|
 
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| EDITORIAL |
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| Year : 2022 | Volume
: 6
| Issue : 3 | Page : 101-104 |
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Expert consensus on diagnosis and treatment of adult mental stress-induced hypertension in China (2022 Revision): Part B
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 Zhang1, 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 | 28-Jun-2022 |
| Date of Acceptance | 25-Jul-2022 |
| Date of Web Publication | 30-Sep-2022 |
Correspondence Address:
Prof. Meiyan Liu
Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/hm.hm_16_22
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, College of Cardiovascular Physicians of Chinese Medical Doctor Association, and Hypertension Group of the 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 two parts. The sections of Part A include (I) Background and epidemiological characteristics, (II) Pathogenesis, and (III) Diagnosis. The sections of Part B contain (IV) Treatment recommendations, and (V) Prospects. This article presents Part B of the consensus.
Keywords: COVID-19, expert consensus, hypertension, mental stress
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, Zhang H, Liu M. Expert consensus on diagnosis and treatment of adult mental stress-induced hypertension in China (2022 Revision): Part B. Heart Mind 2022;6:101-4 |
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, Zhang H, Liu M. Expert consensus on diagnosis and treatment of adult mental stress-induced hypertension in China (2022 Revision): Part B. Heart Mind [serial online] 2022 [cited 2023 Mar 29];6:101-4. Available from: http://www.heartmindjournal.org/text.asp?2022/6/3/101/357542 |
| Treatment Recommendations | |  |
Nondrug therapies
Lifestyle interventions
Lifestyle interventions include salt restriction, smoking cessation, alcohol restriction, weight control, balanced nutrition, and adequate sleep [Figure 1]. | Figure 1: Flow chart of the diagnosis and treatment of mental stress-induced hypertension. PHQ-9 = Patient Health Questionnaire 9, GAD-7 = Generalized Anxiety Disorder Scale 7, MBI = Maslach Burnout Inventory, PSQI = Pittsburgh Sleep Quality Index, TCM = Traditional Chinese Medicine
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Exercise therapy
Exercise therapies include Baduanjin, Tai Chi, jogging, swimming, and yoga.
Psychotherapy
Psychotherapy includes emotional release stress therapy, music therapy, mindfulness, biofeedback, cognitive behavioral therapy, etc.
Medication
It is beneficial to make an early identification of anxiety/depression symptoms in patients with hypertension and make an in-time intervention to control blood pressure. Therefore, it is necessary to perform a comprehensive assessment based on the patient's blood pressure grade and cardiovascular risk level as well as mental stress grade, to develop an individualized diagnosis and treatment plan suitable for patients with differing degrees of mental stress-induced hypertension. The specific drug usage is described as follows.
Antihypertensive drugs
The conventional treatment for hypertension is given to patients with reference to the “2018 Chinese guidelines for the management of hypertension.”[1] The commonly used antihypertensive drugs include calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists, diuretics, and β-blockers, as well as fixed combination preparations composed of the above drugs. Depending on the patients' risk factors, subclinical target organ damage, and combination of clinical diseases, the drugs are used rationally with certain antihypertensive drugs preferentially selected.
It is noted that central antihypertensive drug, such as clonidine, reserpine, and methyldopa, may cause psychological problems (e.g., depression)[2] and should be used with caution in hypertensive patients with mental stress.
Neurometabolic drugs
It is recommended to select drugs (such as oryzanol, adenosylcobalamin, and folic acid) which can regulate neurometabolism on the basis of autonomic nervous function; in addition, it is necessary to consider dietary habits. Appropriate supplementation is beneficial for vitamin and electrolyte dificiency, leading to better treatment of mental stress-induced hypertension.
Antianxiety and antidepressant drugs
According to the “Expert consensus on the diagnosis and treatment of myocardial ischemia in patients with stable coronary heart disease caused by psychological stress,”[3] antianxiety and antidepressant treatment should be given to patients with anxiety and depression-induced hypertension with reference to the actual situation. The commonly used first-line antianxiety and antidepressant drugs in clinical practice are 5-HT selective serotonin reuptake inhibitors (SSRIs), mainly including: (1) fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram, and escitalopram; (2) 5-HT and selective norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine and duloxetine; (3) 5HT1A receptor agonists, such as tandospirone;[4] and (4) benzodiazepines, such as alprazolam, with anxiolytic effects.
SSRIs are effective and safe, with fewer cardiovascular adverse reactions, but attention should still be paid to the initial dose, gradual dose increase, and slow dose reduction during use. The use of SSRIs with warfarin, aspirin, and clopidogrel may increase the risk of bleeding, so it is necessary to control the dose and closely monitor thrombin time.[5] SSRIs are not used in combination with monoamine oxidase inhibitors to prevent 5-HT syndrome.[6] Alcohol consumption during treatment is not recommended in patients taking SSRIs.[7] Notes for the use of SNRIs are as follows: high doses of venlafaxine (such as 300 mg/d) will cause an increase in blood pressure;[8] duloxetine has little effect on blood pressure;[9] a “discontinuation syndrome” exhibited as dizziness, nausea, insomnia, and irritability may occur when venlafaxine and duloxetine are discontinued, so the drug should be gradually discontinued in clinical application, with “discontinuation syndrome” identified and treated in time.[10] Tandospirone and alprazolam have an adjuvant antihypertensive effect, but cardiovascular adverse reactions should also be monitored closely.[11],[12]
Sedative hypnotics
According to the “Chinese Expert Consensus Group on diagnosis and treatment of cardiovascular diseases complicated with insomnia,”[13] for hypertensive patients with sleep disorders, it is recommended to give sedative hypnotics to improve insomnia. Common clinical drugs include benzodiazepines (such as estazolam and alprazolam) and nonbenzodiazepines (such as zolpidem). In addition, melatonin and melatonin receptor agonists such as agomelatine are also used. However, more clinical studies are still needed to confirm their efficacy, and it is necessary to closely monitor the cardiovascular adverse reactions of such drugs and their effects on cognitive function.
Diagnosis and treatment with Traditional Chinese Medicine
Traditional Chinese Medicine (TCM) diagnosis follows the concept of a “holistic view” and “overall analysis of signs and symptoms.” In the TCM understanding of mental stress-induced hypertension, patients can be diagnosed with different patterns of syndromes through the four diagnostic methods of inspection, auscultation and olfaction, inquiry, and palpation based on the theory of syndrome differentiation of Zang and Fu (the viscera), syndrome differentiation with eight principles (Yin and Yang, Exterior and Interior, Cold and Heat, and Excess and Deficiency), and syndrome differentiation of the meridians and collaterals. The disease is then treated according to patterns of syndromes such as hyperactivity of liver-yang, phlegm-fire disturbing mind, liver qi stagnation, qi stagnation and blood stasis, and qi and blood deficiency.
TCM herbal treatment: Root of Chinese Thorowax and Turmeric Root-tuber can be used to disperse stagnated liver qi to relieve depression, and Tuber Fleeceflower Stem, Thinleaf Milkwort Root-bark, as well as Silktree Albizzia Bark can be used to calm the heart and tranquilize the mind. Among the herbal treatment, the application of Chinese patent medicines include: for patients with qi deficiency, ginseng fruit saponins are recommended to replenish qi and calm the mind;[12] for patients with qi stagnation and blood stasis, ginkgolides such as Ginkgo biloba dripping pills and compound Danshen drops can be used to promote blood circulation, remove blood stasis, and promote qi;[14] and for patients with qi and blood deficiency, compound preparations such as Xinling pills can be taken to replenish qi, promote blood circulation, and remove obstruction in collaterals; and Anshen Buxin Liuwei pills can calm and tranquilize the mind.[15]
Acupuncture and moxibustion treatment: Different acupoints can be used such as Hegu and Taichong to regulate qi movement, and Neiguan and Baihui to calm the mind.
Patient self-management model
It is important for patients with stress induced hypertension to self-manage to help them recover from the disease.
Doctors can develop a self-management model for patients, to provide: (1) disease awareness and acceptance; (2) assessment of compliance with medication and self-assessment of emotional state in the face of stress; (3) gradual reduction of repeated blood pressure measurements due to emotional stress by means of psychological adjustment; and (4) reassessment of medication use, emotional state, and effectiveness of the psychological adjustment.
Intended therapeutic target
The patient's subjective symptoms will be significantly relieved and the scores on various mental stress scales will be in the normal range or significantly improved from before; the general hypertensive patient should be reduced to <140/90 mmHg; those who can tolerate it may be further reduced to <130/80 mmHg.
| Prospects | | |
This consensus includes psychological factors in the hypertension assessment system, which helps clinicians to identify and diagnose patients with mental stress-induced hypertension, to control their blood pressure, and reduce their cardiovascular risk. It is hoped that more multicenter longitudinal clinical studies on stress induced hypertension will be conducted to investigate the epidemiology and current status of diagnosis and treatment of stress induced hypertension in China.
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 TCM, 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
Nil.
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-Chiefs 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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