High Dietary Sodium, Measured Using Spot Urine Samples, is Associated with Higher Blood Pressure among Young Adults in Haiti

Background

Hypertension (HTN) is the leading cardiovascular disease (CVD) risk factor in Haiti and is likely driven by poverty-related social and dietary factors. Salt consumption in Haiti is hypothesized to be high but has never been rigorously quantified.

Methods

We used spot urine samples from a subset of participants in the population-based Haiti Cardiovascular Disease Cohort to estimate population mean daily sodium intake. We compared three previously validated formulas for estimating dietary sodium intake using urine sodium, urine creatinine, age, sex, height, and weight. We explored the association between dietary sodium intake and blood pressure, stratified by age group.

Results

A total of 1,240 participants had spot urine samples. Median age was 38 years (range 18-93), and 48% were female. The mean dietary sodium intake was 3.5-5.0 g/day across the three estimation methods, with 94.2%-97.9% of participants consuming above the World Health Organization (WHO) recommended maximum of 2 g/day of sodium. Among young adults aged 18-29, increasing salt intake from the lowest quartile of consumption (<3.73 g/day) to the highest quartile (>5.88 g/day) was associated with a mean 8.71 mmHg higher systolic blood pressure (SBP) (95% confidence interval: 3.35, 14.07; p = 0.001). An association was not seen in older age groups. Among participants under age 40, those with SBP ≥120 mmHg consumed 0.5 g/day more sodium than those with SBP <120 mmHg (95% confidence interval: 0.08, 0.69; p = 0.012).

Conclusions

Nine out of 10 Haitian adults in our study population consumed more than the WHO recommended maximum for daily sodium intake. In young adults, higher sodium consumption was associated with higher SBP. This represents an inflection point for increased HTN risk early in the life course and points to dietary salt intake as a potential modifiable risk factor for primordial and primary CVD prevention in young adults.

Addressing the problem of inaccuracy of measured 24-hour urine collections due to incomplete collection

The 24-hour urine collection is widely considered the gold standard for assessing 24-hour excretion of various analytes. Yet, studies show that >30% of collections are incomplete and hence understate the true 24-hour excretion. We previously validated an equation for estimating an individual's 24-hour creatinine excretion, based on weight, sex, race, and age. The present study examines whether routinely correcting measured 24-hour excretion of an analyte using the ratio of estimated to measured 24-hour urine creatinine mitigates the misleadingly low values that result from undercollection. Ninety-nine participants, recruited from an outpatient hypertension clinic, submitted a 24-hour urine collection for measurement of creatinine and sodium excretion. The urine collections were dichotomized into complete (n = 63) and incomplete (n = 36) collections based on previously described criteria for expected 24-hour creatinine excretion. To adjust for possible incompleteness of collections, the measured 24-hour values were then corrected by multiplying them by the ratio of estimated to measured 24-hour urine creatinine. The mean 24-hour creatinine excretion was 1682 mg/d among complete collectors. Among incomplete collectors, the mean was 1211 mg/d before and 1695 mg/d after, adjustment. Similarly, mean 24-hour sodium excretion was 156 mEq/d among complete collectors, whereas among incomplete collectors it was 121 mEq/d before and 171 mEq/d after, adjustment. Undercollection of 24-hour urines is a common problem and results in misleadingly low values for excretion of analytes being measured. Routine adjustment of 24-hour urine values using estimated values for 24-hour creatinine excretion can greatly mitigate artifactually low 24-hour excretion results.

Loop Diuretics in the Treatment of Hypertension

Loop diuretics are not recommended in current hypertension guidelines largely due to the lack of outcome data. Nevertheless, they have been shown to lower blood pressure and to offer potential advantages over thiazide-type diuretics. Torsemide offers advantages of longer duration of action and once daily dosing (vs. furosemide and bumetanide) and more reliable bioavailability (vs. furosemide). Studies show that the previously employed high doses of thiazide-type diuretics lower BP more than furosemide. Loop diuretics appear to have a preferable side effect profile (less hyponatremia, hypokalemia, and possibly less glucose intolerance). Studies comparing efficacy and side effect profiles of loop diuretics with the lower, currently widely prescribed, thiazide doses are needed. Research is needed to fill gaps in knowledge and common misconceptions about loop diuretic use in hypertension and to determine their rightful place in the antihypertensive arsenal.

Labile and Paroxysmal Hypertension: Common Clinical Dilemmas in Need of Treatment Studies

Although "labile hypertension" is regularly encountered by clinicians, there is a paucity of information available to guide therapeutic decisions. This review discusses its clinical relevance, the limitations of current knowledge, and possible directions for future research and clinical management. Results of studies that assessed measures of blood pressure variability or reactivity are reviewed. The limited information about effects of antihypertensive drugs on blood pressure variability is discussed. Two different clinical presentations are differentiated: labile hypertension and paroxysmal hypertension. Labile hypertension remains a clinical impression without defined criteria or treatment guidance. Paroxysmal hypertension, also called pseudopheochromocytoma, presents as dramatic episodes of abrupt and severe blood pressure elevation. The disorder can be disabling. Although it regularly raises suspicion of a pheochromocytoma, such a tumor is found in <2 % of patients. The cause, which involves both emotional factors and the sympathetic nervous system, and treatment approaches, are presented.

Personalizing the diuretic treatment of hypertension: the need for more clinical and research attention

Neither randomized controlled trials nor efforts to identify genetic markers have been helpful with regard to the goal of individualizing diuretic therapy in the treatment of hypertension, a goal that receives little clinical or research attention. This review will examine, and bring attention to, the considerable yet overlooked information relevant to individualizing diuretic therapy. It will bring attention to clinical, biochemical, and pharmacological clues that can be helpful in identifying who is likely to respond to a diuretic, who needs a stronger diuretic regimen, which diuretic to prescribe, and how to minimize adverse effects. New directions for clinical research aimed at individualizing use in hypertension will be explored. Research and clinical attention to the goal of individualizing diuretic treatment in hypertension need to be renewed, to help us achieve greater hypertension control with fewer adverse effects and lower costs.

Diuretic use in black patients with uncontrolled hypertension

BACKGROUND

Highly publicized recommendations favor the use of diuretics as a first-line or add-on agent in the management of hypertension, particularly among black patients and patients with resistant hypertension. Failure to follow such guidelines might contribute to high rates of uncontrolled hypertension. This study assessed diuretic prescribing patterns in a sample of black patients with uncontrolled hypertension who were identified from a population of home care recipients.

METHODS

The study was conducted in an urban home health organization. Participants were black, aged 21 to 80 years, and had a diagnosis of hypertension. Participants with uncontrolled hypertension were identified, and in-home interviewers collected information on prescribed antihypertensive medications.

RESULTS

Of 658 participants, 5.5% were not prescribed any antihypertensives, and only 46% were prescribed a diuretic. Participants who were not taking a diuretic were taking fewer antihypertensive medications (1.7 vs. 2.9; P < 0.0001), had a higher mean diastolic blood pressure (89.2 vs. 85.5; P = 0.0005), and were more likely to have a systolic blood pressure ≥160mm Hg (57.6% vs. 49.0%; P = 0.04). The adjusted mean systolic and diastolic blood pressures were 5 and 4mm Hg lower, respectively, in patients who were taking a diuretic.

CONCLUSIONS

In this sample of black patients with uncontrolled hypertension, despite wide publicizing of the recommendations for use of diuretics, a majority are still not receiving a diuretic. This important issue merits continued attention.

The clinical spectrum of labile hypertension: a management dilemma

J Clin Hypertens (Greenwich). 2009;11:491-497. (c)2009 Wiley Periodicals, Inc.Although the management of the labile component of blood pressure elevation is a problem often encountered by clinicians, there is a paucity of information available to guide therapeutic decisions. This review discusses the clinical relevance of blood pressure lability, the limitations of current knowledge, and possible directions for future research and clinical management.

Estimation of 24-hour sodium excretion from spot urine samples

Despite the effects of sodium intake on blood pressure and on response to antihypertensive medication, sodium intake is rarely monitored in clinical practice. The current method, the 24-hour urine collection for sodium excretion, is cumbersome, often incorrectly performed, and not commonly ordered. Further, its results have limited meaning because of the substantial day-to-day variation in sodium intake. A spot urine test to enable convenient, inexpensive, and serial monitoring of sodium excretion would be desirable. In this study, the accuracy of predicting 24-hour sodium excretion from a spot urine sample was assessed. The urine sodium/creatinine ratio was determined from the following urine samples: an "AM sample," submitted at the beginning of the 24-hour urine collection; a "PM sample" collected in the later afternoon/early evening before dinner, at roughly the midpoint of the collection; and a "random sample," collected after its completion. The ratio was then corrected for 24-hour creatinine excretion. The strongest correlation between predicted and actual 24-hour sodium excretion was observed with the PM sample collected near the midpoint (r=0.86, P<.001). This sample also identified persons with sodium excretion <100 mEq/d with a sensitivity of 100% and specificity of 82%. The sodium/creatinine ratio from a spot urine sample collected in the late afternoon/early evening at roughly the midpoint of the 24-hour collection, and adjusted for 24-hour creatinine excretion, strongly correlated with 24-hour sodium excretion. Additional studies are merited to further evaluate the role of the spot urine sample in assessing sodium intake.

The silent epidemic of thiazide-induced hyponatremia

Hyponatremia is a recognized complication of treatment with thiazide diuretics, particularly in patients older than 70 years. Severe and symptomatic hyponatremia requires urgent management, usually requiring infusion of normal or hypertonic saline. Milder, asymptomatic, thiazide-induced hyponatremia requires steps to manage the hyponatremia as well as to prevent its future recurrence. This is a particular problem in patients who despite a history of thiazide-induced hyponatremia might require a diuretic in the management of their hypertension. In this review, the acute management of symptomatic and asymptomatic thiazide-induced hyponatremia is reviewed. Emphasis is also placed on the chronic management of patients who have experienced mild hyponatremia, in whom decisions about treatment with diuretic and nondiuretic antihypertensive agents must be made to satisfy the twin goals of controlling hypertension and avoiding recurrent hyponatremia.

Severe paroxysmal hypertension (pseudopheochromocytoma)

Paroxysmal hypertension always engenders a search for a catecholamine-secreting pheochromocytoma. Yet 98% of people with paroxysmal hypertension do not have this tumor. The cause and management of paroxysmal hypertension remain a mystery, and the subject of remarkably few papers. This review presents an approach to understanding and successfully treating this disorder. Patients experience symptomatic blood pressure surges likely linked to sympathetic nervous system stimulation. A specific personality profile associated with this disorder suggests a psychological basis, attributable to repressed emotion related to prior emotional trauma or a repressive (nonemotional) coping style. Based on this understanding, three forms of intervention, alone or in combination, appear successful: antihypertensive therapy with agents directed at the sympathetically mediated blood pressure elevation (eg, combined alpha- and beta-blockade or central alpha-agonists such as clonidine); psychopharmacologic interventions including anxiolytic and/or antidepressant agents; and psychological intervention, particularly reassurance and increased psychological awareness. An appropriately selected intervention can reduce or eliminate attacks in most patients.

Metabolic variables and plasma leptin concentrations in dairy cows exhibiting reproductive cycle abnormalities identified through milk progesterone monitoring during the post partum period

We have used milk progesterone analysis to monitor reproductive function in lactating dairy cows and have then related this reproductive function to a variety of metabolic variables. Monitoring of cows (n = 41) during the period of onset of luteal function (first milk progesterone reading>5 ng/ml) revealed that delayed onset was associated with increased milk yield and greater loss of body weight and body condition but was not related to plasma metabolite or leptin concentrations. Further monitoring of reproductive function in these 41 cows and an additional 33 cows (total n = 74) during the mating period (from weeks 6 to 14 post partum) identified reproductive cycle abnormalities in 29 (39.2% of animals). The occurrence of cycle abnormalities was associated with increased milk yield (P < 0.05), elevated plasma beta hydroxybutyrate (P < 0.05) and reduced plasma leptin (P < 0.01) concentrations as well as a lower (P < 0.05) rate of gain of body weight and condition score but was not associated with plasma urea or glucose concentrations. Furthermore, cows exhibiting cycle abnormalities had a longer (P < 0.01) interval to first service and a smaller percentage had conceived by 100 days post partum (34.5% versus 66.7%; P < 0.01). These results provide further evidence that impaired reproductive function during the post partum period in dairy cows is caused by a poor energy status and not elevated urea concentrations. Reduced plasma leptin concentrations in animals suffering reproductive dysfunction further supports this view.

Characterisation of long term cat placental explant cultures: uptake of taurine by system β

Dietary taurine is essential for cats and deficiency during pregnancy may lead to abortion, growth restriction or impaired neurological function of kittens. We previously described Na(+)- and Cl(-)-dependent taurine transport by system beta in fragments of freshly isolated cat placenta [Champion EE, Bailey SJ, Glazier JD, Jones CJP, Mann SJ, Rawlings JM, et al. Taurine uptake into cat placental tissue fragments. Placenta 2001;22:A.42]. Here we evaluate long term culture of cat placental explants as a model for the future study of chronic nutrient regulation of amino acid transport in this species. The cat placental explants displayed (i) Na(+)-dependent [(3)H]taurine uptake and (ii) taurine transporter protein on day 7 of culture, as observed in fresh cat placental fragments. The explants had preserved the ability to secrete PGF(2alpha) hormone until day 11 of culture and remained morphologically largely intact until day 7 of culture. This model of placental explant culture will provide an important in vitro method for the study of chronic regulation of amino acid transport in the cat.

System beta and system A amino acid transporters in the feline endotheliochorial placenta

There is no knowledge of the transport mechanisms by which solutes cross the cat placenta or any other endotheliochorial placenta. Here, we investigated whether the amino acid transport systems beta and A are present in the cat placenta using a placental fragment uptake technique. Data were compared with studies in the human placenta, in which the presence of these two transport systems has been well established. A time course of [(3)H]taurine (substrate for system beta) and [(14)C]MeAIB (nonmetabolizable substrate for system A) uptake was determined in the term cat and human placental fragments in the presence and absence (choline substituted) of Na(+), and further studies were carried out over 15 min. Taurine uptake into both cat and human placenta fragments was found to be Na(+) and Cl(-) dependent, and Na(+)-dependent taurine uptake was blocked by excess beta-alanine. MeAIB uptake was found to be Na(+) dependent, and Na(+)-dependent MeAIB uptake was blocked by excess MeAIB or glycine. Western blotting and immunohistochemistry performed on cat and human placenta showed expression of TAUT and ATA2 (SNAT2), proteins associated with system beta and system A activity, respectively. This study therefore provides the first evidence of the presence of amino acid transport systems beta and A in the cat placenta.

Neurogenic essential hypertension revisited: the case for increased clinical and research attention

The management of essential hypertension has increasingly focused on the use of diuretics, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers, which lower blood pressure (BP) through effects on blood volume and on the renin-angiotensin system. However, in many individuals these agents, whether given alone or in combination, fail to normalize BP. In such cases it is likely that hypertension is at least partly maintained by pathophysiologic mechanisms other than volume and the renin-angiotensin system, and therefore, that pharmacotherapy directed at other mechanisms is needed. One such form of hypertension is the often overlooked entity of neurogenic hypertension. The purpose of this article is to renew attention to this overlooked entity, to provide a very clinically oriented overview of its possible causes and manifestations, and to discuss the potentially important treatment implications of recognizing this form of hypertension. These implications underscore the need for further clinical and research attention concerning neurogenically mediated hypertension.

Localization of alkaline phosphatase and Ca2+-ATPase in the cat placenta

We localized alkaline phosphatase and plasma membrane calcium-ATPase (PMCA) in the cat placental syncytiotrophoblast to address their polarized distribution and their potential as markers for specific plasma membrane purification. We used enzyme- (alkaline phosphatase) and immuno- (PMCA) histochemistry and, for alkaline phosphatase, compared data to observations on the human placenta. Alkaline phosphatase activity in the cat was localized to the decidual cell membranes, to within the associated interstitial space and on the subjacent apical (maternal facing) plasma membrane of the syncytiotrophoblast. Occasional maternal capillaries were positive on their basal surface and there was focal staining within the syncytiotrophoblast. This widespread distribution is less specific than in the human placenta where alkaline phosphatase was restricted to the apical and basal plasma syncytiotrophoblast membranes, with much greater density on the apical membrane. Expression of PMCA in the cat was restricted to the basal membrane of the syncytiotrophoblast only. This specific localization of PMCA is identical to the human placenta and all other species in which its placental localization has been studied. We conclude that the plasma membranes of the cat syncytiotrophoblast show a broadly similar functional polarization to the human and that PMCA would prove a useful marker in isolation of the cat syncytiotrophoblast basal plasma membrane.

Production of recombinant ovine interferon tau using a Bombyx mori nuclear polyhedrosis baculovirus expression system

Ovine interferon tau (oIFN-tau) is an embryonic protein of critical importance in the establishment of pregnancy in the sheep. We have produced recombinant (r) oIFN-tau using a baculovirus expression system and demonstrated the biological activity of the protein produced. Bombyx mori larvae were infected with B. mori nuclear polyhedrosis virus (BmNPV), modified by inserting a cDNA coding for oIFN-tau downstream of the strong polyhedron promoter. Following infection, antiviral activity of the haemolymph rose to a maximum of 3.6 x 10(8) u/mL (equivalent to 3 mg roIFN-tau/mL) by day 5, when haemolymph was collected and stored frozen. Control haemolymph, collected from uninfected insects at an equivalent time, contained no antiviral activity. The roIFN-tau was partially purified by gel filtration column chromatography and the presence of roIFN-tau confirmed by western blotting. The biological activity of the partially purified roIFN-tau was tested in ewes. Treatment with roIFN-tau caused a significant delay in luteolysis confirming biological potency. The results demonstrate that this system can be successfully used to produce large quantities of roIFN-tau.

Psychological characteristics and responses to antihypertensive drug therapy

The objective of this study was to explore the relationship between psychological characteristics and responses to antihypertensive drug therapy. Twenty-two hypertensive subjects underwent psychological evaluation and treatment with 1) a diuretic, hydrochlorothiazide (HCTZ); 2) an angiotensin-converting enzyme (ACE) inhibitor, quinapril; and 3) combined alpha + beta blockade (doxazosin + betaxolol). Anger-Out scores on the State-Trait Anger Expression Inventory were positively correlated with the HCTZ-induced fall in systolic blood pressure (p<0.01); Anger-In was negatively correlated with the quinapril-induced fall in systolic pressure (p<0.05). The target systolic blood pressure (130 mm Hg) was achieved with either HCTZ or quinapril in 79% of subjects without, vs. 25% of subjects with, childhood trauma (p=0.03). Responses to doxazosin + betaxolol were not correlated with psychological characteristics. The authors conclude that both inhibited anger expression and childhood trauma are associated with reduced response to a diuretic or ACE inhibitor. Combined alpha/beta blockade may be preferable to an ACE inhibitor or diuretic in treating selected hypertensive patients. Further studies should include examination of psychological factors in terms of the response to combined ACE inhibitor + diuretic therapy.

Treatment of atheroembolization with corticosteroids

Aortic atheroembolization is a feared complication of invasive procedures such as arteriography, often leading to devastating complications including renal insufficiency. To date, even in cases with evolving renal failure, there is no recommended treatment. This case report describes the successful treatment with corticosteroids of a patient with deteriorating renal function after renal arteriography and angioplasty, resulting in rapid and sustained improvement in renal function. The implications of this observation are discussed.

Low-dose alpha/beta blockade in the treatment of essential hypertension

Despite the recent emphasis on combination drug therapy for hypertension, little attention has been given to alpha/beta blockade using agents other than labetalol. The purpose of this study was to 1) compare the efficacy of low-dose alpha/beta blockade using doxazosin + betaxolol, versus monotherapy with an angiotensin converting enzyme inhibitor (quinapril) and a diuretic (hydrochlorothiazide [HCTZ]), and 2) assess the efficacy of low-dose doxazosin. In a crossover study, 21 hypertensive subjects were treated for 3 weeks each with HCTZ, 12.5 to 25 mg/day, quinapril, 10 to 40 mg/day, and a combination of doxazosin, 1 to 4 mg + betaxolol, 5 to 10 mg daily. Doses were titrated to achieve a systolic pressure <130 mm Hg, as assessed by self-recorded home measurements. Home blood pressure decreased 11.5/7.5 mm Hg after HCTZ, 12.9/8.8 mm Hg after quinapril, and 21.2/16.5 mm Hg after doxazosin + betaxolol (P < .001/< .001 v HCTZ and P < .002/< .001 v quinapril). The target systolic pressure was achieved by 33%, 43%, and 71% of subjects, respectively (P = .04 v HCTZ, and .03 v quinapril). Among the 8 subjects in whom doxazosin dosage was increased to the maximum of 4 mg, the mean blood pressure achieved at 4 mg did not differ from that achieved at 2 mg (136/87 v 136/88 mm Hg). We conclude that oral alpha/beta blockade is superior to monotherapy with an angiotensin converting enzyme inhibitor or a diuretic and that maximal or near maximal efficacy can be achieved at a 2-mg dose of doxazosin. Low-dose oral alpha/beta blockade merits greater consideration in the drug therapy of essential hypertension.

The mind/body link in essential hypertension: time for a new paradigm

The origin of essential hypertension is believed by many to be at least partially emotion-related. A widely held paradigm is that perceived emotional distress raises blood pressure and leads eventually to sustained hypertension. However, decades of research have not provided strong or consistent support for this view. The purpose of this article is to briefly review this research, and to present a very different view of the mind-body link of hypertension. This view focuses on the role of emotions that are not consciously perceived, emotions that are unknowingly kept from conscious awareness, and largely ignored by patients, physicians and research. It suggests that the mind/body connection is often operative when we least suspect it. The evidence for this understanding, and the important implications regarding treatment of hypertension and other unexplained medical conditions with a suspected mind/body link, are discussed.

Beta-adrenergic receptor blockade as a therapeutic approach for suppressing the renin-angiotensin-aldosterone system in normotensive and hypertensive subjects

Although beta-adrenergic-blocking drugs suppress the renin system (RAAS), plasma angiotensin II (Ang II) responses during beta-blockade have not been defined. This study quantifies the effects of beta-blockade on the RAAS and examines its impact on prorenin processing by measuring changes in the ratio of plasma renin activity (PRA) to total renin. In normotensive (N = 14) and hypertensive (N = 16) subjects, blood pressure (BP), heart rate, PRA, plasma prorenin, plasma total renin (prorenin + PRA), ratio of PRA to total renin (%PRA), plasma Ang II, and urinary aldosterone were measured before and after 1 week of beta-blockade. Plasma renin activity, Ang II, and urinary aldosterone levels were similar for normotensive and hypertensive subjects. Plasma renin activity correlated with Ang II. Total renin, which is proportional to (pro)renin gene expression, was lower in hypertensive subjects and was inversely related to BP. Beta-blockade decreased BP and heart rate in both groups, with medium- and high-renin hypertensive subjects responding more frequently than those with low renin. Beta-blockade consistently suppressed PRA, Ang II, and aldosterone. Total renin was unchanged, thus, %PRA fell. These results indicate that beta-blockers suppress plasma angiotensin II levels, in parallel with the marked reductions in PRA and urinary aldosterone levels in normotensive and hypertensive subjects. The suppression of Ang II levels was comparable to that produced during angiotensin converting enzyme (ACE) inhibition. However, by reducing prorenin processing to renin, beta-blockers do not stimulate renin secretion, unlike ACE inhibitors and Ang II receptor antagonists. This unique action of beta-blockers has important implications for the treatment of cardiovascular disease.

Severe paroxysmal hypertension (pseudopheochromocytoma): understanding the cause and treatment

Severe, symptomatic paroxysmal hypertension always generates suspicion of a pheochromocytoma, a catecholamine-secreting tumor. However, most patients with this disorder do not have this tumor and their condition remains undiagnosed and ineffectively treated. This case series, summarizing the course of 21 such patients, suggests a cause and an effective treatment approach. All 21 patients insisted that the paroxysms were not related to stress or emotional distress, initially discouraging consideration of a link to emotions. Nevertheless, with careful psychosocial interviewing, the disorder could be attributed to emotions patients were not aware of, and, therefore, unable to report. Such emotions were related either to previous severe emotional trauma or to a general tendency to keep distressful emotions out of awareness. With treatment based on this understanding, further paroxysms were eliminated in 13 (62%) of 21 patients. Alpha- plus beta-blockade was used, combined, when necessary, with an antidepressant agent, with or without an anxiolytic agent. In 3 cases, the disorder was cured with psychotherapy alone. Because the presenting symptoms are physical rather than emotional, patients present to internists and primary care physicians rather than to psychotherapists. For this reason, more awareness of this disorder in the medical community is needed.

Defensiveness and essential hypertension

The purpose of this study was to investigate the association between essential hypertension and defensiveness. Fifty normotensive and 74 hypertensive subjects completed the State-Trait Personality Inventory (STPI) and State-Trait Anger Expression Inventory (STAXI) to assess perceived anger and anxiety, and the Marlowe-Crowne Scale of Social Desirability as an indicator of defensiveness. Hypertensive and normotensive groups did not differ in their scores on the anger, anger expression, and anxiety scales. In contrast, Marlowe-Crowne scores were higher in the hypertensive group (18.1+/-5.5 vs. 15.4+/-5.1) (p=0.006). Stepwise logistic regression that included age, gender, BMI, and Marlowe-Crowne scores (dichotomized at 18) showed that a high Marlowe-Crowne score was associated with a relative risk of 3.63 (CI 1.49-8.83) of being hypertensive, independent of age, gender, and BMI. Anger and anxiety scores did not predict hypertensive status and did not affect the relationship between Marlowe-Crowne score and hypertensive status. We conclude that defensiveness is more closely related to essential hypertension than is self-reported anger or anxiety. Better understanding of conscious and unconscious mechanisms of defensiveness are likely to be important in clarifying the link between emotions and hypertension.