Neither Perceived Job Stress Nor Individual Cardiovascular
Reactivity Predict High Blood Pressure
Jean Pierre Fauvel, Ignasse M’Pio, Pierre Quelin, Jean-Pierre Rigaud, Maurice Laville, Michel Ducher
Downloaded from http://hyper.ahajournals.org/ by guest on June 17, 2017
Abstract—We have reported that high job strain was associated with a significantly higher diastolic blood pressure (DBP)
of 4.5 mm Hg during the working hours, irrespective of BP reactivity to a stress test. We report the final results of the
first 5-year follow-up study, which aimed to assess the respective influences of perception of professional strain and
cardiovascular reactivity to a mental stress test on BP. A cohort of 292 healthy subjects (mean⫾SEM age, 38⫾1 years)
was followed up for progression to hypertension outcome, which was defined as an increase in systolic blood pressure
(SBP) or DBP ⬎7 mm Hg or a DBP ⬎95 mm Hg during follow-up. None of the subjects was lost to follow-up, and 209
subjects completed the study. The high-strain (HS) group, representing 20.9% of the subjects, was compared with the
remaining subjects (non– high-strain [NHS]). Similarly, the subjects with the highest BP stress reactivity (HR; 20.9%
of subjects) were compared with the remaining subjects (NHR). Progression to hypertension was reached by 93 subjects
(31.8%). Kaplan-Meier survival estimates revealed that neither HS nor HR increased the incidence of progression to
hypertension. End-of-follow-up 24-hour ambulatory BPs that were similar in HS and NHS (120⫾2 vs 120⫾1 mm Hg,
respectively) and in HR and NHR (122⫾2 vs 120⫾1 mm Hg, respectively) confirmed our findings. Age, alcohol, salt
diet, body mass index, and occupation did not interfere with our results. In conclusion, cardiovascular HR and HS do
not appear to be major risk markers for future high BP in healthy, young adults. (Hypertension. 2003;42:1112-1116.)
Key Words: epidemiology 䡲 stress 䡲 clinical trials 䡲 hypertension, essential 䡲 blood pressure monitoring, ambulatory
P
sychological stress is hypothesized as 1 of the major
environmental factors implicated in the genesis of hypertension. Among various psychological stresses, the most
investigated has been job-related stress. It was defined by
Karasek et al1 as the combination of high psychological
demand and low latitude on the job. To date, only 3 studies
designed to assess the long-term effect of job strain on blood
pressure (BP) have produced controversial results.2– 4 The
most convincing 1 was a case-control study, which found that
high job strain was associated with a 3-year increase in
systolic BP (SBP)/diastolic BP (DBP) of 5/3 mm Hg, supporting the hypothesis that job strain might be an etiologic
factor in the genesis of essential hypertension.4
The effects of stressors on cardiovascular regulation involve 2 components that have never been studied concomitantly. The first component is individual stress perception,
quantified by questionnaires, and the second is individual
cardiovascular reactivity to stress, assessed by a BP surge in
response to stress tests. We recently reported the results of a
cross-sectional analysis5 of a prospective study in which
subjective perception of job strain was evaluated by the
questionnaire developed by Karasek et al,1 and stress cardiovascular reactivity was measured by the Stroop stress test.
The main results were that high professional strain but not
stress BP reactivity was associated with a higher DBP of
4.5 mm Hg during working periods. We hereby report the
final results of the 5-year follow-up study that aimed to
evaluate the potential influence of the 2 stress components
(cardiovascular reactivity and quantification of professional
strain) on progression to hypertension, defined as an increase
in SBP and/or DBP ⬎7 mm Hg or a DBP ⬎95 mm Hg during
follow-up. Furthermore, to increase the reliability of our
study, major factors known to influence BP were analyzed,
and ambulatory blood pressure (ABP), which is more relevant
than casual BP, was assessed at the end of follow-up.
Methods
Study Population
The study was conducted on full-time-employment subjects working
in a chemical company, aged between 18 and 55 years (mean⫾SD
age, 38⫾1 years). Among the 473 eligible subjects, 370 volunteered
to participate in the study. Of them, 303 nonmedicated, healthy,
normotensive (BP ⬍140/90 mm Hg) subjects (278 men and 25
women) were included if their dipstick urinalysis results were within
normal limits and if they were free of any current medication that
could interfere with BP regulation. After inclusion in 1995, subjects
were followed up for outcome until 2001. The mean length of the
follow-up period was 5.0⫾1.4 years, ranging from 1 to 6 years. Two
hundred ninety-two subjects were followed up for at least 1 year and
Received June 9, 2003; first decision July 18, 2003; revision accepted October 10, 2003.
From Département de Néphrologie et d’Hypertension artérielle (J.P.F., I.M’P., M.L., M.D.), EA 645, Hôpital E Herriot, Lyon, and Médecine du travail
(P.Q., J.-P.R.), Rhodia, Saint-Fons, France.
Correspondence to Jean Pierre Fauvel, Département de Néphrologie et d’Hypertension artérielle, Hôpital E Herriot, 69437 Lyon, France. E-mail
[email protected]
© 2003 American Heart Association, Inc.
Hypertension is available at http://www.hypertensionaha.org
DOI: 10.1161/01.HYP.0000102862.93418.EE
1112
Fauvel et al
were analyzed. Two hundred eighty-three subjects were followed up
2 years; 266, for 3 years; 245, for 4 years; and 208 for at least 5
years. The main reasons for discontinuation during follow-up were
retirement (40 subjects) and job transfer (35 subjects). Five subjects
discontinued because of hypertension, and 4 died (1 cardiac failure,
1 sudden death, and 2 cancer). None of the subjects was lost to
follow-up, and each subject who was planned to discontinue the
study had a final evaluation.
Mental Stress, Job Strain, and Blood Pressure
TABLE 1. Baseline Characteristics of the 4 Groups, Classified
by Job Strain and SBP Response to Mental Stress
Parameter
HS
n
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High-strain (HS) and high-reactivity (HR) groups were defined on
the inclusion data as previously described5 but were not revealed to
the investigators (P.Q. and I.M’P.) to ensure blinded measurement of
outcomes. In brief, the self-administered questionnaire included 18
items to assess job demand and job decision latitude.1,6 The medians
of demand and latitude classified the subjects reporting the highest
job demand and the lowest job decision latitude. These subjects
representing the HS group (n⫽61) were compared with the remaining subjects (NHS group, n⫽232; 17 nonvalid questionnaires).
Similarly, the 61 subjects exhibiting the highest stress-induced SBP
increase were considered the HR group and were compared with the
remaining subjects (NHR, n⫽226; 7 nonvalid stress test results).
Mental stress was induced by a computerized version of Stroop’s
color conflict test.7 Rest and stress BPs were recorded beat to beat by
using a Finapres device (model 2300, Ohmeda).
Protocol
The planned sample size of 300 subjects was calculated after
assuming an SE for BP measurement of 7 mm Hg, group sizes of
25% for the HS group versus 75% for the NHS group, and a
difference in DBP of 3 mm Hg between groups. On these bases, it
was estimated that the study would have at least 80% power to detect
the expected difference between groups with a risk ␣ of 0.05. The
mean 5-year increase in DBP was ⬇3 mm Hg for the whole group.
Thus, for the Kaplan-Meier analysis, the primary end point was a
5-year increase in DBP ⬎7 mm Hg (a mean increase in DBP of
3 mm Hg plus a difference between groups of ⬎3 mm Hg) and/or a
DBP ⬎95 mm Hg. During follow-up at the annual working visit,
subjects were given a routine medical examination, which included
a full history, physical examination, body mass index (BMI) determination, and assessment of alcohol intake. Worksite BP was
measured 3 times to the nearest 2 mm Hg with a mercury sphygmomanometer after a 5-minute rest in a reclining position. The mean of
the last 2 (of 3) BP measurements was considered. At entry, a
24-hour urine collection (for measurement of electrolytes, creatinine,
urea, and albumin excretion) was carried out at the worksite and was
available for 288 of the 292 subjects. Alcohol intake was ranked in
5 levels by interview: ⬍1 drink per week, ⬍1 drink per day, 1 to 2
drinks per day, 3 to 4 drinks per day, and ⬎4 drinks per day. At the
end of the 5-year follow-up, each subject was asked to wear an ABP
monitor (Spacelabs 90207) for 24 hours during a regular workday, to
collect a 24-hour urine sample, to complete the job strain questionnaire, and to perform the mental stress test. In cases of premature
withdrawal from the study, only hypertensives were asked to
perform all of the tests. ABP was measured at 15-minute intervals
between 6 AM and 10 PM and at 30-minute intervals during the
remaining hours. The diary information allowed us to calculate
average working, sleeping, and waking BPs. Among the 157 ABPs
performed, 154 were valid according to standard criteria.8,9 The
protocol was approved by the Lyons Ethics Committee for Protection
of Volunteers in Biomedical Research, and written, informed consent
was obtained from each subject.
NHS
HR
NHR
61
213
61
232
Gender, M/F
53/8
198/15
57/4
21/204
Age, y
36⫾1
38⫾1
37⫾1
38⫾1
BMI, kg/m
25.0⫾0.5
24.7⫾0.2
25.2⫾0.4
24.7⫾0.2
SBP, mm Hg
124⫾1
125⫾1
126⫾1
124⫾1
DBP, mm Hg
77⫾1
78⫾1
78⫾1
78⫾1
HR, bpm
63⫾1
63⫾1
62⫾1
63⫾1
Sodium, g/24 h
9.4⫾0.4
9.7⫾0.3
9.6⫾0.5
9.6⫾0.3
Alcohol mean score
1.9⫾0.1
2.1⫾0.1
1.9⫾0.1
2.1⫾0.1
⌬SBP, mm Hg
22⫾2
22⫾1
40⫾1
17⫾1*
⌬DBP, mm Hg
10⫾1
10⫾1
15⫾1
9⫾1*
⌬HR, bpm
9.0⫾1.2
7.5⫾0.5
11⫾1
6.8⫾0.5*
2
Definition of High-Strain and High-Reactivity Groups
1113
HR indicates heart rate, in beats per minute (bpm); ⌬, stress-induced
variation. All other abbreviations are as defined in text. Values are mean⫾SEM.
*P⬍0.001 between complementary groups (HS vs NHS or HR vs NHR).
sodium intake as intersubject factors. Cox proportional-hazards
models were used to evaluate the multivariate relations between the
characteristics at entry and the progression to hypertension. The
Kaplan-Meier method was used to estimate the cumulative incidence
of progression to hypertension according to the characteristics
identified at entry, and the log-rank test was used to assess the
significance of unadjusted differences among the incidence curves.
A value of P⬍0.05 was considered significant.
Results
The only significant determinant of 5-year BP (office and
ambulatory) evolution was age. BMI was the second but did
not reach significance (P⫽0.07). A positive family history of
hypertension (first-degree relatives) was associated with a
higher SBP (130⫾9 vs 127⫾11 mm Hg, P⬍0.05) and a
higher DBP (84⫾6 vs 81⫾8 mm Hg, P⬍0.05) at the end of
follow-up. The rate of discontinuation from the study was
broadly similar between groups. At entry, the main characteristics of the subjects of complementary groups were
similar, as shown in Table 1.
Statistical Analysis
Data are expressed as mean⫾SEM in text, tables, and figures. A
linear multivariate analysis was first performed to evaluate the
determinants of the 5-year BP (office and ambulatory) evolution.
Mean values at inclusion and at end of follow-up were compared
between complementary groups (HS vs NHS and HR vs NHR) with
an ANCOVA with gender, age, alcohol intake, BMI, occupation, and
Figure 1. Cumulative incidence of “progression to hypertension”
in normotensives as a function of job strain (HS and NHS
groups). Progression to hypertension was defined as an
increase in SBP and/or DBP ⬎7 mm Hg or a DBP ⬎95 mm Hg
during follow-up.
1114
Hypertension
December 2003
TABLE 2. Worksite BP, 24-Hour BP (ABP), Working BP, and
Nonworking BP at the End of Follow-Up
Parameter
Figure 2. Cumulative incidence of “progression to hypertension”
in normotensives as a function of SBP stress reactivity to the
Stroop stress test (HR and LR groups [NHR group in text]). Progression to hypertension was defined as an increase in SBP
and/or DBP ⬎7 mm Hg or a DBP ⬎95 mm Hg during follow-up.
Downloaded from http://hyper.ahajournals.org/ by guest on June 17, 2017
Categorization of patients was based on estimated job
strain and cutoff scores to separate subjects. Medians of
demand and latitude scores were respectively 26 and 35. The
HS group included 61 subjects (21%). The stress-induced
increase in SBP of the HR group (61 subjects) was at least
32.0 mm Hg.
Progression to hypertension was reached by 93 subjects
(31.8%) in the whole group, 17 (27.9%) in the HS group, 71
(33.3%) in the NHS group, and 5 (29%) of the 17 whose
questionnaire could not be analyzed. The log-rank test assessed that there was no significant difference among the
incidence curves between HS and NHS groups, as shown in
the Kaplan-Meier curves represented in Figure 1. Eighteen
HR subjects (29.5%), 72 NHR subjects (33.8%), and 3
subjects (47.7%) whose stress test was not reliable progressed
to hypertension. The log-rank test revealed that the difference
among the incidence curves was not significant between HR
and NHR groups, as shown in Kaplan-Meier curves represented in Figure 2. End of follow-up ABPs were similar in HS
and NHS groups and in HR and NHR groups (Table 2). We
checked a posteriori that the main characteristics (age, BMI,
SPB/DBP, salt diet, alcohol consumption, gender ratio, and
ratio of positive family history of hypertension) of the
subjects who had an ABPM did not differ in the mean and
distribution when compared with those of the whole population. Subjects whose job strain was high both at entry and at
the end of study (HS-HS group) had similar BPs compared
with subjects whose job strain was high only at entry
(HS-NHS), was high only at the end of follow-up (NHS-HS),
or was never high (NHS-NHS group; Table 3). Suspected
confounding factors (age, gender, BMI, alcohol intake, and
sodium intake) were not different between groups, and
ANCOVA, controlling for these variables, provided similar
findings.
Discussion
Acute stress is typically associated with increased BP. The
hypothesis that chronic stress exposure could lead to
hypertension is of major interest but still remains debated.
Multifarious mechanisms link psychological stress to hy-
HS
NHS
HR
NHR
n, group/n, ABP
61/36
213/96
61/24
225/107
Worksite SBP
127⫾2
129⫾1
130⫾1
128⫾1
Worksite DBP
82⫾1
82⫾1
82⫾1
82⫾1
24-Hour SBP
120⫾2
120⫾1
122⫾2
120⫾1
24-Hour DBP
77⫾1
77⫾1
77⫾1
77⫾1
Working SBP
124⫾2
126⫾1
125⫾2
126⫾1
Working DBP
82⫾2
83⫾1
80⫾2
84⫾1
Nonworking SBP
117⫾1
118⫾1
119⫾1
117⫾1
Nonworking DBP
74⫾1
74⫾1
75⫾2
74⫾1
n, group indicates No. of subjects by group; n, ABP, No. of subjects having
an ABP measurement. All other abbreviations are as defined in text. Values are
mean⫾SEM, and all BP measurements are in mm Hg.
pertension. The cardiovascular response to mental stress
represents a complex interplay between a personal integrative feeling of stress, the autonomic nervous system, and
cardiovascular function and/or structure. This study was
designed to test long term-effects of stress exposure on BP.
The individual integrative perception of stress (job strain)
was measured by a questionnaire,1 whereas BP response to
the Stroop stress test evaluated personal physiologically
stress-induced increases in BP. The main result of our
study was that neither job strain nor stress BP reactivity
was associated with an increase in the incidence of
“progression to hypertension.” In our study, progression to
hypertension was a composite outcome associating an
increase in SBP or DBP ⬎7 mm Hg or a DBP ⬎95 mm Hg
at the end of follow-up. This composite criterion was
chosen because in this rather young cohort of subjects, the
incidence of hypertension was expected to be low. Similar
ABPs between complementary stress groups reinforced our
results. However, until now, many but not all published
studies tended to find a relation between stress and BP.
Among them, only 5, specifically designed for that purTABLE 3. Worksite BP, 24-Hour BP (ABP), Working BP, and
Nonworking BP at the End of Follow-Up in Groups Classified by
Job Strain at Entry and at the End of Follow-Up
Parameter
HS-HS
HS-NHS
NHS-HS
NHS-NHS
n1, group/n2, ABP
17/14
19/13
19/13
103/71
Worksite SBP
128⫾2
127⫾2
127⫾2
128⫾1
Worksite DBP
82⫾2
81⫾2
81⫾1
82⫾1
24-Hour SBP
118⫾2
123⫾3
123⫾3
120⫾1
24-Hour DBP
76⫾2
81⫾2
81⫾2
77⫾1
Working SBP
123⫾3
128⫾3
128⫾3
126⫾1
Working DBP
82⫾3
87⫾3
87⫾3
83⫾1
Nonworking SBP
117⫾3
119⫾1
119⫾1
119⫾1
Nonworking DBP
75⫾2
76⫾2
76⫾2
74⫾1
HS-HS indicates high strain both at entry and at the end of follow-up;
HS-NHS, high strain only at entry; NHS-HS, high strain only at the end of
follow-up; NHS-NHS, no high strain both at entry and at the end of follow-up;
n2, ABP, No. of ABP measurement in the group of n1. All other abbreviations are
as defined in text. Values are mean⫾SEM.
Fauvel et al
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pose, were conducted prospectively. At a 1-year interval,
change in job strain was associated with a change in BP,2
whereas at a 5-year interval, persistently high job strain
was not associated with a change in BP.3 Three prospective
studies that used ABP measurements provided evidence
that chronic stress exposure could lead to higher BP in the
long run and that changes in stress exposure were associated with a change in ABP. The most convincing 1 was a
prospective case-control study, which reported that 15
subjects with high strain (both at entry and at the end of
follow-up) had a significant 4 mm Hg higher DBP at the
end of follow-up (after controlling for initial BP).4 However, cases were hypertensives (DBP ⬎85 mm Hg or being
treated for hypertension), and controls were unmedicated
normotensives. Because BP evolution is linked to baseline
BP, such a case-control design could have amplified the
stress effect on BP. Case-control studies that have underlined a potential relation between job strain and BP level
might generate methodological bias. Thus, to minimize
potential bias, our study was conducted in a normotensive
population to quantify the association between job strain
and BP. Furthermore, most known risk factors for elevated
BP were controlled for, and none of the subjects was lost
to follow-up. We also verified that the 95 premature
withdrawals (main reasons for withdrawal were retirement
or job transfer) were not related to stress status. These
subjects whose professional status changed might have
been less concerned by their actual job strain and thus,
were not asked to complete the job strain questionnaire.
The percentage of subjects who did not fill out the
questionnaire was similar between groups (41% in the HS
group vs 37% in the NHS group) According to Schnall et
al,4 we compared BPs in groups in relation to their change
in job strain level between entry and the end of follow-up.
In our study, BP values at the end of follow-up were
independent of the level of strain at entry and 5 years apart
(Table 2). Job strain might vary in 5 years. This is a
limitation to our study, which is common to all observational studies. The questionnaire developed by Karasek et
al1 is well suited to record job strain at present. It does not
provide any information on either past or future evolution
of job strain. In that view, job strain might be related only
to simultaneously recorded BP. Because cross-sectional
studies,10 –18 including our analysis at inclusion,5 consistently reported that job strain was associated with a higher
BP level, job strain might be related to concomitant BP but
would not predict BP in the long run.
A lower median job demand and higher median job latitude
could in part explain the lack of job strain effects on BP
evolution. However, median levels are not far from those
reported by Schnall et al.10 Because there is no accepted
threshold, we compared subjects in the high-strain quadrant
(high demand and low latitude) to the remaining subjects, as
recommended by Karasek et al.1 One of the main interests of
our study was to simultaneously evaluate job stress and BP
reactivity to mental stress. Several studies have addressed the
issue that physical stress BP reactivity was predictive of
future hypertension, stress being exercise19 or a cold test.20
Few studies21–25 reported a weak predictive value of mental
Mental Stress, Job Strain, and Blood Pressure
1115
stress reactivity on BP level. We could not find any predictive
value of stress BP reactivity even when using a reproducible
stress test26 that elicited a major and sustained BP response
(22⫾1/10⫾1 mm Hg for SBP/DBP).
Perspectives
Our study is the first to report a lack of job strain effect and
of stress reactivity on 5-year BP evolution. However, the
design of our study increases the confidence in our results.
This is the first study designed to analyze the effects of job
strain and reactivity to mental stress, which was conducted in
a cohort of nonselected normotensive subjects. The number
of subjects was calculated to obtain a power of 80%. The
convergence of our results from the use of various statistical
tools attests to the robustness of our conclusions. If job strain
increases BP in the long run, it might be true only in receptive
subjects. Main BP-related factors (alcohol consumption,
BMI, sodium diet, age, gender, and occupation), which were
equally distributed between complementary groups, did not
influence our conclusions.
Acknowledgments
We would like to thank all participating employees of Rhodia,
Belle-Etoile factory, Saint-Fons, France. This study was supported
by grants from Rhodia (Rhône-Poulenc division) Lederle Laboratories, the Club des Jeunes Hypertensiologues.
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Neither Perceived Job Stress Nor Individual Cardiovascular Reactivity Predict High
Blood Pressure
Jean Pierre Fauvel, Ignasse M'Pio, Pierre Quelin, Jean-Pierre Rigaud, Maurice Laville and
Michel Ducher
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Hypertension. 2003;42:1112-1116; originally published online November 3, 2003;
doi: 10.1161/01.HYP.0000102862.93418.EE
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