|Year : 2022 | Volume
| Issue : 2 | Page : 45-51
Expert consensus on diagnosis and treatment of adult mental stress induced hypertension in China (2022 revision): Part A
Lin Lu1, Qingshan Geng1, Jian’an Wang1, Chunlin Bai1, Gong Cheng1, Yinghua Cui1, Bo Dong1, Jianqun Fang1, Feng Gao1, Ruowen Huang1, Shuwei Huang1, Yuming Li2, Gang Liu1, Yuanyuan Liu1, Yan Lu1, Yanping Ren1, Jialiang Mao1, Dazhuo Shi1, Huimin Su1, Xinyu Sun1, Xingguo Sun1, Xiangdong Tang1, Fengshi Tian1, Hong Tu1, Hao Wang1, Qing Wang1, Xiangqun Wang1, Junmei Wang1, Le Wang1, Yibo Wang1, Yumei Wang1, Zhipeng Wang1, Shaojun Wen1, Hui Wu1, Yanqing Wu1, Peng Xiong1, Guolong Yu1, Ning Yang1, Xiaoling Zhao1, Haicheng Zhan1, Meiyan Liu3
1 Psycho-Cardiology Group, College of Cardiovascular Physicians of Chinese Medical Doctor Association, Beijing, China
2 Psycho-Cardiology Group, College of Cardiovascular Physicians of Chinese Medical Doctor Association; Hypertension Group of the Chinese Society of Cardiology, Beijing, China
3 Psycho-Cardiology Group, College of Cardiovascular Physicians of Chinese Medical Doctor Association; Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
|Date of Submission||29-Mar-2022|
|Date of Acceptance||19-Apr-2022|
|Date of Web Publication||16-May-2022|
Prof. Meiyan Liu
Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029
Source of Support: None, Conflict of Interest: None
Mental stress has been recognized as an essential risk factor for hypertension. Therefore, experts specializing in cardiology, psychiatry, and Traditional Chinese Medicine organized by the Psycho-Cardiology Group of College of Cardiovascular Physicians of Chinese Medical Doctor Association and Hypertension Group of Chinese Society of Cardiology proposed the expert consensus on the diagnosis and treatment of adult mental stress-induced hypertension in March 2021, which includes the epidemiology, etiology, diagnosis, and treatment of the mental stress-induced hypertension. This consensus will hopefully facilitate the clinical practice of this disorder. In addition, the COVID-19 pandemic has become one of the primary global sources of psychosocial stressors since the beginning of 2020, and the revision of this expert consensus in 2022 has increased the relevant content. This consensus consists of Part A and Part B. Part A includes (I) Background and epidemiological characteristics, (II) Pathogenesis, and (III) Diagnosis and Part B includes (IV) Treatment recommendations and (V) Prospects. This part presents the content of Part A.
Keywords: Hypertension, mental stress, expert consensus, COVID-19
|How to cite this article:|
Lu L, Geng Q, Wang J, Bai C, Cheng G, Cui Y, Dong B, Fang J, Gao F, Huang R, Huang S, Li Y, Liu G, Liu Y, Lu Y, Ren Y, Mao J, Shi D, Su H, Sun X, Sun X, Tang X, Tian F, Tu H, Wang H, Wang Q, Wang X, Wang J, Wang L, Wang Y, Wang Y, Wang Z, Wen S, Wu H, Wu Y, Xiong P, Yu G, Yang N, Zhao X, Zhan H, Liu M. Expert consensus on diagnosis and treatment of adult mental stress induced hypertension in China (2022 revision): Part A. Heart Mind 2022;6:45-51
|How to cite this URL:|
Lu L, Geng Q, Wang J, Bai C, Cheng G, Cui Y, Dong B, Fang J, Gao F, Huang R, Huang S, Li Y, Liu G, Liu Y, Lu Y, Ren Y, Mao J, Shi D, Su H, Sun X, Sun X, Tang X, Tian F, Tu H, Wang H, Wang Q, Wang X, Wang J, Wang L, Wang Y, Wang Y, Wang Z, Wen S, Wu H, Wu Y, Xiong P, Yu G, Yang N, Zhao X, Zhan H, Liu M. Expert consensus on diagnosis and treatment of adult mental stress induced hypertension in China (2022 revision): Part A. Heart Mind [serial online] 2022 [cited 2022 Jun 30];6:45-51. Available from: http://www.heartmindjournal.org/text.asp?2022/6/2/45/345284
Data from the Annual Report on Cardiovascular Health and Disease in China 2020 show that China has an estimated 245 million patients with hypertension. Based on hypertension data collected globally, it is predicted that the number of hypertensive patients will reach as many as 1.5 billion by 2025. The latest burden of disease study report for China indicates that the increase in mortality due to hypertensive heart disease, directly caused by hypertension, is 94.5%. Systematic analysis of the global burden of disease study for the most recent 30 years has revealed that high systolic pressure was the primary risk factor affecting the number of deaths and the percentage of disability-adjusted life years in China in 2017, leading to 2.54 million deaths (95% confidence interval [CI] 2.26–2.82). In addition to traditional biological risk factors, a psychogenic factor is also an important risk factor affecting the incidence of hypertension.,,, This type of hypertension, which is closely associated with the action of mental stress, is called mental stress-induced hypertension, stress-induced hypertension, or psychogenic hypertension. At present, there is still a lack of expert consensus on the diagnosis and treatment of mental stress-induced hypertension. Therefore, we are designating the following consensus to elaborate on the epidemiological characteristics and pathogenesis of mental stress-induced hypertension and form a unified understanding for the development of corresponding diagnosis, differential diagnosis, and treatment strategies, so providing a basis for clinicians to identify and diagnose mental stress-induced hypertension and improve the efficiency of diagnosis and treatment.
| The Background to, and Epidemiological Characteristics of, Mental Stress-induced Hypertension|| |
Research into the correlation of mental stress with hypertension has been a long-standing topic. During World War II, researchers found exceptionally elevated blood pressure in soldiers participating in the war which returned to normal after postwar recuperation. In the 1940s, there were some reports on the correlation of psychogenic factors with hypertension, followed by relevant clinical studies, and animal experiments, all proposing the concept of mental stress-induced hypertension. “Mental stress” is listed as one of the important risk factors for hypertension both in the “2010 Chinese Guidelines for the Management of Hypertension” and the “2018 Chinese Guidelines for the Management of Hypertension,” and “reducing mental stress and maintaining psychological balance” is included in the treatment strategy., The latest version of the “Global Hypertension Practice Guidelines” issued by the International Society of Hypertension also clearly describes the correlation of mental stress with hypertension and recommends that hypertensive patients should reduce mental stress by meditation and other means. In addition, the “Chinese Expert Consensus on Diagnosis and Treatment of Resistant Hypertension” indicates that psychogenic factors can lead to uncontrollable hypertension. The “Chinese guidelines for the management of hypertension in the elderly” lists psychogenic factors as risk factors for hypertension and develops relevant diagnosis and treatment plans.,
Mental stress-induced hypertension is triggered by stresses such as life and work and is closely related to psychogenic problems (e.g., anxiety and depression). Its pathogenesis is related to biological pathogenesis associated with mental stress, such as stimulation of the sympathetic nervous system.
Many clinical studies and meta-analyses in China and abroad have shown that mental stress is closely related to hypertension. Meta-analysis of the correlation of psychogenic factors with hypertension has shown that psychogenic factors can significantly increase the risk of hypertension (odd's ratio [OR] = 2.40, 95% CI 1.65–3.49), while hypertensive patients are 2.69 times more prone to psychogenic problems than nonhypertensive patients. Both males and females are prone to develop hypertension under mental stress, and middle-aged men with anxiety have a 2.19 times higher risk of hypertension than those without anxiety. Meanwhile, female participants with a higher level of mental stress show a higher risk of hypertension (OR = 3.27, 95% CI 1.57–8.81, P = 0.003).
Anxiety and depression-related hypertension
Studies on the incidence of anxiety and depression in hypertensive patients in China and elsewhere show consistent results. Most prospective studies on the correlation of anxiety and depression with hypertension have also revealed a close relationship. A prospective cohort study from the Netherlands has shown a clear correlation between anxiety and depression symptoms with hypertension by assessing 455 participants for anxiety and depression and conducting a 5-year follow-up visit. Moreover, most meta-analyses also reveal the correlation between anxiety and depression with hypertension. A meta-analysis on the relationship between anxiety and hypertension, which includes 13 cross-sectional studies with a total of 151,389 cases and 8 prospective cohort studies with a total of 80,146 cases shows that anxiety is closely related to hypertension (OR = 1.18, 95% CI 1.02–1.37; OR = 1.55, 95% CI 1.24–1.94). Another meta-analysis that includes a total of 41 clinical studies related to hypertension and depression shows the incidence of depression in hypertensive patients internationally is 26.8%, and in China, it is 28.5%. In addition, the correlation of anxiety and depression with hypertension may be affected by age. A 24-year follow-up study has revealed that the risk of hypertension is lower in 35–39-year-old patients with severe depression, while after 40, the risk of hypertension is increased by 8% in depressive patients for every 5 years of age.
Here, we should pay special attention to the consideration of depression and anxiety disorders caused by the global pandemic of emerging infectious diseases. For example, according to statistics, in 2020, COVID-19 caused a global estimate of 53.2 million new patients with major depressive disorder and 76.2 million additional patients with anxiety disorders.
Life and work stress-related hypertension
Life stress may come from family, social, and economic status. In response to mental stress, hypertensive patients with lower social support show higher systolic and diastolic blood pressure measurements. Studies have shown that in response to work stress, people showing a more significant increase in systolic blood pressure (SBP), have a higher risk of hypertension, and the degree of risk is associated with the strain of urgent work demands. A cohort study named “Coronary Artery Risk Development in Young Adults” has shown that the risk of hypertension during the follow-up period is higher in subjects in response to the stress of urgent work.
White-coat hypertension occurs when the blood pressure readings at a doctor's office are higher than they are in other settings, such as at home or when provided by a 24-h Ambulatory Blood Pressure Monitor (ABPM). Twenty to thirty percent of patients with mild-to-moderate hypertension on the basis of office occasional blood pressure measurements have white-coat hypertension. Patients with white-coat hypertension show a poorer cardiovascular prognosis in comparison to normotensive participants.
| Pathogenesis|| |
The pathogenesis of mental stress-induced hypertension is still unclear, and it is considered to be mainly a consequence of the following factors: Hypothalamic pituitary adrenal axis (HPA axis), autonomic function, inflammatory response, 5-hydroxytryptamine (5-HT), oxidative stress, genetics, and abnormal regulation of nitric oxide (NO), further the interactions between different forms of pathogenesis play a role in disease development.
Abnormal regulation of the hypothalamic-pituitary adrenal axis and the sympathetic nervous system
In response to acute mental stress, the hypothalamus activates sympathetic and parasympathetic nerves through efferent fibers and angiotensin (Ang) II is abundantly produced accordingly, acting on the Ang II receptor Type-1 (AT1R) to further enhance the activity of autonomic nerves, resulting in a rapid increase in catecholamines in the peripheral blood; meanwhile, the hypothalamus, by activating the HPA axis, leads to a large release of glucocorticoids, whose permissive effect strengthens the vasoconstrictive effect of catecholamines, resulting in an increase in blood pressure., Long-term chronic mental stress can lead to abnormal negative feedback regulation of the HPA axis, excessive central glucocorticoids (inhibiting nerve regeneration), the impairment of autonomic nervous function, and an increase in peripheral glucocorticoids. It can cause water and sodium retention by acting on aldosterone receptors or act on vascular smooth muscle to make it proliferate abnormally and reduce its ability to regulate blood flow, which leads to increased blood pressure.,,
The inflammatory response
Under mental stress, the increased release of central pro-inflammatory mediators (such as C-reactive proteins, inflammatory cytokines, and metalloproteinases) causes the up-regulation of corticotropin-releasing hormones in the paraventricular nucleus of the hypothalamus activating the HPA axis, resulting in increased blood pressure; in the periphery, sympathetic nerve activity is increased, which promotes the activation of immune cells and releases a large number of inflammatory mediators, such as interleukins (IL)-1α and IL-1β, which can strengthen the effect of Ang II by acting on IL-1 receptors to increase blood pressure;, at the same time, increased content of central Ang II, which acts on the blood − brain barrier (BBB) AT1R, BBB permeability is increased, so that peripheral inflammatory mediators and immune cells subsequently enter the central nervous system, increasing the activity of autonomic function, further leading to vasoconstriction and increase in blood pressure.
The 5-hydroxytryptamine system
In response to mental stress, an increase in Ang II can activate tryptophan hydroxylase, and promote the synthesis of 5-HT. In the central nervous system, 5HT acts as a neurotransmitter, whose effect is related to the corresponding receptors activated. The activation of central 5HT1A receptors causes a sympathoinhibitory effect, while that of 5HT2A receptors can cause sympathetic stimulation. 5-HT3 receptors are distributed in sympathetic ganglia. During the response to mental stress, 5-HT acts on 5-HT3 receptors, which continuously enhances the long-term gain effect of sympathetic ganglia, increases the tone of sympathetic nerves and peripheral resistance, leading to increased blood pressure; in the periphery 5-HT acts as a vasoconstrictor, playing a role in vasoconstriction when vascular endothelium is damaged, leading to increased blood pressure together with other vasoconstrictors.,,
Other relevant sources of pathogenesis
In addition, there are some other factors such as oxidative stress, genetics, and abnormal NO regulation reports, of which run through the pathogenesis of mental stress-induced hypertension.
| Diagnosis|| |
In combination, medical history, blood pressure measurement, and mental stress assessment allow mental stress-induced hypertension to be comprehensively diagnosed [Figure 1].
|Figure 1: Flow chart of the diagnosis and treatment of mental stress-induced hypertension. Notes: PHQ 9 is the Patient Health Questionnaire 9; GAD 7 is the Generalized Anxiety Disorder Scale 7; MBI is the Maslach burnout inventory; and PSQI is the Pittsburgh Sleep Quality Index; TCM is Traditional Chinese Medicine|
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The general common symptoms seen in patients with mental stress-induced hypertension are as follows: dizziness, headache, neck stiffness, fatigue, and palpitations, which may be accompanied by insomnia, reduced interest, decreased attention, tension, fear, temper impatience, and in some severe cases, the patients also show a certain sensitivity to sound, spatial, and temperature cues as well as other manifestations.
It is essential for clinicians to focus on asking patients about emotional and sensory changes. It is recommended to ask whether the patient has a family history of hypertension, anxiety, depression, or other mental diseases and whether he/she has recently encountered major life events.
There is a requirement to focus on the examination of peripheral vascular pulse, vascular murmur, heart murmur, lower limb edema, and other conditions. Cardiac auscultation often shows an accentuated second heart sound in the aortic valve area, a slight systolic murmur, and occasionally early systolic ejection sounds.
Routine blood and urine, biochemistry, coagulation, electrocardiogram, echocardiography, carotid artery color ultrasound, 24 h ambulatory blood pressure, and other basic examinations should be conducted. If necessary, it is recommended to perform renin, epinephrine, aldosterone, renal ultrasound, computed tomography, or magnetic resonance imaging examinations.
The diagnosis of hypertension
Changes in blood pressure should be comprehensively assessed in combination with office blood pressure measurement, ABPM, and home blood pressure monitoring. Hypertension is diagnosed according to the “2018 Chinese Guidelines for the Management of Hypertension,” with office SBP ≥140 mmHg (1 mmHg = 0.133 kPa) and/or diastolic blood pressure ≥90 mmHg in the absence of anti-hypertensive drugs. SBP ≥140 mmHg and diastolic blood pressure <90 mmHg are considered isolated systolic hypertension. Patients who have a history of hypertension and currently use anti-hypertensive drugs are also diagnosed as having hypertension, although their blood pressure is still lower than 140/90 mmHg.
Hypertension can be classified into Grades 1, 2, and 3 according to the degree of blood pressure elevation. According to the cardiovascular risk level of hypertension, it is divided into four levels: Low risk, intermediate risk, high risk, and very high risk.
The assessment of mental stress
The patients' mental stress can be quantitatively assessed through their chief complaints and scale assessment, which includes anxiety and depression assessment, work stress, and sleep assessment, as follows:
The Patient Health Questionnaire-9 is a self-rating scale commonly used in clinical practice to screen for depression, it scores range as: 0–4 points for no depression; 5–9 points for slight depression; 10–14 points for moderate depression; 15–19 points for moderate-to-severe depression; and 20–27 points for severe depression. For patients with severe depression, referral to a psychiatric specialist is recommended.
The Generalized Anxiety Disorder Scale-7 is a self-rating scale commonly used in clinical practice to screen for anxiety, and it scores range as: 0–4 points for no anxiety; 5–9 points for slight anxiety; 10–13 points for moderate anxiety; 14–18 points for moderate-to-severe anxiety; and 19–21 points for severe anxiety. For patients with severe anxiety, referral to a psychiatric specialist is recommended.
Work stress assessment
The Maslach Burnout Inventory can assess work burnout by considering three dimensions; emotional exhaustion, work apathy, and lack of job fulfillment. The three dimensions can be used separately to assess the different aspects of work burnout, or in combination, with a high level of burnout being considered when all three dimensions score highly.
The patient's sleep status is assessed in conjunction with the patient's history of insomnia and the Sleep Assessment Scale and Classification, Third Edition International Classification of Sleep Disorders. The Pittsburgh Sleep Quality Index is applicable to the assessment, considering the preceding 1 month, of sleep disorders and psychological problems as well as sleep quality among the general population. The total score ranges from 0 to 21, a greater score indicating poorer sleep quality, and a total score >7 is used as the reference cutoff value for adult sleep quality problems.
Depending on the characteristics of mental stress-induced hypertension, the common clinically specific types of hypertension and mental stress-induced hypertension are compared to produce a differential diagnosis.
Refractory hypertension intersects with but does not completely overlap with stress-related hypertension. Refractory hypertension is defined as failure to effectively control blood pressure either, after >1 month of reasonably tolerable treatment with ≥3 antihypertensive medications (including diuretics) with lifestyle improvement, or after ≥4 antihypertensive medications; some patients with mental stress-induced hypertension have the characteristics of refractory hypertension, but when the mental stress is relieved, or combined with anti-anxiety, depression and other drug treatment, the blood pressure can be well controlled, and the types and the dose of anti-hypertensive drugs are reduced.
Mental stress-induced hypertension needs to be differentiated from secondary hypertension such as pheochromocytoma, paraganglioma, primary hyperaldosteronism, and drug-induced hypertension. Pheochromocytoma and paraganglioma can synthesize and secrete a large amount of catecholamines, causing a series of clinical syndromes such as elevated blood pressure, which may be accompanied by symptoms such as headache, palpitation, hyperhidrosis, anxiety, fear, or impending death, and they are easily confused with mental stress-induced hypertension.
Occult hypertension indicates that patients show normal office blood pressure, while home self-measured blood pressure or ambulatory blood pressure meets the diagnosis standards of hypertension; it is the opposite of the manifestations of white-coat hypertension.
The members of the consensus expert committee are listed as follows (in alphabetical order): Bo Dong (Department of Cardiology, Shandong Provincial Hospital, China); Jianqun Fang (Department of Psychosomatic Medicine, General Hospital of Ningxia Medical University, China); Feng Gao (Department of Cardiology, Yan'an University Affiliated Hospital, China); Qingshan Geng (Department of Cardiology, Guangdong General Hospital, China); Ruowen Huang (Department of Cardiology, No. 1 Affiliated Hospital of Medical School, Xi'an Jiaotong University, China); Shuwei Huang (Department of Cardiology, No. 2 Affiliated Hospital of Zhejiang Chinese Medical University, China); Yuming Li (Department of Cardiology, TEDA International Cardiovascular Hospital, China); Gang Liu (Department of Cardiology, The First Hospital of Hebei Medical University, China); Meiyan Liu (Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, China); Lin Lu (The Institute of Mental Health, Peking University Sixth Hospital, China); Jialiang Mao (Department of Cardiology, Renji Hospital of Shanghai Jiao Tong University School of Medicine, China); Dazhuo Shi (Department of Cardiology, China Academy of Chinese Medical Sciences Xiyuan Hospital, China); Xiangdong Tang (Sleep Medicine Center, West China Hospital of Sichuan University, China); Fengshi Tian (Department of Cardiology, Tianjin Chest Hospital, China); Hong Tu (Department of Cardiology, Fuwai Cardiovascular Hospital, Chinese Academy of Medical Sciences Shenzhen, China); Hao Wang (Department of Hypertension, Henan People's Hospital, China); Jian'An Wang (Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, China); Qing Wang (Department of Cardiology, Fuxing Hospital, Capital Medical University, China); Xiangqun Wang (Department of Psychiatry, Peking University Sixth Hospital, China); Hui Wu (Department of Cardiology, The First Affiliated Hospital of Guangzhou Medical University, China); Yanqing Wu (Department of Cardiology, No. 2 Affiliated Hospital of Nanchang University, China); Peng Xiong (Department of Psychiatry, No. 1 Affiliated Hospital of Kunming Medical University, China); Guolong Yu (Department of Cardiology, Xiangya Hospital Central South University, China); Xiaoling Zhao (Department of Cardiology, Chengde Central Hospital, China).
The members of the writing committee are listed as follows (in alphabetical order): Chunlin Bai (Department of Cardiology, No. 1 Hospital of Shanxi Medical University, China); Gong Cheng (Department of Cardiology, Shaanxi Provincial People's Hospital, China); Yinghua Cui (Department of Cardiology, Affiliated Hospital of Jining Medical College, China); Yuming Li (Department of Cardiology, TEDA International Cardiovascular Hospital, China); Meiyan Liu (Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, China); Yuanyuan Liu (Department of Cardiology, Tianjin Chest Hospital, China); Yan Lu (Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, China); Yanping Ren (Department of Geriatric Cardiology, No. 1 Affiliated Hospital of Medical School, Xi'an Jiaotong University, China); Huimin Su (Department of Cardiovascular Disease Diagnosis and Treatment Center, The First Affiliated Hospital of Henan University of TCM, China); Xinyu Sun (Department of Psychiatry, Peking University Sixth Hospital, China); Xingguo Sun (Department of Cardiopulmonary Function, Fuwai Cardiovascular Hospital, Chinese Academy of Medical Sciences, China); Junmei Wang (Department of Neurology, Ordos Center Hospital, China); Le Wang (Department of Cardiology, The First Hospital of Hebei Medical University, China); Yibo Wang (Department of Cardiology, Jiao Tong Univ. No. 9 Hosp. Huangpu, China); Yumei Wang (Department of Mental Health, The First Hospital of Hebei Medical University, China); Ning Yang (Department of Hypertension, TEDA International Cardiovascular Hospital, China); Zhipeng Wang (Department of Cardiology, Beijing Changping Hospital of Traditional Chinese Medicine, China); Shaojun Wen (Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, China); Haicheng Zhang (Department of Cardiology, Peking University People's Hospital, China).
Financial support and sponsorship
Conflicts of interest
Prof. Lin Lu is the Editor-in-Chief, Prof Jian'An Wang is the Deputy Editor-in-Chief, Prof. Meiyan Liu and Prof. Qingshan Geng are the Executive Editor-in-Chief of the Heart and Mind journal. The article was subject to the journal's standard procedures, with peer review handled independently of them and their research groups. There are no conflicts of interest.
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