high blood pressure case study

Case Studies: BP Evaluation and Treatment in Patients with Prediabetes or Diabetes

—the new acc/aha blood pressure guidelines call for a more aggressive diagnostic and treatment approach in most situations..

By Kevin O. Hwang, MD, MPH, Associate Professor, McGovern Medical School, Houston, TX

The following case studies illustrate how the new ACC/AHA guideline specifies a shift in the definition of BP categories and treatment targets.

A 59-year-old man with type 2 diabetes presents with concerns about high blood pressure (BP). At a recent visit to his dentist he was told his BP was high. He was reclining in the dentist’s chair when his BP was taken, but he doesn’t remember the exact reading. He has no symptoms. He has never taken medications for high BP. He takes metformin for type 2 diabetes.

His BP is measured once at 146/95 mm Hg in the left arm while sitting. Physical exam is unremarkable except for obesity. EKG is unremarkable.

BP Measurement

Controlling BP in patients with diabetes reduces the risk of cardiovascular events, but the available data are not sufficient to classify this patient with respect to BP status. The reading taken while reclining in the dentist’s chair was likely inaccurate. A single reading in the medical clinic, even with correct technique, is not adequate for clinical decision-making because individual BP measurements vary in unpredictable or random ways.

The accuracy of BP measurement is affected by patient preparation and positioning, technique, and timing. Before the first reading, the patient should avoid smoking, caffeine, and exercise for at least 30 minutes and should sit quietly in a chair for at least 5 minutes with back supported and feet flat on the floor. An appropriately sized cuff should be placed on the bare upper arm and with the arm supported at heart level. For the first encounter, BP should be recorded in both arms. The arm with the higher reading should be used for subsequent measurements.

It is recommended that one use an average of 2 to 3 readings, separated by 1 to 2 minutes, obtained on 2 to 3 separate visits. Some of those readings should be performed outside of the clinical setting, either with home BP self-monitoring or 24-hour ambulatory BP monitoring, especially when confirming the diagnosis of sustained hypertension. Note that a clinic BP of 140/90 corresponds to home BP values of 135/85. Multiple BP readings in the clinic and at home allow for classification into one of the following categories.


Sustained hypertension (HTN)	Hypertensive	Hypertensive
White coat HTN	Hypertensive	Normal
Masked HTN	Normal	Hypertensive
Normal blood pressure	Normal	Normal

The BP is measured in the office with the correct technique and timing referenced above. The patient is educated on how on to measure BP at home with a validated monitor. He should take at least 2 readings 1 minute apart in the morning and in the evening before supper (4 readings per day). The optimal schedule is to measure BP every day for a week before the next clinic visit, which is set for a month from now. Obtaining multiple clinic and home BP readings on multiple days will support a well-informed assessment of the patient’s BP status and subsequent treatment decisions.

A 62 year old African-American woman with prediabetes presents for her annual physical. She has no complaints. The average of 2 BP readings in her right arm is BP 143/88. Her physical exam is unremarkable except for obesity. She has no history of myocardial infarction, stroke, kidney disease, or heart failure. After the visit, she measures her BP at home and returns 1 month later. The average BP from multiple clinic and home readings is 138/86.

Her total cholesterol is 260 mg/dL, HDL 42 mg/dL, and LDL 165 mg/dL. She does not smoke.

Stage 1 Hypertension

Under the 2017 ACC/AHA guideline, she has stage 1 hypertension (HTN). This guideline uses a uniform BP definition for HTN without regard to patient age or comorbid illnesses, such as diabetes or chronic kidney disease.


Normal	< 120	and	< 80
Elevated	120-129	and	< 80
Stage 1 HTN	130-139	or	80-89
Stage 2 HTN	≥ 140	or	≥ 90

In patients with stage 1 HTN and no known atherosclerotic cardiovascular disease (ASCVD) , the new guideline recommends treating with BP-lowering medications if the 10-year risk for ASCVD risk is 10% or greater. With input such as her age, gender, race, lipid profile, and other risk factors, the ACC/AHA Pooled Cohort Equations tool estimates her 10-year risk to be approximately 10.5%.

With stage 1 HTN and 10-year ASCVD risk of 10% or higher, she would benefit from a BP-lowering medication. Thiazide diuretics, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and calcium channel blockers are first-line agents for HTN because they reduce the risk of clinical events. In African-Americans, thiazide diuretics and calcium channel blockers are more effective for lowering BP and preventing cardiovascular events compared to ACE inhibitors or ARBs.

Patient-specific factors, such as age, comorbidities, concurrent medications, drug adherence, and out-of-pocket costs should be considered. Shared decision making should drive the ultimate choice of antihypertensive medication(s).

Nonpharmacologic strategies for prediabetes and HTN include dietary changes, physical activity, and weight loss. If clinically appropriate, she should also avoid agents which could elevate BP, such as NSAIDs, oral steroids, stimulants, and decongestants.

A goal BP of 130/80 is recommended. After starting the new BP medication, she should monitor BP at home and return to the clinic in 1 month. If the BP goal is not met at that time despite adherence to treatment, consideration should be given to intensifying treatment by increasing the dose of the first medication or adding a second agent.

A 63 year old man with type 2 diabetes has an average BP of 151/92 over the span of several weeks of measuring at home and in the clinic. He also has albuminuria.

Stage 2 Hypertension:

The BP treatment goal patients with diabetes and HTN is less than 130/80. While some patients can be effectively treated with a single agent, serious consideration should be given to starting with 2 drugs of different classes, especially if BP is more than 20/10 mm Hg above their BP target. Giving both medications as a fixed-dose combination may improve adherence.

In this man with diabetes and HTN, any of the first-line classes of antihypertensive agents (diuretics, ACE inhibitors, ARBs, and CCBs) would be reasonable choices. Given the presence of albuminuria, an ACE inhibitor or ARB would be beneficial for slowing progression of kidney disease. However, an ACE inhibitor and ARB should not be used simultaneously due to an increase in cardiovascular and renal risk observed in clinical trials.

He is started on a fixed-dose combination of an ACE-inhibitor and thiazide diuretic. He purchases a validated BP monitor which can transmit BP readings to his provider’s electronic health records system. Direct transmission of BP data to the provider has been shown to help patients achieve greater reductions in BP compared to self-monitoring without transmission of data. One month follow-up is recommended to determine if the treatment goal has been met.

Published: April 30, 2018

2. Final Recommendation Statement: High Blood Pressure in Adults: Screening. U.S. Preventive Services Task Force. September 2017.

High Blood Pressure Research

Language switcher.

As part of its broader commitment to research on cardiovascular diseases, the NHLBI leads and supports research and programs on hypertension (high blood pressure). The NHLBI has funded several studies and programs to help develop new treatments for high blood pressure, many of which focus on women’s health, lifestyle interventions, and health disparities. Current studies aim to prevent pregnancy complications and improve blood pressure among people who are at high risk.

NHLBI research that really made a difference

Find funding opportunities and program contacts for high blood pressure research.

The Dietary Approaches to Stop Hypertension (DASH) Sodium Trial showed that lowering sodium as part of a healthy eating plan significantly lowers blood pressure for people with high blood pressure. Researchers saw the greatest change when lowering sodium was combined with eating a diet rich in fruits and vegetables and low in saturated fat.
The NHLBI’s Systolic Blood Pressure Intervention Trial (SPRINT) study found that treating to a lower systolic blood pressure target — less than 120 mm Hg — helped lower deaths from heart attack and stroke, particularly among older people who have high blood pressure. These findings informed the latest high blood pressure guidelines in 2017. A follow-up study called SPRINTMIND found that treating to this lower blood pressure target also reduced mild cognitive impairment , a condition that can lead to dementia.
The NHLBI Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT ) was the largest hypertension clinical trial ever conducted, involving more than 600 clinics and 42,000 participants. The study compared the effectiveness of three commonly used blood pressure-lowering medicines (a calcium channel blocker, amlodipine; an ACE-inhibitor, lisinopril; and an alpha-receptor blocker, doxazosin) with a diuretic, chlorthalidone. The trial concluded that the diuretic worked better than the other medicines to manage high blood pressure and prevent stroke, as well as some types of heart disease, especially heart failure.

Current research funded by the NHLBI

Our Division of Cardiovascular Sciences and its Vascular Biology and Hypertension Branch oversee much of the research we fund on the regulation of blood pressure.

Current research on the treatment of high blood pressure

NHLBI-supported research has led to creating and updating blood pressure treatments that have helped people around the world. High blood pressure affects millions of U.S. adults. We continue to support work on new treatments and also new approaches that tailor the right treatment to the right patient.

Researchers in the NHLBI-funded Levy Lab are studying the role of genetics in cardiovascular disease using resources from the Framingham Heart Study to develop promising blood pressure medicines and treatments.
The NHLBI funds research into the connection between inflammation and high blood pressure . Better understanding of the causes of hypertension helps researchers develop treatments to improve blood pressure management and prevent early death from cardiovascular disease.
The NHLBI supports research to improve adherence to long-term cardiovascular medicines that help regulate blood pressure. Researchers use pharmacy data to identify patients who fail to refill their medicines. They then test whether reminders using text messages or interactive chat bots can improve medicine adherence.
The NHLBI funds research into the connection between the microbiome and high blood pressure . One study found that bacterial strains in the mouth were linked to high blood pressure in older women. Another study showed that intermittent fasting in an animal model could reduce hypertension by reshaping the gut microbiota.
Findings from the Offspring Cohort of the Framingham Heart Study (FHS) and the Coronary Artery Risk Development in Young Adults (CARDIA) study showed a close association between hypertension and late-onset epilepsy and other brain changes, respectively, which may increase the risk of cognitive decline later in life.
A clinical trial called Treating Resistant Hypertension Using Lifestyle Modification to Promote Health (TRIUMPH) showed that lifestyle modification, such as following the DASH eating plan, could significantly reduce blood pressure even in patients with resistant hypertension. Another study found that DASH was effective in adolescents with high blood pressure.
A clinical trial Chlorthalidone in Chronic Kidney Disease (CLICK) showed that the diuretic chlorthalidone can improve blood pressure control in patients with advanced chronic kidney disease.
A recent meta-analysis showed that use of anti-hypertension medicines that can cross the blood-brain barrier is linked to more cognitive benefits than those that do not cross the barrier.

Find more NHLBI-funded studies on the high blood pressure treatment at NIH RePORTER.

heart shaped plate with fruits next to stethoscope and medical equipment

Find out more about how the DASH diet and exercise help fight resistant high blood pressure.

Current research on women’s health and high blood pressure

NHLBI-supported research has helped reveal how pregnancy complications, including high blood pressure, affect the long-term health of women and their children.

One study found that women who have a preterm birth have a greater chance of later developing high blood pressure.
The NHLBI continues to fund the nuMoM2b Heart Health Study , which helps scientists understand how cardiovascular disease starts and develops in women. Researchers, funded by the NHLBI and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, found that women who developed complications during their first pregnancy were more likely to have had higher levels of blood sugar, blood pressure, and inflammation during their first trimester than women who did not develop complications. They are also more likely to develop chronic hypertension within 7 years after delivery. The study is also looking at the links between pregnancy, sleep health, and cardiovascular health .
The NHLBI’s CHAP Maternal Follow-up Study is examining the impact of treatment for preeclampsia and high blood pressure during pregnancy on a woman’s future chance for developing cardiovascular disease. The results will help identify the best ways to improve the health of women younger than age 40 who have mild, long-term high blood pressure.

Find more NHLBI-funded studies on women’s health and high blood pressure at NIH RePORTER.

Current research on health disparities and high blood pressure

Black adults in the United States have a higher prevalence of high blood pressure than other racial and ethnic groups. The NHLBI supports research to understand and reduce high blood pressure disparities, as part of our broader commitment to addressing health disparities and inequities .

Other studies and research areas we fund to understand and lower the impacts of health disparities are listed below:

Our RURAL: Risk Underlying Rural Areas Longitudinal Cohort Study reaches 4,000 young and middle-aged men and women from different racial and ethnic groups living in poor rural counties in four southern states. The goal of the study is to understand what causes the high rates of heart and lung disease in these regions and how to lower those rates and improve prevention efforts .
Co-funded by the NHLBI and the NIH Office of Research on Women’s Health, the Maternal Health Community Implementation Program (MH-CIP) supports community-engaged implementation research, working with affected communities to improve heart, lung, blood, and sleep health before, during, and after pregnancy. MH-CIP focuses on bringing effective maternal health interventions — including projects related to hypertension — into communities severely impacted by maternal health disparities.
An NHLBI-funded study aims to improve implementation of the SPRINT findings in underserved populations. The study puts into practice a plan for blood pressure treatment at 30 clinics that serve people with little or no income in southeast Louisiana. The study’s findings will help lower barriers to blood pressure treatment faced by people who experience poverty.

Find more NHLBI-funded studies on high blood pressure and health disparities at NIH RePORTER.

High blood pressure research labs at the NHLBI

The NHLBI Division of Intramural Research and its Cardiovascular Branch conduct research on diseases that affect the heart and blood vessels, including high blood pressure. Other Division of Intramural Research groups, such as the Center for Molecular Medicine and Systems Biology Center , perform research on heart and vascular diseases.

Related programs

In 2023, the NHLBI convened the Transforming Hypertension Diagnosis and Management in the Era of Artificial Intelligence (AI) workshop to discuss gaps and opportunities in leveraging AI technologies for hypertension diagnosis and management.
Nurse case management, in which a nurse provides behavioral counseling and monitors blood pressure through telehealth, adjusting blood pressure medications as needed
Community health workers providing health coaching and information about community resources

Explore more NHLBI research on high blood pressure

The sections above provide you with the highlights of NHLBI-supported research on high blood pressure. You can explore the full list of NHLBI-funded studies on the NIH RePORTER .

To find more studies:

Type your search words into the Quick Search box and press enter.
Check Active Projects if you want current research.
Select the Agencies arrow, then the NIH arrow, then check NHLBI .

If you want to sort the projects by budget size — from the biggest to the smallest — click on the FY Total Cost by IC column heading.

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

View all journals
Explore content
About the journal
Publish with us
Sign up for alerts
Review Article
Review Series-Implication of Blood Pressure Variation
Published: 29 May 2018

Clinical significance of stress-related increase in blood pressure: current evidence in office and out-of-office settings

Masanori Munakata 1

Hypertension Research volume 41 , pages 553–569 ( 2018 ) Cite this article

6355 Accesses

54 Citations

22 Altmetric

Metrics details

High blood pressure is the most significant risk factor of cardiovascular and cerebrovascular diseases worldwide. Blood pressure and its variability are recognized as risk factors. Thus, hypertension control should focus not only on maintaining optimal levels but also on achieving less variability in blood pressure. Psychosocial stress is known to contribute to the development and worsening of hypertension. Stress is perceived by the brain and induces neuroendocrine responses in either a rapid or long-term manner. Moreover, endothelial dysfunction and inflammation might be further involved in the modulation of blood pressure elevation associated with stress. White-coat hypertension, defined as high clinic blood pressure but normal out-of-office blood pressure, is the most popular stress-related blood pressure response. Careful follow-up is necessary for this type of hypertensive patients because some show organ damage or a worse prognosis. On the other hand, masked hypertension, defined as high out-of-office blood pressure but normal office blood pressure, has received considerable interest as a poor prognostic condition. The cause of masked hypertension is complex, but evidence suggests that chronic stress at the workplace or home could be involved. Chronic psychological stress could be associated with distorted lifestyle and mental distress as well as long-lasting allostatic load, contributing to the maintenance of blood pressure elevation. Stress issues are common in patients in modern society. Considering psychosocial stress as the pathogenesis of blood pressure elevation is useful for achieving an individual-focused approach and 24-h blood pressure control.

You have full access to this article via your institution.

Stress and cardiovascular disease: an update

Do any kinds of perceived stressors lead to hypertension? A longitudinal cohort study

Short- to long-term blood pressure variability: Current evidence and new evaluations

Introduction.

Hypertension is the most significant risk factor of cardiovascular morbidity and mortality [ 1 , 2 ]. According to the global report of the World Health Organization, hypertension-related complications are estimated to cause 7.5 million deaths worldwide, comprising nearly 13% of annual mortality [ 3 ]. Of these deaths, over 45% were due to coronary heart disease and 50% were due to stroke [ 4 ]. Accumulated evidence has shown that consistently high blood pressure and its variability are risk factors of cardiovascular events [ 5 , 6 , 7 , 8 , 9 ]. Thus, hypertension control should focus not only on maintaining an optimal level of blood pressure but also on achieving less variability.

The etiology of high blood pressure is complex and multifactorial. Genes, the neuroendocrine system, organ failure, lifestyle and environmental factors are involved at the individual level [ 10 , 11 , 12 , 13 ]. Because of the development of satisfactory antihypertensive agents, the treatment of hypertension has considerably improved over the last decades [ 14 , 15 , 16 ]. However, hypertension and its cardiovascular complications are the most prevalent non-communicable diseases worldwide [ 3 ]. The number of people diagnosed with hypertension is increasing. This increase may be largely attributed to social or environmental factors, such as aging populations, increased obesity prevalence, air pollution due to industrialization, and exposure to various types of mental stress [ 13 , 14 , 17 ].

Stress-related increases in blood pressure include a large spectrum in terms of pathophysiology. This increase includes not only temporal blood pressure elevation induced by emotional stress but also long-lasting high blood pressure due to distorted lifestyle or mental distress derived from stress [ 18 , 19 ]. Recent studies have shown that the stress-related blood pressure response is modified by endothelial function [ 20 ], inflammation [ 21 , 22 , 23 ], or immune function [ 24 ]. Because stress-induced blood pressure elevation could be deeply involved in the pathogenesis of both short- and long-term blood pressure variabilities, considering stress as a pathogenesis of high blood pressure seems necessary to individualize hypertension management and achieve a 24-h blood pressure control.

This article will provide an update on the mechanisms of stress-related blood pressure elevation. Stress generally represents a series of bodily reactions to various types of external and internal stimuli, such as physical, traumatic, psychological, biochemical, infectious and radiological stimuli. This article mainly focuses on psychosocial stress, which has received considerable attention as a cardiovascular risk that modern civilization brings to society [ 25 ]. The clinical significance of stress-related blood pressure elevation was subsequently reviewed for clinic and out-of-clinic settings.

Psychosocial stress is a relatively fixed risk factor for hypertension in the 2017 high blood pressure clinical practice guidelines of the USA because it is usually difficult to modify [ 26 ]. The latest systematic reviews on the clinical effectiveness of stress-reduction techniques in hypertensive patients have shown that such interventions appear to indicate some hypotensive effects, but the results require cautious interpretation due to major methodological limitations [ 27 ]. However, the recent largest interventional study conducted in China has demonstrated that 2-year psychological intervention could improve blood pressure control, health-related quality of life, and stroke prevalence in Chinese mine workers [ 28 ]. This finding suggests that adequate stress management could improve hypertension treatment.

Mechanisms of stress-induced blood pressure elevation

Mechanisms of stress-induced blood pressure elevation are complex and not completely understood. Figure 1 indicates a global schema of stress-induced blood pressure elevation. Psychological stress is often induced by environmental changes, which are perceived by the brain. Some are integrated in the neocortex, but others are sensed by the limbic system in a situation of “fight or flight” [ 29 , 30 ]. Neuroendocrine stress responses occur if an individual feels afraid or anxious against such changes or if a demand exceeds an individual’s capability [ 31 ]. In humans, stress responses to the same situation largely differ among individuals because they are determined by the integration of personality characteristics, knowledge, previous experience, and skills [ 32 ]. Subsequent activation of the sympathetic nervous system and hypothalamic–pituitary–adrenocortical axis are the main characteristics of stress responses [ 31 ]. These systems promote adaptation to challenges, called “allostasis,” meaning the process of maintaining stability under environmental changes. However, these adaptive systems could be harmful if their function is inadequate or excessive [ 33 ]. For example, it has been reported that larger blood pressure increases in response to mental stress are associated with more severe vascular damage [ 34 , 35 ], although there are some exceptions [ 36 ]. Moreover, stress-related blood pressure elevation is largely influenced by vascular condition or volume status. Increased arterial stiffness and a diminished natriuretic response are known to be associated with higher blood pressure response to acute psychological stress [ 37 , 38 , 39 ]. Insulin resistance may be further involved in daily life blood pressure variability through the augmentation of peripheral vascular resistance [ 40 ].

Global schema of stress-induced blood pressure increase

The mechanisms of long-lasting blood pressure elevation induced by chronic stress are much more complex and multifactorial than acute stress response. In chronic stress conditions, repeated and/or continuous activation of the sympathetic nervous system, hypothalamic–pituitary–adrenal axis, and renin–angiotensin–aldosterone system occur, leading to blood pressure elevation, increased shear stress, and endothelial damage [ 19 , 20 ]. Neuroendocrine activation associated with chronic stress has been shown to trigger an inflammatory response through the stimulation of cytokines and acute phase reactant production [ 41 ], which can further impair endothelial function. The endothelium is well recognized as an endocrine homeostatic organ that regulates vascular tone and structure. Endothelial dysfunction leads to increased vasomotor tone, cellular hypertrophy, and remodeling, becoming a pro-atherosclerotic structure [ 42 ]. An altered endothelium also becomes a source of hypertensive substrates from the arterial wall, such as reactive oxygen species, thromboxane A2, endothelin, and prostaglandin H2 [ 43 ]. All these changes could contribute to chronic blood pressure elevation. Even worse, psycho-behavioral factors could be further involved in the maintenance of high blood pressure associated with chronic stress. Chronic psychological stress has been reported to increase the risk of unhealthy lifestyle behaviors, such as physical inactivity [ 39 , 44 ], smoking [ 45 ], and heavy drinking [ 46 ], which are risk factors for hypertension. Associated mental distress, such as depression [ 47 ], could cause or worsen hypertension due to coexistence with autonomic or hypothalamic–pituitary–adrenal axis dysregulation [ 48 , 49 ], distorted lifestyle [ 46 ], and insomnia [ 50 ].

Stress-induced blood pressure elevation in a clinic setting

Blood pressure measurement by a doctor is well known to trigger a defense reaction, which causes a rise in blood pressure [ 51 , 52 ]. This phenomenon is called the “white-coat effect,” and it is clinically important because it may often lead to misdiagnosis [ 53 ]. Moreover, the temporal pressor response may reflect inherent hyper-reactivity to stress in some cases and be harmful in the long term [ 54 ]. In humans with mild hypertension, a doctor’s visit induces a sudden, marked, and prolonged pressor and tachycardic response accompanied by a significant increase in skin sympathetic nerve traffic and a significant decrease in muscle sympathetic nerve traffic [ 55 ]. Thus, the sympathetic nervous response induced by the doctor’s blood pressure measurement is not homogenous but rather differs among organs. This response might be reasonably understood in that the diencephalic area coordinates the systemic sympathetic response to an increase skeletal muscle blood flow to adjust the “fight or flight” situation [ 56 , 57 ].

The clinic-ambulatory difference in blood pressure has been conventionally used as a surrogate measure of the white-coat effect. However, this difference has no or low correlation with the pressor response triggered by a doctor’s measurement of blood pressure or the true white-coat effect [ 58 , 59 ]. Clinic-ambulatory difference in blood pressure is positively correlated with clinic blood pressure and negatively correlated with daytime ambulatory blood pressure [ 60 ]. This finding indicates that the clinic-ambulatory difference in blood pressure is not a pure measure of pressor response in the clinic but rather a variable largely affected by environmental factors outside the clinic [ 61 ]. These factors may include physical activity, workload, and smoking. In the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale study on 1522 subjects, the clinic-ambulatory blood pressure difference was not correlated with left ventricular mass nor long-term cardiovascular morbidity, indicating that this measure had no clinical significance [ 60 ]. The absence of clinical significance was also confirmed by the study on ambulatory monitoring of blood pressure and lisinopril evaluation. This study reported that 12-month treatment-induced reductions in left ventricular mass index and those in the clinic-daytime or clinic-home differences in systolic and diastolic blood pressure showed no significant relationship [ 62 ].

Only a few studies have examined the clinical significance of the pure white-coat effect, which can be investigated by monitoring beat-to-beat blood pressure at rest and at a doctor’s visit (Fig. 2 ) [ 54 , 58 , 59 ]. The true white-coat effect is defined as the mean value of the pressor response or the maximum point triggered by the doctor’s measurement of blood pressure relative to measurement in the resting period. Lantelme et al. [ 59 ] examined the relationship between the pure white-coat effect and organ damage in 88 hypertensive patients. They found no difference in terms of cardiac mass, diastolic function, arterial distensibility, or renal function between the groups with high and low white-coat effects. In our study conducted in 75 hypertensive patients who were never treated, the pure white-coat effect was an independent predictor of left ventricular mass index in men and left ventricular diastolic function in women [ 54 ]. Thus, our data showed that the white-coat effect has clinical significance. Men showed a positive correlation between blood pressure response to the doctor’s visit and a stress-induced increase in blood pressure, whereas women did not. These data suggest that the white-coat effect correlates with blood pressure reactivity to real-life stressors in men; thus, it predicts left ventricular mass. In our study, clinic blood pressures and pure white-coat effects were similar between men and women, whereas the clinic-ambulatory difference in blood pressure in men was nearly half of that in women (14 ± 3/8 ± 2 vs. 28 ± 3/14 ± 2 mmHg, p < 0.03 for both). This finding indicates that an increase in daytime ambulatory blood pressures in men resulted in considerable underestimation of the white-coat effect. Therefore, it is plausible that the clinic-ambulatory difference in blood pressure could reflect the white-coat effect in subjects with truly normal ambulatory blood pressure, where the influence of pressor factors during ambulatory conditions would be minimized. Correlation between the systolic white-coat effect and clinic-ambulatory difference in systolic blood pressure was significant for women ( r = 0.442, p = 0.007) but not for men ( r = 0.364, p = 0.07) in our study.

Representative beat-to-beat recording of RR interval and systolic and diastolic blood pressures (SBP and DBP, respectively) during doctor’s visit and mental stress in a 52-year-old man. Blood pressure was measured in the finger using the Finapres device. The figure was adapted from Munakata et al. [ 54 ]

Patients with high clinic blood pressure but normal daytime ambulatory blood pressure were defined as having white-coat hypertension (WCH) [ 53 ]. The method for the treatment of these patients has been long debated because long-term follow-up studies and interventional studies were necessary. The majority of evidence derived from cross-sectional studies supports increased target organ damage in subjects with WCH compared with those with normotension [ 63 , 64 , 65 , 66 ], and the data were confirmed by meta-analysis [ 67 , 68 ]. However, longitudinal studies seem to provide inconsistent results. Several observational event-based cohort studies [ 69 , 70 , 71 ] and meta-analyses [ 72 , 73 , 74 ] addressed the issue of the cardiovascular event risk of WCH. Most data showed little or no difference in the risk between untreated patients with WCH and their normotensive comparators [ 69 , 70 , 73 , 74 ], but some data showed significant differences [ 71 , 72 ]. One meta-analysis demonstrated that the incidence of stroke tended to increase in the WCH group. The corresponding hazard curve caught up with that of the ambulatory hypertension group by the 9th year of follow-up, raising some concerns about the long-term safety of WCH [ 72 ]. In this regard, Mancia et al. [ 71 ] provided novel evidence indicating different cardiovascular risks in individuals with stable or unstable WCH, that is, those in whom ambulatory blood pressure normality was associated with a persistent or non-persistent office blood pressure elevation at 2 consecutive visits, respectively. Compared with the normotensive group, the risk of cardiovascular and all-cause death was not significantly different in unstable WCH. In stable WCH, the risk was also increased when data were adjusted for baseline confounders, including ambulatory blood pressure (hazard ratio (HR) 16; p = 0.001 for cardiovascular death and 1.92; p = 0.02 for all-cause death). This study strongly suggests that stable WCH is a risk factor for cardiovascular events.

We should observe other points when considering cardiovascular risk in WCH. First, in a long-term follow-up study, WCH was associated with an increased risk of developing sustained hypertension compared with true normotension. The odds ratio (OR) was 2.86 in the Ohasama study (home BP based) [ 75 ] and 2.5 in the PAMELA study (both ABPM and home BP based) [ 76 ]. Second, WCH was associated with metabolic abnormality [ 77 , 78 ] and with an increased risk of incident diabetes compared with normotension [ 79 ]. In the International Database on Ambulatory Blood Pressure in Relation to Cardiovascular Outcomes (IDACO) study, cardiovascular event risk was higher in WCH than in normotension in a diabetic population in contrast to a non-diabetic population [ 74 ]. Third, recent data showed that some organ damage depends more on clinic blood pressure than out-of-office blood pressure. Increased left atrium diameter is known to be associated with an elevated risk of cardiovascular morbidity and mortality. Bombelli et al. [ 80 ] evaluated new-onset left atrial enlargement and their correlates over a 10-year period in the PAMELA study. In multivariate analysis, office systolic blood pressure was an independent risk factor for left atrial enlargement, whereas home and ambulatory blood pressure were not. Thus, some organ damage depends more on temporal blood pressure elevation in the clinic rather than stable blood pressure in the out-of-office setting. The clinical characteristics of WCH are heterogeneous and could change over time with aging and subsequent environmental factors. Careful follow-up of the hypertension phenotype, metabolic risks, and organ damage is necessary in the management of WCH.

Whether home blood pressure could be substituted for daytime ambulatory blood pressure in the diagnosis of WCH is a controversial topic [ 81 , 82 , 83 ]. Home blood pressure measurement is much more feasible than ambulatory blood pressure monitoring [ 84 ], but these measurements monitor different aspects of blood pressure behavior [ 83 ]. In our recent study conducted in a worksite setting, of the 157 employees who showed normal clinic (<140/90 mmHg) and normal morning home blood pressures (<135/85 mmHg), 27 (17%) demonstrated high worksite blood pressure (≥135/85 mmHg) [ 85 ]. Thus, some subjects with normal home and clinic blood pressures show worksite hypertension. The percentage of worksite hypertension would be higher in WCH than in normotension because some patients with a greater white-coat effect demonstrate larger pressor reactivity to daily life stress as noted above. In other words, home blood pressure-based WCH could include true WCH and persistent hypertension with high worksite blood pressure (Fig. 3 ). In the International Database on Home Blood Pressure in Relation to Cardiovascular Outcome (IDHOCO) study, 6458 participants from five populations were followed up for 8.3 years [ 86 ]. Among the untreated subjects ( n = 5007), cardiovascular risk was significantly higher in WCH than in normotensive subjects (adjusted HR 1.42, 95% confidence interval (CI) 1.06–1.91, p = 0.02). Therefore, in the home blood pressure-based study, cardiovascular event risk was higher in WCH than in normotension. The reasons for the difference in results between IDACO and IDHOCO studies are unclear. However, as speculated above, WCH patients defined by home blood pressure might include some degree of ambulatory hypertensive patients, leading to higher risk for this group than for the normotensive group. Examining worksite blood pressure either by ambulatory monitoring or by self-measurement is recommended to improve the diagnostic accuracy of WCH in subjects on the job.

White-coat hypertension based on home blood pressure measurements (left panel) can be classified into true white-coat hypertension (right upper) and sustained hypertension (right lower) if work blood pressure is considered

Work environment as a profound modulator of blood pressure

Work may be the most influential factor for out-of-office blood pressure in subjects on the job [ 87 ]. The clinic-daytime blood pressure difference has been shown to be positively correlated with age [ 61 ]. Clinic blood pressures are higher than daytime blood pressures in elderly people aged over 60 years, unlike the differences in people aged 50 years or younger. Many people usually retire in their 60 s, suggesting that work conditions considerably influence blood pressure balance between clinic and out-of-clinic settings. In working people, blood pressures tend to be higher on a workday than on a day away from work [ 88 , 89 ]. Moreover, the correlation between left ventricular mass and blood pressure is closer for blood pressure measured at work than for blood pressure measured at home or during sleep [ 90 ]. These data strongly suggest that work-related blood pressure increase is an important target for managing hypertension. In this section, our review focuses on the relationship between qualitative work stress, work hours, shift work, and blood pressures; all of these factors have received a great interest as a cause of cardiovascular diseases [ 91 , 92 , 93 ].

Work stress and blood pressure

The two internationally recognized theoretical models for examining the effects of job stress on blood pressure are demand–control support (DCS) [ 94 , 95 ] and effort–reward imbalance (ERI) [ 96 ]. The DCS model indicates that workers experiencing high psychological demands (e.g., excessive workload, very hard or fast work, and conflicting demands) and low job control are associated with a higher risk of developing stress-related diseases [ 91 ]. Job control is a combination of skill discretion (e.g., learning new things, opportunities to develop skills, creativity, a variety of activities, and non-repetitive work) and decision authority (i.e., taking part in decisions affecting oneself, making one’s own decisions, having a say on the job and freedom as to how the work is accomplished). Poor social support has been introduced as a third component of the demand–control model [ 97 ]. This component refers to a lack of help and cooperation from supervisors and coworkers. The ERI model suggests that extrinsic efforts (i.e., pressure to work overtime, increasingly demanding work, constant time pressure, repeated interruptions) should be rewarded in various ways, such as financially (income), socially (respect and esteem), and organizationally (job security and promotion prospects) [ 96 ]. Workers are in an unhealthy condition if high extrinsic efforts are accompanied by low reward. A third component is overcommitment, which is a personal coping style that presents as being unable to withdraw from work obligations and being impatient and irritable [ 98 ]. Overcommitment has been considered to be an amplifier of the ERI effect.

Gilbert-Ouimet et al. [ 99 ] published a systematic review on the relationship between work stress and blood pressure in 2014, which included studies published from 1982 to 2011. Prospective cohorts and cross-sectional or case–control studies were considered. Cross-sectional or case–control studies that compare working and non-working conditions are important because blood pressure at work is closely related to organ damage, as described above. Sixty-four studies investigated the DCS model, twelve studies examined the ERI model, and two studies considered both models. Studies were conducted in 18 countries and included various working populations. Either clinic or ambulatory blood pressures were used, and changes in blood pressure or incident hypertension were evaluated as outcome measures. In the prospective studies, the follow-up period ranged from 6 weeks to 12 years.

DCS model: of the 40 cross-sectional studies on job strain, 16 demonstrated a significant pressor effect, namely, the difference in systolic blood pressure and diastolic blood pressure means ranging from +2 to +10.2 mmHg and +2 to +17.97 mmHg, respectively, and OR for hypertension ranging from 1.18 to 2.9. The remaining 24 studies showed no significant effects on blood pressures. If the data were analyzed by gender, worse effects were more frequent in men (blood pressure level: 6/18 studies, hypertension: 2/5 studies) than in women (blood pressure level: 1/10, hypertension: 0/7 studies). Of the 12 prospective studies on job strain, 9 demonstrated a significant pressor effect, namely, the difference in systolic blood pressure and diastolic blood pressure means ranging from +1.2 to +7.7 mmHg and +0.8 to +7 mmHg, respectively, and OR for hypertension ranging from 1.27 to 2.06. Worse effects were also more frequently observed in men than in women in studies on blood pressure level as an outcome measure (5/5 vs. 2/4 studies). Moreover, in one study on incident hypertension as an outcome measure, a significant effect was observed in men but not in women.

The method of blood pressure measurements could considerably influence the results. Overall, a higher percentage of studies using ambulatory blood pressure measures demonstrated more worse effects of job strain than those using office blood pressure measures (13/20 vs. 12/35 studies). This tendency was more evident in cross-sectional studies (9/15 vs. 7/27 studies) than in prospective studies (4/5 vs. 3/4 studies).

Some studies examined the relationship between job stress components, i.e., job demand or job control, and blood pressures. Significantly worse effects were observed for high psychological demands in 7/25 studies on blood pressure level and 2/7 studies on hypertension and for low social support in 1/9 studies on blood pressure levels. A significant protective effect was observed for high job control in 9/25 studies on blood pressure level and 3/6 studies on hypertension. Thus, not only job strain but also its components should be considered as measures of work-related stress. This concept was confirmed by our recent study conducted in Japanese male hospital employees [ 100 ]. We examined resting blood pressures and job stress components in 113 Japanese male hospital clerks (38.1 ± 4.4 years). Subjects were classified into normotensive (<130/85 mmHg, n = 83) and mildly elevated blood pressure (≥130/85 mmHg, n= 30) groups. Subjects with low job control demonstrated higher diastolic blood pressure than those with high job control (89.1 ± 2.1 vs. 82.3 ± 2.3 mmHg, p = 0.042) in the mildly elevated blood pressure group, even after adjustments for co-variates. Diastolic blood pressure did not differ between low and high job control subjects in the normotensive group. Systolic blood pressure did not differ between high and low job control subjects in both groups. Neither systolic blood pressure nor diastolic blood pressure differed between high- and low-demand groups in either group. Thus, low job control was independently related to high diastolic blood pressure in men with mildly elevated blood pressure but not in normotensive men. This result suggests higher stress blood pressure reactivity in the former [ 100 ].

ERI model: of the 11 cross-sectional studies with the ERI model, 7 demonstrated a significant pressor effect, namely, the difference in systolic blood pressure and diastolic blood pressure means ranging from +1.86 to +4.52 mmHg and +1.31 to +4.17 mmHg, respectively, and OR for hypertension ranging from 1.62 to 5.77. In addition, two cross-sectional studies evaluated the separate effect of effort and reward, but none of the studies observed significant effects. When the effects were analyzed by gender, six cross-sectional studies presented results separately for men and women. The worse effect was more frequent in men than in women (5/6 vs. 1/6 studies). In line with the results of the DCS model, adverse effects tended to be more frequently observed in studies conducted using ambulatory blood pressure measure than those using office blood pressure measure (3/4 vs. 5/8 studies). A significantly worse effect of overcommitment was observed in one out of three cross-sectional studies. This study observed a higher ambulatory systolic blood pressure mean among men, but no effects were noted among women.

Some new evidence after this review will also be discussed. In a Canadian prospective study including >3000 white-collar male and female workers, women with high ERI scores demonstrated a significant increase in systolic ambulatory blood pressure after 3 years. Moreover, a significant increase in incident hypertension was found among older women, whereas no significant effect was observed among men [ 101 ]. This trend among women was further confirmed over a 5-year observation period [ 102 ]. The double exposure of ERI and family obligations among women resulted in a significant rise in ambulatory blood pressure after 5 years [ 102 ]. The finding that ERI was associated with significantly increased risks of untreated hypertension [ 103 ] and masked hypertension is important [ 104 ].

Taken together, current evidence suggests that the deleterious effects of work stress on blood pressures are more frequently observed in studies using ambulatory blood pressure than those with clinic blood pressure either in cross-sectional or prospective studies. This finding is quite reasonable because work stress could increase blood pressure only at work, leading to masked hypertension. However, temporal blood pressure increases, even when restricted to work times, could lead to the development of organ damage if they are repeated over time. An examination of work-related blood pressure changes by ambulatory blood pressure monitoring in subjects involved in high-stress jobs is strongly recommended.

However, self-blood pressure measurement at the workplace may be more useful and practical than ambulatory blood pressure monitoring in some situations. Cardiovascular events have been reported to often occur on Monday morning compared with other week days among the working population [ 105 , 106 ]. This effect has been attributed in part to high Monday morning blood pressure [ 105 , 107 ]. However, repeating ambulatory blood pressure monitoring within a week is difficult. To address this issue, we conducted a multicenter study to examine the hypothesis of whether blood pressure is higher on Monday morning than on other days of the week [ 108 ]. We studied 207 treated hypertensive subjects working for 29 Rosai hospitals. Blood pressures and heart rate were measured with an automated device at standardized conditions 4 times a day: immediately after waking, 10:00 h, 16:00 h, and before going to bed on three days (Monday, Friday, and Saturday or Sunday). Job stress was examined using the Japanese version of the JDC model [ 109 ]. Urinary albumin excretion was examined as a measure of endothelial damage and future cardiovascular event risk [ 110 ]. Recorded data were automatically transferred to a data center through a wireless telephone. A significant interaction was found between the rate pressure product (systolic blood pressure × heart rate) and weekly and daily variations (Fig. 4 ). The rate pressure product was higher in the morning on Monday than at other times or on other days. This tendency was more evident in women than in men. The increase in rate pressure product on Monday morning was significantly correlated with urinary albumin excretion and job strain index in women. Thus, higher cardiovascular load partially due to work stress on Monday morning seemed to be associated with endothelial damage in treated hypertensive subjects. In our study, the compliance for self-measurement of blood pressure was satisfactory, and no patient dropout was noted. Self-measurement of blood pressure seemed to be suitable for examining work-related daily and weekly variations.

Double product elevation on Monday morning during work. A significant interaction (alternative action) was found between the double product (systolic BP × heart rate: mmHg × bpm) and weekly and circadian rhythms, particularly in women and in the overall population. In the graphs, small square, large square, and triangle represent the weekend (Saturday or Sunday), Monday, and Friday, respectively. The figure was modified from Kimura et al. [ 108 ]

Work hours and blood pressure

Long working hours are associated with an increased risk of cardiovascular disease [ 93 ], but their relationship with hypertension remains unclear. Long working hours are officially recognized as a causal factor for “Karoshi,” death from overwork, or work-related cardiovascular events in Japan, Chinese Taiwan, and Korea [ 111 , 112 ]. However, to the best of our knowledge, no systematic review has been conducted on work hours and elevation of blood pressure. Thus, we surveyed studies on the relationship between work hours and blood pressure (Table 1 ).

The results were inconsistent among studies. Six studies reported a positive relationship between long work hours and blood pressure increase or increased risk of incident hypertension, whereas two studies demonstrated no relationship. Surprisingly, three studies from Japan reported an inverse relationship between work hours and incident or prevalent hypertension. The first pioneering work was conducted by Hayashi et al. [ 113 ]. They compared ambulatory blood pressures at normal control work periods and those at very long overtime work period in white-collar workers. Blood pressure was significantly higher when working overtime (average overtime of 96 h per month) than in a “control” period (average overtime of 43 h per month). Iwasaki et al. [ 114 ] showed significantly higher systolic blood pressure among salesmen aged 50–60 years who spent >61 h per week commuting and working than among those who spent <57 h. However, blood pressure did not differ between longer and shorter working subgroups younger than 50 years of age. Yang et al. [ 115 ] showed that in the US working population, individuals who worked 40, 41–50, and >50 h per week were 1.14-fold (95% CI, 1.01–1.28), 1.17-fold (95% CI, 1.04–1.33), and 1.29-fold (95% CI, 1.10–1.52) more likely to have self-reported hypertension, respectively, than individuals who worked 11–39 h per week. Although the study was cross-sectional, the findings were important because it included a large range of age groups and all occupational categories. Artazcoz et al. [ 116 ] showed in the Catalonian Health Survey that long work hours were associated with hypertension (adjusted OR, 2.25; 95% CI, 1.17–4.32) among female workers only in a cross-sectional study. Nakamura et al. [ 117 ] were the first to report a positive relationship between overtime work and blood pressure increase in a longitudinal study. The multivariate-adjusted mean for 1-year change in diastolic blood pressure in 611 male assembly-line workers was 1.5 mmHg (95% CI; 0.8–2.2) for <40.0 h per month, 2.3 mmHg (95% CI 1.3–3.2) for 40.0–79.9 h per month and 5.3 mmHg (95% CI 2.7–7.9) for ≥80.0 h per month ( p for heterogeneity = 0.02). A largely similar pattern was observed for systolic blood pressure. No such relationship was noted for clerks or engineers/special technicians. This study showed that work type may modify the relationship between overtime work hours and blood pressure progression. Similarly, Yoo et al. [ 118 ] reported that the HR for incident hypertension significantly increased as the number of working hours per week increased in Korean wage workers. Compared with those working 40 h or less per week, the HR of subjects working 41–50 h per week was 2.20 (95% CI; 1.19–4.06), that of subjects working 51–60 h per week was 2.40 (95% CI, 1.07–5.39) and that of subjects working 61 h and over per week was 2.87 (95% CI, 1.33–6.20).

On the other hand, several Japanese studies have reported negative associations between work hours or overtime work and the incident or prevalent hypertension. Nakanishi et al. [ 119 ] showed in 941 hypertension-free (<140/90 mmHg) Japanese male white-collar workers that the relative risk for hypertension above the borderline level (140/90 mmHg) was 0.63 (95% CI: 0.43, 0.91) for those who worked 10.0–10.9 h per day and 0.48 (95% CI: 0.31, 0.74) for those who worked ≥11.0 h per day compared with those who worked <8.0 h per day. In this study, architects or research workers worked more overtime than clerks, and being an architect or a research worker (vs. being a clerk) was negatively associated with the slope of blood pressure. The authors speculated that the work type would be important to determining the perception of overwork or stress and its associated responses in blood pressure. A similar prospective study was also reported in Japanese male workers [ 120 ]. Imai et al. [ 121 ] conducted a large-scale cross-sectional study to examine long working hours and prevalent hypertension. Their participants consisted of 52,365 workers from four companies that provided both health-checkup data and self-reported data on overtime work. Logistic regression analysis was performed to determine the OR for hypertension in each category of overtime work (<45, 45–79, 80–99 or ≥100 h per month) with adjustments for co-variates. The adjusted ORs (95% CI) for hypertension were 1.00 (reference), 0.81 (0.75–0.86), 0.73 (0.62–0.86), and 0.58 (0.44–0.76) for <45, 45–79, 80–99, and ≥100 h/month, respectively. Two studies showed no relationship between work hours and blood pressure or incident hypertension [ 122 , 123 ].

Thus, current evidence suggests that the relationship between work hours and blood pressure varies among studies and is not conclusive. The type of job and job satisfaction are assumed to largely modify the relationship.

Shift work and blood pressure

Shift workers play an important role in the maintenance of production, health-care, and service industries in many countries [ 92 ]. Approximately 15–30% of workers are employed as rotational shift workers, which include working day, afternoon, and night shifts [ 124 ]. The human body has an inherent biological circadian rhythm, which is programmed to be active during the day and to rest at night. Shift workers are forced to adapt their behavior against such an inherent rhythm and thus experience complex stress from psychological, physiological, and behavioral aspects [ 125 ]. Therefore, shift work is hazardous to one’s health [ 126 , 127 ]. The risk of cardiovascular disease has been reported to be increased in shift workers compared with non-shift workers. A recent meta-analysis has shown that shift workers had a 26% higher risk of coronary artery disease than non-shift workers [ 92 ]. This finding might be mediated partially by an altered circadian blood pressure rhythm or a blood pressure elevation induced by shift work.

Circadian blood pressure profiles of rotating shift workers have been compared in several studies using ambulatory blood pressure monitoring. Some studies have shown that these profiles are identical or nearly the same between normal work and shift work days and concluded that circadian blood pressure change is largely determined by the cycle of physical or mental activity and sleep [ 128 , 129 , 130 ]. However, others reported an altered circadian blood pressure rhythm in shift workers. Chau et al. carefully examined the circadian blood pressure profile curve of morning, afternoon, and night shifts by Fourier series [ 131 ]. They found that high pressure periods did not coincide entirely with the times of activity. They concluded that factors other than the subject’s activity contribute to the circadian blood pressure profiles of shift workers. Ohira et al. [ 132 ] compared 24-h ambulatory blood pressure between 27 shift workers and 26 day workers. Even after adjustment for co-variates, the blood pressure during waking and work periods was higher in shift workers than in day workers, although sleep blood pressures were similar. This study showed greater pressor reactivity during work in shift workers than in day workers. To precisely examine the dynamic changes in blood pressure and autonomic nervous activity associated with shift work, we studied 18 healthy nurses engaged in a shift rotation system (day work, 8:15–17:15; evening work, 16:00–22:00; night work, 21:30–8:30) [ 133 ]. Blood pressure, heart rate, RR interval variability, and physical activity were measured for 24 h from the start of work during the night and day shifts. Systolic blood pressure and heart rate during work were lower during the night shift than the during day shift. Both parameters were still lower ( p < 0.005 and p < 0.05) when they were measured outside of the hospital under waking conditions following a night shift than following a day shift, even though the levels of physical activity were similar. The high-frequency power spectrum of RR interval variability, a measure of cardiac vagal modulation, was greater not only during work but also during the awake period after a night shift compared with a day shift. Blood pressures during sleep were similar between day and night shifts. Thus, our data showed that waking blood pressure could be lower after a night shift due to altered autonomic regulation compared with day shift in subjects involved in rotating shift work. This finding was a new cause of the flattening of circadian blood pressure rhythms in rotating shift workers. Kitamura et al. [ 134 ] examined the changes in circadian blood pressure patterns in response to work shift changes in hypertensive patients. Ambulatory blood pressure monitoring was performed three times: the last day of a 4-day period of day shifts, the first day of a 4-day period of night shifts, and the fourth day of night shifts. Circadian rhythm was dipper on the day of a day shift and the last day of night shifts but was non-dipper on the first day of night shifts. Non-dipper patterns on the first day of night shifts were associated with high sleep blood pressure compared with pressures on day shifts, but awake blood pressure also tended to be lower in the night shift than in the day shift, confirming our results. The results suggest that the sympathetic modulation of awake and sleep blood pressures dynamically changes within a period of rotating shift. Later studies also confirmed these findings [ 135 , 136 ]. Therefore, the results of the cross-sectional comparison of blood pressure between shift workers and non-shift workers might be inconsistent [ 131 , 137 , 138 , 139 , 140 ]. Overall evidence suggests that rotating shift workers repeatedly suffer from a non-dipper pattern of circadian blood pressure rhythm partially due to altered sympathetic cardiovascular modulation. Repeated experiences of non-dipper circadian blood pressure rhythms are speculated to increase the risk of cardiovascular events [ 141 ].

How about the circadian blood pressure rhythm of subjects involved in fixed rotating shifts? Are they completely adjusted to environmental changes? Sternberg et al. [ 142 ] reported that the awake–sleep difference in mean systolic/diastolic ambulatory blood pressure was smaller in night workers than in day workers (7.9/7 vs. 15.5/13 mmHg). In another study evaluating 58 day-shift workers and 35 evening + night-shift workers, the evening + night workers had a significantly smaller decrease in systolic blood pressure during sleep than the day-shift workers. This result was largely attributed to higher sleep systolic blood pressure in the evening + night-shift group [ 143 ]. Urinary noradrenaline and adrenaline were higher during work than non-work in day-shift workers. However, in evening + night-shift workers, the difference was small and in the opposite direction, suggesting an altered sympathetic nervous rhythm of the evening + night-shift group. Kario et al. [ 144 ] examined the hypothesis of whether cardiovascular reactivity to acute stress and/or delayed recovery predicts greater diurnal blood pressure variation between day and fixed night-shift female workers. Night-shift workers demonstrated higher sleep systolic blood pressure than day-shift workers (105 vs. 99 mmHg), although the awake systolic blood pressure was similar between groups (118 vs. 116 mmHg). In the night-shift group, the sleep/awake systolic blood pressure ratio was negatively correlated with relative systolic blood pressure reactivity ( r = −0.41, p = 0.02) and relative stress response of systolic blood pressure ( r = −0.48, p = 0.006) induced by anger recall, but it was positively correlated with recovery rate ( r = 0.34, p = 0.06). These correlations were not significant in the day-shift group. The sleep/awake systolic blood pressure ratio was inversely correlated with an exercise-induced systolic blood pressure increase in day-shift workers ( r = −0.30, p = 0.03), but this association was not found in night-shift workers. These lines of evidence suggest that fixed night-shift workers never demonstrate normal circadian blood pressure rhythm but are associated with less dipping patterns of circadian blood pressure rhythms partially due to altered sympatho-adrenal modulation of the cardiovascular system.

Finally, the influence of long-term shift work on incident hypertension or blood pressure progression is discussed. Morikawa et al. [ 145 ] conducted a 5-year prospective study in a cohort of 1551 male manual workers and found that the OR for incident hypertension in shift workers relative to daytime workers was 3.6 in the group aged 18–29 years. Sakata et al. [ 146 ] reported a significant relationship between alternating shift work and hypertension based on a prospective cohort study of 5338 workers over a 10-year period. The OR of the onset of hypertension in shift workers for daytime workers was 1.10 and significant. Furthermore, in the same group, alternating shift work was significantly associated with the progression of mild hypertension to severe hypertension [ 147 ] and an increase in blood pressure in a cohort study over a 10-year period [ 148 ]. Notably, the effects of shift work on blood pressure increase were more pronounced than those of age or body mass index [ 148 ]. Thus, many Japanese studies confirmed that long-term shift work increases the risk of incident hypertension and blood pressure progression, but some exceptions have been reported in other countries [ 149 , 150 ]. Therefore, the relationship between shift work and blood pressure progression might be modified by Japan-specific lifestyle factors, such as high salt intake. This important issue should be elucidated in the future.

In this section, the review focuses on home stress because not only work stress but also home stress considerably influences ambulatory blood pressures [ 151 ].

The world’s population is rapidly aging. The number of old people (aged 65 and over) was 562 million (8% of 7 billion total population) in 2012, and it increased by 595 million (to 8.5% of total population) in 2015 [ 152 ]. In Japan, life expectancy at birth is currently nearly the highest in the world. However, the duration of life with light or moderate disability increases with an increase in life expectancy at birth for both genders [ 153 ]. Thus, the number of elderly people who require caregiving is expected to markedly increase.

Family caregiving can be a positive and rewarding experience [ 154 ]. However, it is associated with a variety of deleterious health behaviors and outcomes [ 155 , 156 ]. In a nationally representative sample of US adults, spousal caregiving is associated with a significant elevation in the risk of cardiovascular disease [ 157 ]. Hypertension may partially explain this connection between caregiving and an increase in cardiovascular disease risk.

In a cross-sectional study conducted in USA, Switzerland, and Japan, blood pressures were consistently higher in caregivers than in non-caregivers after adjustments for co-variates [ 158 , 159 , 160 ]. King et al. [ 158 ] compared ambulatory blood pressure and heart rate responses to the stress of work and caregiving in older women. Caregivers demonstrated a significant increase in systolic blood pressure when returning home to the care recipient, whereas systolic blood pressure declined when leaving work and returning home in non-caregivers. These observations strongly suggest that caregiving stress could be a cause of home hypertension. Only a few longitudinal studies have examined whether caregiving could be a risk of incident hypertension [ 161 , 162 ]. Shaw et al. [ 161 ] compared the risk of incident hypertension between spousal caregivers of Alzheimer’s disease patients and non-caregiving controls ( n = 47). Based on periodic 6-month assessments of blood pressure over 6 years, the risk for borderline hypertension was greater for caregivers than for controls (HR 4.86, p = 0.03). Capistrant et al. [ 162 ] examined this issue in a large, nationally representative sample of American older adults. Married, hypertension-free, health and retirement study respondents ( n = 5708) were followed for up to 8 years. After adjusting for multiple co-variates, current caregiving significantly predicted hypertension incidence (RR = 1.36, 95% CI: 1.01–1.83). For long-term caregivers, significant evidence of the risk of hypertension onset was associated with caregiving (RR = 2.29, 95% CI: 1.17–4.49). Thus, available evidence strongly suggests a link between caregiving stress and the risk of incident hypertension and temporal blood pressure elevation.

This article reviewed the clinical significance of stress-related elevations in blood pressure in office and out-of-office settings separately. WCH was the most common office stress-related hypertension phenotype. Currently, there is no definite evidence indicating that untreated WCH is associated with increased cardiovascular event risk compared with normotension. However, WCH is associated with long-term risk of sustained hypertension and diabetes. Moreover, WCH demonstrates worse cardiovascular prognosis as compared with normotension in the diabetic population. The risk of WCH is never determined from temporal data but must be evaluated from long-term observation of hypertension phenotype and development of complication. Masked hypertension is a well-known poor prognostic hypertension phenotype. The cause of masked hypertension is complex, but stress at workplace or home could be involved. Chronic stress as well as allostatic load, distorted lifestyle, and mental distress could increase blood pressure.

Removal of such stress is difficult, and the evidence is limited if stress-reduction techniques have hypotensive effects. However, considering patients’ background and giving them an opportunity to present their concern help to establish rapport [ 163 ], which is essential to keep long-term compliance for hypertension treatment.

Bromfield S, Muntner P. High blood pressure: the leading global burden of disease risk factor and the need for worldwide prevention programs. Curr Hypertens Rep. 2013;15:134–6.

Article PubMed PubMed Central Google Scholar

Forouzanfar MH, Liu P, Roth GA, Ng M, Biryukov S, Marczak L, Alexander L, Estep K, Abate KH, Akinyemiju TF, Ali R, Alvis-Guzman N, Azzopardi P, Banerjee A, Baernighausen T, Basu A, Bekele T, Bennett DA, Biadgilign S, Catala-Lopez F, Feigin VL, Fernandes JC, Fischer F, Gebru AA, Gona P, Gupta R, Hankey GJ, Jonas JB, Judd SE, Khang Y-H, Khosravi A, Kim YJ, Kimokoti RW, Kokubo Y, Kolte D, Lopez A, Lotufo PA, Malekzadeh R, Melaku YA, Mensah GA, Misganaw A, Mokdad AH, Moran AE, Nawaz H, Neal B, Ngalesoni FN, Ohkubo T, Pourmalek F, Rafay A, Rai RK, Rojas-Rueda D, Sampson UK, Santos IS, Sawhney M, Schutte AE, Sepanlou SG, Shifa GT, Shiue I, Tedla BA, Thrift AG, Tonelli M, Truelsen T, Tsilimparis N, Ukwaja KN, Uthman OA, Vasankari T, Venketasubramanian N, Vlassov VV, Vos T, Westerman R, Yan LL, Yano Y, Yonemoto N, Zaki MES, Murray CJL. Global burden of hypertension and systolic blood pressure of at least 110 to 115 mmHg, 1990-2015. JAMA. 2017;317:165–82.

Article PubMed Google Scholar

Mendis S, Davis S, Norrving B. Organizational update: the world health organization global status report on noncommunicable diseases 2014; one more landmark step in the combat against stroke and vascular disease. Stroke. 2015;46:e121–2.

Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Judd SE, Kissela BM, Lackland DT, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Matchar DB, McGuire DK, Mohler ER 3rd, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Willey JZ, Woo D, Yeh RW, Turner MB, American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015;131:e29–322.

Kario K, Pickering TG, Umeda Y, Hoshide S, Hoshide Y, Morinari M, Murata M, Kuroda T, Schwartz JE, Shimada K. Morning surge in blood pressure as a predictor of silent and clinical cerebrovascular disease in elderly hypertensives: a prospective study. Circulation. 2003;107:1401–6.

Ohkubo T, Kikuya M, Metoki H, Asayama K, Obara T, Hashimoto J, Totsune K, Hoshi H, Satoh H, Imai Y. Prognosis of “masked” hypertension and “white-coat” hypertension detected by 24-h ambulatory blood pressure monitoring 10-year follow-up from the Ohasama study. J Am Coll Cardiol. 2005;46:508–15.

Mancia G, Bombelli M, Facchetti R, Madotto F, Corrao G, Trevano FQ, Grassi G, Sega R. Long-term prognostic value of blood pressure variability in the general population: results of the Pressioni Arteriose Monitorate e Loro Associazioni Study. Hypertension. 2007;49:1265–70.

Article CAS PubMed Google Scholar

Rothwell PM, Howard SC, Dolan E, O’Brien E, Dobson JE, Dahlöf B, Sever PS, Poulter NR. Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension. Lancet. 2010;375:895–905.

Kikuya M, Ohkubo T, Metoki H, Asayama K, Hara A, Obara T, Inoue R, Hoshi H, Hashimoto J, Totsune K, Satoh H, Imai Y. Day-by-day variability of blood pressure and heart rate at home as a novel predictor of prognosis: the Ohasama study. Hypertension. 2008;52:1045–50.

Singh M, Singh AK, Pandey P, Chandra S, Singh KA, Gambhir IS. Molecular genetics of essential hypertension. Clin Exp Hypertens. 2016;38:268–77.

Waken RJ, de Las Fuentes L, Rao DC. A review of the genetics of hypertension with a focus on gene-environment interactions. Curr Hypertens Rep. 2017;19:23.

Article CAS PubMed PubMed Central Google Scholar

Hall JE, Granger JP, do Carmo JM, da Silva AA, Dubinion J, George E, Hamza S, Speed J, Hall ME. Hypertension: physiology and pathophysiology. Compr Physiol. 2012;2:2393–442.

PubMed Google Scholar

Brook RD. The environment and blood pressure. Cardiol Clin. 2017;35:213–21.

Miura K, Nagai M, Ohkubo T. Epidemiology of hypertension in Japan: where are we now? Circ J. 2013;77:2226–31.

Falaschetti E, Chaudhury M, Mindell J, Poulter N. Continued improvement in hypertension management in England: results from the Health Survey for England 2006. Hypertension. 2009;53:480–6.

Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. JAMA. 2010;303:2043–50.

Cuffee Y, Ogedegbe C, Williams NJ, Ogedegbe G, Schoenthaler A. Psychosocial risk factors for hypertension: an update of the literature. Curr Hypertens Rep. 2014;16:483.

Huang CJ, Webb HE, Zourdos MC, Acevedo EO. Cardiovascular reactivity, stress, and physical activity. Front Physiol. 2013;4:314.

Ushakov AV, Ivanchenko VS, Gagarina AA. Psychological stress in pathogenesis of essential hypertension. Curr Hypertens Rev. 2016;12:203–14.

Puzserova A, Bernatova I. Blood pressure regulation in stress: focus on nitric oxide-dependent mechanisms. Physiol Res. 2016;65:S309–342.

CAS PubMed Google Scholar

Rohleder N. Stimulation of systemic low-grade inflammation by psychosocial stress. Psychosom Med. 2014;76:181–9.

Cheung BM, Ong KL, Tso AW, Leung RY, Xu A, Cherny SS, Sham PC, Lam TH, Lam KS. C-reactive protein as a predictor of hypertension in the Hong Kong Cardiovascular Risk Factor Prevalence Study (CRISPS) cohort. J Hum Hypertens. 2012;26:108–16.

Michishita R, Ohta M, Ikeda M, Jiang Y, Yamato H. An exaggerated blood pressure response to exercise is associated with nitric oxide bioavailability and inflammatory markers in normotensive females. Hypertens Res. 2016;39:792–8.

Marvar PJ, Vinh A, Thabet S, Lob HE, Geem D, Ressler KJ, Harrison DG. T lymphocytes and vascular inflammation contribute to stress-dependent hypertension. Biol Psychiatry. 2012;71:774–82.

Lagraauw HM, Kuiper J, Bot I. Acute and chronic psychological stress as risk factors for cardiovascular disease: insights gained from epidemiological, clinical and experimental studies. Brain Behav Immun. 2015;50:18–30.

Whelton PK, Carey RM, Aronow WS, Casey DE Jr., Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC Jr., Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA Sr., Williamson JD, Wright JT Jr.. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Hypertension. 2017;71:e13–115.

Nagele E, Jeitler K, Horvath K, Semlitsch T, Posch N, Herrmann KH, Grouven U, Hermanns T, Hemkens LG, Siebenhofer A. Clinical effectiveness of stress-reduction techniques in patients with hypertension: systematic review and meta-analysis. J Hypertens. 2014;32:1936–44.

Liu L, Li M, Song S, Shi A, Cheng S, Dang X, Chen H, Zhang H, Ziguli A, Cao L, Wang P, Luan H, Ma Y, Zhang S, Wang Z, Wang X, Gao R, Tian G. Effects of long-term psychological intervention on blood pressure and health-related quality of life in patients with hypertension among the Chinese working population. Hypertens Res. 2017;40:999–1007.

Ordaz S, Luna B. Sex differences in physiological reactivity to acute psychosocial stress in adolescence. Psychoneuroendocrinology. 2012;37:1135–57.

Dampney RA. Central neural control of the cardiovascular system: current perspectives. Adv Physiol Educ. 2016;40:283–96.

Selye H. Stress and the general adaptation syndrome. Br Med J. 1950;1:1383–92.

Keller A, Litzelman K, Wisk LE, Maddox T, Cheng ER, Creswell PD, Witt WP. Does the perception that stress affects health matter? The association with health and mortality. Health Psychol. 2012;31:677–84.

McEwen BS. Stress, adaptation, and disease. Allostasis and allostatic load. Ann N Y Acad Sci. 1998;840:33–44.

Jennings JR, Kamarck TW, Everson-Rose SA, Kaplan GA, Manuck SB, Salonen JT. Exaggerated blood pressure responses during mental stress are prospectively related to enhanced carotid atherosclerosis in middle-aged Finnish men. Circulation. 2004;110:2198–203.

Matthews KA, Zhu S, Tucker DC, Whooley MA. Blood pressure reactivity to psychological stress and coronary calcification in the Coronary Artery Risk Development in Young Adults Study. Hypertension. 2006;47:391–5.

Cardillo C, Degen C, De Felice F, Folli G. Relationship of stress testing blood pressure with electrocardiographic and fundoscopy indices of hypertensive end-organ damage. Clin Exp Hypertens A. 1992;14:469–88.

Lipman RD, Grossman P, Bridges SE, Hamner JW, Taylor JA. Mental stress response, arterial stiffness, and baroreflex sensitivity in healthy aging. J Gerontol A Biol Sci Med Sci. 2002;57:B279–84.

Harshfield GA, Dong Y, Kapuku GK, Zhu H, Hanevold CD. Stress-induced sodium retention and hypertension: a review and hypothesis. Curr Hypertens Rep. 2009;11:29–34.

Gerber M, Puhse U. Review article: do exercise and fitness protect against stress-induced health complaints? A review of the literature. Scand J Public Health. 2009;37:801–19.

Kidambi S, Kotchen JM, Krishnaswami S, Grim CE, Kotchen TA. Cardiovascular correlates of insulin resistance in normotensive and hypertensive African Americans. Metabolism. 2011;60:835–42.

Black PH, Garbutt LD. Stress, inflammation and cardiovascular disease. J Psychosom Res. 2002;52:1–23.

Schiffrin EL. The endothelium and control of blood vessel function in health and disease. Clin Invest Med. 1994;17:602–20.

Versari D, Daghini E, Virdis A, Ghiadoni L, Taddei S. Endothelium-dependent contractions and endothelial dysfunction in human hypertension. Br J Pharmacol. 2009;157:527–36.

Hamer M. Psychosocial stress and cardiovascular disease risk: the role of physical activity. Psychosom Med. 2012;74:896–903.

Aro S, Hasan J. Occupational class, psychosocial stress and morbidity. Ann Clin Res. 1987;19:62–8.

McQueen DV, Celentano DD. Social factors in the etiology of multiple outcomes: the case of blood pressure and alcohol consumption patterns. Soc Sci Med. 1982;16:397–418.

Artinian NT, Washington OG, Flack JM, Hockman EM, Jen KL. Depression, stress, and blood pressure in urban African-American women. Prog Cardiovasc Nurs. 2006;21:68–75.

Udupa K, Sathyaprabha TN, Thirthalli J, Kishore KR, Lavekar GS, Raju TR, Gangadhar BN. Alteration of cardiac autonomic functions in patients with major depression: a study using heart rate variability measures. J Affect Disord. 2007;100:137–41.

Malan L, Schutte CE, Alkerwi A, Stranges S, Malan NT. Hypothalamic-pituitary-adrenal-axis dysregulation and double product increases potentiate ischemic heart disease risk in a Black male cohort: the SABPA study. Hypertens Res. 2017;40:590–7.

Ulmer CS, Bosworth HB, Germain A, Lindquist J, Olsen M, Brancu M, VA Mid-Atlantic Mental Illness Research Education and Clinical Center Registry Workgroup, Beckham JC. Associations between sleep difficulties and risk factors for cardiovascular disease in veterans and active duty military personnel of the Iraq and Afghanistan conflicts. J Behav Med. 2015;38:544–55.

Mancia G, Bertinieri G, Grassi G, Parati G, Pomidossi G, Ferrari A, Gregorini L, Zanchetti A. Effects of blood-pressure measurement by the doctor on patient’s blood pressure and heart rate. Lancet. 1983;2:695–8.

Mancia G, Parati G, Pomidossi G, Grassi G, Casadei R, Zanchetti A. Alerting reaction and rise in blood pressure during measurement by physician and nurse. Hypertension. 1987;9:209–15.

Pickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH. How common is white coat hypertension? JAMA. 1988;259:225–8.

Munakata M, Saito Y, Nunokawa T, Ito N, Fukudo S, Yoshinaga K. Clinical significance of blood pressure response triggered by a doctor’s visit in patients with essential hypertension. Hypertens Res. 2002;25:343–9.

Grassi G, Turri C, Vailati S, Dell’Oro R, Mancia G. Muscle and skin sympathetic nerve traffic during the “white-coat” effect. Circulation. 1999;100:222–5.

Adams DB, Baccelli G, Mancia G, Zanchetti A. Cardiovascular changes during preparation for fighting behaviour in the cat. Nature. 1968;220:1239–40.

Folkow B. Physiology of behaviour and blood pressure regulation in animals. In: Julius S, Bassett DR, editors. Handbook of hypertension: behavioral factors in hypertension. Amsterdam: Elsevier Science Publishers; 1987. p. 1–18.

Parati G, Ulian L, Santucciu C, Omboni S, Mancia G. Difference between clinic and daytime blood pressure is not a measure of the white coat effect. Hypertension. 1998;31:1185–9.

Lantelme P, Milon H, Vernet M, Gayet C. Difference between office and ambulatory blood pressure or real white coat effect: does it matter in terms of prognosis? J Hypertens. 2000;18:383–9.

Verdecchia P, Schillaci G, Borgioni C, Ciucci A, Porcellati C. Prognostic significance of the white coat effect. Hypertension. 1997;29:1218–24.

Conen D, Aeschbacher S, Thijs L, Li Y, Boggia J, Asayama K, Hansen TW, Kikuya M, Björklund-Bodegård K, Ohkubo T, Jeppesen J, Gu YM, Torp-Pedersen C, Dolan E, Kuznetsova T, Stolarz-Skrzypek K, Tikhonoff V, Schoen T, Malyutina S, Casiglia E, Nikitin Y, Lind L, Sandoya E, Kawecka-Jaszcz K, Mena L, Maestre GE, Filipovský J, Imai Y, O’Brien E, Wang JG, Risch L, Staessen JA. Age-specific differences between conventional and ambulatory daytime blood pressure values. Hypertension. 2014;64:1073–9.

Parati G, Ulian L, Sampieri L, Palatini P, Villani A, Vanasia A, Mancia G. Attenuation of the “white-coat effect” by antihypertensive treatment and regression of target organ damage. Hypertension. 2000;35:614–20.

Glen SK, Elliott HL, Curzio JL, Lees KR, Reid JL. White-coat hypertension as a cause of cardiovascular dysfunction. Lancet. 1996;348:654–7.

Muscholl MW, Hense HW, Brockel U, Doring A, Riegger GA, Schunkert H. Changes in left ventricular structure and function in patients with white coat hypertension: cross sectional survey. BMJ. 1998;317:565–70.

Hara A, Ohkubo T, Kikuya M, Shintani Y, Obara T, Metoki H, Inoue R, Asayama K, Hashimoto T, Harasawa T, Aono Y, Otani H, Tanaka K, Hashimoto J, Totsune K, Hoshi H, Satoh H, Imai Y. Detection of carotid atherosclerosis in individuals with masked hypertension and white-coat hypertension by self-measured blood pressure at home: the Ohasama study. J Hypertens. 2007;25:321–7.

Puato M, Palatini P, Zanardo M, Dorigatti F, Tirrito C, Rattazzi M, Pauletto P. Increase in carotid intima-media thickness in grade I hypertensive subjects: white-coat versus sustained hypertension. Hypertension. 2008;51:1300–5.

Cuspidi C, Rescaldani M, Tadic M, Sala C, Grassi G, Mancia G. White-coat hypertension, as defined by ambulatory blood pressure monitoring, and subclinical cardiac organ damage: a meta-analysis. J Hypertens. 2015;33:24–32.

Cuspidi C, Sala C, Tadic M, Rescaldani M, Grassi G, Mancia G. Is white-coat hypertension a risk factor for carotid atherosclerosis? A review and meta-analysis. Blood Press Monit. 2015;20:57–63.

Khattar RS, Senior R, Lahiri A. Cardiovascular outcome in white-coat versus sustained mild hypertension: a 10-year follow-up study. Circulation. 1998;98:1892–7.

Kario K, Shimada K, Schwartz JE, Matsuo T, Hoshide S, Pickering TG. Silent and clinically overt stroke in older Japanese subjects with white-coat and sustained hypertension. J Am Coll Cardiol. 2001;38:238–45.

Mancia G, Facchetti R, Grassi G, Bombelli M. Adverse prognostic value of persistent office blood pressure elevation in white coat hypertension. Hypertension. 2015;66:437–44.

Verdecchia P, Reboldi GP, Angeli F, Schillaci G, Schwartz JE, Pickering TG, Imai Y, Ohkubo T, Kario K. Short- and long-term incidence of stroke in white-coat hypertension. Hypertension. 2005;45:203–8.

Pierdomenico SD, Cuccurullo F. Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis. Am J Hypertens. 2011;24:52–8.

Franklin SS, Thijs L, Hansen TW, Li Y, Boggia J, Kikuya M, Björklund-Bodegård K, Ohkubo T, Jeppesen J, Torp-Pedersen C, Dolan E, Kuznetsova T, Stolarz-Skrzypek K, Tikhonoff V, Malyutina S, Casiglia E, Nikitin Y, Lind L, Sandoya E, Kawecka-Jaszcz K, Imai Y, Wang J, Ibsen H, O’Brien E, Staessen JA, International Database on Ambulatory Blood Pressure in Relation to Cardiovascular Outcomes Investigators. Significance of white-coat hypertension in older persons with isolated systolic hypertension: a meta-analysis using the International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes population. Hypertension. 2012;59:564–71.

Ugajin T, Hozawa A, Ohkubo T, Asayama K, Kikuya M, Obara T, Metoki H, Hoshi H, Hashimoto J, Totsune K, Satoh H, Tsuji I, Imai Y. White-coat hypertension as a risk factor for the development of home hypertension: the Ohasama study. Arch Intern Med. 2005;165:1541–6.

Mancia G, Bombelli M, Facchetti R, Madotto F, Quarti-Trevano F, Polo Friz H, Grassi G, Sega R. Long-term risk of sustained hypertension in white-coat or masked hypertension. Hypertension. 2009;54:226–32.

Weber MA, Neutel JM, Smith DH, Graettinger WF. Diagnosis of mild hypertension by ambulatory blood pressure monitoring. Circulation. 1994;90:2291–8.

Kario K, Pickering TG. White-coat hypertension or white-coat hypertension syndrome: which is accompanied by target organ damage? Arch Intern Med. 2000;160:3497–8.

Mancia G, Bombelli M, Facchetti R, Madotto F, Quarti-Trevano F, Grassi G, Sega R. Increased long-term risk of new-onset diabetes mellitus in white-coat and masked hypertension. J Hypertens. 2009;27:1672–8.

Bombelli M, Cuspidi C, Facchetti R, Sala C, Tadic M, Brambilla G, Re A, Villa P, Grassi G, Mancia G. New-onset left atrial enlargement in a general population. J Hypertens. 2016;34:1838–45.

Stergiou GS, Nasothimiou E, Giovas P, Kapoyiannis A, Vazeou A. Diagnosis of hypertension in children and adolescents based on home versus ambulatory blood pressure monitoring. J Hypertens. 2008;26:1556–62.

Bayo J, Cos FX, Roca C, Dalfo A, Martin-Baranera MM, Albert B. Home blood pressure self-monitoring: diagnostic performance in white-coat hypertension. Blood Press Monit. 2006;11:47–52.

Kang YY, Li Y, Huang QF, Song J, Shan XL, Dou Y, Xu XJ, Chen SH, Wang JG. Accuracy of home versus ambulatory blood pressure monitoring in the diagnosis of white-coat and masked hypertension. J Hypertens. 2015;33:1580–7.

Imai Y, Obara T, Asamaya K, Ohkubo T. The reason why home blood pressure measurements are preferred over clinic or ambulatory blood pressure in Japan. Hypertens Res. 2013;36:661–72.

Munakata M, Kimura G, Inoue N. Final report on “lifestyle-related disease research” (in Japanese). 3rd stage medical research on work-related disease. Japan Organization of Occupational Health and Safety; 2018. Tokyo: p. 50–5.

Stergiou GS, Asayama K, Thijs L, Kollias A, Niiranen TJ, Hozawa A, Boggia J, Johansson JK, Ohkubo T, Tsuji I, Jula AM, Imai Y, Staessen JA, International Database on Home Blood Pressure in Relation to Cardiovascular Outcome (IDHOCO) Investigators. Prognosis of white-coat and masked hypertension: International Database of Home Blood Pressure in Relation to Cardiovascular Outcome. Hypertension. 2014;63:675–82.

Pickering TG. Reflections in hypertension: work and blood pressure. J Clin Hypertens. 2004;6:403–5.

Article Google Scholar

Pieper C, Warren K, Pickering TG. A comparison of ambulatory blood pressure and heart rate at home and work on work and non-work days. J Hypertens. 1993;11:177–83.

del Arco-Galan C, Suarez-Fernandez C, Gabriel-Sanchez R. What happens to blood pressure when on-call? Am J Hypertens. 1994;7:396–401.

Devereux RB, Pickering TG, Harshfield GA, Kleinert HD, Denby L, Clark L, Pregibon D, Jason M, Kleiner B, Borer JS, Laragh JH. Left ventricular hypertrophy in patients with hypertension: importance of blood pressure response to regularly recurring stress. Circulation. 1983;68:470–6.

Szerencsi K, van Amelsvoort LG, Viechtbauer W, Mohren DC, Prins MH, Kant I. The association between study characteristics and outcome in the relation between job stress and cardiovascular disease - a multilevel meta-regression analysis. Scand J Work Environ Health. 2012;38:489–502.

Torquati L, Mielke GI, Brown WJ, Kolbe-Alexander T. Shift work and the risk of cardiovascular disease. A systematic review and meta-analysis including dose-response relationship. Scand J Work Environ Health. 2017;44:229–38.

Kivimaki M, Jokela M, Nyberg ST, Singh-Manoux A, Fransson EI, Alfredsson L, Bjorner JB, Borritz M, Burr H, Casini A, Clays E, De Bacquer D, Dragano N, Erbel R, Geuskens GA, Hamer M, Hooftman WE, Houtman IL, Jöckel KH, Kittel F, Knutsson A, Koskenvuo M, Lunau T, Madsen IE, Nielsen ML, Nordin M, Oksanen T, Pejtersen JH, Pentti J, Rugulies R, Salo P, Shipley MJ, Siegrist J, Steptoe A, Suominen SB, Theorell T, Vahtera J, Westerholm PJ, Westerlund H, O’Reilly D, Kumari M, Batty GD, Ferrie JE, Virtanen M, IPD-Work Consortium. Long working hours and risk of coronary heart disease and stroke: a systematic review and meta-analysis of published and unpublished data for 603,838 individuals. Lancet. 2015;386:1739–46.

Schnall PL, Dobson M, Landsbergis P. Globalization, work, and cardiovascular disease. Int J Health Serv. 2016;46:656–92.

Karasek R, Baker D, Marxer F, Ahlbom A, Theorell T. Job decision latitude, job demands, and cardiovascular disease: a prospective study of Swedish men. Am J Public Health. 1981;71:694–705.

Siegrist J. Adverse health effects of high-effort/low-reward conditions. J Occup Health Psychol. 1996;1:27–41.

Johnson JV, Hall EM, Theorell T. Combined effects of job strain and social isolation on cardiovascular disease morbidity and mortality in a random sample of the Swedish male working population. Scand J Work Environ Health. 1989;15:271–9.

Siegrist J, Starke D, Chandola T, Godin I, Marmot M, Niedhammer I, Peter R. The measurement of effort-reward imbalance at work: European comparisons. Soc Sci Med. 2004;58:1483–99.

Gilbert-Ouimet M, Trudel X, Brisson C, Milot A, Vezina M. Adverse effects of psychosocial work factors on blood pressure: systematic review of studies on demand-control-support and effort-reward imbalance models. Scand J Work Environ Health. 2014;40:109–32.

Hattori T, Munakata M. Low job control is associated with higher diastolic blood pressure in men with mildly elevated blood pressure: the Rosai Karoshi study. Ind Health. 2015;53:480–8.

Gilbert-Ouimet M, Brisson C, Vezina M, Milot A, Blanchette C. Repeated exposure to effort-reward imbalance, increased blood pressure, and hypertension incidence among white-collar workers: effort-reward imbalance and blood pressure. J Psychosom Res. 2012;72:26–32.

Trudel X, Brisson C, Milot A, Masse B, Vezina M. Adverse psychosocial work factors, blood pressure and hypertension incidence: repeated exposure in a 5-year prospective cohort study. J Epidemiol Community Health. 2016;70:402–8.

Trudel X, Milot A, Gilbert-Ouimet M, Duchaine C, Guénette L, Dalens V, Brisson C. Effort-reward imbalance at work and the prevalence of unsuccessfully treated hypertension among white-collar workers. Am J Epidemiol. 2017;186:456–62.

Boucher P, Gilbert-Ouimet M, Trudel X, Duchaine CS, Milot A, Brisson C. Masked hypertension and effort-reward imbalance at work among 2369 white-collar workers. J Hum Hypertens. 2017;31:620–6.

Willich SN, Lowel H, Lewis M, Hormann A, Arntz HR, Keil U. Weekly variation of acute myocardial infarction. Increased Monday risk in the working population. Circulation. 1994;90:87–93.

Witte DR, Grobbee DE, Bots ML, Hoes AW. Excess cardiac mortality on Monday: the importance of gender, age and hospitalisation. Eur J Epidemiol. 2005;20:395–9.

Murakami S, Otsuka K, Kubo Y, Shinagawa M, Yamanaka T, Ohkawa S, Kitaura Y. Repeated ambulatory monitoring reveals a Monday morning surge in blood pressure in a community-dwelling population. Am J Hypertens. 2004;17:1179–83.

Kimura G, Inoue N, Mizuno H, Izumi M, Nagatoya K, Ohtahara A, Munakata M. Workplace hypertension co-operative study by 29 Rosai hospitals belonging to the Japan Organization of Occupational Health and Safety. Increased double product on Monday morning during work. Hypertens Res. 2017;40:671–4.

Inoue N, Otsui K, Yoshioka T, Suzuki A, Ozawa T, Iwata S, Takei A. A simultaneous evaluation of occupational stress and depression in patients with lifestyle-related diseases. Intern Med. 2016;55:1071–5.

Konno S, Munakata M. Moderately increased albuminuria is an independent risk factor of cardiovascular events in the general Japanese population under 75 years of age: the Watari study. PLoS ONE. 2015;10:e0123893.

Iwasaki K, Takahashi M, Nakata A. Health problems due to long working hours in Japan: working hours, workers’ compensation (Karoshi), and preventive measures. Ind Health. 2006;44:537–40.

Ke DS. Overwork, stroke, and karoshi-death from overwork. Acta Neurol Taiwan. 2012;21:54–9.

Hayashi T, Kobayashi Y, Yamaoka K, Yano E. Effect of overtime work on 24-hour ambulatory blood pressure. J Occup Environ Med. 1996;38:1007–11.

Iwasaki K, Sasaki T, Oka T, Hisanaga N. Effect of working hours on biological functions related to cardiovascular system among salesmen in a machinery manufacturing company. Ind Health. 1998;36:361–7.

Yang H, Schnall PL, Jauregui M, Su TC, Baker D. Work hours and self-reported hypertension among working people in California. Hypertension. 2006;48:744–50.

Artazcoz L, Cortes I, Borrell C, Escriba-Aguir V, Cascant L. Gender perspective in the analysis of the relationship between long workhours, health and health-related behavior. Scand J Work Environ Health. 2007;33:344–50.

Nakamura K, Sakurai M, Morikawa Y, Miura K, Ishizaki M, Kido T, Naruse Y, Suwazono Y, Nakagawa H. Overtime work and blood pressure in normotensive Japanese male workers. Am J Hypertens. 2012;25:979–85.

Yoo DH, Kang MY, Paek D, Min B, Cho SI. Effect of long working hours on self-reported hypertension among middle-aged and older wage workers. Ann Occup Environ Med. 2014;26:25.

Nakanishi N, Yoshida H, Nagano K, Kawashimo H, Nakamura K, Tatara K. Long working hours and risk for hypertension in Japanese male white collar workers. J Epidemiol Community Health. 2001;55:316–22.

Wada K, Katoh N, Aratake Y, Furukawa Y, Hayashi T, Satoh E, Tanaka K, Satoh T, Aizawa Y. Effects of overtime work on blood pressure and body mass index in Japanese male workers. Occup Med. 2006;56:578–80.

Imai T, Kuwahara K, Nishihara A, Nakagawa T, Yamamoto S, Honda T, Miyamoto T, Kochi T, Eguchi M, Uehara A, Kuroda R, Omoto D, Nagata T, Pham NM, Kurotani K, Nanri A, Akter S, Kabe I, Mizoue T, Sone T, Dohi S, Japan Epidemiology Collaboration on Occupational Health Study Group. Association of overtime work and hypertension in a Japanese working population: a cross-sectional study. Chronobiol Int. 2014;31:1108–14.

Park J, Kim Y, Cho Y, Woo KH, Chung HK, Iwasaki K, Oka T, Sasaki T, Hisanaga N. Regular overtime and cardiovascular functions. Ind Health. 2001;39:244–9.

Pimenta AM, Beunza JJ, Bes-Rastrollo M, Alonso A, López CN, Velásquez-Meléndez G, Martínez-González MA. Work hours and incidence of hypertension among Spanish university graduates: the Seguimiento Universidad de Navarra prospective cohort. J Hypertens. 2009;27:34–40.

Boivin DB, Boudreau P. Impacts of shift work on sleep and circadian rhythms. Pathol Biol. 2014;62:292–301.

Reinberg A, Ashkenazi I. Internal desynchronization of circadian rhythms and tolerance to shift work. Chronobiol Int. 2008;25:625–43.

Scheer FA, Hilton MF, Mantzoros CS, Shea SA. Adverse metabolic and cardiovascular consequences of circadian misalignment. Proc Natl Acad Sci USA. 2009;106:4453–8.

Puttonen S, Harma M, Hublin C. Shift work and cardiovascular disease - pathways from circadian stress to morbidity. Scand J Work Environ Health. 2010;36:96–108.

Sundberg S, Kohvakka A, Gordin A. Rapid reversal of circadian blood pressure rhythm in shift workers. J Hypertens. 1988;6:393–6.

Baumgart P, Walger P, Fuchs G, Dorst KG, Vetter H, Rahn KH. Twenty-four-hour blood pressure is not dependent on endogenous circadian rhythm. J Hypertens. 1989;7:331–4.

Goto T, Yokoyama K, Araki T, Miura T, Saitoh H, Saitoh M, Satoh S. Identical blood pressure levels and slower heart rates among nurses during night work and day work. J Hum Hypertens. 1994;8:11–4.

Chau NP, Mallion JM, de Gaudemaris R, Ruche E, Siche JP, Pelen O, Mathern G. Twenty-four-hour ambulatory blood pressure in shift workers. Circulation 1989;80:341-7.

Ohira T, Tanigawa T, Iso H, Odagiri Y, Takamiya T, Shimomitsu T, Hayano J, Shimamoto T. Effects of shift work on 24-hour ambulatory blood pressure and its variability among Japanese workers. Scand J Work Environ Health. 2000;26:421–6.

Munakata M, Ichi S, Nunokawa T, Saito Y, Ito N, Fukudo S, Yoshinaga K. Influence of night shift work on psychologic state and cardiovascular and neuroendocrine responses in healthy nurses. Hypertens Res. 2001;24:25–31.

Kitamura T, Onishi K, Dohi K, Okinaka T, Ito M, Isaka N, Nakano T. Circadian rhythm of blood pressure is transformed from a dipper to a non-dipper pattern in shift workers with hypertension. J Hum Hypertens. 2002;16:193–7.

Su TC, Lin LY, Baker D, Schnall PL, Chen MF, Hwang WC, Chen CF, Wang JD. Elevated blood pressure, decreased heart rate variability and incomplete blood pressure recovery after a 12-hour night shift work. J Occup Health. 2008;50:380–6.

Lo SH, Liau CS, Hwang JS, Wang JD. Dynamic blood pressure changes and recovery under different work shifts in young women. Am J Hypertens. 2008;21:759–64.

Knutsson A, Akerstedt T, Jonsson BG. Prevalence of risk factors for coronary artery disease among day and shift workers. Scand J Work Environ Health. 1988;14:317–21.

Murata K, Yano E, Hashimoto H, Karita K, Dakeishi M. Effects of shift work on QTc interval and blood pressure in relation to heart rate variability. Int Arch Occup Environ Health. 2005;78:287–92.

Inoue M, Morita H, Inagaki J, Harada N. Influence of differences in their jobs on cardiovascular risk factors in male blue-collar shift workers in their fifties. Int J Occup Environ Health. 2004;10:313–8.

Sfreddo C, Fuchs SC, Merlo AR, Fuchs FD. Shift work is not associated with high blood pressure or prevalence of hypertension. PLoS ONE. 2010;5:e15250.

White WB. Ambulatory blood pressure monitoring: dippers compared with non-dippers. Blood Press Monit. 2000;5(Suppl 1):S17–23.

Sternberg H, Rosenthal T, Shamiss A, Green M. Altered circadian rhythm of blood pressure in shift workers. J Hum Hypertens. 1995;9:349–53.

Yamasaki F, Schwartz JE, Gerber LM, Warren K, Pickering TG. Impact of shift work and race/ethnicity on the diurnal rhythm of blood pressure and catecholamines. Hypertension. 1998;32:417–23.

Kario K, Schwartz JE, Gerin W, Robayo N, Maceo E, Pickering TG. Psychological and physical stress-induced cardiovascular reactivity and diurnal blood pressure variation in women with different work shifts. Hypertens Res. 2002;25:543–51.

Morikawa Y, Nakagawa H, Miura K, Ishizaki M, Tabata M, Nishijo M, Higashiguchi K, Yoshita K, Sagara T, Kido T, Naruse Y, Nogawa K. Relationship between shift work and onset of hypertension in a cohort of manual workers. Scand J Work Environ Health. 1999;25:100–4.

Sakata K, Suwazono Y, Harada H, Okubo Y, Kobayashi E, Nogawa K. The relationship between shift work and the onset of hypertension in male Japanese workers. J Occup Environ Med. 2003;45:1002–6.

Oishi M, Suwazono Y, Sakata K, Okubo Y, Harada H, Kobayashi E, Uetani M, Nogawa K. A longitudinal study on the relationship between shift work and the progression of hypertension in male Japanese workers. J Hypertens. 2005;23:2173–8.

Suwazono Y, Dochi M, Sakata K, Okubo Y, Oishi M, Tanaka K, Kobayashi E, Nogawa K. Shift work is a risk factor for increased blood pressure in Japanese men: a 14-year historical cohort study. Hypertension. 2008;52:581–6.

Virkkunen H, Harma M, Kauppinen T, Tenkanen L. Shift work, occupational noise and physical workload with ensuing development of blood pressure and their joint effect on the risk of coronary heart disease. Scand J Work Environ Health. 2007;33:425–34.

Gholami Fesharaki M, Kazemnejad A, Zayeri F, Rowzati M, Akbari H. Historical cohort study of shift work and blood pressure. Occup Med. 2014;64:109–12.

Article CAS Google Scholar

Kario K, James GD, Marion R, Ahmed M, Pickering TG. The influence of work- and home-related stress on the levels and diurnal variation of ambulatory blood pressure and neurohumoral factors in employed women. Hypertens Res. 2002;25:499–506.

He W, Goodkind D, Kowal P. An aging world: 2015. Washington: US Census Bureau; 2016.

Google Scholar

Hashimoto S, Kawado M, Seko R, Murakami Y, Hayashi M, Kato M, Noda T, Ojima T, Nagai M, Tsuji I. Trends in disability-free life expectancy in Japan, 1995-2004. J Epidemiol. 2010;20:308–12.

Tarlow B, Wisniewski S, Belle S, Rubert M, Ory M, Gallagher-Thompson D. Positive aspects of caregiving. Res Aging. 2004;26:429–53.

Pinquart M, Sorensen S. Correlates of physical health of informal caregivers: a meta-analysis. J Gerontol B Psychol Sci Soc Sci. 2007;62:P126–37.

Schulz R, Beach SR. Caregiving as a risk factor for mortality: the caregiver health effects study. JAMA. 1999;282:2215–9.

Haley WE, Roth DL, Howard G, Safford MM. Caregiving strain and estimated risk for stroke and coronary heart disease among spouse caregivers: differential effects by race and sex. Stroke. 2010;41:331–6.

King AC, Oka RK, Young DR. Ambulatory blood pressure and heart rate responses to the stress of work and caregiving in older women. J Gerontol. 1994;49:M239–45.

von Kanel R, Mausbach BT, Patterson TL, Dimsdale JE, Aschbacher K, Mills PJ, Ziegler MG, Ancoli-Israel S, Grant I. Increased Framingham coronary heart disease risk score in dementia caregivers relative to non-caregiving controls. Gerontology. 2008;54:131–7.

Torimoto-Sasai Y, Igarashi A, Wada T, Ogata Y, Yamamoto-Mitani N. Female family caregivers face a higher risk of hypertension and lowered estimated glomerular filtration rates: a cross-sectional, comparative study. BMC Public Health. 2015;15:177.

Shaw WS, Patterson TL, Semple SJ, Dimsdale JE, Ziegler MG, Grant I. Emotional expressiveness, hostility and blood pressure in a longitudinal cohort of Alzheimer caregivers. J Psychosom Res. 2003;54:293–302.

Capistrant BD, Moon JR, Glymour MM. Spousal caregiving and incident hypertension. Am J Hypertens. 2012;25:437–43.

Butalid L, Verhaak PF, Boeije HR, Bensing JM. Patients’ views on changes in doctor-patient communication between 1982 and 2001: a mixed-methods study. BMC Fam Pract. 2012;13:80.

Download references

Acknowledgements

This study was supported by the grants and aid from the Japan Organization of Occupational Health and Safety. We would like to express his gratitude to Dr. Genjiro Kimura, a past president of Asahi Rosai Hospital, for his great contribution to the research on workplace hypertension conducted by 29 Rosai hospital groups, which hold an important framework of this article.

Author information

Authors and affiliations.

Research Center for Lifestyle-related Disease, Tohoku Rosai Hospital, Sendai, 981-8563, Japan

Masanori Munakata

You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Masanori Munakata .

Ethics declarations

Conflict of interest.

The authors declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Cite this article.

Munakata, M. Clinical significance of stress-related increase in blood pressure: current evidence in office and out-of-office settings. Hypertens Res 41 , 553–569 (2018). https://doi.org/10.1038/s41440-018-0053-1

Download citation

Received : 31 January 2018

Revised : 16 March 2018

Accepted : 16 March 2018

Published : 29 May 2018

Issue Date : August 2018

DOI : https://doi.org/10.1038/s41440-018-0053-1

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

This article is cited by

Immune and inflammatory mechanisms in hypertension.

Tomasz J. Guzik
Ryszard Nosalski
Grant R. Drummond

Nature Reviews Cardiology (2024)

Microglia-derived TNF-α contributes to RVLM neuronal mitochondrial dysfunction via blocking the AMPK–Sirt3 pathway in stress-induced hypertension

Linping Wang
Tianfeng Liu

Journal of Neuroinflammation (2023)

Structure and dynamics of the course of chronic non-infectious somatic diseases in patients during war events on the territory of Ukraine

Liudmyla Kiro
Oleh Chernyshov

BMC Public Health (2023)

Hypertension paradox in Japan: the road ahead

Shigeru Shibata

Hypertension Research (2023)

Investigation of the effect of music listened to by patients with moderate dental anxiety during restoration of posterior occlusal dental caries

Elif Karapicak
Kivanc Dulger
Ahmet Alver

Clinical Oral Investigations (2023)

Quick links

Explore articles by subject
Guide to authors
Editorial policies

Search Menu
Sign in through your institution
Advance articles
Editor's Choice
Graphical Abstracts and Tidbit
Author Guidelines
Submission Site
Open Access
About American Journal of Hypertension
Editorial Board
Board of Directors
Advertising and Corporate Services
Journals Career Network
Self-Archiving Policy
Dispatch Dates
AJH Summer School
Journals on Oxford Academic
Books on Oxford Academic

Article Contents

Clinical management and treatment decisions, hypertension in black americans, pharmacologic treatment of hypertension in black americans.

< Previous
Article contents
Figures & tables
Supplementary Data

Suzanne Oparil, Case study, American Journal of Hypertension , Volume 11, Issue S8, November 1998, Pages 192S–194S, https://doi.org/10.1016/S0895-7061(98)00195-2

Permissions Icon Permissions

Ms. C is a 42-year-old black American woman with a 7-year history of hypertension first diagnosed during her last pregnancy. Her family history is positive for hypertension, with her mother dying at 56 years of age from hypertension-related cardiovascular disease (CVD). In addition, both her maternal and paternal grandparents had CVD.

At physician visit one, Ms. C presented with complaints of headache and general weakness. She reported that she has been taking many medications for her hypertension in the past, but stopped taking them because of the side effects. She could not recall the names of the medications. Currently she is taking 100 mg/day atenolol and 12.5 mg/day hydrochlorothiazide (HCTZ), which she admits to taking irregularly because “... they bother me, and I forget to renew my prescription.” Despite this antihypertensive regimen, her blood pressure remains elevated, ranging from 150 to 155/110 to 114 mm Hg. In addition, Ms. C admits that she has found it difficult to exercise, stop smoking, and change her eating habits. Findings from a complete history and physical assessment are unremarkable except for the presence of moderate obesity (5 ft 6 in., 150 lbs), minimal retinopathy, and a 25-year history of smoking approximately one pack of cigarettes per day. Initial laboratory data revealed serum sodium 138 mEq/L (135 to 147 mEq/L); potassium 3.4 mEq/L (3.5 to 5 mEq/L); blood urea nitrogen (BUN) 19 mg/dL (10 to 20 mg/dL); creatinine 0.9 mg/dL (0.35 to 0.93 mg/dL); calcium 9.8 mg/dL (8.8 to 10 mg/dL); total cholesterol 268 mg/dL (< 245 mg/dL); triglycerides 230 mg/dL (< 160 mg/dL); and fasting glucose 105 mg/dL (70 to 110 mg/dL). The patient refused a 24-h urine test.

Taking into account the past history of compliance irregularities and the need to take immediate action to lower this patient’s blood pressure, Ms. C’s pharmacologic regimen was changed to a trial of the angiotensin-converting enzyme (ACE) inhibitor enalapril, 5 mg/day; her HCTZ was discontinued. In addition, recommendations for smoking cessation, weight reduction, and diet modification were reviewed as recommended by the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). 1

After a 3-month trial of this treatment plan with escalation of the enalapril dose to 20 mg/day, the patient’s blood pressure remained uncontrolled. The patient’s medical status was reviewed, without notation of significant changes, and her antihypertensive therapy was modified. The ACE inhibitor was discontinued, and the patient was started on the angiotensin-II receptor blocker (ARB) losartan, 50 mg/day.

After 2 months of therapy with the ARB the patient experienced a modest, yet encouraging, reduction in blood pressure (140/100 mm Hg). Serum electrolyte laboratory values were within normal limits, and the physical assessment remained unchanged. The treatment plan was to continue the ARB and reevaluate the patient in 1 month. At that time, if blood pressure control remained marginal, low-dose HCTZ (12.5 mg/day) was to be added to the regimen.

Hypertension remains a significant health problem in the United States (US) despite recent advances in antihypertensive therapy. The role of hypertension as a risk factor for cardiovascular morbidity and mortality is well established. 2–7 The age-adjusted prevalence of hypertension in non-Hispanic black Americans is approximately 40% higher than in non-Hispanic whites. 8 Black Americans have an earlier onset of hypertension and greater incidence of stage 3 hypertension than whites, thereby raising the risk for hypertension-related target organ damage. 1 , 8 For example, hypertensive black Americans have a 320% greater incidence of hypertension-related end-stage renal disease (ESRD), 80% higher stroke mortality rate, and 50% higher CVD mortality rate, compared with that of the general population. 1 , 9 In addition, aging is associated with increases in the prevalence and severity of hypertension. 8

Research findings suggest that risk factors for coronary heart disease (CHD) and stroke, particularly the role of blood pressure, may be different for black American and white individuals. 10–12 Some studies indicate that effective treatment of hypertension in black Americans results in a decrease in the incidence of CVD to a level that is similar to that of nonblack American hypertensives. 13 , 14

Data also reveal differences between black American and white individuals in responsiveness to antihypertensive therapy. For instance, studies have shown that diuretics 15 , 16 and the calcium channel blocker diltiazem 16 , 17 are effective in lowering blood pressure in black American patients, whereas β-adrenergic receptor blockers and ACE inhibitors appear less effective. 15 , 16 In addition, recent studies indicate that ARB may also be effective in this patient population.

Angiotensin-II receptor blockers are a relatively new class of agents that are approved for the treatment of hypertension. Currently, four ARB have been approved by the US Food and Drug Administration (FDA): eprosartan, irbesartan, losartan, and valsartan. Recently, a 528-patient, 26-week study compared the efficacy of eprosartan (200 to 300 mg/twice daily) versus enalapril (5 to 20 mg/daily) in patients with essential hypertension (baseline sitting diastolic blood pressure [DBP] 95 to 114 mm Hg). After 3 to 5 weeks of placebo, patients were randomized to receive either eprosartan or enalapril. After 12 weeks of therapy within the titration phase, patients were supplemented with HCTZ as needed. In a prospectively defined subset analysis, black American patients in the eprosartan group (n = 21) achieved comparable reductions in DBP (−13.3 mm Hg with eprosartan; −12.4 mm Hg with enalapril) and greater reductions in systolic blood pressure (SBP) (−23.1 with eprosartan; −13.2 with enalapril), compared with black American patients in the enalapril group (n = 19) ( Fig. 1 ). 18 Additional trials enrolling more patients are clearly necessary, but this early experience with an ARB in black American patients is encouraging.

Efficacy of the angiotensin II receptor blocker eprosartan in black American with mild to moderate hypertension (baseline sitting DBP 95 to 114 mm Hg) in a 26-week study. Eprosartan, 200 to 300 mg twice daily (n = 21, solid bar), enalapril 5 to 20 mg daily (n = 19, diagonal bar). †10 of 21 eprosartan patients and seven of 19 enalapril patients also received HCTZ. Adapted from data in Levine: Subgroup analysis of black hypertensive patients treated with eprosartan or enalapril: results of a 26-week study, in Programs and abstracts from the 1st International Symposium on Angiotensin-II Antagonism, September 28–October 1, 1997, London, UK.

Approximately 30% of all deaths in hypertensive black American men and 20% of all deaths in hypertensive black American women are attributable to high blood pressure. Black Americans develop high blood pressure at an earlier age, and hypertension is more severe in every decade of life, compared with whites. As a result, black Americans have a 1.3 times greater rate of nonfatal stroke, a 1.8 times greater rate of fatal stroke, a 1.5 times greater rate of heart disease deaths, and a 5 times greater rate of ESRD when compared with whites. 19 Therefore, there is a need for aggressive antihypertensive treatment in this group. Newer, better tolerated antihypertensive drugs, which have the advantages of fewer adverse effects combined with greater antihypertensive efficacy, may be of great benefit to this patient population.

1. Joint National Committee : The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure . Arch Intern Med 1997 ; 24 157 : 2413 – 2446 .

Google Scholar

2. Veterans Administration Cooperative Study Group on Antihypertensive Agents : Effects of treatment on morbidity in hypertension: Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg . JAMA 1967 ; 202 : 116 – 122 .

3. Veterans Administration Cooperative Study Group on Antihypertensive Agents : Effects of treatment on morbidity in hypertension: II. Results in patients with diastolic blood pressures averaging 90 through 114 mm Hg . JAMA 1970 ; 213 : 1143 – 1152 .

4. Pooling Project Research Group : Relationship of blood pressure, serum cholesterol, smoking habit, relative weight and ECG abnormalities to the incidence of major coronary events: Final report of the pooling project . J Chronic Dis 1978 ; 31 : 201 – 306 .

5. Hypertension Detection and Follow-Up Program Cooperative Group : Five-year findings of the hypertension detection and follow-up program: I. Reduction in mortality of persons with high blood pressure, including mild hypertension . JAMA 1979 ; 242 : 2562 – 2577 .

6. Kannel WB , Dawber TR , McGee DL : Perspectives on systolic hypertension: The Framingham Study . Circulation 1980 ; 61 : 1179 – 1182 .

7. Hypertension Detection and Follow-Up Program Cooperative Group : The effect of treatment on mortality in “mild” hypertension: Results of the Hypertension Detection and Follow-Up Program . N Engl J Med 1982 ; 307 : 976 – 980 .

8. Burt VL , Whelton P , Roccella EJ et al. : Prevalence of hypertension in the US adult population: Results from the third National Health and Nutrition Examination Survey, 1988–1991 . Hypertension 1995 ; 25 : 305 – 313 .

9. Klag MJ , Whelton PK , Randall BL et al. : End-stage renal disease in African-American and white men: 16-year MRFIT findings . JAMA 1997 ; 277 : 1293 – 1298 .

10. Neaton JD , Kuller LH , Wentworth D et al. : Total and cardiovascular mortality in relation to cigarette smoking, serum cholesterol concentration, and diastolic blood pressure among black and white males followed up for five years . Am Heart J 1984 ; 3 : 759 – 769 .

11. Gillum RF , Grant CT : Coronary heart disease in black populations II: Risk factors . Heart J 1982 ; 104 : 852 – 864 .

12. M’Buyamba-Kabangu JR , Amery A , Lijnen P : Differences between black and white persons in blood pressure and related biological variables . J Hum Hypertens 1994 ; 8 : 163 – 170 .

13. Hypertension Detection and Follow-up Program Cooperative Group : Five-year findings of the Hypertension Detection and Follow-up Program: mortality by race-sex and blood pressure level: a further analysis . J Community Health 1984 ; 9 : 314 – 327 .

14. Ooi WL , Budner NS , Cohen H et al. : Impact of race on treatment response and cardiovascular disease among hypertensives . Hypertension 1989 ; 14 : 227 – 234 .

15. Weinberger MH : Racial differences in antihypertensive therapy: evidence and implications . Cardiovasc Drugs Ther 1990 ; 4 ( suppl 2 ): 379 – 392 .

16. Materson BJ , Reda DJ , Cushman WC et al. : Single-drug therapy for hypertension in men: A comparison of six antihypertensive agents with placebo . N Engl J Med 1993 ; 328 : 914 – 921 .

17. Materson BJ , Reda DJ , Cushman WC for the Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents : Department of Veterans Affairs single-drug therapy of hypertension study: Revised figures and new data . Am J Hypertens 1995 ; 8 : 189 – 192 .

18. Levine B : Subgroup analysis of black hypertensive patients treated with eprosartan or enalapril: results of a 26-week study , in Programs and abstracts from the first International Symposium on Angiotensin-II Antagonism , September 28 – October 1 , 1997 , London, UK .

19. American Heart Association: 1997 Heart and Stroke Statistical Update . American Heart Association , Dallas , 1997 .

hypertension
blood pressure
african american

Month:	Total Views:
December 2016	3
February 2017	6
March 2017	36
April 2017	43
May 2017	60
June 2017	34
July 2017	48
August 2017	65
September 2017	91
October 2017	101
November 2017	130
December 2017	1,093
January 2018	1,497
February 2018	1,580
March 2018	2,337
April 2018	1,946
May 2018	1,644
June 2018	1,387
July 2018	1,323
August 2018	1,495
September 2018	1,605
October 2018	1,999
November 2018	2,310
December 2018	1,730
January 2019	1,377
February 2019	1,651
March 2019	2,229
April 2019	1,943
May 2019	1,686
June 2019	1,547
July 2019	1,895
August 2019	1,860
September 2019	1,794
October 2019	1,601
November 2019	1,106
December 2019	788
January 2020	761
February 2020	936
March 2020	1,023
April 2020	1,173
May 2020	589
June 2020	916
July 2020	838
August 2020	747
September 2020	1,041
October 2020	956
November 2020	1,003
December 2020	1,048
January 2021	747
February 2021	672
March 2021	784
April 2021	775
May 2021	683
June 2021	520
July 2021	592
August 2021	457
September 2021	656
October 2021	763
November 2021	695
December 2021	545
January 2022	548
February 2022	654
March 2022	1,042
April 2022	1,230
May 2022	1,244
June 2022	884
July 2022	655
August 2022	721
September 2022	1,253
October 2022	1,503
November 2022	1,550
December 2022	1,308
January 2023	1,081
February 2023	1,090
March 2023	1,363
April 2023	1,123
May 2023	1,273
June 2023	768
July 2023	734
August 2023	796
September 2023	869
October 2023	1,155
November 2023	1,365
December 2023	1,206
January 2024	1,295
February 2024	1,450
March 2024	1,402
April 2024	1,415
May 2024	1,273
June 2024	804
July 2024	1,023
August 2024	221

Email alerts

Citing articles via.

Recommend to your Library

Affiliations

Online ISSN 1941-7225
Copyright © 2024 American Journal of Hypertension, Ltd.
About Oxford Academic
Publish journals with us
University press partners
What we publish
New features
Open access
Institutional account management
Rights and permissions
Get help with access
Accessibility
Advertising
Media enquiries
Oxford University Press
Oxford Languages
University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

Copyright © 2024 Oxford University Press
Cookie settings
Cookie policy
Privacy policy
Legal notice

This Feature Is Available To Subscribers Only

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Publications
Account settings
My Bibliography
Collections
Citation manager

Save citation to file

Email citation, add to collections.

Create a new collection
Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

Search in PubMed
Search in NLM Catalog
Add to Search

Grounding Patients With Hypertension Improves Blood Pressure: A Case History Series Study

PMID: 30982019

Background: Research conducted during the last 15 y has demonstrated that grounding (Earthing) the human body to Earth's surface charge generates multiple beneficial physiological effects. Anecdotal reports include lowering of high blood pressure (BP).

Objective: To test such reports, a pilot case history series was undertaken with hypertensive patients in a single physician cardiology practice.

Intervention: Patients grounded themselves at home for at least 10 h/d for several mo.

Outcome measure: BP was measured at baseline in the clinic, and then, after starting grounding, 3 subsequent times in the clinic again at approximately monthly intervals. Patients were also given a BP monitor and were asked to measure their BP on Mondays, Thursdays, and Saturdays at 8:00 AM and 8:00 PM for 12 wk.

Results: All 10 patient measurements were found to be significantly improved at the end of the trial period, and some, well before the end. Systolic levels decreased during this time, ranging individually from 8.6% to 22.7%, with an average decrease of 14.3%.

Conclusion: This is the first known study measuring the influence of grounding the body on hypertension. The results indicate that grounding appears to be a safe BP-reducing therapy warranting further research.

PubMed Disclaimer

Related information

Cited in Books

LinkOut - more resources

MedlinePlus Health Information
Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

Case Study: Beyond High BP — Thorough Evaluation

Published on Mar 16, 2016

Hypertension Clinic

A 17-year-old female presented to the Hypertension and Vascular Evaluation (HAVE) Program for high blood pressure (BP) during multiple office visits in the setting of morbid obesity and type 2 diabetes mellitus. Family history was significant for high blood pressure and high cholesterol. On exam, her weight was 176.9 kg (99th percentile) and her BMI was 60.92 kg/m2 (99.7th percentile). She had acanthosis nigricans with an otherwise unremarkable cardiac exam. We assessed for target-organ abnormalities associated with hypertension on the same day of the visit. Her cardiac status was evaluated by echocardiogram, which demonstrated an elevated LV mass index of 82 g/m2 (>95th percentile). The health of her arteries was evaluated by measuring the pulse wave velocity (PWV) in the aorta, which was elevated to 7.5 m/s. Her carotid artery intima-media thickness (cIMT) was increased to 0.72 mm. An ambulatory blood pressure monitor (ABPM) demonstrated sustained systolic hypertension on antihypertensive medication.

Over the last 5 decades, there has been a steady rise in obesity in children. In conjunction with this epidemiologic shift, prevalence of other cardiovascular co-morbidities, including systemic hypertension, has also increased. These risk factors track into adulthood. Therefore, early recognition and treatment of hypertension in childhood has the potential to reduce adverse cardiovascular events later in life.

Blood pressure should be measured annually in patients > 3 years of age and in those at risk for secondary hypertension < 3 years of age. Multiple high BP readings, along with certain medical conditions (see below), may warrant referral to the HAVE Program, a joint clinical program between the Cardiac Center and the Division of Nephrology . At the initial visit, a comprehensive history and physical exam is performed for clues to the cause of hypertension. A work-up for a secondary cause of hypertension may include a renal ultrasound, urinalysis, and blood work to assess for renal and endocrine causes and an echocardiogram to assess for aortic arch obstruction. Placement of 24-hour ABPM further assesses for hypertension outside the healthcare setting.

Medical conditions that put children at risk for hypertension *

Chronic kidney disease
Renal artery stenosis
Coarctation of the aorta
Solid organ transplant (eg, heart, kidney)
Obesity Diabetes, type 1 and type 2
Lipid disorders (eg, homozygous FH)
Kawasaki disease (with or without coronary artery involvement)
Chronic inflammatory disease (eg, vasculitis, Lupus)
Sickle cell disease
Cancer treatment survivors

* Cardiovascular risk reduction in high-risk pediatric patients. Circulation. 2006;12;114(24):2710-2738.

We also assess cardiovascular impact of chronically elevated BP using simple, non-invasive tests. These results aid in assessing overall risk, tailoring treatment strategies, making recommendations for activity levels, and in counseling patients and families. On echocardiogram, left ventricular hypertrophy and increased left ventricular mass index (LVMI) are associated with hypertension and contribute to the adverse cardiovascular profile in these patients. In addition, evidence suggests that fatty streaks are present in the intimal layer of arteries as early as 3 years of age and can progress to atherosclerotic plaque in adolescence—a process further stimulated by the presence of risk factors such as hypertension. One marker of subclinical atherosclerotic disease easily measured by ultrasound is cIMT (see Figure 1). Hypertension also alters the structure of the arteries and increasing the vascular load to the heart. Pulse wave velocity (PWV) in the aorta measured by Doppler technology evaluates one component of vascular structure: arterial stiffness. An increased cIMT and elevated aortic PWV are noted in children with cardiovascular risk factors and can improve with interventions.

To round out our comprehensive evaluation, we counsel on healthy diet and exercise. In addition to caring for patients with primary hypertension, we have diagnosed hypertension and guided treatment in patients with high-risk conditions, such as solid organ transplant, rheumatologic disease, and coarctation of the aorta. Our team recognizes the critical role that primary care providers play in the treatment of hypertension. Communication and collaboration with the patient’s primary team remains an important part of our care for each patient.

Despite optimizing BP medications, our patient continued to have hypertension and was unable to lose weight. She underwent a sleeve gastrectomy. At a recent HAVE Program visit, her BMI decreased to 47 kg/m2, her BP was normal, echocardiography demonstrated a normal LVMI of 46 g/m2, and vascular profile included a normal PWV at 6.2 m/s and decreased cIMT to 0.68 mm. We decreased her anti-hypertensive medications. We relayed encouraging results to the patient and her care team, which suggest that markers of cardiovascular risk were slowly improving with efforts to address her co-morbidities. Hopefully, this information will motivate our patient to pursue further weight loss, adhere to her medication regimen, and continue to develop a healthy lifestyle.

References and suggested readings

The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents, Pediatrics . 2004;114(2 Suppl 4th Report):555-576.

Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report, Pediatrics . 2011;128 Suppl 5:S213-256.

Contributed by: Shobha S. Natarajan, MD , Kevin E. Meyers, MBBCh

Categories: Children's Doctor Spring 2016

Masks Strongly Recommended but Not Required in Maryland, Starting Immediately

Due to the downward trend in respiratory viruses in Maryland, masking is no longer required but remains strongly recommended in Johns Hopkins Medicine clinical locations in Maryland. Read more .

Vaccines
Masking Guidelines
Visitor Guidelines

High Blood Pressure: Prevention, Treatment and Research

Reviewed By:

Roger Scott Blumenthal, M.D.

Michael Joseph Blaha, M.D. M.P.H.

We all have “blood pressure.” This simply refers to the way blood pushes against the walls of your arteries as your heart pumps. However, one in three American adults have a potentially dangerous condition known as high blood pressure, also called hypertension. For those with high blood pressure, blood moves more forcefully through the arteries than it should.

It’s normal for blood pressure to increase when you exercise or are under stress. But when the pressure is too high even when you’re at rest, and stays too high for too long, it can stretch and damage your arteries. The resulting health problems from high blood pressure can include heart disease, heart failure, stroke, kidney damage, vision loss, and memory loss and cognitive decline.

/sebin/j/h/HighBloodPressure_640x300.jpg"

Following a healthy lifestyle is considered the best way to maintain blood pressure within the recommended range. How to do it:

Keep your weight healthy. The higher your body mass index (BMI), the greater your odds of developing high blood pressure. Learn your BMI from your doctor and aim for the normal range of weight for your height.

Track your blood pressure. “Take your blood pressure at home often and bring a blood pressure log of your readings to the doctor,” suggests Blaha. It’s especially important to have it checked often if you’re over age 40, overweight, sedentary, or have a family history of heart disease or high blood pressure.

Eat heart-healthy foods. That means a diet high in whole grains, fruits and vegetables, and lean protein, and low in sodium and alcohol. Get practical ideas to eat for heart health in Eat Smart .

Get, or stay, fit. Being active helps keep weight in check and reduces your odds of many different heart problems.

Don’t smoke, or, if you do now, quit. Smoking damages blood vessels.

Learn healthy ways to manage stress. Many people find yoga , meditation , music and tai chi helpful.

A blood pressure reading has two numbers: systolic (“sis-TOL-ick,” the first or top number in a reading) and diastolic (“dye-a-STOL-ick,” the second or bottom number in a reading). Systolic pressure is the force of the blood against the artery walls when the heart contracts to pump blood. Systolic pressure is always the higher number. Diastolic pressure is the pressure against the arteries between heartbeats, as the heart relaxes. The unit of measurement is in millimeters of mercury (mm Hg).

Optimal blood pressure is 120/80 mm Hg (referred to as “120 over 80”) or below. High blood pressure is defined for adults as systolic pressure above 140 or diastolic pressure above 90. Generally, a diagnosis of high blood pressure results when you have high readings on three different occasions during a single week. Some people’s blood pressure is changeable, and others have what’s called “white coat hypertension”—higher readings as a result of feeling stressed in a doctor’s office, says Blaha. You may be asked to wear a portable blood pressure monitor to get an accurate reading.

Move more. A good guideline: Aim for 30 minutes a day of aerobic exercise (fast walking, running, swimming) on most days of the week. If you’re new to exercise, get your doctor’s OK before you start a workout program.

Quit smoking. Talk to your doctor about support programs that can help.

Take medications as prescribed. Because drugs for high blood pressure work in different ways, you may be prescribed more than one.

Living With...

Controlling your blood pressure is a long-term effort. Once diagnosed, most people need lifetime treatment. The payoff, though, is improved overall health and a reduced risk of serious heart problems, such as stroke and heart attack. In addition to following healthy lifestyle habits:

Let your doctor know immediately if you notice any side effects from blood pressure medications. Take medications as directed and never discontinue use without consulting your doctor.

Know the warning signs of too-high blood pressure. In most cases the condition is symptomless, but in extreme cases of dangerously high blood pressure, a person may develop ringing in the ears, dizziness, headaches, nosebleeds, tingling or numbness in the hands and feet, drowsiness or confusion.

Learn how to take your blood pressure at home. It’s easy to learn, devices are readily available at pharmacies and elsewhere, and your doctor can show you how, says Blaha.

Johns Hopkins researchers and clinicians continue to explore ways to prevent and manage high blood pressure and its effects. Among their noteworthy research:

Antihypertensive drugs may help preserve cognitive function in people with high blood pressure. Johns Hopkins researchers led a study showing that hypertension in midlife raises the odds of memory problems in old age. When treated early, though, this risk may drop.

Higher weight and weight gain raises the risk of high blood pressure. This is especially true from young adulthood through midlife. A Johns Hopkins study helped to solidify the link between high body mass index and high blood pressure.

Find a Doctor

Specializing In:

High Blood Pressure (Hypertension)
Dyslipidemia and Hypertension

Find a Treatment Center

Hypertension Center
Center for Resistant Hypertension

Find Additional Treatment Centers at:

Howard County Medical Center
Sibley Memorial Hospital
Suburban Hospital

Request an Appointment

5 Heart Facts That May Surprise You

Water bottle, weight, measuring tape and apple on the floor

ABCs of Knowing Your Heart Risk

Pill supplements in form of monitored heartbeat.

The Truth About 4 Popular Heart Health Supplements

Presentation

Clinical pearls, case study: treating hypertension in patients with diabetes.

Split-Screen
Article contents
Figures & tables
Supplementary Data
Peer Review
Open the PDF for in another window
Cite Icon Cite
Get Permissions

Evan M. Benjamin; Case Study: Treating Hypertension in Patients With Diabetes. Clin Diabetes 1 July 2004; 22 (3): 137–138. https://doi.org/10.2337/diaclin.22.3.137

Download citation file:

Ris (Zotero)
Reference Manager

L.N. is a 49-year-old white woman with a history of type 2 diabetes,obesity, hypertension, and migraine headaches. The patient was diagnosed with type 2 diabetes 9 years ago when she presented with mild polyuria and polydipsia. L.N. is 5′4″ and has always been on the large side,with her weight fluctuating between 165 and 185 lb.

Initial treatment for her diabetes consisted of an oral sulfonylurea with the rapid addition of metformin. Her diabetes has been under fair control with a most recent hemoglobin A 1c of 7.4%.

Hypertension was diagnosed 5 years ago when blood pressure (BP) measured in the office was noted to be consistently elevated in the range of 160/90 mmHg on three occasions. L.N. was initially treated with lisinopril, starting at 10 mg daily and increasing to 20 mg daily, yet her BP control has fluctuated.

One year ago, microalbuminuria was detected on an annual urine screen, with 1,943 mg/dl of microalbumin identified on a spot urine sample. L.N. comes into the office today for her usual follow-up visit for diabetes. Physical examination reveals an obese woman with a BP of 154/86 mmHg and a pulse of 78 bpm.

What are the effects of controlling BP in people with diabetes?

What is the target BP for patients with diabetes and hypertension?

Which antihypertensive agents are recommended for patients with diabetes?

Diabetes mellitus is a major risk factor for cardiovascular disease (CVD). Approximately two-thirds of people with diabetes die from complications of CVD. Nearly half of middle-aged people with diabetes have evidence of coronary artery disease (CAD), compared with only one-fourth of people without diabetes in similar populations.

Patients with diabetes are prone to a number of cardiovascular risk factors beyond hyperglycemia. These risk factors, including hypertension,dyslipidemia, and a sedentary lifestyle, are particularly prevalent among patients with diabetes. To reduce the mortality and morbidity from CVD among patients with diabetes, aggressive treatment of glycemic control as well as other cardiovascular risk factors must be initiated.

Studies that have compared antihypertensive treatment in patients with diabetes versus placebo have shown reduced cardiovascular events. The United Kingdom Prospective Diabetes Study (UKPDS), which followed patients with diabetes for an average of 8.5 years, found that patients with tight BP control (< 150/< 85 mmHg) versus less tight control (< 180/< 105 mmHg) had lower rates of myocardial infarction (MI), stroke, and peripheral vascular events. In the UKPDS, each 10-mmHg decrease in mean systolic BP was associated with a 12% reduction in risk for any complication related to diabetes, a 15% reduction for death related to diabetes, and an 11% reduction for MI. Another trial followed patients for 2 years and compared calcium-channel blockers and angiotensin-converting enzyme (ACE) inhibitors,with or without hydrochlorothiazide against placebo and found a significant reduction in acute MI, congestive heart failure, and sudden cardiac death in the intervention group compared to placebo.

The Hypertension Optimal Treatment (HOT) trial has shown that patients assigned to lower BP targets have improved outcomes. In the HOT trial,patients who achieved a diastolic BP of < 80 mmHg benefited the most in terms of reduction of cardiovascular events. Other epidemiological studies have shown that BPs > 120/70 mmHg are associated with increased cardiovascular morbidity and mortality in people with diabetes. The American Diabetes Association has recommended a target BP goal of < 130/80 mmHg. Studies have shown that there is no lower threshold value for BP and that the risk of morbidity and mortality will continue to decrease well into the normal range.

Many classes of drugs have been used in numerous trials to treat patients with hypertension. All classes of drugs have been shown to be superior to placebo in terms of reducing morbidity and mortality. Often, numerous agents(three or more) are needed to achieve specific target levels of BP. Use of almost any drug therapy to reduce hypertension in patients with diabetes has been shown to be effective in decreasing cardiovascular risk. Keeping in mind that numerous agents are often required to achieve the target level of BP control, recommending specific agents becomes a not-so-simple task. The literature continues to evolve, and individual patient conditions and preferences also must come into play.

While lowering BP by any means will help to reduce cardiovascular morbidity, there is evidence that may help guide the selection of an antihypertensive regimen. The UKPDS showed no significant differences in outcomes for treatment for hypertension using an ACE inhibitor or aβ-blocker. In addition, both ACE inhibitors and angiotensin II receptor blockers (ARBs) have been shown to slow the development and progression of diabetic nephropathy. In the Heart Outcomes Prevention Evaluation (HOPE)trial, ACE inhibitors were found to have a favorable effect in reducing cardiovascular morbidity and mortality, whereas recent trials have shown a renal protective benefit from both ACE inhibitors and ARBs. ACE inhibitors andβ-blockers seem to be better than dihydropyridine calcium-channel blockers to reduce MI and heart failure. However, trials using dihydropyridine calcium-channel blockers in combination with ACE inhibitors andβ-blockers do not appear to show any increased morbidity or mortality in CVD, as has been implicated in the past for dihydropyridine calcium-channel blockers alone. Recently, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) in high-risk hypertensive patients,including those with diabetes, demonstrated that chlorthalidone, a thiazide-type diuretic, was superior to an ACE inhibitor, lisinopril, in preventing one or more forms of CVD.

L.N. is a typical patient with obesity, diabetes, and hypertension. Her BP control can be improved. To achieve the target BP goal of < 130/80 mmHg, it may be necessary to maximize the dose of the ACE inhibitor and to add a second and perhaps even a third agent.

Diuretics have been shown to have synergistic effects with ACE inhibitors,and one could be added. Because L.N. has migraine headaches as well as diabetic nephropathy, it may be necessary to individualize her treatment. Adding a β-blocker to the ACE inhibitor will certainly help lower her BP and is associated with good evidence to reduce cardiovascular morbidity. Theβ-blocker may also help to reduce the burden caused by her migraine headaches. Because of the presence of microalbuminuria, the combination of ARBs and ACE inhibitors could also be considered to help reduce BP as well as retard the progression of diabetic nephropathy. Overall, more aggressive treatment to control L.N.'s hypertension will be necessary. Information obtained from recent trials and emerging new pharmacological agents now make it easier to achieve BP control targets.

Hypertension is a risk factor for cardiovascular complications of diabetes.

Clinical trials demonstrate that drug therapy versus placebo will reduce cardiovascular events when treating patients with hypertension and diabetes.

A target BP goal of < 130/80 mmHg is recommended.

Pharmacological therapy needs to be individualized to fit patients'needs.

ACE inhibitors, ARBs, diuretics, and β-blockers have all been documented to be effective pharmacological treatment.

Combinations of drugs are often necessary to achieve target levels of BP control.

ACE inhibitors and ARBs are agents best suited to retard progression of nephropathy.

Evan M. Benjamin, MD, FACP, is an assistant professor of medicine and Vice President of Healthcare Quality at Baystate Medical Center in Springfield, Mass.

Email alerts

Online ISSN 1945-4953
Print ISSN 0891-8929
Diabetes Care
Clinical Diabetes
Diabetes Spectrum
Standards of Medical Care in Diabetes
Scientific Sessions Abstracts
BMJ Open Diabetes Research & Care
ShopDiabetes.org
ADA Professional Books

Clinical Compendia

Clinical Compendia Home
Latest News
DiabetesPro SmartBrief
Special Collections
DiabetesPro®
Diabetes Food Hub™
Insulin Affordability
Know Diabetes By Heart™
About the ADA
Journal Policies
For Reviewers
Advertising in ADA Journals
Reprints and Permission for Reuse
Copyright Notice/Public Access Policy
ADA Professional Membership
ADA Member Directory
Diabetes.org
X (Twitter)
Cookie Policy
Accessibility
Terms & Conditions
Get Adobe Acrobat Reader

This Feature Is Available To Subscribers Only

Hypertension: A Case Study

January 2022
8(7):379 - 381

Eternal University

Akal College of Nursing Eternal University Baru Sahib.

Discover the world's research

25+ million members
160+ million publication pages
2.3+ billion citations
Muthu Kumaran

Suzanne Oparil
Recruit researchers
Join for free
Login Email Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google Welcome back! Please log in. Email · Hint Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google No account? Sign up

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Publications
Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

Advanced Search
Journal List
Medicine (Baltimore)
v.99(52); 2020 Dec 24

Nursing case management for people with hypertension

To explore the effect of management of nursing case on blood pressure control in hypertension patients.

This is a randomized controlled study which will be carried out from May 2021 to May 2022. The experiment was granted through the Research Ethics Committee of the People's Hospital of Chengyang District (03982808). Our research includes 200 patients. Patients who meet the following conditions will be included in this experiment: the patients aged 18 to 60 years; the patients had the diagnosis of hypertension; and the urban residents. While patients with the following conditions will be excluded: having renal failure, liver failure, heart and respiratory failure; and known pregnancy. Primary result is blood pressure, while secondary results are treatment compliance, waist circumference, body mass index (BMI), type and number of antihypertensive agents used, and the existence of metabolic and cardiovascular comorbidities.

Table 1 shows the clinical outcomes between the two groups.

Conclusion:

Nursing case management is effective to improve the prognosis of hypertension patients.

1. Introduction

Hypertension is one of the cause of death worldwide, which is preventable. [ 1 , 2 ] It is also a significant risk factor for myocardial infarction, heart failure, stroke, as well as other serious renal and cardiovascular diseases. [ 3 – 5 ] The incidence rate of hypertension rises with the age of adults. It is reported that 36% of the adults aged 40 to 64 suffer from hypertension; among adults aged 65 and above, the proportion has increased to 70%. [ 6 , 7 ] It has become a serious problem of public health. Since the hypertension is asymptomatic, its detection and control remains a challenge. The hypertension patients are managed via the primary health care provider. [ 8 ] Nevertheless, although the progress has been made in the management of chronic diseases, the hypertensive patients who receive regular treatment from primary care providers do not meet their targets of blood pressure.

In recent years, more and more researches begin to pay attention to the significant role of the management of nursing case in treating hypertension. [ 9 , 10 ] It requires a complex care, involving major lifestyle changes such as adherence to medication, reduced salt intake, the measurement of blood pressure and exercise. Nevertheless, the hypertension patients have poor self-management behaviors. The self-care and self-efficacy behavior of uncontrolled hypertension patients are lower. Case management is a kind of healthcare strategy that determines patients at high risk, prevents complications and disease progression, and promotes the patients participation in self-care. Other targets involve caring for the perspectives and needs of patients, developing personalized care programs, improving the quality of health care, and decreasing decentralized patient care. The former researches have suggested that management of case may have a positive effect on hypertension. [ 11 – 13 ] In addition, it can increase the knowledge about the disease; adhere to the treatment plans and help the patients improve their own lifestyle. Although it has achieved positive results in the case management of chronic disease, it has not been applied in patients with hypertension. Hence, we conduct the randomized controlled study protocol to explore the effect of management of nursing case on blood pressure control in hypertension patients.

2. Materials and methods

This is a randomized controlled study which will be carried out from May 2021 to May 2022 at the People's Hospital of Chengyang District. The experiment was granted through the Research Ethics Committee of the People's Hospital of Chengyang District (03982808) and recorded in research registry (researchregistry6244).

2.1. Inclusion criteria and exclusion criteria

Patients who meet the following conditions will be included in this experiment: the patients aged 18 to 60 years; the patients had the diagnosis of hypertension; and the urban residents. While patients with the following conditions will be excluded: having renal failure, liver failure, heart and respiratory failure; and known pregnancy. All the patients are randomly assigned to the random number through utilizing a random-number table, and the result of distribution is kept in a random envelope and is invisible. All the patients are randomly divided to the control group and study group, and there are 100 patients in each group.

2.2. Nursing case management

The nursing standards of the control group are as follows: renewal of prescriptions in meetings, free distribution of hypertension medication, and the monitor of blood pressure every 2 months, nursing and medical appointments, and consultation with psychologists and nutritionists based on the needs of patients.

In intervention group, patients are given management of nursing case. From the existing management activities, the arrangements are as follows: telephone contacts, nursing consultations, personal health education activities, and home visits. The nursing consultations are implemented every 6 months. The purpose of the consultation is to gather information that can be utilized to draft personal care plans and to set mutually agreed targets. The consultation lasts about an hour, involving the targeted health education, the measurement of waist circumference and blood pressure, and the calculation of BMI. Telephone contact is conducted every 1 month to reassess the healthcare plans of patients and remind the patients to consult the agendas in a timely manner. WeChat is a kind of instant messaging tool, which allows the voice calls through using the mobile phone, and it is also utilized for communication. Each telephone meeting lasts about 10 min. In the process of home visits, the case manager will observe the home environment, for instance, the living conditions and family's interaction. They offer the health education, check the weight of patient and their blood pressure, and then review the targets and medical plans. All the verbal instructions will be recorded and the patients will be provided the copy for consultation if needed. For the home visits, it lasts about 45 min. And the group activities contain the interactive activities and informational lectures. The focus of these activities is to develop healthy habits. The theme of educational activities is selected according to patients’ main needs. The activities of collective health education are carried out in community space. These group activities last about 1 h. Personalized educational activities are offered in the process of nursing consultation, telephone consultation, and home visit. All information acquired in the process of nursing management will be recorded.

2.3. Outcomes

Primary result is blood pressure, while secondary results are treatment compliance, waist circumference, BMI, type and number of antihypertensive agents used, and the existence of metabolic and cardiovascular comorbidities.

2.4. Statistical analysis

The analysis of all the data are conducted with the software of IBM SPSS Statistics for Windows, version 20 (IBM Corp, Armonk, NY). Afterwards, all the data acquired are represented through the appropriate characteristics, for example, standard deviation, and mean, median as well as percentage. And independent t tests and χ 2 -tests are respectively utilized to analyze the categorical variable and continuous variable. P value < .05 indicates that there is statistical significance.

Table Table1 1 shows the clinical outcomes between the two groups.

The clinical outcomes between the two groups.

Outcomes	Study group	(n = 100)	Control group (n = 100)
Systolic blood pressure
Diastolic blood pressure
Mean arterial pressure
Waist circumference
Body mass index
Quality of life score

4. Discussion

Hypertension is the most significant risk factor for disability and death worldwide, which affects more than one billion people and causes ∼9.4 million deaths each year. [ 14 ] On the basis of a report by the World Health Organization, hypertension is the single most significant risk factor, which accounts for 13% of global mortality. Human hypertension may be the result of lifestyle and genetic factors. [ 15 , 16 ] The current evidence-based treatment for the hypertension is a key intervention measure to reduce the incidence rate and mortality of cardiovascular diseases. Researches have determined a variety of barriers to the control of hypertension in routine care that are composed of factors related to patients, physicians, healthcare system, and healthcare services.

People with lower income and education levels are more likely to be insufficiently physically active, which predisposes them to the risk of complications associated with chronic diseases, particularly the hypertension. [ 17 ] In contrast, people with higher educational and economic levels tend to be more effective at controlling the levels of blood pressure. Therefore, it is essential to consider the effect of these variables and then incorporate these variables into the development of nursing planning and educational activities for hypertension patients. Case management can be utilized for this objective by providing a personalized plan based on each person's needs.

5. Conclusion

Author contributions.

Shiqiang Song designs the protocol. Xianhong Li reviews the protocol. Xueling Ning performs the data collection. Chunjing Song finishes the manuscript. All of the authors approved the submission.

Conceptualization: Xianhong Li.

Data curation: Xianhong Li.

Funding acquisition: Shiqiang Song.

Investigation: Xueling Ning.

Methodology: Xueling Ning.

Writing – original draft: Chunjing Song.

Abbreviations: BMI = body mass index, Trial registration = The protocol was registered in Research Registry (researchregistry6244).

How to cite this article: Song C, Li X, Ning X, Song S. Nursing case management for people with hypertension: A randomized controlled trial protocol. Medicine . 2020;99:52(e23850).

Qingdao Health Bureau project (2013-WSZD120).

The authors have no conflicts of interest to disclose.

The datasets generated during and/or analyzed during the present study are publicly available.

Get new issue alerts Get alerts

Secondary Logo

Journal logo.

Colleague's E-mail is Invalid

Your message has been successfully sent to your colleague.

Save my selection

Nursing case management for people with hypertension

A randomized controlled trial protocol.

Song, Chunjing MB; Li, Xianhong MB; Ning, Xueling MB; Song, Shiqiang MM ∗

Department of Urology, People's Hospital of Chengyang District, Qingdao, China.

∗Correspondence: Shiqiang Song, Department of Urology, People's Hospital of Chengyang District, Qingdao 266109, China (e-mail: [email protected] ).

Abbreviations: BMI = body mass index, Trial registration = The protocol was registered in Research Registry (researchregistry6244).

How to cite this article: Song C, Li X, Ning X, Song S. Nursing case management for people with hypertension: A randomized controlled trial protocol. Medicine . 2020;99:52(e23850).

Qingdao Health Bureau project (2013-WSZD120).

The authors have no conflicts of interest to disclose.

The datasets generated during and/or analyzed during the present study are publicly available.

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

Objective:

To explore the effect of management of nursing case on blood pressure control in hypertension patients.

Method:

Results:

Table 1 shows the clinical outcomes between the two groups.

Conclusion:

Nursing case management is effective to improve the prognosis of hypertension patients.

1 Introduction

Hypertension is one of the cause of death worldwide, which is preventable. [1,2] It is also a significant risk factor for myocardial infarction, heart failure, stroke, as well as other serious renal and cardiovascular diseases. [3–5] The incidence rate of hypertension rises with the age of adults. It is reported that 36% of the adults aged 40 to 64 suffer from hypertension; among adults aged 65 and above, the proportion has increased to 70%. [6,7] It has become a serious problem of public health. Since the hypertension is asymptomatic, its detection and control remains a challenge. The hypertension patients are managed via the primary health care provider. [8] Nevertheless, although the progress has been made in the management of chronic diseases, the hypertensive patients who receive regular treatment from primary care providers do not meet their targets of blood pressure.

In recent years, more and more researches begin to pay attention to the significant role of the management of nursing case in treating hypertension. [9,10] It requires a complex care, involving major lifestyle changes such as adherence to medication, reduced salt intake, the measurement of blood pressure and exercise. Nevertheless, the hypertension patients have poor self-management behaviors. The self-care and self-efficacy behavior of uncontrolled hypertension patients are lower. Case management is a kind of healthcare strategy that determines patients at high risk, prevents complications and disease progression, and promotes the patients participation in self-care. Other targets involve caring for the perspectives and needs of patients, developing personalized care programs, improving the quality of health care, and decreasing decentralized patient care. The former researches have suggested that management of case may have a positive effect on hypertension. [11–13] In addition, it can increase the knowledge about the disease; adhere to the treatment plans and help the patients improve their own lifestyle. Although it has achieved positive results in the case management of chronic disease, it has not been applied in patients with hypertension. Hence, we conduct the randomized controlled study protocol to explore the effect of management of nursing case on blood pressure control in hypertension patients.

2 Materials and methods

2.1 Inclusion criteria and exclusion criteria

2.2 Nursing case management

2.3 Outcomes

2.4 Statistical analysis

Outcomes	Study group	(n = 100)	Control group (n = 100)
Systolic blood pressure
Diastolic blood pressure
Mean arterial pressure
Waist circumference
Body mass index
Quality of life score

4 Discussion

Hypertension is the most significant risk factor for disability and death worldwide, which affects more than one billion people and causes ∼9.4 million deaths each year. [14] On the basis of a report by the World Health Organization, hypertension is the single most significant risk factor, which accounts for 13% of global mortality. Human hypertension may be the result of lifestyle and genetic factors. [15,16] The current evidence-based treatment for the hypertension is a key intervention measure to reduce the incidence rate and mortality of cardiovascular diseases. Researches have determined a variety of barriers to the control of hypertension in routine care that are composed of factors related to patients, physicians, healthcare system, and healthcare services.

People with lower income and education levels are more likely to be insufficiently physically active, which predisposes them to the risk of complications associated with chronic diseases, particularly the hypertension. [17] In contrast, people with higher educational and economic levels tend to be more effective at controlling the levels of blood pressure. Therefore, it is essential to consider the effect of these variables and then incorporate these variables into the development of nursing planning and educational activities for hypertension patients. Case management can be utilized for this objective by providing a personalized plan based on each person's needs.

5 Conclusion

Author contributions.

Shiqiang Song designs the protocol. Xianhong Li reviews the protocol. Xueling Ning performs the data collection. Chunjing Song finishes the manuscript. All of the authors approved the submission.

Conceptualization: Xianhong Li.

Data curation: Xianhong Li.

Funding acquisition: Shiqiang Song.

Investigation: Xueling Ning.

Methodology: Xueling Ning.

Writing – original draft: Chunjing Song.

Cited Here |
Google Scholar

nursing case management; hypertension; blood pressure; protocol

+ Favorites
View in Gallery

Readers Of this Article Also Read

The evaluation of a nurse-led hypertension management model in an urban..., a comprehensive exploration of twist1 to identify a biomarker for tumor..., knowledge of cancer symptoms and risk factors: a cross-sectional study from a..., multidisciplinary management based on clinical nursing pathway model for the....

OTC Case Studies: High Blood Pressure

Four pharmacy cases address high blood pressure.

Case 1: Weight Loss for Controlling High Blood Pressure (HBP)

Q: TA, a 38-year-old man, has a history of HBP and morbid obesity and has been taking a 3-drug combination pill once daily for many years to control his hypertension. TA’s primary care provider recently brought up his eligibility for weight loss surgery to help with blood pressure (BP) control and reduce his risk for other medical complications. However, TA would like to try to lose weight on his own before taking this approach. He has never attempted weight loss before and is not sure where to start. What information can you provide regarding nonpharmacologic and self-care approaches to weight loss?

A: The American College of Cardiology (ACC)/American Heart Association’s (AHA) updated 2017 primary prevention guidelines underscore the importance of weight loss as a nonpharmacologic approach to helping control and reduce BP in patients who are obese or overweight. 1 Weight loss efforts should be multimodal, encompassing both dietary modification and exercise. In terms of dietary modifications, individuals should reduce their sodium intake to less than 1500 mg a day and consume a diet low in saturated and total fat that is full of fruits, vegetables, whole grains, and low-fat dairy, all of which are found in the Dietary Approaches to Stop Hypertension and Mediterranean diet plans, along with reducing their daily caloric consumption. 1 Finally, if TA consumes alcohol, it is recommend that he limit his intake to 2 or fewer drinks each day. Physical activity recommendations include aerobic, dynamic resistance or isometric resistance exercises several times each week. Nonetheless, although dietary and lifestyle modifications are prudent, weight loss surgery may be indicated based on the degree of obesity and presence of underlying medical complications. Encourage TA to try these changes but to follow up with his physician about next steps after a 3- or 6-month trial period.

Case 2: Smoking Cessation for Reducing Cardiovascular Disease (CVD) Risk

Q : WT, a 45-year-old man, recently discharged from the local hospital’s emergency department (ED) after experiencing chest pain, is inquiring about recommendations for smoking cessation. His medical history is significant for dyslipidemia, generalized anxiety, and hypertension, and he says that he takes atorvastatin (Lipitor), escitalopram (Lexapro) with as-needed lorazepam (Ativan), and lisinopril/hydrochlorothiazide for treating these conditions, respectively. WT was ruled out for acute coronary syndrome while in the ED, although the physician there recommended that he stop smoking to improve his BP control and reduce his risk of CVD. WT would like a recommendation for a nonprescription treatment option that he can start immediately to prevent chest pain recurrence and reduce his desire to smoke. He says he has smoked a pack of cigarettes a day for the past 20 years and that he often lights his first cigarette while still in bed each morning. What recommendations can you provide?

A : Cigarette smoking is a known modifiable risk factor for development of CVD, and the effects may manifest as acute increases in BP and arterial stiffening. Beyond the obvious health benefits on pulmonary function and reducing other long-term health consequences, smoking cessation may reduce WT’s CVD risk and his elevated BP. Make sure to provide a recommendation for establishing a quit date, along with education on the symptoms of nicotine withdrawal and how to manage those with pharmacologic approaches. Notably, for WT, who has a comorbid anxiety condition, point out that anxiety, insomnia, and irritability may worsen with the withdrawal of nicotine and this should be monitored accordingly. Additionally, discuss exploration of smoking triggers and the need for other lifestyle modifications to support the cessation effort. In terms of supporting quitting smoking using pharmacologic approaches, drug therapy often works best in conjunction with behavioral support and counseling. Sharing local or regional programs to support smoking cessation may be helpful in this case. Because WT is seeking a nonprescription medication to immediately help support this effort, either the nonprescription nicotine gum, lozenge, or patch could be considered, based on his preference. Make sure to offer education on the dosage, depending on the product selected. Appropriate follow-up should be established with the pharmacist or primary care provider to gauge the success of the effort.

Case 3: Nutrient Depletion Associated with Diuretic Therapy

Q : AA, a 62-year-old man, was recently discharged from the hospital after having palpitations. His physician told him that his potassium level was very low and that, upon discharge, he should continue to take his water pill with a banana each day. AA’s medical history is significant for allergies, diabetes, gout, and hypertension, and he takes allopurinol, amlodipine, atorvastatin, hydrochlorothiazide, an intranasal steroid, metformin, and pioglitazone each day. He was prescribed a potassium supplement. However, the pills are too large to swallow and unpalatable, and AA would like to talk to a pharmacist about alternatives. What information can you provide regarding the need for electrolyte supplementation with concomitant diuretic use?

A : Thiazide diuretics are known to deplete many electrolytes and other nutrients through various pathways, including increasing urinary potassium, sodium, zinc, and thiamine excretion and reducing magnesium reabsorption in the kidneys. 2 Common electrolyte disturbances associated with thiazides include thiazide-induced hyponatremia, hypokalemia, and hypomagnesemia. Additionally, dietary potassium intake, independent of the need for supplementation, has been linked to improvements in BP control and is recommended as long as comorbid kidney disease and the risks of potassium accumulation do not exceed these benefits. 1 In AA’s case, suggest that he consider dissolving the potassium tablets in applesauce or pudding, depending on the formulation, to ensure that he is obtaining the amount of potassium recommended by his physician. If AA’s potassium levels are chronically low upon follow-up, it may be appropriate for him to consider increasing his dietary fruit and vegetable consumption, along with low-fat dairy, some fish and meats, nuts, or soy-containing foods, which are all considered good sources of potassium. 1 Remind him that a medium-size banana contains, on average, about 12 mEq of potassium, as well. 3

Case 4: BP Self-monitoring

Q : KM, a 30-year-old pregnant woman, is looking for a recommendation for a BP cuff. At her 20-week prenatal visit, her obstetrician/gynecologist (OB/GYN) was concerned about her borderline-high BP. After a 24-hour urine collection, KM was instructed to purchase a BP monitor and to record her reading twice daily at home to share at her next follow-up. She has no significant past medical history, had 1 previous pregnancy with no complications, and only takes a prescription prenatal vitamin. What recommendations or education on self-monitoring BP can you offer?

A : BP self-monitoring is commonly recommended for evaluation and medical decision making for patients outside the ambulatory-care office. The ACC/AHA’s 2017 update for detection and management of HBP delineates a 6-step checklist for ensuring patients who are self-monitoring accurately obtain their BP readings to appropriately inform health decisions. 1 Notably, ACC/AHA recommends the following 1 :

Assurance of optimal technique (eg, supporting the arm with the middle of the cuff placed on the upper arm, depending on the type of device selected; use of proper-sized cuff; and use of a validated/calibrated BP measuring device)
Average BP readings from 2 or more assessments performed on 2 or more occasions
Document findings (eg, helping the patient create or obtain a log for recording results at the frequency recommended by her OB/GYN, specifying the time of day the reading was recorded and any other relevant variables)
Record benchmarking and repeated measures (eg, taking BP in both arms at the first medical visit and separating subsequent measurements by 1 to 2 minutes)
Proper patient preparation (eg, avoiding caffeine, exercise, and smoking in the 30 minutes prior to the assessment and talking during the measurement; back supported for 5 minutes or longer; relaxing; and sitting on a chair with feet flat on the floor)
Provide a record of in-office readings to the patient

A pharmacist is well positioned to help KM select an appropriate BP monitoring device, including a cuff of appropriate size, and reminding the proper technique for using it and recording her readings at home.

1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension . 2018;71(6):e13-e115. doi: 10.1161/HYP.0000000000000065.
Nutrient depletion tool: hydrochlorothiazide. Natural Medicines website. naturalmedicines.therapeuticresearch.com. Accessed December 2018.
Mayo Clinic. Potassium supplements (oral route, parenteral route). Mayo Clinic website. mayoclinic.org/drugs-supplements/potassium-supplement-oral-route-parenteral-route/description/drg-20070753. Updated October 1, 2018. Accessed December 15, 2018.

July 2024 Condition Watch: Diabetes

Science, students and education in a medical laboratory writing notes during scientist lecture or lesson with mentor or teacher. Medical men and women for training and learning in chemistry class - Image credit: D Lahoud/peopleimages.com | stock.adobe.com

MTM-Focused Residencies Can Enhance Pharmacists’ Skill Set

Health care provider with model of human heart -- Image credit: NanSan | stock.adobe.com

Optimizing Cholesterol Management With Injectable Lipid-Lowering Therapies

Medical students listening to a lecture in the lab - Image credit: luckybusiness | stock.adobe.com

Unique Roles for Pharmacy Technicians Can Enhance Patient Care and Safety

Cardiovascular system -- Image credit: Sebastian Kaulitzki | stock.adobe.com

Adjunct Lipid Therapies Offer Options for Lowering LDL

medical marijuana - Image credit: goodmanphoto | stock.adobe.com

DEA Proposed Rule Seeks to Reclassify Marijuana

2 Commerce Drive Cranbury, NJ 08512

609-716-7777

COMMENTS

Case 18-2018: A 45-Year-Old Woman with Hypertension, Fatigue, and
The high-dose dexamethasone suppression test, the CRH stimulation test, imaging studies of the pituitary gland, and sampling of blood from the inferior petrosal sinus are some of the tests that ...
Trial of Intensive Blood-Pressure Control in Older Patients with
Previous studies have shown that, among older people with a pulse pressure of more than 60 mm Hg or a diastolic blood pressure of less than 60 mm Hg (or both), a very low systolic blood pressure ...
Investigation and Treatment of High Blood Pressure in Young People
Furthermore, diastolic hypertension is more common among patients under the age of 50 years (62.5% compared with 42% in over 50s). 31. Additionally, there is uncertainty regarding the significance of isolated systolic hypertension in the young (SBP ≥140 mm Hg, DBP <90 mm Hg). Less than 20% of untreated hypertensives below the age of 40 years ...
Clinical case scenarios for primary care
Definitions used in these clinical case scenarios. Definitions Stage 1 hypertension Clinic blood pressure is 140/90 mmHg or higher and. subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg or higher. Stage 2 hypertension Clinic blood pressure is 160 ...
High Blood Pressure and Cardiovascular Disease
High blood pressure (BP), cigarette smoking, diabetes mellitus, and lipid abnormalities are major modifiable risk factors for cardiovascular disease (CVD). Among these, high BP is associated with the strongest evidence for causation and has a high prevalence of exposure. However, there is considerable evidence that a biologically normal level ...
Case Studies: BP Evaluation and Treatment in Patients with Prediabetes
Learn how to apply the new ACC/AHA blood pressure guidelines for patients with prediabetes or diabetes. See examples of BP measurement, classification, and management in two case scenarios.
Guideline-Driven Management of Hypertension: An Evidence-Based Update
Introduction. Globally, high blood pressure (BP) is the leading risk factor for cardiovascular disease (CVD) morbidity and mortality. 1 In the United States, high BP ranks first among modifiable risk factors in population attributable CVD risk, accounting for the largest proportion of coronary heart disease (CHD), heart failure (HF) and stroke events. 2 In adults with hypertension, control of ...
High Blood Pressure Research
NHLBI-supported research has helped reveal how pregnancy complications, including high blood pressure, affect the long-term health of women and their children. One study found that women who have a preterm birth have a greater chance of later developing high blood pressure. The NHLBI continues to fund the nuMoM2b Heart Health Study. external link.
High Blood Pressure (Hypertension) Clinical Trials
Early hypertension studies showed that treating elevated blood pressure (BP) reduces patients' risk of cardiovascular disease and all-cause mortality. In subsequent research, patients achieved greater improvement in cardiovascular outcomes when their treatment was aimed at a moderate systolic BP target (<150mmHg) than at higher targets.
Clinical significance of stress-related increase in blood pressure
High blood pressure is the most significant risk factor of cardiovascular and cerebrovascular diseases worldwide. ... Cross-sectional or case-control studies that compare working and non-working ...
Case study
Recently, a 528-patient, 26-week study compared the efficacy of eprosartan (200 to 300 mg/twice daily) versus enalapril (5 to 20 mg/daily) in patients with essential hypertension (baseline sitting diastolic blood pressure [DBP] 95 to 114 mm Hg). After 3 to 5 weeks of placebo, patients were randomized to receive either eprosartan or enalapril.
Grounding Patients With Hypertension Improves Blood Pressure: A Case
Anecdotal reports include lowering of high blood pressure (BP). Objective: To test such reports, a pilot case history series was undertaken with hypertensive patients in a single physician cardiology practice. Intervention: Patients grounded themselves at home for at least 10 h/d for several mo. Outcome measure: BP was measured at baseline in ...
PDF Home Blood Pressure Monitoring: Patient Case Studies
a further two weeks. Again, his average home blood pressure was found to be 118/80mmHg and his clinic blood pressure 126/83mmHg. Following further discussion, the GP decided to stop his blood pressure lowering medication. Home blood pressure readings after this point indicated that the patient's blood pressure remained at approximately 134 ...
Most Important Outcomes Research Papers on Hypertension
Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation. 2005;111:697-716.
Case Study: Beyond High BP
A 17-year-old female presented to the Hypertension and Vascular Evaluation (HAVE) Program for high blood pressure (BP) during multiple office visits in the setting of morbid obesity and type 2 diabetes mellitus. Family history was significant for high blood pressure and high cholesterol. On exam, her weight was 176.9 kg (99th percentile) and her BMI was 60.92 kg/m2 (99.7th percentile).
PDF A Case of a Young Man with Severe Hypertension
Case Presentation. The patient was a 17-year-old male who was admitted to our hospital in May 2020 due to uncontrolled hypertension for 6 months and weakness of limbs for 20 days. Six months prior to admission, blood pressure of the patient was found to have increased to 200/120 mmHg during the physical examination.
High Blood Pressure: Prevention, Treatment and Research
Diastolic pressure is the pressure against the arteries between heartbeats, as the heart relaxes. The unit of measurement is in millimeters of mercury (mm Hg). Optimal blood pressure is 120/80 mm Hg (referred to as "120 over 80") or below. High blood pressure is defined for adults as systolic pressure above 140 or diastolic pressure above 90.
Case Study: Treating Hypertension in Patients With Diabetes
Hypertension was diagnosed 5 years ago when blood pressure (BP) measured in the office was noted to be consistently elevated in the range of 160/90 mmHg on three occasions. L.N. was initially treated with lisinopril, starting at 10 mg daily and increasing to 20 mg daily, yet her BP control has fluctuated.
(PDF) Hypertension: A Case Study
This study reveals that In this study the Majority of were having (60%) optimal systolic blood pressure, 15% normal, 11% having high normal, 7% grade I (mild), 4% grade II (moderate), 3% grade III ...
Association of Cardiovascular Risk Factors and Lifestyle Behaviors With
The prevalence of high blood pressure has increased over the past decades. 1 Hypertension is a major risk factor for cardiovascular disease (CVD) 1 and typically coexists with other CVD risk factors and unhealthy lifestyle behaviors, such as smoking, diabetes, dyslipidemia, overweight, physical inactivity, and unhealthy diet. 2 From randomized controlled trials, we have learned that weight ...
Nursing case management for people with hypertension
Abstract. Objective: To explore the effect of management of nursing case on blood pressure control in hypertension patients. Method: This is a randomized controlled study which will be carried out from May 2021 to May 2022. The experiment was granted through the Research Ethics Committee of the People's Hospital of Chengyang District (03982808).
Nursing case management for people with hypertension
Hence, we conduct the randomized controlled study protocol to explore the effect of management of nursing case on blood pressure control in hypertension patients. 2 Materials and methods. This is a randomized controlled study which will be carried out from May 2021 to May 2022 at the People's Hospital of Chengyang District.
OTC Case Studies: High Blood Pressure
Issue 2. Four pharmacy cases address high blood pressure. Case 1: Weight Loss for Controlling High Blood Pressure (HBP) Q: TA, a 38-year-old man, has a history of HBP and morbid obesity and has been taking a 3-drug combination pill once daily for many years to control his hypertension. TA's primary care provider recently brought up his ...

Case Studies: BP Evaluation and Treatment in Patients with Prediabetes or Diabetes

More On This Topic

High Blood Pressure Research

NHLBI research that really made a difference

Current research funded by the NHLBI

Current research on the treatment of high blood pressure

Current research on women’s health and high blood pressure

Current research on health disparities and high blood pressure

High blood pressure research labs at the NHLBI

Related programs

Explore more NHLBI research on high blood pressure

Clinical significance of stress-related increase in blood pressure: current evidence in office and out-of-office settings

Similar content being viewed by others

Stress and cardiovascular disease: an update

Do any kinds of perceived stressors lead to hypertension? A longitudinal cohort study

Short- to long-term blood pressure variability: Current evidence and new evaluations

Mechanisms of stress-induced blood pressure elevation

Stress-induced blood pressure elevation in a clinic setting

Work environment as a profound modulator of blood pressure

Work stress and blood pressure

Work hours and blood pressure

Shift work and blood pressure

Acknowledgements

Author information

Corresponding author

Ethics declarations

Rights and permissions

About this article

Share this article

This article is cited by

Microglia-derived TNF-α contributes to RVLM neuronal mitochondrial dysfunction via blocking the AMPK–Sirt3 pathway in stress-induced hypertension

Structure and dynamics of the course of chronic non-infectious somatic diseases in patients during war events on the territory of Ukraine

Hypertension paradox in Japan: the road ahead

Investigation of the effect of music listened to by patients with moderate dental anxiety during restoration of posterior occlusal dental caries

Quick links

Article Contents

Email alerts

Affiliations

This Feature Is Available To Subscribers Only

Save citation to file

Add to My Bibliography

Grounding Patients With Hypertension Improves Blood Pressure: A Case History Series Study

Similar articles

Related information

LinkOut - more resources

Case Study: Beyond High BP — Thorough Evaluation

Hypertension Clinic

References and suggested readings

Masks Strongly Recommended but Not Required in Maryland, Starting Immediately

High Blood Pressure: Prevention, Treatment and Research

Living With...

Find a Doctor

Find a Treatment Center

Request an Appointment

Related Topics

Presentation

Email alerts

Clinical Compendia

This Feature Is Available To Subscribers Only

Hypertension: A Case Study

Nursing case management for people with hypertension

Conclusion:

1. Introduction

2. Materials and methods

2.1. Inclusion criteria and exclusion criteria

2.2. Nursing case management

2.3. Outcomes

2.4. Statistical analysis

4. Discussion

5. Conclusion

Secondary Logo

Nursing case management for people with hypertension

Objective:

Method:

Results:

Conclusion:

1 Introduction

2 Materials and methods

2.1 Inclusion criteria and exclusion criteria

2.2 Nursing case management