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Is There Tension in Hypertension?

Jerome H. Markovitz, MD, MPH; Karen A. Matthews, PhD; William B. Kannel, MD; Janet L. Cobb, MPH; Ralph B. D'Agostino, PhD

JAMA. 1993;270(20):2439-2443.

Abstract
Objective.
—To test the hypothesis that heightened anxiety, heightened anger intensity, and suppressed expression of anger increase the risk of hypertension, using the Framingham Heart Study.

Design.
—A cohort of men and women without evidence of hypertension at baseline were followed up for 18 to 20 years. Baseline measures of anxiety (tension), anger symptoms, and expression of anger (anger-in and anger-out) were taken, along with biological and behavioral predictors of hypertension (initial systolic blood pressure, heart rate, relative weight, age, hematocrit, alcohol intake, smoking, education, and glucose intolerance).

Participants.
—A total of 1123 initially normotensive persons (497 men, 626 women) were included. Analyses were stratified by age (45 to 59 or 60 years) and gender.

Main Outcome Measures.
—Hypertension was defined as either taking medication for hypertension or blood pressures higher than 160/95 mm Hg at a biennial examination.

Results.
—In univariate analyses, middle-aged men who went on to develop hypertension had greater baseline anxiety levels than men who remained normotensive (P=.04). Older hypertensive men had fewer anger symptoms at baseline (P=.04) and were less likely to hold their anger in (P=.01) than normotensives. In multivariate Cox regression analysis including biological predictors, anxiety remained an independent predictor of hypertension in middle-aged men (P=.02). Among older men, anger symptoms and anger-in did not remain significant predictors in the multivariate analysis. Further analysis showed that only middle-aged men with very high levels of anxiety were at increased risk (relative risk, 2.19; 95% confidence interval, 1.22 to 3.94). No psychological variable predicted hypertension in middle-aged or older women in either univariate or multivariate analyses.

Conclusions.
—The results indicate that among middle-aged men, but not women, anxiety levels are predictive of later incidence of hypertension.

(JAMA. 1993;270:2439-2443)

Author Affiliations
From the Division of Preventive Medicine, Department of Medicine, The University of Alabama School of Medicine, Birmingham (Dr Markovitz); Department of Psychiatry, University of Pittsburgh (Pa) (Dr Matthews); and Section of Preventive Medicine and Epidemiology, School of Medicine (Dr Kannel), and Department of Mathematics (Ms Cobb and Dr D'Agostino), Boston (Mass) University.

Footnotes
Presented in part at the American Heart Association Council on Epidemiology and Prevention, Santa Fe, NM, March 18, 1993.

Reprint requests to Division of Preventive Medicine, The University of Alabama School of Medicine, 1717 11th Ave S, Seventh Floor, Birmingham, AL 35205 (Dr Markovitz).

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