White-Coat Effect on Systemic Blood Pressure in
Retired Racing Greyhounds
C.L. Marino, R.E. Cober, M.C. Iazbik, and C.G. Couto
Background: Greyhounds are known to have a higher systemic arterial blood pressure (BP) than non-Greyhound dogs.
Objectives: The purpose of this study was to determine whether the high systemic BP was because of the white-coat effect.
Animals: Twenty-two healthy retired racing Greyhounds (RRG) enrolled in a blood donation program.
Materials/Methods: We prospectively measured systemic BP in 3 environments: in the hospital by the investigator (Hosp),
in the home by the investigator (H/I), and in the home by the owner (H/O). Five serial measurements of systolic, diastolic, and
mean arterial pressures (SAP, DAP, MAP) as well as heart rate (HR) were measured by an oscillometric method on the distal
forelimb and distal hind limb in all 3 environments.
Results: There was a significant difference for SAP, MAP, and HR between the Hosp and both H/I and H/O (P o .001);
there wereno significantdifferences for anyof the parameters betweenthe H/I and H/O environments. HR, butnot SAP, MAP,
or DAP (P o .05) decreased in RRG with multiple hospital visits for blood donation before this study. The hind limb SAP was
significantly higher than the forelimb SAP (P o .05).
Conclusions and Clinical Importance: We conclude that the high SAP, MAP, and HR seen in the hospital setting are likely
because of a white-coat effect. Furthermore, consideration should be given to defining the parameters of normal BP in RRG
according to the environment in which they are obtained.
Key words: Dog; Hypertension; Oscillometric; Stress.
living in homes as pets.1This increasing popularity has
precipitated considerable research into the many differ-
ent cardiovascular features of Greyhounds, including
higher hematocrit and blood viscosity,2large left ventric-
ular mass and volume,3,4and high systemic arterial blood
pressure (BP).2,5Greyhound BP is reported to be ap-
proximately 10–20mmHg higher than that of mixed
breed dogs when measured in the hospital.6Most of
these cardiovascular differences are physiologic adapta-
tions, presumed to be advantages for racing. Systemic
hypertension, however, can have detrimental effects on
the cardiovascular, ocular, neural, and renal systems
resulting in reversible or irreversible pathologic changes.
White-coat hypertension is defined as an increased BP
in the hospital setting when compared with the subject’s
usual environment (eg, ambulatory BP). The white-coat
effect appears to be because of activation of the sympa-
thetic nervous system secondary to stress and resulting in
a transient increase in BP.7,8–11In humans, white-coat
hypertension can cause target organ damage (TOD) in
the kidneys, eyes, and cardiovascular system.7,8,12–14In
cats, the white-coat effect can cause an increase in sys-
tolic arterial blood pressure (SAP) of up to 30mmHg
when compared with ambulatory BP.9Cats with experi-
he adoption of retired racing Greyhounds (RRG)
has increased in the past decade, with over 120,000
mentally induced renal insufficiency also have white-coat
hypertension of even higher magnitude and for a longer
duration,9illustrating that when present in animals with
concurrent diseases, white-coat effect can lead to an
erroneous diagnosis of hypertension.
In dogs, the most common cause of systemic hyper-
tension is renal disease and, the kidneys bear most of the
TOD.6According to the 2007 ACVIM Consensus State-
ment, SAP of 160–179mmHg represents a moderate risk
of TOD, and a SAP4180mmHg represents a high risk
of TOD.6Renal autoregulation maintains renal blood
flow constant up to a SAP of 180mmHg to protect the
tension may cause renal vascular changes that can be
identified by the presence of microalbuminuria and pro-
teinuria.6,14,15Previous BP studies in RRG showed
in-hospital hypertension (4160mmHg) that was sustained
Microalbuminuria also was observed in 84% of Grey-
hounds classified as hypertensive.17We hypothesized that
clinically healthy RRG would have lower systemic arterial
BP at home than in the hospital. We also hypothesized that
From the Department of Veterinary Clinical Sciences, The Ohio
State University College of Veterinary Medicine (Marino, Cober,
Couto), Veterinary Medical Center (Iazbik, Couto), and The OSU
Comprehensive Cancer Center (Couto), Columbus, OH.
Corresponding author: C. G. Couto, The OSU Comprehensive
Cancer Center, Columbus, OH 43201; e-mail: guillermo.couto@
Submitted January 5, 2011; Revised March 25, 2011;
Accepted April, 15 2011.
Copyrightr2011 by the American College of Veterinary Internal
diastolic arterial pressure
investigator at home
owner at home
mean arterial pressure
Blood Donor Program at the Transfusion Medicine
Service, Veterinary Medical Center, The Ohio State
retired racing Greyhounds
systolic arterial pressure
J Vet Intern Med 2011;25:861–865
BP would be lower at home when the owner obtained
the measurements compared with veterinary medical
Materials and Methods
Twenty-two RRG (12 males, 10 females) enrolled in the Blood
Donor Program at the Transfusion Medicine Service, Veterinary
Medical Center, The Ohio State University (OSUVMC) were eval-
uated. All dogs in the Blood Donor Program were appropriately
screened and considered healthy. The median age of the males was
7.5 years (range, 4–9 years) with a median body weight of 33.7kg
(range, 30.8–35.7kg), and the median age of the females was 5.5
years (range, 4–8 years) with a median body weight of 28.3kg
(range, 25.1–32.7kg). Six dogs weighed o30kg (all females). Before
measuring BP and heart rate (HR) for this study, the number of
prior visits to the OSUVMC for blood donation was recorded.
BP measurements were obtained by an oscillometric deviceaand
an appropriately sized cuff with a width that measured 40–60% of
the circumference of the front and rear limbs.6,18The instrument
was set to the large cuff size with a cuff inflation pressure of
200mmHg. Two cuff sites were chosen, the left distal forelimb site
(median artery), just proximal to the carpus, placing the cuff arrow
on the medial aspect of the leg, and the left distal hind limb site
(cranial tibial artery), just proximal to the tarsus, with the cuff ar-
row on the cranial aspect of the leg. Before application, the cuff was
measured and deemed appropriate for each RRG and each limb.
The cuff size remained constant for all environments. All dogs were
placed in right lateral recumbency with the cuff at or near the level
of the heart. The oscillometric device gave readings for systolic, di-
astolic, and mean arterial blood pressures (SAP, DAP, and MAP),
as well as HR. The investigator obtained a femoral pulse during in-
hospital measurements to ensure accuracy of the instrument read-
ings. All values were printed directly from the instrument and the
values were manually entered in a spreadsheet.
Measurements were taken in 3 environments: in the hospital by
the investigator (C.L.M.), in the home by the same investigator, and
in the home by the owner (H/O). For 17 dogs, the cranial tibial ar-
tery was used before the median artery, and the remaining 5 dogs
wereevaluated in the oppositeorder; the orderremainedconstant in
the 3 environments. All measurements were obtained between 7:00
and 11:30 AM to eliminate diurnal variation in BP.
Within 15–20 minutes upon arrival at the OSUVMC, the dogs
were taken to the blood bank and placed in right lateral recumbency
on a cushioned floor. The cuff was placed once the dog was com-
fortable. The investigator wore scrub clothing and recorded 5
consecutive measurements of SAP, DAP, MAP, and HR for each
cuff site. Motion was defined as limb withdrawal and attempts at
standing during the measurement process; associated recordings
were discarded. Only 18 of the 22 dogs donated blood after obtain-
ing the measurements. All at-home BP and HR measurements were
made between 7 and 28 days after the hospital measurements to
avoid any effects of blood donation.
The same investigator (wearing scrub clothing) arrived at the
dog’s home. The dog was taken to a known comfortable place in the
home, as identified by the owner, and placed in right lateral recum-
bency. The cuff was placed as described above when the dogs were
calm (ie, they lay motionless without restraint) about 5–10 minutes
after arrival. Five consecutive readings were obtained while the in-
vestigator instructed the owner on how to operate the device.
Detailed written instructions also were left with the owner. The
owner was provided with a questionnaire to ensure the dog was
calm, motionless, and had not recently exercised before their mea-
surements. The owner repeated the BP measurement process
described previously 24 hours after the investigator. The question-
naire was returned with the printed values. This study was
performed in accordance with The Ohio State University Institu-
tional Animal Care and Use Committee.
By GraphPad Prism software,bnormality was evaluated by the
D’Agostino-Pearson method. A one-way repeated-measures analy-
sis of variance was used to comparedifferences in SAP, DAP, MAP,
and HR among the 3 environments: in the hospital (Hosp), in the
home by the investigator (H/I), and in the H/O. A t-test was used to
compare the SAP, DAP, MAP, and HR between the median artery
and the cranial tibial artery. A t-test was used to compare the values
for SAP, DAP, MAP, and HR between males and females, and be-
tween dogs weighing o30kg and 430kg. A Pearson correlation
was used to evaluate the effect of number of blood donations on
SAP, DAP, MAP, and HR. A P-value of o.05 was considered sig-
nificant. All values are reported as mean ? SD.
All BP measurement results are presented in Table 1.
The Hosp SAP and MAP were significantly higher than
both the H/O and H/I SAP and MAP (P o .001 and P o
.001, respectively; Table 1, a, b, e, f; Fig 1); there were no
significant differences for SAP and MAP between the H/
O andthe H/I (Table 1). The HospDAP was significantly
higher than the H/O DAP (P 5 .02), but not the H/I
DAP (Table 1, c and d). The Hosp HR was significantly
higher than the H/I and H/O HR (P o .001; Table 1, g
and h), but there was no significant difference in HR
between H/I and H/O. The mean number of donations
before this study was 11 (range, 0–32). The HR decreased
significantly (P 5 .04) with increasing number of dona-
tions; there were no significant differences among SAP,
MAP, and DAP and number of donations (Fig 2).
The Hosp SAP was significantly higher when mea-
sured using the cranial tibial than when using the median
Table1.Average SAP, MAP, DAP, and HR in the median and cranial tibial arteries across 3 different environments.
Cranial Tibial Arteryz
HospH/I H/OHospH/I H/O
154 ? 17a
88 ? 15c
110 ? 14e
111 ? 17g
133 ? 13a
82 ? 15
98 ? 13e
77 ? 27g
130 ? 12a
80 ? 11c
95 ? 10e
65 ? 26g
165 ? 17b
96 ? 14d
116 ? 14f
116 ? 15h
147 ? 17b
86 ? 15
104 ? 15f
78 ? 24h
141 ? 13b
84 ? 14d
101 ? 13f
67 ? 21h
Significant difference within same letter.
zSignificant difference in parameter between groups.
DAP, diastolic arterial pressure; H/I, investigator at home; H/O, owner at home; Hosp, in-hospital; HR, heart rate; MAP, mean arterial
pressure; SAP, systolic arterial pressure.
862Marino et al
(P 5 .008; Table 1; Fig 3). In contrast, DAP, MAP, and
HR were not significantly different between the front
limb and the rear limb in any of the 3 environments. The
Hosp SAP in the median artery (but not in the cranial
tibial artery) was significantly higher in males than in
females (P 5 .02; data not shown). No significant differ-
ence was found in SAP between groups for dogs that
weighed o30kg or 430kg (data not shown).
Results of this study demonstrate that RRG do experi-
ence white-coat effect on BP in the hospital environment.
The mean hind limb SAP in hospital was 165mmHg,
whereas at home it was lower, with or without the investi-
gator’s presence, at 131 and 133mmHg, respectively.
MAP, DAP, and HR followed a similar pattern. HR was
lowest in RRG that had been acclimated previously to the
environment with multiple hospital visits, but, BP did not
follow a similar pattern. Although RRG are thought to
have higher BP than mongrel dogs, this study emphasizes
the need to consider the environment in which the BP is
measured before diagnosing or eliminating hypertension,
Several cardiovascular features in RRG that differ from
those in other dog breeds have been recognized over the
past few decades. Most of these features are considered
adaptations to racing because of the increased oxygen re-
serve required for acceleration and speed. Previous reports
documented that RRG have SAP approximately 10–
20mmHg higher than that of the average mixed breed
dog.2,5,6Interestingly, SAP in untrained Greyhounds
was not different from that in other breeds.3,13,6Also, in a
recent study of 48 RRG, mean SAP recorded in the hospi-
tal was 161mmHg, SAP remained constant after 3 days of
hospitalization, and half of the dogs were classified as
‘‘hypertensive’’ according to current guidelines.17Our re-
sults are similar to these previous studies, with a high Hosp
mean SAP of 155–165mmHg, depending on the limb used
for cuff placement. However, our study also showed that
compared with Hosp measurements, at-home BP (H/I and
H/O) was significantly lower, indicating that a white-coat
effect on BP occurs in RRG. There also was a significant
decrease in HR between the Hosp and at-home measure-
ments, suggesting alterations in sympathetic tone and
stress level between environments, and further supporting
the occurrence of white-coat effect in the dogs studied.
The low at-homemean
130mmHg for the median artery and 140mmHg for the
cranial tibial artery in RRG challenges the concept that
RRG have a physiologically higher SAP than other breeds.
The white-coat effect has been demonstrated previously in
clinically healthy mongrel dogs, by an oscillometric BP
technique, with the highest in-hospital SAP of 158mmHg
and the mean in-home SAP of 128mmHg,19pressures sim-
ilar to those in our study. Interestingly, in our study we
found no differences in BP in the home environment when
either the investigator or the owner obtained the readings,
suggesting that the decrease in stress level and BP may be
because of the environment of BP measurement or the
owner’spresenceduring themeasurement. Additional stud-
ies are indicated to determine whether the owner’s presence
in the hospital decreases white-coat effect in RRG.
In most humans, white-coat effect on BP lasts for a
short time and BP returns to normal.20Cats are similar,
with acclimation to the environment in just 10 minute.
When the cat is moved or handled again, the white-coat
effect diminishes more quickly each time during that
office visit.9A study using clinically healthy Beagles also
showed a decrease in BP over 3 weeks after acclimation
ronments. Whiskers indicate 5th and 95th percentiles.
Systolic arterial pressure (SAP) in both legs across 3 envi-
diastolic arterial pressures (SAP, MAP, and DAP) with prior num-
ber of blood donations. There was a significant decrease in HR with
increased number of donations (P 5 .04).
Relationship among heart rate (HR), systolic, mean, and
back legs. Whiskers indicate 5th and 95th percentiles.
Systolic arterial pressure (SAP) difference from front and
863 Blood Pressure in Retired Racing Greyhounds
to the environment and procedures.21Although not all
dogs acclimate to the hospital, many studies indicate the
majority of dogs do adapt over time.6,19,21Thus, the
standard for measuring BP is to wait 8–10 minutes once
the animal is in the hospital to allow for acclimation to
occur. RRG do not appear to experience this acclimat-
ion, and maintain higher SAP over the course of hours to
days.16,17This finding is supported by our study where
there was no significant difference in the hospital SAP
between those RRG that had donated blood multiple
times before this study (ie, ‘‘veteran donors’’ acclimated
to the blood bank) and those that had never donated
before. This feature of RRG can make it difficult to dis-
tinguish true hypertension from white-coat hypertension
in the hospital setting, regardless of their familiarity with
surroundings and procedures.
HR is an indicator of stress and anxiety in humans.20
As discussed above, HR was significantly higher in the
hospital than in the home environment, likely because of
a stress response and increased sympathetic nervous sys-
tem activation. However, HR in RRG were significantly
lower in the ‘‘veteran donors.’’ The familiarity of sur-
roundings and routine may eliminate some stress, but
unexpectedly, SAP, MAP, and DAP were not different in
the ‘‘veteran donors.’’ The reason for this finding is un-
clear, but may be because of humoral or local vasomotor
factors contributing to a persistent increase in systemic
vascular resistance despite decreased sympathetic activa-
tion. These findings are additional evidence supporting a
lack of BP acclimation and an indication that HR mea-
surement may notbe anaccurate indicationof stresslevel
and white-coat effect in RRG.
White-coat hypertension in humans is associated with an
increasedriskforsubsequently developing hypertensionand
TOD.22High SAP, or hypertension, can cause vascular
changes in the kidney leading to microalbuminuria, protein-
uria, and an increased risk for developing renal disease. We
have observed that protein-losing nephropathy (PLN)
because of glomerulonephritis is common in RRG (data
not shown). Possible explanation for the high prevalence of
PLNis that RRG havesustained high SAP, and thus mimic
humans with hypertension-induced renal disease. Interest-
ingly, in another study17most of the ‘‘hypertensive’’
Greyhounds had microalbuminuria, whereas the ‘‘norm-
otensive’’ ones did not. Whether white-coat hypertension
Oscillometric SAP and MAP appear to correlate with
direct arterial pressure with a difference o10mmHg.23
However, other studies indicate that both Doppler and
oscillometric methods underestimate SAP, DAP, and
MAP in laterally recumbent dogs, with SAP having a
greater difference from direct measurements than DAP
and MAP.6,24In Sighthounds, indirect SAP tended to
show an even greater difference from direct pressures,
but correlations with direct pressure improved with serial
measurements.24DAP has the highest variation and
weakest correlation with direct pressures at all cuff
sites,24which may explain the lack of difference between
the in-hospital DAP and the at-home DAP (obtained by
the investigator). This finding also may represent a type
II error, and a larger sample size may have shown a sig-
nificant difference in DAP across all 3 environments.
Finally, some studies indicate that all Doppler measure-
ments correlate better with direct pressures than
oscillometric measurements,24whereas others show both
Doppler and oscillometric SAP have similar correlations
with oscillometric MAP correlating best.23Oscillometric
measurements were used in this study because of the ease
of having owners measure BP at home.
A study that included Sighthounds found the closest
correlation with direct pressures for all measurements
with the cuff on the median artery, followed by the
coccygeal artery, but the correlation of direct with indi-
rect pressures of the cranial tibial artery also was
significant.24Another study using Beagles showed the
best correlation with the cranial tibial artery and the coc-
cygeal artery.25Using the distal forelimb site just proxi-
mal to the carpus (median artery) and the distal hind
limb site just proximal to the tarsus (cranial tibial artery)
in this study, the cuff size remained constant across all
measurements. We found SAP measured at the cranial
tibial artery to be significantly higher than that measured
at the median artery, which was assumed to be related to
acclimation because the hind limb was measured before
the forelimb. However, when the order of readings was
reversed with the remaining 5 dogs, the hind limb SAP
remained higher (data not shown). Interestingly, a study
in mongrel dogs showed BP measured from the meta-
tarsus was significantly higher than BP measured from
the metacarpus in the hospital and home environments
similar to our findings, but, the decrease was attributed
to acclimation which did not occur in our study.19After
selecting cuff size based upon previously stated criteria
for this study, the same cuff size was used for the fore-
limb and hind limb, and the hind limbs were measured
to be slightly larger (3–4mm) than the forelimbs (data
not shown). SAP measured in the forelimb may have
been lower because of the slightly larger circumference
to cuff ratio than the hind limb, but it is unlikely this
small difference in size would have an important effect.
The difference between limb BP measurements might
also be because of the vascular conformation of Grey-
hounds and their higher oxygen demand in the hind
limbs for racing, or a different anatomical conformation
of the hind limb musculature that alters the oscillometric
reading when compared with the forelimb. The reason
for the increased hind limb SAP could not be determined
from this study.
The limitations of this study include the inability to
obtain paired direct and indirect arterial pressures in all
environments, the inability to monitor and assess the
owner’s competency in performing the procedure, and
the lack of environmental randomization. Direct arterial
pressures would not have been possible in the home en-
vironment, with or without the investigator, and would
have been much more invasive and technically difficult in
the hospital. The reason for the increased hind limb SAP
is unclear, but without direct arterial pressures it is diffi-
cult to determine whether the difference was caused by
instrument error because of muscle conformation or cuff
size, or if SAP actually is increased in the hind limb in
RRG. Although monitoring was notpossible, the owners
864 Marino et al
witnessed the procedure and were left with detailed Download full-text
instructions and a questionnaire to perform on their
own. The owner readings were similar to the investigator
readings in the home environment, leading us to believe
the procedure was followed appropriately. Finally, the
BP measurements in the 3 environments were not com-
pleted in a random order, suggesting the decrease in BP
from the hospital to the home environment could be be-
cause of procedural acclimation. A final BP reading in
the hospital would discredit this suggestion of acclimat-
ion. It is known, however, that RRG do not acclimate to
the procedure across hours after blood donation with the
fourth measurement similar to the first, or across days
in the hospital with 2 separate measurements.16,17Addi-
tionally, in a study using Beagles, each time BP was
measured over the course of 135 days, a decrease oc-
curred, with the greatest decrease during the first 4
measurements.21Therefore, with procedural acclimation
one would expect BP measured in the home environment
without the investigator to have been lower than that
measured with the investigator present. Although a final
BP was not taken in hospital, it is likely that the RRG BP
would be increased similar to their first BP experience.
In conclusion, when attempting to differentiate true
systemic hypertension from white-coat hypertension in
RRG, acclimation to the environment does not appear to
be sufficient. Rather, the BP should be measured in the
home environment, keeping in mind that the hind limb
cuff site will result in higher SAP readings. Additionally,
we propose that RRG may have similar BP to other
dogs, but that when measured in the clinic, white-coat
effect results in a falsely increased reading. Future studies
areneeded todetermine whetherwhite-coat hypertension
leads to clinically relevant TOD (eg, microalbuminuria
and renal disease) in RRG.
aCardell, model 9402; Sharn Veterinary Inc, Tampa, FL
bGradpad Prism v.4, GraphPad Software Inc, San Diego, CA
Supported by The Ohio State University College of
Veterinary Medicine Summer Student Research Fellow-
ship Program and by the OSU Greyhound Health and
Wellness Development Funds.
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865 Blood Pressure in Retired Racing Greyhounds