Journal of Feline Medicine and Surgery (2011) 13, 733e737

doi:10.1016/j.jfms.2011.07.003

Evaluation of the effects of hospital visit stress

on physiologic parameters in the cat
Jessica M Quimby DVM, DACVIM*, Melissa L Smith DVM,
Katharine F Lunn BVMS, MS, PhD, MRCVS, DACVIM

Department of Clinical Sciences,
College of Veterinary Medicine and
Biomedical Sciences, Colorado State
University, 300 West Drake Road,
Fort Collins, CO 80523, USA
Date accepted: 21 June 2011
Physiologic parameters such as blood pressure, rectal temperature, heart rate,
and respiratory rate are an important part of the medical assessment of a patient.
However, these factors can potentially be affected by stress. The purpose of this
study was to compare physiologic parameter data gathered from cats in the
home environment with those gathered in a veterinary hospital. Thirty healthy
cats were evaluated both at home and at Colorado State University’s Veterinary
Medical Center. Doppler systolic blood pressure, temperature, heart rate, and
respiratory rate were recorded, and the differences between the values obtained
in the home and veterinary clinic environments were evaluated using the
Wilcoxon sign rank test. A significant difference was found in blood pressure,
heart rate, and respiratory rate between the home and veterinary hospital
environments. This information may help practitioners recognize that
physiologic abnormalities can sometimes be due to transportation or
environmental stress rather than medical illness.
Ó 2011 ISFM and AAFP. Published by Elsevier Ltd. All rights reserved.

A
n important part of veterinary patient assess-
ment is obtaining physiologic parameters
such as blood pressure, temperature, heart
rate, and respiratory rate. Measurement of body tem-
perature and determination of hyperthermia (temper-
ature > 102.5
F) are important in the assessment of
sick animals. Classification of body temperature as eu-
thermic, hyperthermic or febrile is critical to the diag-
nostic process.1 Although a clinical history of heat
exposure and subsequent resolution may differentiate
hyperthermia from fever, on initial assessment it can
be challenging to do so. Determination of respiratory
rate and heart rate are also important for assessing
the health status of a patient. Increased respiratory
rate could indicate respiratory disease, cardiac dis-
ease, pleural space disease, or pain; while tachycardia
may suggest cardiac or metabolic disease, pain, or hy-
povolemia. Measurement of blood pressure is critical
in sick animals and those at risk for hypotension
and hypertension as both can be associated with or-
gan damage and should be addressed promptly.2e4
The measurement of blood pressure is also an impor-
tant part of the clinical staging of chronic kidney
*Corresponding author. Fax: þ1-970-297-1275. E-mail:
jquimby@colostate.edu
disease (CKD), which is a relatively common problem
in the cat.5
Changes in any of these physiological parameters
due to stress could confound the clinical assessment
of the patient, with the detection of hypertension in
cats providing particular challenges for veterinarians
in this regard. The existing standard of care is to con-
duct multiple blood pressure measurements over a pe-
riod of time before diagnosing hypertension and
prescribing medications, unless the blood pressure is
elevated (>160 mm Hg) in conjunction with signs of
organ damage, or a concurrent illness associated
with hypertension is present.3,6 Even with multiple as-
sessments, it is unclear how much the hospital visit it-
self and the act of measuring the blood pressure
affects cats.
In humans, elevation in blood pressure due to the
stress of the clinical setting is referred to as the ‘white
coat syndrome’ and has been recognized for decades.7
This phenomenon is thought to be mediated by the
sympathetic system, but the precise mechanism is un-
known. In cats the existence of the ‘white coat syn-
drome’ was explored in a study in which research
cats with radiotelemetry implants underwent a simu-
lated veterinary office visit.8 Based on the findings, it
was concluded that cats do experience a ‘white coat
effect’. As the actual act of measuring blood pressure

1098-612X/11/100733+05 $36.00/0 Ó 2011 ISFM and AAFP. Published by Elsevier Ltd. All rights reserved.
734 JM Quimby et al
may also affect the reading, the results of this study
are difficult to extrapolate to client-owned cats for
which readings are obtained using a non-invasive
method of measuring blood pressure.
Belew et al8 also assessed heart rate by radiotelem-
etry in cats in the home environment and clinic envi-
ronment, and found that there was a significant
increase in heart rate in the clinic. To the best of the
authors’ knowledge, no previous studies exist to doc-
ument the extent to which a cat’s respiratory rate can
become elevated as a result of the stress of a hospital
visit. Similarly, no previous studies have explored the
degree of elevation that may occur in a cat’s tempera-
ture purely as a result of the hospital visit, or as a re-
sult of resistance or struggling while the reading is
obtained. The objectives of the present study were,
therefore, to determine whether the stress associated
with a hospital visit has an effect on the feline physi-
ologic parameters of blood pressure, rectal tempera-
ture, heart rate and respiratory rate. Our hypothesis
was that the value of all of these parameters is in-
creased in the hospital environment, compared to
values obtained at home.
Materials and methods
Animals
The study population consisted of 30 apparently
healthy cats (based on a normal clinical history and
physical examination) owned by veterinary students
and faculty at Colorado State University (CSU). The
Institutional Animal Care and Use Committee at CSU
approved the study, and all owners reviewed and
signed consent forms prior to participation in the study.
Data collection
Systolic blood pressure, rectal temperature, heart rate,
and respiratory rate were measured in the home envi-
ronment and at the veterinary clinic on the same day
by a single student researcher. Physiologic parameters
were first measured in the home environment in the fol-
lowing order; blood pressure, heart rate, respiratory
rate and temperature. The owners then drove the cats
to the veterinary clinic, where physiologic parameters
were again obtained, in the same order, after a 10 min
acclimatization period. Systolic blood pressure was
measured as an average of five readings obtained using
a Parks Doppler unit (Parks Medical Electronics, Las
Vegas, NV) on the right or left forelimb and sized to
40% of the circumference of the forelimb. Temperature
was measured with a 10 s digital thermometer (Vicks
V900F/V901F, Kaz, Hudson, NY) following blood
pressure assessment. Heart rate was determined by
auscultation and respiratory rate by visual observation.
The cats’ attitude during manipulation was scored on
a scale of 0e3 using the following parameters: calm
(0) or agitated (1); compliant (0) or struggling (1);
quiet (0) or vocalizing/hissing (1).
Statistical analysis
The physiologic parameter data for cats in their home
environment and at the veterinary hospital were com-
pared using a non-parametric Wilcoxon sign rank test.
Statistical significance was set at P < 0.05.
Quality control
Calibration of the Parks Doppler unit was performed
at the beginning of the study, after every five readings
during the study, and at the end of the study using
a pressure manometer. The student researcher con-
ducted these calibrations.
Results
Animals
Thirty cats participated in the study. Three additional
cats were disqualified after becoming intractably frac-
tious in the home environment. Sixteen cats were neu-
tered males and 14 cats were spayed females. Breeds
included 20 domestic shorthairs, two domestic long-
hairs, three Siamese mixes, and one each of Ragdoll,
Persian, Russian Blue, Himalayan, and Burmese.
Median age of participating cats was 4 years (range
0.6e11 years). Five cats were reported to have an
indoor/outdoor lifestyle and the remaining 25 were in-
door only. Median transportation time to the veterinary
hospital was 12 min with a range of 5e40 min.
Physiologic parameters
Median and range of physiologic parameters obtained
from cats in the home environment and the veterinary
hospital environment are reported in Table 1. A statis-
tically significant difference was found between the
home environment and the veterinary hospital envi-
ronment for blood pressure (P ¼ 0.04), heart rate
(P < 0.0001), and respiratory rate (P ¼ 0.01).
Measured physiological parameters in the home
and hospital environments are depicted in Fig 1AeD
as BlandeAltman plots to allow the variability
between environments to be appreciated for each sub-
ject. Two cats were disqualified from respiratory rate
analysis, one due to constant sniffing in the home
environment and one due to panting in the hospital
environment. The mean difference between blood
pressure in the home environment and the hospital
environment was a 6 mmHg increase, with a range
of 26 mmHg decrease to a 31 mmHg increase. The
mean difference between temperature in the home
environment and the hospital environment was
a 0.3
F increase, with a range of a 1.3
F decrease to
a 2.1
F increase. The mean difference between heart
rate in the home environment and the hospital envi-
ronment was 33 beats/min increase, with a range of
a 20 beats/min decrease to a 76 beats/min increase.
The mean difference between respiratory rate in the
 Physiologic parameters in cats 735

Table 1. Recorded differences in physiologic parameters measured in cats in the home environment
followed by the hospital environment. A statistically significant difference was detected between the
home environment and the veterinary hospital environment for the parameters blood pressure
(P ¼ 0.04), heart rate (P < 0.0001), and respiratory rate (P ¼ 0.01).
Home environment Hospital environment
Median Range Median Range
Blood pressure (mmHg) 131 96e167 138 106e164
Rectal temperature (
F) 101.2 98.6e102.7 101.5 100.4e103.0
Heart rate (beats/min) 153 110e250 190 128e256
Respiratory rate (breaths/min) 50 24e84 58 18e192

home environment and the hospital environment was
12 breath/min increase, with a range of a 30 breath/
min decrease to a 108 breath/min increase.
When attitude scores were compared between the
two environments, 50% of cats experienced a decrease
in their score in the hospital environment compared to
home, 20% of cats experienced an increase in their
score, and 30% of cats experienced no change in their
attitude score.
Discussion
This study examined the physiologic parameters of
blood pressure, temperature, heart rate, and respira-
tory rate in cats in the home environment in compar-
ison to the veterinary hospital. A statistically
significant difference was seen between the home
environment and the veterinary hospital environment
for the parameters blood pressure, heart rate, and
respiratory rate.
Although the changes in systolic blood pressure,
heart rate and respiratory rate were all found to be
statistically significant, the clinical relevance of these
changes is not uniformly apparent. An increase in
blood pressure of 6 mmHg would usually not be
considered to be highly clinically significant, given
the inherent variability of blood pressure measure-
ment via Doppler, which has been previously docu-
mented.9 However, the mean increases in heart rate
(33 beats/min) and respiratory rate (12 breaths/min)
could have more clinical relevance. In addition, exam-
ination of the largest observed increases in each of
the physiologic parameters suggests that the effects
of stress should be considered when assessing

Fig 1. BlandeAltman plots illustrating the difference between the home and clinic environment for (A) blood pressure, (B)
rectal temperature, (C) heart rate and (D) respiratory rate. The horizontal line represents no difference. Cats below the line
experienced an increase in the measured parameter in the clinic environment. Using a Wilcoxon sign rank test, a statistically
significant difference was found between the home environment and the veterinary hospital environment for blood pressure
(P ¼ 0.04), heart rate (P < 0.0001), and respiratory rate (P ¼ 0.01).
736 JM Quimby et al
individual patients. Specifically, the highest docu-
mented increase in blood pressure between the
home and veterinary hospital environment was
31 mmHg, the greatest change in temperature was
an increase of 2.1
F, the largest increase in heart rate
was 76 beats/min, and the greatest increase in respira-
tory rate was 108 breaths/min. Each of these changes
would be considered to be clinically important in a fe-
line patient. For example, in the classification of feline
CKD, a difference in blood pressure of >10 mmHg is
sufficient to move a cat from a ‘low risk’ to a ‘moderate
risk’ arterial pressure substage.5
In this study, the mean increase in rectal tempera-
ture of 0.3
F between the home and hospital environ-
ments was not statistically significant, and would also
not be regarded as clinically significant. However, it is
noteworthy that three cats that had temperatures
<102.5
F in the home environment subsequently de-
veloped an elevation in temperature in the hospital
environment that potentially could be considered to
be medically significant. Rectal thermometry is re-
garded as an acceptable method for estimating core
body temperature,10 although stress or physical exer-
tion may potentially increase this parameter.11 Based
on the results of this study, the stress of transport
and the hospital environment should be considered
a differential for hyperthermia in felines. Conversely,
one cat that had a temperature over 102.5
F in the
home environment subsequently had a normal tem-
perature in the hospital environment, implying that
the stress of temperature measurement alone is suffi-
cient to elevate rectal temperature.
The results of this study support the concept that
a ‘white coat effect’ exists for some cats in the hospital
environment. Past studies have noted that blood pres-
sure in dogs is affected by stress12e14 and a previous
study in which telemetry was used to assess blood
pressure and heart rate in cats came to a similar con-
clusion.8 It appears that this effect is also found in cats
in which the non-invasive Doppler measurement of
blood pressure is used, a technique used commonly
in practice, but one that may also induce stress due
to manipulation. The cats utilized in this study were
healthy adults, and potentially these effects may be
magnified in sick animals, particularly those with re-
nal compromise.8
Interestingly, measurement of physiologic parame-
ters in the home environment was not as straightfor-
ward as anticipated. Cats in this environment were
more likely to object to manipulation by apparent ag-
itation, struggling, and vocalizing, and thus many cats
experienced a decrease in their attitude score in the
hospital environment compared to the home. This
serves as a reminder that the act of obtaining physio-
logic measurements in cats contributes to stress that
may affect the readings. Struggling and vocalization
are behaviors that are likely associated with a sympa-
thetic response, as indicated by a study showing an
increase in epinephrine, norepinephrine, cortisol and
glucose in cats stressed by a spray bath.15 Anecdotally,
measurement of blood pressure in the home environ-
ment has been recommended to circumvent the sym-
pathetic ‘white coat effect’ in the clinic environment,
but the results of the present study imply that obtain-
ing measurements in the home environment may also
provide a significant source of stress, as cats may be
less tolerant of manipulations in their own territory.
Three cats that were previously considered by their
owners to be generally malleable in the clinic environ-
ment were fractious when physiologic parameter
measurement was attempted in the home environ-
ment, and subsequently were disqualified from the
study for the safety of the handlers.
Factors that could have affected the outcome of this
study include a potential bias due to the volunteer
based selection of participants, and disqualification
of fractious cats, both of which may have inadver-
tently predisposed the study population towards
less stress-prone individuals. It should also be noted
that the order in which physiologic parameters were
measured may have affected the results of the subse-
quent measurements. For instance, measured parame-
ters such as respiratory rate may not be representative
of the normal feline population as they occurred after
restraint and manipulation, and not at rest.
In conclusion, a statistically significant difference
was detected between the home environment and
the veterinary hospital environment for the parame-
ters blood pressure, heart rate, and respiratory rate.
Although mean differences in parameters may not
be uniformly clinically relevant, the observed range
of increase for all the parameters could be very signif-
icant in individual animals. Thus the results of this
study support the idea that stress may result in ele-
vated physiologic parameters for cats in the hospital
environment, and clinicians should bear this in mind
when assessing feline patients upon presentation. In
addition, medical assessment in the home environ-
ment does not necessarily preclude stress-related
changes in physiologic parameters.
Acknowledgements
This study was supported by funding from the
Professional Veterinary Medicine Student Grant
Program at the Center for Companion Animal Studies
at Colorado State University. The study sponsors had
no role in study design, the collection, analysis and
interpretation of the data, or the writing and decision
to submit the manuscript.
References
1. Flood J. The diagnostic approach to fever of unknown
origin in cats. Compend Contin Educ Vet 2009; 31: 26e31.
2. Jepson RE. Feline systemic hypertension: classification
and pathogenesis. J Feline Med Surg 2011; 13: 25e34.
3. Stepien RL. Feline systemic hypertension: diagnosis and
management. J Feline Med Surg 2011; 13: 35e43.
 Physiologic parameters in cats
4. Kreisberg JI, Bulger RE, Trump BF, Nagle RB. Effects of
transient hypotension on the structure and function of
rat kidney. Virchows Arch B Cell Pathol 1976; 22: 121e33.
5. Polzin DJ, Osborne CA, Ross SJ. Chronic kidney disease.
In: Ettinger SJ, Feldman EC, eds. Textbook of veterinary
internal medicine. 6th edn. St Louis, MO: WB Saunders,
2005: 1756e85.
6. Brown S, Atkins C, Bagley R, et al. Guidelines for the
identification, evaluation, and management of systemic
hypertension in dogs and cats. J Vet Intern Med 2007;
21: 542e58.
7. Ayman D, Goldschein A. Blood pressure determinations
by patients with essential hypertension. Am J Med Sci
1940; 200: 465e74.
8. Belew AM, Barlett T, Brown SA. Evaluation of the white-
coat effect in cats. J Vet Intern Med 1999; 13: 134e42.
9. Sparkes AH, Caney SMA, King MCA, Gruffydd-Jones
TJ. Inter- and intraindividual variation in Doppler ultra-
sonic indirect blood pressure measurement in healthy
cats. J Vet Intern Med 1999; 13: 314e8.
Available online at www.sciencedirect.com
737
10. Greer RJ, Cohn LA, Dodam JR, Wagner-Mann CC, Mann
FA. Comparison of three methods of temperature mea-
surement in hypothermic, euthermic, and hyperthermic
dogs. J Am Vet Med Assoc 2007; 230: 1841e8.
11. Nobel JJ. Infrared ear thermometry. Pediatr Emerg Care
1992; 8: 54e8.
12. Vincent IC, Michell AR. Relationship between blood
pressure and stress-prone temperament in dogs. Physiol
Behav 1996; 60: 135e8.
13. Vincent IC, Michell AR, Leahy RA. Non-invasive mea-
surement of arterial blood pressure in dogs: a potential
indicator for the identification of stress. Res Vet Sci
1993; 54: 195e201.
14. Remillard RL, Ross JN, Eddy JB. Variance of indirect blood
pressure measurements and prevalence of hypertension
in clinically normal dogs. Am J Vet Res 1991; 52: 561e5.
15. Rand JS, Kinnaird E, Baglioni A, Blackshaw J, Priest J.
Acute stress hyperglycemia in cats is associated with
struggling and increased concentrations of lactate and
norepinephrine. J Vet Intern Med 2002; 16: 123e32.