In the JournalsPerspective

High levels of stress increase hypertension risk in black individuals

Tanya Spruill

Black adults who reported higher stress over time had elevated risk for hypertension, according to an analysis of the Jackson Heart Study published in the Journal of the American Heart Association.

“African Americans have higher rates of hypertension and heart disease compared with other racial and ethnic groups,” Tanya Spruill, PhD, associate professor in the departments of population health and medicine at NYU School of Medicine, told Healio. “They are also exposed to more chronic stressors than whites, so if future studies show that stress management is effective at lowering blood pressure and reducing hypertension incidence, this could help to reduce disparities in hypertension and heart disease.”

Researchers analyzed data from 1,829 black participants (mean age, 49 years; 40% men) from the Jackson Heart Study with a systolic BP less than 140 mm Hg and a diastolic BP less than 90 mm Hg who were not taking antihypertensive medications at the first examination.

Data were collected at baseline and at two follow-up visits by in-home interview and clinic examination. Annual telephone interviews were also conducted between follow-up visits. Measurements that were taken included weight, height and BP, in addition to the collection of blood and urine samples. Questionnaires were completed to collect data on medical history, sociodemographic factors, health behaviors, medication use and psychosocial factors.

Chronic stress exposure was assessed during each annual follow-up visit, where participants were asked how much stress they have experienced during the past year. Participants were then categorized as having low-, moderate- or high-perceived stress based on their responses during follow-up visits.

“A strength of the study is the annual assessments of perceived stress over the prior year,” Spruill said in an interview. “This is important because stress levels fluctuate, and most studies only assess stress at a single point in time.”

During a median follow-up of 7 years, 48.5% of participants developed hypertension. This developed in 30.6% of participants with low-perceived stress, 34.6% of those with moderate-perceived stress and 38.2% of participants with high-perceived stress.

The age-, sex- and time-adjusted RR for participants with moderate-perceived stress was 1.19 (95% CI, 1.04-1.37) and 1.37 for those with high-perceived stress (95% CI, 1.2-1.57) compared with those with low-perceived stress (P for trend < .001).

The association between higher-perceived stress and incident hypertension continued to be statistically significant after adjusting for baseline stress (moderate vs. low, RR = 1.17; 95% CI, 1.02-1.33; high vs. low, RR = 1.24; 95% CI, 1.09-1.42; P for trend < .001), hypertension risk factors (moderate vs. low, RR = 1.18; 95% CI, 1.04-1.34; high vs. low, RR = 1.27; 95% CI, 1.12-1.45; P for trend < .001) and health behaviors (moderate vs. low, RR = 1.15; 95% CI, 1.01-1.31; high vs. low, RR = 1.22; 95% CI, 1.07-1.39; P for trend = .001).

“This is an observational study, so we can’t conclude that reducing chronic stress would lower the risk of developing hypertension in African Americans,” Spruill told Healio. “Additional studies are needed to examine whether screening for chronic stress in clinical practice helps identify patients who could benefit from stress management, and to test whether stress management interventions can lower blood pressure and hypertension risk in these patients.” – by Darlene Dobkowski

For more information:

Tanya Spruill, PhD, can be reached at NYU School of Medicine, 180 Madison Ave., Room 714, New York, NY 10016; email: tanya.spruill@nyumc.org.

Disclosures: The authors report no relevant financial disclosures.

Tanya Spruill

Black adults who reported higher stress over time had elevated risk for hypertension, according to an analysis of the Jackson Heart Study published in the Journal of the American Heart Association.

“African Americans have higher rates of hypertension and heart disease compared with other racial and ethnic groups,” Tanya Spruill, PhD, associate professor in the departments of population health and medicine at NYU School of Medicine, told Healio. “They are also exposed to more chronic stressors than whites, so if future studies show that stress management is effective at lowering blood pressure and reducing hypertension incidence, this could help to reduce disparities in hypertension and heart disease.”

Researchers analyzed data from 1,829 black participants (mean age, 49 years; 40% men) from the Jackson Heart Study with a systolic BP less than 140 mm Hg and a diastolic BP less than 90 mm Hg who were not taking antihypertensive medications at the first examination.

Data were collected at baseline and at two follow-up visits by in-home interview and clinic examination. Annual telephone interviews were also conducted between follow-up visits. Measurements that were taken included weight, height and BP, in addition to the collection of blood and urine samples. Questionnaires were completed to collect data on medical history, sociodemographic factors, health behaviors, medication use and psychosocial factors.

Chronic stress exposure was assessed during each annual follow-up visit, where participants were asked how much stress they have experienced during the past year. Participants were then categorized as having low-, moderate- or high-perceived stress based on their responses during follow-up visits.

“A strength of the study is the annual assessments of perceived stress over the prior year,” Spruill said in an interview. “This is important because stress levels fluctuate, and most studies only assess stress at a single point in time.”

During a median follow-up of 7 years, 48.5% of participants developed hypertension. This developed in 30.6% of participants with low-perceived stress, 34.6% of those with moderate-perceived stress and 38.2% of participants with high-perceived stress.

The age-, sex- and time-adjusted RR for participants with moderate-perceived stress was 1.19 (95% CI, 1.04-1.37) and 1.37 for those with high-perceived stress (95% CI, 1.2-1.57) compared with those with low-perceived stress (P for trend < .001).

The association between higher-perceived stress and incident hypertension continued to be statistically significant after adjusting for baseline stress (moderate vs. low, RR = 1.17; 95% CI, 1.02-1.33; high vs. low, RR = 1.24; 95% CI, 1.09-1.42; P for trend < .001), hypertension risk factors (moderate vs. low, RR = 1.18; 95% CI, 1.04-1.34; high vs. low, RR = 1.27; 95% CI, 1.12-1.45; P for trend < .001) and health behaviors (moderate vs. low, RR = 1.15; 95% CI, 1.01-1.31; high vs. low, RR = 1.22; 95% CI, 1.07-1.39; P for trend = .001).

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“This is an observational study, so we can’t conclude that reducing chronic stress would lower the risk of developing hypertension in African Americans,” Spruill told Healio. “Additional studies are needed to examine whether screening for chronic stress in clinical practice helps identify patients who could benefit from stress management, and to test whether stress management interventions can lower blood pressure and hypertension risk in these patients.” – by Darlene Dobkowski

For more information:

Tanya Spruill, PhD, can be reached at NYU School of Medicine, 180 Madison Ave., Room 714, New York, NY 10016; email: tanya.spruill@nyumc.org.

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    LaPrincess C. Brewer

    LaPrincess C. Brewer

    This noteworthy study by Spruill and colleagues undoubtedly adds further evidence to a rich body of literature demonstrating the crucial role of chronic stress in the CV health of African Americans, particularly for hypertension. They present a comprehensive analysis of how high stress levels over time can have negative downstream effects within this group. This is manifested as a new diagnosis of hypertension which, when untreated or uncontrolled, can exponentially increase their risk for CVD. This is especially important in African Americans given their disproportionate burden of hypertension and their unique stressors including discrimination, structural racism and socioeconomic disadvantage.

    These findings have clinical implications in that high stress can potentially widen hypertension disparities between African American and white individuals. The simple act of asking patients about the stressors they experience in their daily lives can go a long way. This then allows clinicians to better understand the patient’s perspective in the context of their psychosocial influences, which then can lead to the development of culturally tailored stress management interventions at both the individual and community level. 

    Cardiologists can work as partners with patients and their primary care providers to locate resources to reduce stress among this special population. We must take time to truly understand the influence of the negative social determinants of health that these patients face which consequently generates stress. Becoming more involved in health care policy and health equity advocacy efforts is also a key means to make a difference.

    Further research is needed to identify effective stress management or behavioral interventions to positively impact hypertension among African American indivuduals. This should occur in a variety of clinical and community settings including community health centers and prominent community-based locales centric to the African American community such as barbershops, salons and churches. Tapping into social networks to reduce stress among African Americans is also a ripe area of research. Given that African American women in the study had significant associations with higher levels of stress and hypertension, consideration of their distinct responses to stress for intervention development is imperative.

    Culturally tailored interventions such as the Barbershop Study (Victor RG, et al. N Engl J Med. 2018;doi:10.1056/NEJMoa1717250), the FAITH study (Schoenthaler AM, et al. Circ Cardiovasc Qual Outcomes. 2018;doi:10.1161/CIRCOUTCOMES.118.004691) and our work at Mayo Clinic (Brewer LC, et al. J Gen Intern Med. 2019;doi:10.1007/s11606-019-04936-5) in African American churches in Minnesota have had substantial impacts on BP and the CV health of African Americans.

    • LaPrincess C. Brewer, MD, MPH, FACC, FACP, FASPC
    • Cardiologist
      Assistant Professor of Medicine
      Mayo Clinic College of Medicine

    Disclosures: Brewer reports no relevant financial disclosures.