Differences in behavior profile between normotensive subjects and patients with white-coat and sustained hypertension

Social support and trait personality are independently associated with resting cardiovascular function in women

OBJECTIVES

Social support is thought to positively influence appraisals of stressors and coping resources, thereby attenuating the harmful effects of stress. Notably, perceived available support (rather than actually received support) is believed to benefit well-being independent of the sense of obligation or threats to self-esteem that receiving support may entail. This study examined whether perceived support levels were associated with reduced cardiovascular levels, an important predictor of cardiovascular disease risk, independent of broad trait personality variables frequently reported to overlap with perceived support. In doing so, we sought to determine whether the effects of perceived support are independent of links between personality and social support.

DESIGN

A cross-sectional design was employed.

METHODS

Resting cardiovascular levels were measured using a Finometer in a sample of healthy women (N = 145). The Short-Form Social Support Questionnaire and the Revised Eysenck's Personality Questionnaire were used to assess support levels and personality. Regression was used to compare associations with psychometric indices of support (namely, perceived network size and perceived satisfaction with support) and personality (psychoticism, extraversion and neuroticism).

RESULTS

Support independently predicted systolic blood pressure (SBP; p = .03) and HR (p = .02) when personality was controlled for, while personality also predicted SBP (p = .01) and DBP (p = .02). Support effects were not mediated by personality.

CONCLUSIONS

The findings corroborate previous research indicating links between support and resting cardiovascular levels and additionally demonstrate these to be independent of associations between support and personality.

The misdiagnosis of hypertension: the role of patient anxiety

BACKGROUND

The white coat effect (defined as the difference between blood pressure [BP] measurements taken at the physician's office and those taken outside the office) is an important determinant of misdiagnosis of hypertension, but little is known about the mechanisms underlying this phenomenon. We tested the hypothesis that the white coat effect may be a conditioned response as opposed to a manifestation of general anxiety.

METHODS

A total of 238 patients in a hypertension clinic wore ambulatory blood pressure monitors on 3 separate days 1 month apart. At each clinic visit, BP readings were manually triggered in the waiting area and the examination room (in the presence and absence of the physician) and were compared with the mercury sphygmomanometer readings taken by the physician in the examination room. Patients completed trait and state anxiety measures before and after each BP assessment.

RESULTS

A total of 35% of the sample was normotensive, and 9%, 37%, and 19% had white coat, sustained, and masked hypertension, respectively. The diagnostic category was associated with the state anxiety measure (F(3,237) = 6.4, P < .001) but not with the trait anxiety measure. Patients with white coat hypertension had significantly higher state anxiety scores (t = 2.67, P < .01), with the greatest difference reported during the physician measurement. The same pattern was observed for BP changes, which generally paralleled the changes in state anxiety (t = 4.86, P < .002 for systolic BP; t = 3.51, P < .002 for diastolic BP).

CONCLUSIONS

These findings support our hypothesis that the white coat effect is a conditioned response. The BP measurements taken by physicians appear to exacerbate the white coat effect more than other means. This problem could be addressed with uniform use of automated BP devices in office settings.

Anxiety and outcome expectations predict the white-coat effect

OBJECTIVE

To determine whether elevated clinic blood pressure compared with daytime ambulatory blood pressure, referred to as the white-coat effect, is associated with anxiety and increased blood pressure expectancy in the doctor's office.

METHODS

The 24-h ambulatory blood pressure measurements and physicians' blood pressure measurements were obtained in 226 normotensive and hypertensive study participants. Anxiety levels were assessed multiple times during the clinic visit using a Visual Analog Scale. Participants' expectations regarding the clinic visit were assessed using a six-item scale (Expectations of Outcomes Scale). The white-coat effect was computed as the difference between the mean clinic blood pressure and the mean daytime ambulatory blood pressure. Multiple regression analysis was performed to examine the association between anxiety, outcome expectations and the white-coat effect, adjusting for age, sex, and ambulatory blood pressure level.

RESULTS

As predicted, outcome expectations and anxiety during the clinic visit were significantly associated with the white-coat effect. Results of the regression analysis indicated that only expectancy had an independent effect on the systolic white-coat effect; however, both anxiety and expectancy had independent effects on the diastolic white-coat effect.

CONCLUSION

Our results provide empirical support to the hypothesis that anxiety and blood pressure expectancy may elevate clinic blood pressure.

Prevalence and determinants of isolated clinic hypertension in the Finnish population: the Finn-HOME study

BACKGROUND

Previous studies performed in selected hypertensive subjects have reported several possible determinants of isolated clinic hypertension (ICH). The purpose of this study was to assess the prevalence and determinants of ICH in a randomly selected nationwide population.

METHODS

We studied a representative sample of the general adult population (1440 45-74-year-old subjects) in Finland not treated for hypertension. The subjects were drawn from the participants of a multidisciplinary epidemiological survey, the Health 2000 Study. Subjects included in the study underwent a clinical interview, determination of serum lipids and glucose, measurement of clinic and home blood pressure (BP), and psychometric tests for psychological distress, hypochondriasis, depression, and alexithymia. The diagnosis of ICH was based on a clinic BP of 140/90 mmHg or greater and a home BP less than 135/85 mmHg.

RESULTS

The prevalence of ICH in the untreated Finnish adult population was 15.6 and 37.5% among untreated clinic hypertensive individuals. In a multivariate logistic regression analysis, ICH was associated with mildly elevated systolic and diastolic BP, lower body mass index (BMI), and non-smoking status. Subjects with ICH represent an intermediate group between the normotensive and sustained hypertensive individuals where cardiovascular risk is concerned (age, BP, diabetes prevalence, lipid profile, and BMI).

CONCLUSION

ICH is a common phenomenon in the general population. Non-smoking individuals with mildly elevated BP and low BMI have a higher risk of ICH. Physicians should disassociate the diagnosis of ICH from any psychosocial disorders, but should remember that patients with ICH have an increased risk of cardiovascular disease.

Coping styles and quality of life in patients with non-insulin-dependent diabetes mellitus

The authors examined the relationship between coping style and perceived quality of life in patients with non-insulin-dependent diabetes mellitus. Diabetic patients (N=123) and nondiabetic comparison patients (N=124) treated at a Portuguese health center completed the Nottingham Health Profile, a quality-of-life measure. The diabetic patients also completed the Coping Responses Inventory, a measure of coping styles. In both groups, female subjects had poorer quality-of-life ratings than male subjects. Diabetic patients were more likely to regard diabetes and the consequent changes in lifestyle as a threat than as a challenge. A greater proportion of diabetic patients used avoidance coping styles, which overall were related to worse quality of life, than used active confrontation coping styles. Coping style was significantly correlated with several dimensions of quality of life in diabetic patients.

Health-related quality of life of subjects with known and unknown hypertension: results from the population-based Hortega study

OBJECTIVE

Analyze the impact of known and unknown hypertension on health-related quality of life (HRQOL).

DESIGN AND SETTING

A descriptive cross-sectional study in the health coverage area of the Rio Hortega University Hospital, in north-western Spain, on a simple random sample of 33022 individuals.

PARTICIPANTS

Following a multiphase sampling, a final sample of 466 people, representative of the general population, was analyzed. The blood pressure of patients with known hypertension and those with a blood pressure of >or= 140/90 mmHg was subjected to ambulatory monitoring in order to evaluate the degree of blood pressure control and to detect those patients with white-coat hypertension, respectively.

RESULTS

After adjustment for sociodemographic variables, associated cardiovascular risk factors, hypertension complications and comorbidity, the patients with known hypertension presented lower scores on four SF-36 scales: physical function, general health, vitality and mental health. The group of subjects with hypertension, whether diagnosed or not, displayed a poorer HRQOL with respect to the non-hypertensive patients, solely in physical functioning and general health. Those patients with known hypertension reported more bodily pain than those subjects with unknown hypertension, while there were no differences between patients with unknown hypertension and the non-hypertensive ones.

CONCLUSIONS

Patients with known hypertension presented a poorer HRQOL. This deterioration of the subjective state of health was not observed in patients who had not yet been diagnosed, which suggests it is due, above all, to the labeling effect and/or to the treatment more than to the hypertension per se.

Common mental disorder and physical illness in the Renfrew and Paisley (MIDSPAN) study

OBJECTIVE AND METHODS

The relationship between psychological distress measured by the General Health Questionnaire 30 (GHQ-30) and risk factors for coronary heart disease, angina, electrocardiogram (ECG) abnormalities and chronic sputum was modelled using logistic regression on baseline data from a community study of 15,406 men and women.

RESULTS

Psychological distress was associated with low forced expiratory volume (FEV(1)) and low body mass index (BMI) in men, and low systolic blood pressure only in women. There were associations between psychological distress and coronary heart disease and cardiorespiratory outcomes. The associations were particularly strong for angina without ECG abnormalities (Men: OR 3.26, 95% CI 2.52-4.21; Women: OR 2.89, 95% CI 2.35-3.55) and for angina with ECG abnormalities (Men: OR 2.68, 95% CI 2.03-4.52; Women: OR 2.88, 95% CI 1.89-4.39), in both men and women, even after adjusting for classical CHD and cardiorespiratory risk factors. An association between psychological distress and severe chest pain, indicative of previous myocardial infarction, was found in both men and women (Men: OR 1.89, 95% CI 1.44-2.47; Women: OR 1.91, 95% CI 1.48-2.47), respectively, and between psychological distress and ECG ischaemia, but in men only (OR 1.32, 95% CI 1.00-1.76).

CONCLUSION

The association between psychological distress and cardiorespiratory outcomes is likely to be a consequence of the pain and discomfort of the symptoms of the illness. Chest pain may also be a symptom of psychological distress. However, psychological distress, as a predictor and possible risk factor increasing the risk of coronary heart disease, cannot be ruled out.

Relation between clinical and therapeutic variables and quality of life in hypertension

OBJECTIVE

Study the relation between quality of life (QoL) and various clinical, therapeutic and sociodemographic variables in treated hypertensive patients.

MATERIAL AND METHODS

A prospective study was carried out in 92 primary care centres in Spain. A total of 269 hypertensive patients were selected and 106 healthy normotensive individuals were included as controls. At the time of inclusion a wide range of clinical variables was documented. QoL was assessed at baseline and 1 month after the intensification of antihypertensive therapy, using a self-administered, specific hypertension, 56-item questionnaire in addition to the generic EuroQoL-5D.

RESULTS

QoL was poorer among the hypertensive subjects than among the normotensive individuals, even adjusting for the differences observed between the groups (age, sex, education and working status). The same was found with the EuroQol-5D. In the hypertensive subjects, after applying a multiple regression equation, only four variables significantly retained their negative impact on QoL: sex (female), greater organ damage and higher heart rate and weight. After the intensification of antihypertensive therapy with irbesartan, QoL improved significantly. Neither the presence of side-effects during the month of follow-up, nor the degree of BP reduction showed a significant impact on QoL, although the latter came close to statistical significance.

CONCLUSIONS

Hypertensive patients have significantly poorer QoL than normotensive subjects, even with adjustment for differences. In hypertensives, QoL is affected by some clinical variables that might help us to identify those with worse QoL. Intensification of antihypertensive therapy produced a positive impact on QoL.

[Evolution of white coat hypertension to sustained hypertension. One year follow-up by ambulatory blood pressure monitoring]

BACKGROUND

To analyse the evolution of the white coat hypertension (WCH) to sustained hypertension, by means of ambulatory blood pressure monitoring (ABPM) during the first year after its diagnosis.

SUBJECTS AND METHOD

A prospective study of cohorts was designed in La Orden Health Center of Huelva, Spain. 86 individuals divided in two groups: a) group not exposed (GNE): 43 voluntary normotensives, and b) group exposed (GE): 43 individuals with WCH, defined as the blood pressure was superior or above 140 and/or 90 mmHg, respectively, with a mean diurnal ABPM below 135 and 85 mmHg in both cases. A ABPM was performed (Spacelabs 90207) at the beginning of the study, after 6 months and after 12 months. The clinical and ambulatory blood pressure and the incidence of sustained hypertension by ABPM in the two groups were compared. Sustained hypertension was considered when the diurnal blood pressure was superior to 135 and/or 85 mmHg for SBP and DBP.

RESULTS

At the end of the study, 82 patients were evaluate. The incidence of hypertension at 6 months of follow-up was of 4,76% (CI, 0-26.9) in GNE and 19.04% (95% CI, 0-42,6) in GE (RR: 3.8; 95% CI, 0.86-16.9) (p = 0.052). At one year of follow-up the incidence of hypertension in GNE was of 9.8% (95% CI, 0.31-1) as opposed to 46.3% (95% CI, 20.5-72.1) in GE (RR: 4.63; CI, 1.7-12.4) (p = 0.001).

CONCLUSIONS

The patients with WCH present a higher incidence of hypertension as compared to the normotensives, after 12 months of our follow-up.