are stable with 4 times a year, measure blood pressure during these appointments.

Client education. Why is that crucial? It is challenging to convince clients to treat something that they can't appreciate to be the problem.

And with the blood pressure, unless they have an acute onset of blindness or bleed into the eyes or develop neurological signs, you might struggle to convince them that this treatment is important. And, and it's sometimes, remember I told you, you have 4 brain lesions in the patients. What happens is that in many instances, when you start treating the blood pressure and the patient and the clients actually appreciate the changes in their patients, yeah, that over gradual over time, they will know, OK, the treatment is important because my doctor's been lethargic and didn't want to go for a walk, now actually enjoys the walks.

So these are sort of the circumstances which, to be honest, As we see quite a lot of patients with sort of a hypertension, but not obvious clinical signs associated with this will not always be the case. Yes, so it's important that you educate the clients why it's important to treat hypertension, but also tell them that they won't always appreciate, how this treatment will improve the animal's quality of life. Now, general treatment guidelines is, as I said before, treat underlying conditions concurrently with treatment of hypertension.

Treatment is individualist. There is no cookbook scenario available for you. And the, the decrease of blood pressure is always gradual.

The rapid decrease in blood pressure is rarely, rarely indicated. We'll talk about the hypertensive retinopathy where we tend to be more aggressive, in treatments of those we would be considering as more Hypertensive emergency, but the goal of treatment is gradual and the treatment should be that systolic blood pressure should be below 140. And the treatment should be adjusted if the blood pressure when you see the patient in back is still above 160.

And again guys, bear in mind here that situation of hypertension will be a factor that will Make things a little bit tricky, but what I usually use is I have a very stressy dog. From one appointment to another, if I don't see a difference, for let's say I had a play dog who was very stressy and we established a blood pressure of 180 on an appointment. One, when we start treatment.

On a second appointment, I will see this patient back is I would want to see a blood pressure significantly lower than during the first appointment, not necessarily targeting below 140, yeah. But it has to be significantly lower than what it was before for me to be happy. Will I, in a stress the patient adjust the treatment?

Depends. This is very difficult. Again, it's very difficult to give a guideline here and say in which patients you should continue increasing the dose of anti-hypertensive in which not because there is a multifactorial.

So for if you have a patient that has retinal problems, it's different, the patients get got. Neurological side effects of patient that has a CKD. But as I said, I try to follow these guidelines, and I would say that in the majority of times, you will be successful if you follow the guidelines and target what the goals that the consensus has established are.

And, very rarely you will achieve this, as I outlined last year, point is that, hypertension and hypertension will Discussed where you have a blood pressure or consider about 120, and it's combined with clinical signs of weakness, syncope tachycardia, and very rarely have I seen this. So personally, I feel more comfortable in increasing, or I am quite aggressive in increasing the doses of anti-hypertensive medication, targeting the goals outlined in a consensus. Management of hypertension in dogs, let's start this.

So in dogs, always, in dogs and cats. I'm going to go into a little bit of how these drugs works, but the message is, I still see way too many vets using ACE inhibitors or angiotazine receptor blockers along for treatment of hypertension. No, no, and no, the calcium channel blocker should be the core of treatment of hypertension in all your patients and in dogs, because what the Carton channel blockers do is they will dilate the afferent arterul that it will increase into blue marral pressure, which is not brilliant.

therefore in dogs we'd love to combine them with ACE inhibitors kind of achieve the, levelling of the blue marral pressure. Combination of these drugs. So the way I will treat them is I will always start a calcium channel blockers, the initial dose outline to you here on the start on the slide, and then I will titrate it above, sort of a, up to the outline dose in, in, in the consensus.

A lot of vets will ask me, do you go above this dose? Do you double the dose? I have done it.

Yes, I have done it. I have went above, up to 0.5.

I went even higher some patients, but these instances where I had to do it were extremely, extremely rare. So I'll point it to you again. Typically, we'll manage the majority of your patients with the doses from 0.1 to 0.25 of the, of lodipine, so milligramme per kilogramme per day.

. Rarely, you need to go up to high 0.5 kick in cats and dogs, and then in cats, the dose also outlined is 0.65, 1.22 makes per cat per day.

RAs inhibitors, you know, the dose is from 0.25 to 2 me per cake, which you didrate and miser dose applying for treatment can be from 0.5 to 1 me per kg per day.

And next we can see, as I said, already combination of these drugs, . It is necessary in, in, in dogs for me. Now, for the hypertension treatment in cases of pheochromocytoma, you will have to prescribe H beta adrenergic blockers and aldosterone receptor blockers for hypertension associated with hyperaldosterinism.

In cats, again, amlodipine, amlodipine. Alodipine should be the core of your treatment. In cats, The, as I told you before, if you stick to therapeutic doses which are blind to you in this slight, you should be quite OK.

It's very, very rarely that you will need higher doses up to 2.5 mg per cat per day. I have done it.

I'm not gonna lie to you. I have done, but as I explained to you before, very rarely. Now, treatment with amlodipine, unfortunately, hasn't been shown to extend median survival time of cuts with hypertension.

Now, what about other drugs in cats? Do ACE inhibitors make any difference? Should we add this medication on top of it?

Because in cats with hypertension, the proteinuria is shown to be the predicting factor of survival, and, but it has been shown that the proteinuria is significantly decreased in cats were treated with amlodipine alone. In cats, the additional survival benefit of end on entrepreneuric agents like ACE inhibitors and telmisartan has not been shown, so the evidence is lacking. Now there was a study where they showed that telmisartan is the dose of tinic per day led to desirable decrease in blood pressure.

So that systolic blood pressure of more than 20 millimetres mercury, but guess what? In this study, if you read carefully, so they advertise it as a holy grail, butsartan can be used as a sole agent. But the thing is that in these cats, in this study, the cats with severe hypertension and target organ damage were excluded.

There you go. So those are the ones that we're most interested in. So, but also bear in mind that for example, as I told you, this study so meaning that the miserton in cats with severe hypertension and those with ocular damage or CNS hypertension has not been demonstrated.

Let's go next. Hypertensive emergencies. How many hypertensive emergencies do we actually really see?

Now, I'm not gonna lie to you. I do consider hypertensive emergencies the ones that have the ocular sign. And the patients with neurological signs.

Do I have a cookbook a recipe for you on how to treat those patients? I would use infiltrate so we will keep those patients in a hospital. Tetra amlodipine up until we reach a desirable effect.

Do we always reach a desirable effect? Of course not because these patients are, are remain stressed, but we try to do our best but we work together, and I think that you, I'd say also I noticed this because in our hospital, we do have first-line beds, so the hospital splits. Referral and the first line hospital that first line that's are very, very good in following up ocular signs of improvement of the retinal changes associated with hypertension once we start treatment.

So I think if you just observe patients clinically, if they have neurological signs, measure their blood pressure to treat medication up . I think you will be able to achieve desirable effects in all of these patients with aggressive treatment. Now, how many of other drugs do I actually use?

Have I used phenol the pump? Have, have I used hydralazine? No, I personally haven't have seen it being used by my colleagues.

I can't comment on the success of this treatment. These, recommendations to use any other drugs are anecdotal. They're extrapolated from human studies.

They require closer. Observation of your patients, but I will definitely encourage you to use other drugs like hydralazine, for example, in case your patients are severely debilitated. So for example, patients in a coma, massively decrease mentation and you have an achieve desirable effects with amlodipine.

So with this slide, I'm also closing, so finishing my presentation on hypertension. If I can ask the answer, I'll end up with the questions, but I will briefly summarise what my message for you would be is, Try and recognise target organ damages, be very attentive to neurological signs. Ocular changes and proteinuria.

So as I said, pay more attention to this in a practise and try and remember to measure blood pressure in patients with this kind of changes. Try and remember. To measure blood pressure in patients with kidney diseases, cats with hyperthyroidism, dogs with protein and we have dogs with Cushing's, I think majority of you know that you need to measure blood pressure lyochromocytoma hyperaldosterinism.

Learn and apply correct techniques. I know that perfection is outlined in consensus, it is very difficult to achieve in a first-line hospital. I've been there.

I tried it myself. It's very difficult, especially because you do not always have enough hands available to help you. But try to use methods consistently.

Whatever device you have for measurement of the blood pressure in your practise, use it. This not having a Doppler versus HDO should never be a reason for not measuring the blood pressure in your patients, and the measurements that you get to trust them. If you don't trust them, if you're worried, repeats them, try not to take too much time to repeat the measurements in patients that have targeted organ damage and really high blood pressure.

But with any less, you can be a little bit more relaxed as I told you pre-hypertensive or low blood pressure, be more relaxed. And when you repeat it, so 4 to 8 weeks, and as the last, please use amlodipine, use amlodipine. Don't be afraid to increase the dose.

Don't forget to combine it with ACE inhibitors, . In dogs and don't use just ACE inhibitors and or any rust system inhibitors in, in cats. So amlodipine, amlodipine, amlodipine, and I think that's it from my end, and do let me know or my colleagues from Webinar vet if you have any questions.

Thank you.