What’s next in behavioral hypertension research?

The good news is that according to a recent report from the Centers for Disease Control and Prevention, Americans’ life expectancy hit an all-time high in 2001. However, the report also states that mortality increased for some leading causes of deaths, including a 3% increase for hypertension related mortality (1). This increase comes despite significant advances in hypertension treatment and control. Hypertension is a major risk factor for heart disease and the leading risk factor for stroke and heart failure affecting approximately one in four adults (2). With the recent introduction of the “prehypertension” category (blood pressure of 120–139/80–89 mm Hg) and the realization that such individuals are at an increased risk of progression to hypertension (2), it is more important than ever to adopt a comprehensive approach to the study of psychosocial and lifestyle factors that cause even the most transient elevations in blood pressures. The NHANES study demonstrated that women, non-Hispanic Blacks, and older individuals have the highest rates of hypertension (3). The greater hypertension prevalence in women, non-Hispanic Blacks, and older individuals highlights the need to examine the possible psychosocial factors responsible for this health disparity. Large stress-induced blood pressure elevations are hypothesized to lead to elevations of tonic blood pressure levels and subsequent development of hypertension. Stress-induced blood pressure responses are affected by a variety of psychosocial factors, including gender, ethnicity, social support, depression, and anxiety, to name a few. This issue of Annals of Behavioral Medicine presents two very interesting articles that examine the role of ethnicity (4) and anger response styles (5) on blood pressure. The third article assesses predictors of stress in coronary artery disease patients (6). In the United States, Blacks suffer from hypertension at a rate nearly twice that of White Americans (7). However, there is a significant variation in mortality from cardiovascular causes among Black subgroups in the United States (8). Cardiovascular reactivity to psychological stress is considered a risk marker for the development of coronary artery disease (9) and is believed to be among the factors contributing to the heightened prevalence of essential hypertension in Blacks (10). Arthur, Katkin, and Mezzacappa (4) examined patterns of cardiovascular reactivity to stressors among African Americans, Caribbean Americans, and White Americans. A complex pattern of ethnic differences in cardiovascular reactivity was evident during the cold pressor task. African Americans displayed the greatest decrease in interbeat interval and an increase in pre-ejection period. Caribbean Americans displayed the largest decrease in cardiac output and least increase in systolic blood pressure in response to the stressor. This study provides evidence of important differences in cardiovascular reactivity to stress among Black ethnic groups in the United States and further highlights the need for assessing ethnicity in future cardiovascular reactivity research. In another article, Hogan and Linden (5) explored the effect of rumination as a moderating variable in the relationship between anger response preferences and blood pressure. They found that high levels of avoidance coupled with high rumination predicted higher levels of ambulatory blood pressure, whereas high avoidance/low rumination predicted lower levels of ambulatory blood pressure. On the other hand, low assertion/low rumination was associated with high resting and ambulatory blood pressure and an increase in assertion without an associated increase in rumination resulted in a decrease in blood pressure levels. Gender differences emerged when considering the interaction between rumination and support seeking. In men, high rumination weakened the favorable effects of support seeking on resting blood pressure levels. In women, rumination had a beneficial effect on blood pressure at high levels of support seeking. Surprisingly, low support seeking/low rumination was associated with the lowest blood pressure in women. This study provides novel insight into the moderating effect of rumination on anger response styles and its subsequent relation to blood pressure levels. However, further research is needed to clarify the influence of rumination on long-term blood pressure changes and cardiovascular disease risk. In an impressive longitudinal study, Brummett and colleagues (6) evaluated demographic, clinical, social, and personality variables as predictors of nine repeated assessments of stress over a 2-year period in 322 coronary artery disease patients. Young female participants demonstrated the highest levels of stress. Higher levels of stress over the follow-up period were also observed in those with moderate income, congestive heart failure, high social conflict, low social support, and negative coping style. In practice, clinicians should consider such factors to help identify patients who are at high risk of experiencing increasing stress over a prolonged period following a coronary artery disease diagnosis. Future research should assess the utility of stress reduction interventions in this high-risk population. To reach the target for hypertension control by 2010 (11), a multifaceted approach that includes behavioral interventions