Psychosocial Stressors at Work and Ambulatory Blood Pressure.

PURPOSE OF REVIEW: Psychosocial stressors at work from the demand-latitude and effort-reward imbalance models are adverse exposures affecting about 20-25% of workers in industrialized countries. This review aims to summarize evidence on the effect of these stressors on blood pressure (BP). RECENT FINDINGS: Three systematic reviews have recently documented the effect of these psychosocial stressors at work on BP. Among exposed workers, statistically significant BP increases ranging from 1.5 to 11 mmHg have been observed in prospective studies using ambulatory BP (ABP). Recent studies using ABP have shown a deleterious effect of these psychosocial stressors at work on masked hypertension as well as on blood pressure control in pharmacologically treated patients. Evidence on the effect of these psychosocial stressors on BP supports the relevance to tackle these upstream factors for primary prevention and to reduce the burden of poor BP control. There is a need for increased public health and clinical awareness of the occupational etiology of high BP, hypertension, and poor BP control.

Masked hypertension and effort-reward imbalance at work among 2369 white-collar workers.

Hypertension is an important risk factor of cardiovascular diseases, the leading cause of death worldwide. Adverse effects of psychosocial factors at work might increase the risk of masked hypertension, but evidences are still scarce. The objective of this study is then to determine whether adverse psychosocial work factors from the effort-reward imbalance (ERI) model are associated with the prevalence of masked hypertension in a population of white-collar workers. White-collar workers were recruited from three public organizations. Blood pressure was measured at the workplace for manually operated measurements (mean of the first three readings taken by a trained assistant) followed by ambulatory measurements (mean of all subsequent readings taken during the working day). Masked hypertension was defined as manually operated BP<140/90 mm Hg and ambulatory BP ⩾135/85 mm Hg. ERI exposure at work was measured using Siegrist's validated questionnaire. Blood pressure readings were obtained from 2369 workers (participation proportion: 85%). ERI exposure (OR: 1.53 (95% CI: 1.16-2.02) and high efforts at work (OR: 1.61 (95% CI: 1.13-1.29) were associated with masked hypertension, after adjusting for sociodemographic and cardiovascular risk factors. Workers exposed to an imbalance between efforts spent at work and reward had a higher prevalence of masked hypertension. High efforts at work might be of particular importance in explaining this association. Future studies should be designed to investigate how clinicians can include questions on psychosocial work factors to screen for masked hypertension and how workplace interventions can decrease adverse psychosocial exposures to lower BP.

Examination of Several Physiological and Psychosocial Factors Potentially Associated With Masked Hypertension Among Low-Risk Adults.

The authors examined the association of factors, in addition to prehypertensive office blood pressure (BP) level, that might improve detection of masked hypertension (MH), defined as nonelevated office BP with elevated out-of-office BP average, among individuals at otherwise low risk. This sample of 340 untreated adults 30 years and older with average office BP <140/90 mm Hg all had two sets of paired office BP measurements and 24-hour ambulatory BP monitoring (ABPM) sessions 1 week apart. Other than BP levels, the only factors that were associated (at P<.10) with MH at both sets were male sex (75% vs 66%) and working outside the home (72% vs 59% for the first set and 71% vs 45% for the second set). Adding these variables to BP level in the model did not appreciably improve detection of MH. No demographic, clinical, or psychosocial measures that improved upon prehypertension as a potential predictor of MH in this sample were found.

Impact of depression on masked hypertension and variability in home blood pressure in treated hypertensive patients.

This study was conducted to determine the effects of depression and/or insomnia on masked hypertension (MHT) compared with other types of HT and on variability in home-measured blood pressure (HBP) and clinic BP (CBP). Three hundred and twenty-eight hypertensives (132 women) aged 68±10 years were classified into four BP types: controlled HT (CHT), white-coat HT, MHT and sustained HT (SHT), based on CBP (140/90 mm Hg) and morning HBP (135/85 mm Hg) measurements. A score of ⩾16 on the Center for Epidemiologic Studies Depression Scale (CES-D) was defined as depression. The mean values and s.d. of BP were calculated from measurements taken during the 14 consecutive days just before the CES-D evaluation. Compared with the CHT group, the risk of depression was 2.77-fold higher in the SHT group and even higher in the MHT group (7.02-fold). The association between depression and MHT was augmented in the presence of insomnia and was somewhat stronger in women. A HBP variability index defined as s.d./mean BPs in both morning and night time was significantly higher in MHT than in the other BP types, whereas that of CBP was not. Both morning and night-time HBP variability were significantly higher in depressive patients than in non-depressives. These suggest that depression is associated with MHT and that increases both morning and night-time HBP variability but not CBP variability. Physicians should be mindful of mental stresses such as depression in their hypertensive patients when forming strategies to control BP over the diurnal cycle.

Are personality traits associated with white-coat and masked hypertension?

OBJECTIVES: Anxiety and other psychological dispositions are thought to be associated with blood pressure. This study tests whether personality traits have long-term associations with masked and white-coat effects. METHODS: A community-based sample of 2838 adults from Sardinia (Italy) completed the Revised NEO Personality Inventory, and 7 years later, blood pressure was assessed in the clinic and with ambulatory monitoring. Logistic regressions were used to test whether anxiety, neuroticism, extraversion, openness, agreeableness, and conscientiousness predicted the white-coat and masked hypertension phenomena. Age, sex, and antihypertensive medication use were tested as moderators. RESULTS: Significant interactions were found between personality traits and antihypertensive medications in predicting masked and white-coat effects. Only among those taking antihypertensive medication, higher anxiety was associated with a higher risk of pseudo-resistant hypertension due to white-coat effect (odds ratio 1.39, 95% confidence interval 1.01-1.91) and higher conscientiousness was associated with a lower risk of masked uncontrolled hypertension (odds ratio 0.70, 95% confidence interval 0.49-0.99). There were no significant interactions with age or sex. CONCLUSIONS: Among those on antihypertensive medications, anxious individuals were more likely to have pseudo-resistant hypertension due to white-coat effect and less conscientious individuals were at increased risk of masked uncontrolled hypertension. Particularly among anxious and less conscientious individuals, ambulatory monitoring may improve the tailoring of pharmacological treatments.

Predicting out-of-office blood pressure level using repeated measurements in the clinic: an observational cohort study.

OBJECTIVES: Identification of people with lower (white-coat effect) or higher (masked effect) blood pressure at home compared to the clinic usually requires ambulatory or home monitoring. This study assessed whether changes in SBP with repeated measurement at a single clinic predict subsequent differences between clinic and home measurements. METHODS: This study used an observational cohort design and included 220 individuals aged 35-84 years, receiving treatment for hypertension, but whose SBP was not controlled. The characteristics of change in SBP over six clinic readings were defined as the SBP drop, the slope and the quadratic coefficient using polynomial regression modelling. The predictive abilities of these characteristics for lower or higher home SBP readings were investigated with logistic regression and repeated operating characteristic analysis. RESULTS: The single clinic SBP drop was predictive of the white-coat effect with a sensitivity of 90%, specificity of 50%, positive predictive value of 56% and negative predictive value of 88%. Predictive values for the masked effect and those of the slope and quadratic coefficient were slightly lower, but when the slope and quadratic variables were combined, the sensitivity, specificity, positive and negative predictive values for the masked effect were improved to 91, 48, 24 and 97%, respectively. CONCLUSION: Characteristics obtainable from multiple SBP measurements in a single clinic in patients with treated hypertension appear to reasonably predict those unlikely to have a large white-coat or masked effect, potentially allowing better targeting of out-of-office monitoring in routine clinical practice.

Working conditions and masked hypertension.

INTRODUCTION: Masked hypertension, i.e., normal clinic blood pressure but elevated blood pressure during normal daily activities as measured by ambulatory monitoring, is a common problem and a serious cardiovascular risk factor. Given previously reported associations between work stressors and ambulatory blood pressure, an inquiry into the relationship between work stressors and masked hypertension is warranted. OBJECTIVE: To assess the relationship between working conditions and masked hypertension. DESIGN: Cross-sectional study. SETTING: Hospital and home care employers in New York City. STUDY PARTICIPANTS: Forty-five male and 119 female hospital and home care employee volunteers wore an ambulatory blood pressure monitor during working hours. MAIN OUTCOME MEASURES: Masked hypertension was defined as work systolic ambulatory blood pressure ≥135 mmHg or diastolic ambulatory blood pressure ≥85 mmHg, and casual blood pressure <140/90 mmHg with no use of antihypertensive medications. Associations between work stressors and masked hypertension were tested by multiple logistic regression. RESULTS: Masked hypertension, observed in 24.0% of males and 17.6% of females with normal casual office obtained blood pressure, was associated with evening, night or rotating shiftwork (odds ratio (OR) 8.25, 95% confidence interval (CI) 2.11-40.31) and with the combination of job strain and effort-reward imbalance (OR 2.97, 95% CI 1.02-8.60) after controlling for age. Associations remained substantial, and statistically significant for shiftwork, after individual adjustment for each of 10 potential confounders. Masked hypertension was not associated with total weekly work hours. CONCLUSIONS: Masked hypertension is a significant individual and public health concern. Additional research is needed to clarify the role of work-related risk factors in the development of masked hypertension, and to develop an appropriate clinical and public health strategy for diagnosis, treatment and prevention.

Prognostic significance of masked and white-coat hypertension in the general population: the Finn-Home Study.

OBJECTIVE: The clinical significance of masked and white-coat hypertension is still somewhat controversial. The aim of the present study was to investigate the prognosis of masked and white-coat hypertension using home blood pressure (BP) measurement. DESIGN AND METHODS: A nationwide population sample (n = 2046, age 44-74 years) underwent office (duplicate measurements on one visit by a nurse) and home (duplicate measurements on 7 days) BP measurements and risk factor evaluation. During the follow-up of 7.5 years, 221 fatal and nonfatal cardiovascular events and 142 all-cause deaths occurred. Masked hypertension was defined as office BP less than 140/90 mmHg with home BP at least 135/85 mmHg. RESULTS: The prevalence of baseline risk factors and the incidence of cardiovascular events and all-cause deaths increased from normotension to white-coat, masked and sustained hypertension. Unadjusted hazard ratios for white-coat hypertension were 1.18 (P = 0.5) for cardiovascular events and 1.23 (P = 0.5) for all-cause deaths. Masked hypertension had a significantly higher age-adjusted risk of cardiovascular events and a higher risk of all-cause mortality after adjustment for age, sex and office BP than normotension (hazard ratios 1.64, P = 0.05, and 2.09, P = 0.01). Masked hypertension lost its predictive significance after adjustment for home BP or concomitant other cardiovascular risk factors. CONCLUSION: Neither masked nor white-coat hypertension was an independent predictor of cardiovascular risk or all-cause mortality when concomitant other risk factors or baseline home BP levels were taken into account. The present study suggests that home BP level, along with other traditional risk factors, may be enough to stratify cardiovascular risk.

Determinants of masked hypertension in the general population: the Finn-Home study.

INTRODUCTION: Home blood pressure (BP) measurement has allowed the identification of individuals with normal office and elevated out-of-office BP (masked hypertension). It is, however, not feasible to measure home BP on all office normotensive individuals. The objective of the present study was to identify demographic, lifestyle, clinical and psychological characteristics suggestive of masked hypertension. METHODS: Study population was drawn from the participants of a multidisciplinary epidemiological survey, the Health 2000 Study. The untreated nationwide population sample (n = 1459, age 45-74 years) underwent office (duplicate measurements on one visit) and home (duplicate measurements on 7 days) BP measurements and risk factor evaluation. Psychometric tests assessed psychological distress, hypochondriasis, depression and alexithymia. Masked hypertension was defined as normal office BP (<140/90 mmHg) with elevated home BP (≥135/85 mmHg). RESULTS: The prevalence of masked hypertension was 8.1% in the untreated Finnish adult population. The cardiovascular risk profile of masked hypertensive patients resembled that of sustained hypertensive patients. High-normal systolic and diastolic office BP, older age, greater BMI, current smoking, excessive alcohol consumption, diabetes and electrocardiographic left-ventricular hypertrophy were independent determinants of masked hypertension in multivariate logistic regression analysis. Masked hypertension was also independently associated with hypochondria. CONCLUSION: Masked hypertension is a common phenomenon in an untreated adult population. Physicians should consider home BP measurement if a patient has high-normal office BP, diabetes, left-ventricular hypertrophy, or several other conventional cardiovascular risk factors.