| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
ORIGINAL ARTICLE |
School of Sport and Exercise Sciences (D.C.), University of Birmingham, Birmingham; the Department of Social Medicine (G.D.S.), University of Bristol, Bristol; and the Department of Epidemiology and Public Health (M.J.S., A.S., E.J.B., M.G.M.), University College London, London, England.
Address reprint requests to: Douglas Carroll, PhD, School of Sport and Exercise Sciences, University of Birmingham, Birmingham B15 2TT, England. Email: carrolld{at}bham.ac.uk
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
|---|
METHODS: Blood pressure was recorded at an initial medical screening examination after which blood pressure reactions to a mental stress task were determined. A follow-up screening assessment of blood pressure and antihypertensive medication status was undertaken 10 years later. Data were available for 796 male public servants, between 35 and 55 years of age upon entry to the study.
RESULTS: Systolic blood pressure reactions to mental stress were positively correlated with follow-up screening systolic blood pressure and to a lesser extent, follow-up diastolic pressure. In multivariate tests, by far the strongest predictors of follow-up blood pressures were initial screening blood pressures. In the case of follow-up systolic blood pressure, systolic reactions to stress emerged as an additional predictor of follow-up systolic blood pressure. With regard to follow-up diastolic blood pressure, reactivity did not enter the analogous equations. The same outcomes emerged when the analyses were adjusted for medication status. When hypertension at 10-year follow-up was the focus, both systolic and diastolic reactions to stress were predictive. However, with correction for age and initial screening blood pressure, these associations were no longer statistically significant.
CONCLUSIONS: The results of this study provide modest support for the hypothesis that heightened blood pressure reactions to mental stress contribute to the development of high blood pressure. At the same time, they question the clinical utility of stress testing as a prognostic device.
Key Words: systolic blood pressure • diastolic blood pressure • reactivity • hypertension • prospective study
Abbreviations: SBP = systolic blood pressure;; DBP = diastolic blood pressure;; OR = odds ratio;; CI = confidence interval;; B = regression coefficient;; ß = standardized regression coefficient;; SD = standard deviation;; SE = standard error.
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
|---|
The available prospective data, however, are far from consistent. Many of the prospective studies have adopted the cold pressor test as the acute stress exposure. Several studies present evidence that the magnitude of the blood pressure reactions to brief immersion of the hand in cold water predicts future blood pressure status independently of resting blood pressure at entry to the study (14–17). In contrast, a similar number of studies have found either minimal, or no independent association between blood pressure reactions to the cold pressor test and prospective blood pressure status (18–22). However, it has been argued that the cold pressor procedures are far from optimal in this context (3, 13). First, as originally conceived and propagated (1, 2), the hypothesis linking reactivity and pathology has as its focus reactions to active mental stress tasks rather than passive physical stress tasks. Second, the cold pressor test would seem to be a poor analogue of everyday stress (23).
The results of studies using mental stress exposures are somewhat more compelling. Earlier studies, however, were limited by either small and highly selected samples (24–26) or the failure to control for resting blood pressure at entry (25, 26). In a study of 246 children, blood pressure reactions to a video game were found to add significantly to the prediction, offered by resting blood pressure at entry, of blood pressure levels 5 years later; unfortunately, the size of the effect cannot be discerned (27). No such difficulty attends the report of a 3- to 4-year follow-up of 83 adolescents (28). In this case, however, the bivariate association between SBP reactivity to a video game and follow-up SBP was not statistically significant. Nevertheless, SBP reactivity emerged as a predictor in multivariate analysis and contributed an additional 4% to the variance in follow-up SBP explained by age, body mass index, and baseline SBP. In a study of 152 children and 168 middle-aged adults, blood pressure reactions were measured to a range of laboratory stress tasks, and observed to predict blood pressure levels 6.5 years later, independently of resting blood pressure at entry (29). For the adult sample, magnitude of blood pressure reaction accounted for an additional 1% to 6% of the variance in prospective blood pressure, depending on the stress task. Effects of a similar order emerged for the child sample. Using established hypertension as the 4-year outcome, blood pressure reactions to the anticipation of exercise in 508 adult men were found to predict subsequent hypertension in logistic regression models that adjusted for age and resting blood pressure level (30). High SBP reactivity conferred an increased risk of 3% (OR = 1.03) and high diastolic blood pressure (DBP) reactivity an increased risk of 7% (OR = 1.07). In the CARDIA study of over 3000 adult men and women, blood pressure reactions to cold pressor and a star-tracing task were not significant predictors of subsequent change in blood pressure or hypertension. SBP reactions to a video game, however, were independently associated with an increased risk of upward drift in blood pressure over 5 years of follow-up (31). The pattern of results in the CARDIA study reinforce the view that reactions to active mental stress tasks are more consistently predictive of future blood pressure than reactions to passive physical ones. Finally, in an earlier report of a 5-year follow-up of part of the Whitehall II cohort, SBP, but not DBP reactions, of 1003 middle-aged men to a mental stress task were found to predict follow-up blood pressure. In multivariate models which included age and measures of initial resting blood pressure, however, SBP reactivity accounted for less than 1% of the variance in follow-up SBP (32).
The overall impression from the outcomes of the prospective studies of mental stress is that the magnitude of blood pressure reactions is predictive, albeit modestly, of future blood pressure status. However, inasmuch as the median follow-up period in these studies is 5 years, the question remains as to whether larger effects will emerge with longer follow-up. The completion of a 10-year follow-up screening of the Whitehall II cohort allows us to pursue this question.
|
METHODS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
|---|
Apparatus and Procedure
Initial and follow-up screening blood pressures were measured using a Hawksley random zero sphygmomanometer and were in each case the average of two readings, taken after 5 minutes at seated rest by a trained nurse in a work-site clinic. The mean interlude between the initial and follow-up screenings was 10.77 years (SD = 0.52). The laboratory baseline blood pressure and the blood pressure during exposure to a mental stress task were measured using a Copal (UA251) semiautomatic digital sphygmomanometer. Previous research has shown the Copal to be an accurate and reliable monitor (33, 34). Raven’s matrices served as the mental stress task. This challenge has been found to provoke sizeable increases in cardiovascular activity although requiring little in the way of energy expenditure (35). Problems were selected from sets A, B, C, D, and E (36). The matrices were reproduced as slides and presented by a computer controlled carousel projector. Individual problems were presented for 10 seconds, within which time the subject had to select the correct solution from the alternatives displayed; choice was signaled by pressing the appropriate computer key. Slide change took 1 second. In all, 34 matrix problems were presented. During the task, participants received through headphones four 3-second bursts of white noise, timed to immediately precede four of the more difficult matrix problems. The timing of the noise bursts was identical for all participants and was independent of their performance.
Instructions regarding the mental stress task and the overall protocol were given on arrival at the laboratory. Participants were seated in a comfortable armchair, the blood pressure cuff attached, and an initial blood pressure reading taken to acquaint them with the measurement system; this reading was not used in the analyses. Eight minutes of rest followed during which time two blood pressure readings were taken; the average of these constituted the laboratory baseline blood pressure. With regard to the mental stress task, participants were told that the computer would track their performance and, if it fell below an unspecified criterion, a short burst of noise would be delivered through the headphones. As indicated, in reality, noise delivery was preprogrammed and independent of performance. Four evenly spaced blood pressure readings were taken during the third, 11th, 19th, and 27th matrix problems. The average of these four was used for the calculation of blood pressure reactions to the mental stress task; blood pressure reactions were computed as the arithmetic difference between the average stress task blood pressure and laboratory baseline blood pressure.
Statistical Analyses
Paired t tests were used to determine whether the increases in blood pressure from laboratory baseline to mental stress were statistically significant, as well as for comparing initial and 10-year follow-up screening blood pressures. Analysis of the possible predictors of 10-year follow-up blood pressure was by correlation and multiple linear regression. Various stepwise models were tested, but with age always forced into the equation at the outset. Multiple linear regression was undertaken both before and after correction for follow-up antihypertensive medication status: in the latter case, either by entering medication status into the regression equation or by omitting from the analyses those participants who, at follow-up, reported taking antihypertensive medication. In addition, as an additional check, the measured blood pressure values of participants on antihypertensive medication were replaced by 160 mm Hg SBP and 90 mm Hg DBP, if the measured values were lower than 160/90 mm Hg, and the multiple regression analyses repeated. Ten-year hypertension status (those who were taking antihypertensive medication or had blood pressures 
160/90 mm Hg were defined as hypertensive for this purpose) was analyzed by logistic regression to determine the optimal predictive models. These latter analyses permitted comparison with the findings from the Kuopio cohort (30).
|
RESULTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
|---|
|
Predictors of Blood Pressure at 10-Year Follow-Up
Table 2 summarizes the results of bivariate correlational analyses. The strongest predictors of follow-up blood pressure were initial screening blood pressure and laboratory baseline blood pressure. The magnitude of SBP reactions to the mental stress was positively related to follow-up SBP and, although to a far lesser extent, follow-up DBP. There were no such significant associations for DBP reactions. Age at entry was significantly associated with 10-year follow-up SBP (r(794) = 0.24, p < .001) but not DBP (r(794) = 0.05, p = .13).
|
Based on these bivariate outcomes, the following variables, in addition to age, were examined as potential independent predictors of follow-up SBP, using stepwise multiple regression: initial screening SBP, laboratory baseline SBP, and SBP reactions to mental stress. The outcome is summarized in Table 3. As might be expected, initial screening SBP provided the strongest prediction of follow-up SBP; together with age it accounted for 29% of the variance in follow-up SBP. Laboratory baseline SBP accounted for an additional 4.5%. SBP reactions to mental stress entered the model, and accounted for less than 1% of the variance not explained by the two resting measures. The full model accounted for 34% of the variance in follow-up SBP. The outcome of an analogous analysis of follow-up DBP is summarized in Table 4.
|
|
The following variables, in addition to age, were tested: initial screening DBP, laboratory baseline DBP, and DBP reactions to mental stress. In addition, given its significant bivariate association with this outcome, SBP reactions to mental stress were also tested. Two variables, initial screening DBP, and laboratory baseline DBP, entered the equation and together accounted for 21% of the variance in follow-up DBP.
These analyses were repeated with adjustment for medication status, as indicated either by entering medication status into the equation or by omitting those on antihypertensive medication from the analyses. For follow-up SBP, the same outcomes emerged from these supplementary analyses; SBP reactions to mental stress predicted follow-up SBP, but again accounted for less than 1% of the residual variance in each case. Similarly, for follow-up DBP, the adjustments did not affect the outcome, and blood pressure reactions to stress still failed to predict follow-up DBP. Virtually identical results also emerged from the analyses in which the measured blood pressures of participants on antihypertensive medication were replaced by 160 mm Hg SBP and 90 mm Hg. Again, SBP reactions to mental stress accounted for less than 1% of the variance in follow-up SBP and neither SBP nor DBP reactions entered the equation in the case of follow-up DBP.
Predictors of Follow-Up Hypertension
Logistic regression analyses were conducted on hypertension status (as indicated, those who were taking antihypertensive medication or had blood pressures 160 and 90 mm Hg at 10-year follow-up were regarded as hypertensive for this purpose). Various models were explored. First, in a univariate test, SBP reactions to mental stress significantly predicted subsequent hypertension status (OR = 1.04, 95% CI, 1.02–1.06, p < .001). This association was attenuated, although still significant, after adjustment for age and laboratory baseline SBP (OR = 1.02, 95% CI, 1.00–1.05, p = .02). However, in models entering initial screening SBP, either by itself or in combination age, SBP reactions to stress no longer predicted future hypertension status (OR = 1.02, 95% CI, 0.99–1.04, p = .15 and OR = 1.01, 95% CI, 0.99–1.03, p = .39, respectively). In both models, SBP at initial screening was significantly associated with subsequent hypertension (OR = 1.08, 95% CI, 1.06–1.10, p < .001 in both cases).
Similar models were used to explore the relationship between DBP reactions to stress and future hypertension. Again, there was a significant univariate association (OR = 1.04, 95% CI, 1.00–1.07, p = .03), which was actually enhanced after correction for age and laboratory baseline DBP (OR = 1.07, 95% CI, 1.03–1.11, p < .001). The association also withstood correction for initial screening DBP (OR = 1.04, 95% CI, 1.00–1.08, p = .05), but was no longer statistically significant when both age and initial screening DBP were entered (OR = 1.03, 95% CI, 0.99–1.07, p = .07). In both of these latter models, initial screening DBP was highly predictive of future hypertension (OR = 1.15, 95% CI, 1.12–1.18, p < .001 in both cases).
These analyses were repeated, but including as hypertensive only those who, at follow-up screening, reported taking antihypertensive medication. The outcomes were virtually identical to those reported above, with one exception. In these analyses, the association between DBP reactions to mental stress and subsequent hypertension status was no longer statistically significant after correction for initial screening DBP only (OR = 1.03, 95% CI, 0.99–1.07, p = .08).
|
DISCUSSION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
|---|
One difference between the 5- and 10-year follow-up assessments of this cohort was the increased number who reported taking antihypertensive medication. Only 31 of the participants at the time of the 5-year follow-up were taking antihypertensive medication compared with 109 of those available at 10-year follow-up. Combined with a small number of participants whose follow-up blood pressures registered in the hypertensive range, but were not on antihypertensive medication, the effective size of the sample who could reasonably be considered to have hypertension at follow-up was 114. SBP and DBP reactions to mental stress emerged as significant predictors of future hypertension. These associations withstood correction for some potential confounders, such as age and laboratory baseline blood pressure, and were associated with an increased risk for hypertension of between 2% and 7% per mm Hg increase in blood pressure reaction to mental stress, depending on the regression model. Such outcomes resonate well with the findings of Everson and her associates (30) in the Kuopio cohort using the anticipation of exercise as the stress exposure. However, in the present study, the associations between blood pressure reactions to mental stress and future hypertension were no longer statistically significant in models correcting for initial screening blood pressures or age and initial screening pressures. In the Kuopio study, the associations remained significant in all the multivariate models reported. However, it is worth noting that there was no equivalent of initial screening blood pressures and that the resting blood pressures entered into their models were more akin to the present laboratory baseline pressures.
Initial screening and laboratory baseline blood pressures were, to an extent, independent; they certainly made independent contributions to follow-up blood pressure status in regression models in which both were entered. In addition, whereas the prediction of follow-up hypertension offered by blood pressure reactivity remained statistically significant after adjustment for age and laboratory baseline pressure, it was no longer significant in models that included age and initial screening pressure. One possibility here is that initial screening blood pressure encompasses an element of reactivity. The white-coat effect, whereby the first clinic blood pressure reading is often elevated, is now widely recognized (38). In a study that used the difference between the first and fourth initial-screening SBP assessments as a reactivity measure, reactivity was found to predict elevated SBP at 2- to 4-year follow-up, independently of initial resting SBP, age, or body mass index (39). In this study, however, the first of the two initial screening values (M = 122.57 mm Hg) was not significantly higher than the second (M = 122.31 mm Hg) and the difference between these two initial screening SBP measures was not significantly associated with blood pressure status at 10 years.
The present results may be particular to middle-aged men, and this study is limited by the absence of women and younger individuals. Blood pressure reactions to mental stress would seem to vary with both age and sex; women and young adults have been reported to exhibit smaller reactions (40). However, in the one prospective study that has relevant data, the relationship between blood pressure reactions to stress and future blood pressure seems to be of the same order in women and men and in children and adults (29). Nevertheless, future studies would do well to extend the age range and to include women as well as men. A second caveat concerns the stress task used in this study: Raven’s matrices. It is possible that larger and less equivocal effects would have been seen with other tasks. Cardiovascular reactions to Raven’s matrices, however, correlate well with those to mental arithmetic stress (35).
The version of the reactivity hypothesis examined in these analyses is one that proposes a main effect for blood pressure reactivity in the determination of future blood pressure status. Virtually all of the prospective tests of the reactivity hypothesis, to date, have been directed at this version. Nevertheless, it remains possible that cardiovascular health outcomes are more strongly predicted by the interaction of reactivity with other factors, such as high levels of stress exposure. The argument, that for large magnitude blood pressure reactions to have a pathological impact they must be frequently elicited, seems a reasonable one. There is some preliminary evidence in favor (37). Reactivity to stress was found to have an interactive effect with self-reported life stress on 10-year follow-up blood pressure, as well as potentiating the association between family history of hypertension and follow-up blood pressure. Although beyond the scope of the present report, further analyses of our data will allow us to explore such interaction effects.
The results of prospective tests of the relationship between blood pressure reactions to acute psychological stress and future blood pressure status inform two areas of deliberation. The first is theoretical and the present results provide some, albeit modest, support for that version of the reactivity hypothesis that considers that heightened blood pressure reactions to psychological stress contribute to the development of high blood pressure. SBP reactions to mental stress were positively related to blood pressure levels 10 years on and, in multivariate models, the association remained, although it appeared only with follow-up SBP as the outcome measure. When hypertension at 10-year follow-up was the focus, both SBP and DBP reactions to mental stress were predictive, although with correction for age and initial screening blood pressure levels, the associations no longer met the usual criterion for statistical significance. The second area of deliberation is clinical and concerns the utility of stress testing as a prognostic device. It is clear from the present analyses that resting blood pressure measures offer a much better prediction of future blood pressure status than blood pressure reactions to a psychological stress task. In our report on the 5-year follow-up of this cohort (32), we concluded that, "At present, however, measurement of reactivity of blood pressure cannot be advocated as a useful clinical index of the course of future blood pressure." The results of this 10-year follow-up would not seem to require us to revise this conclusion.
|
ACKNOWLEDGMENTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
|---|
|
NOTES |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
|---|
Received for publication August 8, 2000.
Revision received January 26, 2001.
|
REFERENCES |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
|---|
This article has been cited by other articles:
 |
|
 |
|
  C. M.M. Licht, E. J.C. de Geus, A. Seldenrijk, H. P.J. van Hout, F. G. Zitman, R. van Dyck, and B. W.J.H. Penninx Depression Is Associated With Decreased Blood Pressure, but Antidepressant Use Increases the Risk for Hypertension Hypertension, April 1, 2009; 53(4): 631 - 638. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. D. Lane, S. R. Waldstein, H. D. Critchley, S. W. G. Derbyshire, D. A. Drossman, T. D. Wager, N. Schneiderman, M. A. Chesney, J. R. Jennings, W. R. Lovallo, et al. The Rebirth of Neuroscience in Psychosomatic Medicine, Part II: Clinical Applications and Implications for Research Psychosom Med, February 1, 2009; 71(2): 135 - 151. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Jones, A. Beda, C. Osmond, K. M. Godfrey, D. M. Simpson, and D. I.W. Phillips Sex-specific programming of cardiovascular physiology in children Eur. Heart J., September 1, 2008; 29(17): 2164 - 2170. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Flaa, I. K. Eide, S. E. Kjeldsen, and M. Rostrup Sympathoadrenal Stress Reactivity Is a Predictor of Future Blood Pressure: An 18-Year Follow-Up Study Hypertension, August 1, 2008; 52(2): 336 - 341. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A L Markel, O E Redina, M A Gilinsky, G M Dymshits, E V Kalashnikova, Y. V Khvorostova, L A Fedoseeva, and G S Jacobson Neuroendocrine profiling in inherited stress-induced arterial hypertension rat strain with stress-sensitive arterial hypertension J. Endocrinol., December 1, 2007; 195(3): 439 - 450. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Authors/Task Force Members:, G. Mancia, G. De Backer, A. Dominiczak, R. Cifkova, R. Fagard, G. Germano, G. Grassi, A. M. Heagerty, S. E. Kjeldsen, et al. 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) Eur. Heart J., June 11, 2007; (2007) ehm236v1. [Full Text] [PDF]
|
|
|
|
|
|
J. V. Moseley and W. Linden Predicting Blood Pressure and Heart Rate Change With Cardiovascular Reactivity and Recovery: Results From 3-Year and 10-Year Follow Up Psychosom Med, November 1, 2006; 68(6): 833 - 843. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. Mutaner and H. J. Chung Psychosocial epidemiology, social structure, and ideology J Epidemiol Community Health, July 1, 2005; 59(7): 540 - 541. [Full Text] [PDF]
|
|
|
|
 |
|
 K. A. Matthews, C. R. Katholi, H. McCreath, M. A. Whooley, D. R. Williams, S. Zhu, and J. H. Markovitz Blood Pressure Reactivity to Psychological Stress Predicts Hypertension in the CARDIA Study Circulation, July 6, 2004; 110(1): 74 - 78. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. Clark Subjective Stress and Coping Resources Interact to Predict Blood Pressure Reactivity in Black College Students Journal of Black Psychology, November 1, 2003; 29(4): 445 - 462. [Abstract] [PDF]
|
|
|
|
|
|
R. Clark Parental History of Hypertension and Coping Responses Predict Blood Pressure Changes in Black College Volunteers Undergoing a Speaking Task About Perceptions of Racism Psychosom Med, November 1, 2003; 65(6): 1012 - 1019. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Carroll, C. Ring, K. Hunt, G. Ford, and S. Macintyre Blood Pressure Reactions to Stress and the Prediction of Future Blood Pressure: Effects of Sex, Age, and Socioeconomic Position Psychosom Med, November 1, 2003; 65(6): 1058 - 1064. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 W De Vente, M Olff, J G C Van Amsterdam, J H Kamphuis, and P M G Emmelkamp Physiological differences between burnout patients and healthy controls: blood pressure, heart rate, and cortisol responses Occup. Environ. Med., June 1, 2003; 60(90001): i54 - 61. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. A. Matthews, K. Salomon, S. S. Brady, and M. T. Allen Cardiovascular Reactivity to Stress Predicts Future Blood Pressure in Adolescence Psychosom Med, May 1, 2003; 65(3): 410 - 415. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. P. Harrell, S. Hall, and J. Taliaferro Physiological Responses to Racism and Discrimination: An Assessment of the Evidence Am J Public Health, February 1, 2003; 93(2): 243 - 248. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. A. Treiber, T. Kamarck, N. Schneiderman, D. Sheffield, G. Kapuku, and T. Taylor Cardiovascular Reactivity and Development of Preclinical and Clinical Disease States Psychosom Med, January 1, 2003; 65(1): 46 - 62. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. S. Knox, J. Hausdorff, and J. H. Markovitz Reactivity as a Predictor of Subsequent Blood Pressure: Racial Differences in the Coronary Artery Risk Development in Young Adults (CARDIA) Study Hypertension, December 1, 2002; 40(6): 914 - 919. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. J. Gianaros, M. E. Bleil, M. F. Muldoon, J.R. Jennings, K. Sutton-Tyrrell, J. M. McCaffery, and S. B. Manuck Is Cardiovascular Reactivity Associated With Atherosclerosis Among Hypertensives? Hypertension, November 1, 2002; 40(5): 742 - 747. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. L. Hassett and L. H. Sigal Unforeseen Consequences of Terrorism: Medically Unexplained Symptoms in a Time of Fear Arch Intern Med, September 9, 2002; 162(16): 1809 - 1813. [Full Text] [PDF]
|
|
|
|
 |
|
 R. D. Lipman, P. Grossman, S. E. Bridges, J.W. Hamner, and J. A. Taylor Mental Stress Response, Arterial Stiffness, and Baroreflex Sensitivity in Healthy Aging J Gerontol A Biol Sci Med Sci, July 1, 2002; 57(7): B279 - B284. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. C. Light Hypertension and the Reactivity Hypothesis: The Next Generation Psychosom Med, September 1, 2001; 63(5): 744 - 746. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
