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Hypertension (HTN) in children is increasing at an alarming rate, with current estimates ranging from 2 to 5% [1–3]. A recent metanalysis reported that the prevalence of stage 1 and 2 HTN in children was 4 and 0.95%, respectively [4]. The highest prevalence of HTN is observed in pubertal children aged 14–15, with an estimate of 7.9% [4]. Although secondary HTN is the leading cause of HTN in preschool children, the majority of children 6 years and older with HTN have no identifiable cause and are, therefore, considered to have primary HTN [5–8]. The risk factors for primary HTN in children include nonmodifiable factors such as older age of the child, family history, and genetics, as well as modifiable factors like obesity and high salt intake [6,8–10]. Although obesity epidemic in children may explain partially higher rates of pediatric HTN [11–14], it is unlikely to be the only factor responsible for it as many pediatric patients with obesity remain normotensive [12]. Identifying additional modifiable risk factors for HTN is critical for the care of individual patients and the overall health of society. Other determinants, including social and psychosocial factors, may also play a role in pediatric HTN [15]. The American Academy of Pediatrics (AAP) recommends considering those factors when assessing blood pressure control in children and adolescents in their recent guidelines [5].
Anxiety is a common problem among children [16,17]. Anxiety has been linked to increased sympathetic activation and peripheral vascular resistance, which can lead to hypertension [18–20]. Anxiety screening is becoming a standard part of primary care for children and recently the US preventive services task force (USPSTF) recommends screenings for children aged 8–18 years [21]. It is estimated that 15% of children and 30% of adolescents meet the criteria for anxiety [22].
Association between anxiety and elevated blood pressure (BP) has been studied in adults but not in children [23,24]. Recent studies and meta-analyses have confirmed the benefits of early detection and treatment of anxiety in hypertensive adult patients [23,25,26]. In children, both anxiety and HTN peak at age of 14–15 [12,15,17], suggesting a possible link between those conditions.
The purpose of this study was to examine the relationship between anxiety and elevated BP in adolescent children at our clinic.
METHODSThis is a prospective, single-center study of adolescents, 12–18 years of age, referred to a pediatric nephrology clinic. This study was approved by the New York Medical College Committee for Protection of Human Subjects General Medical and Behavioral Panel (Valhalla, NY, Protocol L-11,934) and informed consent was obtained from all participants.
Patient inclusion criteria for the study included age between 12 and 18 years, ability to provide informed consent in English or Spanish, and having both the patient and parent present. Data collected included mean clinic blood pressure measurement, demographic data, height, weight, referring diagnosis, and medication list.
BP measurements were taken while the patient was sitting comfortably, resting at least 5 min prior to measurement and between measurements, using the Dynamap device, with the appropriate cuff sizes for the patient's arm diameter. An average of two measurements was recorded. For the purpose of this study, elevated BP was defined as a mean clinic measurement of either SBP or DBP above the 95th percentile for age, height, and sex.
All patients completed the validated modified Screen for Child Anxiety-Related Disorders (SCARED-C) questionnaire [27,28]. Parent (one for each patient) independently completed the SCARED-P questionnaire assessing the child. The SCARED questionnaire is a standard validated clinical research tool for childhood anxiety [29]. A score of at least 9 was defined as a positive screen for anxiety.
Descriptive statistical methods were used and a nonparametric test, Mann–Whitney U to analyze the difference in groups. We examined the association between elevated BP and anxiety by two methods. First, we examined the correlation between the prevalence of elevated BP, systolic and diastolic, with positive SCARED by either self (SCARED-C) or parental (SCARED-P) reporting using chi-square analysis. The correlation between mean SBP and DBP with SCARED scoring was assessed by the Mann–Whitney U test. Association between proportions assessing blood pressure and SCARED score were compared using Pearson chi-square tests. Statistical analysis of the patient and parental anxiety score was performed separately. Two-tailed P values of less than 0.05 were considered significant.
RESULTSA total of 200 adolescents (54% boys and 46% girls) with a mean age of 15.4 ± 1.7 years participated in this study. Demographic data is presented in Table 1. A total of 42% (83) of the adolescents were found to have elevated BP, with 61 (31%) having systolic and 57 (29%) diastolic elevated BP. The mean SBP and elevated DBP were 123.2 ± 14.9 and 75.9 ± 14.9 mmHg, respectively. A total of 89 (45%) and 58 (29%) had positive SCARED scores based on self or parental evaluation, respectively. Thirty-four percent of the adolescents were on blood pressure-modifying medications (Table 1). Patients’ referral diagnoses included renal diseases such as glomerular diseases, tubulointerstitial diseases, and vascular diseases, and HTN (Table 1). Glomerular diseases were more common within the nonanxious group whereas diagnosis of essential HTN was more common in anxious children.
TABLE 1 - Demographic data of participants on referral to pediatric nephrology clinic Parental reporting Total AnxiousIn the complete cohort of adolescents (No 200), 31 (53%) of SCARED-P positive participants were found to have elevated BP compared with 27 (19%) of SCARED-P negative, P 0.03 (Table 2). Twenty-two (38%) and 25 (43%) of SCARED-P positive had either systolic or diastolic elevated BP compared with 30 (34%) and 31 (28%) of SCARED-P negative respectively, with only diastolic reaching statistical significance (P = 0.003) (Table 2). In SCARED-P positive, mean SBP (125.2 ± 13.3) and mean DBP (78.4 ± 9.9) were higher compared with SCARED-P negative mean SBP (123.59 ± 15.6) and mean DBP (74.9 ± 9.2), respectively; with only the differences in mean DBP reaching statistical significance (P = 0.03) (Table 2). Referring diagnosis of primary renal diseases were more common in the SCARED negative patients whereas HTN was more common in SCARED positive patients (Table 1) suggesting that renal diseases were not accounting for higher prevalence of elevated BP in SCARED-P positive patients.
TABLE 2 - Association between anxiety and elevated BP in the complete cohort of adolescents Parental reporting Self-reporting Total AnxiousHR, heart rate; SD, standard deviation.
∗P < 0.05.
To eliminate the effect of blood pressure medications on the results, we performed separate analysis as a subgroup of adolescents, who were not taking any blood pressure-modifying medications. In this subgroup (N 130), 58 (45%) had positive SCARED-C and 37 (29%) positive SCARED-P scores. Twenty (54%) of SCARED-P positive had elevated BP compared with 33 (36%) of SCARED-P negative, P = 0.05 (Table 3). Fourteen (38%) and 16 (43%) of SCARED-P positive had either systolic or diastolic elevated BP, compared with 16 (43%) and 18 (19%) of SCARED-P negative, respectively, with only diastolic elevated BP reaching significance P = 0.005 (Table 3). In this subgroup, mean DBP was significantly higher in both SCARED-P positive (78.98 ± 10.1) and SCARED-C positive (77.1 ± 10.4) compared with the SCARED-P negative (73.6 ± 9.3) and SCARED-C negative (73 ± 8.9) groups, respectively (Table 3). In this subgroup of patients as in complete cohort, renal diseases were less common in SCARED positive patients compared with SCARED negative (data not shown).
TABLE 3 - Association between anxiety and elevated BP in the subgroup of adolescents not treated with antihypertensive medications Parental reporting Self-reporting AnxiousHR, heart rate; SD, standard deviation.
∗P < 0.05.
To eliminate the effect of obesity on the results, separate analysis was performed in subgroup of adolescents with BMI less than 95th percentile. In this subgroup of patients (N = 123), 49 (40%) had positive SCARED-C and 32 (26%) had positive SCARED-P scores. Eleven (34%) of SCARED-P positive had systolic and 13 (41%) diastolic elevated BP compared with 20 (22%) systolic and 16 (23%) diastolic of SCARED-P negative, with only diastolic elevated BP reaching significance (P = 0.01). In this subgroup, both systolic (124.0 ± 14.1) and diastolic (78.4 ± 8.9) BP in SCARED-P positive were significantly higher compared with the SCARED-P negative (SBP 118.5 ± 14.7, DBP 73.0 ± 9.1, P = 0.03 and 0.01 accordingly) (Table 4).
TABLE 4 - Association between anxiety and elevated BP in the subgroup of adolescents with BMI less than 95th percentile Parental reporting Self-reporting AnxiousSD, standard deviation.
∗P < 0.05.
Adult HTN is a well recognized risk factor for cardiovascular and chronic kidney diseases worldwide [30,31]. Pediatric HTN can result in cardiovascular morbidity at a young age [32,33]. Studies have demonstrated that children as young as 11 years can exhibit organ damage because of HTN [34]. HTN in childhood and adolescence is linked to HTN in adulthood, contributing to cardiovascular diseases burden in adulthood [35–37]. Majority of pediatric patients with primary HTN have no modifiable risk factors as obesity and high salt intake [6,8]. Search for additional risk factors for pediatric HTN is clearly indicated.
It is well established that anxiety is a common problem among both adults and children [17,38]. Cross-sectional studies in adults have shown an association between anxiety and HTN and prospective studies have directly linked the two [20,23]. There are many factors that may contribute to the rise in pediatric anxiety, including inequalities, substance abuse, internet gaming, bullying, the COVID-19 pandemic, and others [13,39–41].
To the best of our knowledge, our study is the first to examine the association between anxiety and elevated BP in adolescent children. Our study included 200 adolescents referred to a single-center nephrology clinic. In our cohort, we demonstrated an association between elevated BP and anxiety assessed by SCARED scoring. Anxious participants had higher SBP and DBP compared with nonanxious participants, with only the differences in DBP being statistically significant. The tendency for higher blood pressures was observed in all anxious patients with statistically significant correlation between parental assessment of anxiety (SCARED-P) and elevated BP in complete cohort of patients. SCARED is a very brief questionnaire showing only moderate correlation between parental and self-assessments [29,42], which may explain the differences observed in our study; more robust evaluation of anxiety is required in a future studies. In the subgroup of patients not treated with any BP-modifying medications, mean SBP was elevated by 0.6 and 2.8 mmHg and mean DBP by 4.1 and 5.4 in anxious compared with nonanxious participants by self and parental assessment, respectively. The pathophysiology of diastolic HTN is not well understood; we cannot provide explanation of more significant differences observed in DBP versus SBPs in our study. We did observe significant difference in pulse between anxious and nonanxious participants (Tables 2 and 3). These findings challenge the common belief that stress and anxiety result primarily in tachycardia and systolic HTN. This is an important consideration for primary care providers as our study suggests that anxiety may have a greater impact on DBP in adolescent patients. Recent analysis of 1.3 million adults confirmed that both systolic and diastolic hypertension independently influence the risk of adverse cardiovascular outcomes further emphasizing the importance of appropriate diagnosis of diastolic hypertension [43]. Both anxiety and HTN peak at 14–15 years of age in pediatric patients [12,15,17], suggesting potential link between those conditions. In our cohort of patients, we did not observe higher incidence of anxiety and elevated blood pressure in children 14–15 years old comparing to 12–14 and 16–18 years old (data not shown); larger study is required to address changes during adolescence maturation.
Obesity is a well recognized risk factor for HTN in both adults and children. In our cohort, obesity was seen in almost 40% of adolescents, and anxious participants were more likely to be obese compared with nonanxious (Table 1). Analysis of nonobese subgroup of patients (Table 4) confirmed association between parentally assessed anxiety and both systolic and diastolic elevated BP; therefore, suggesting that anxiety is an independent risk factor for elevated BP. Moreover, multiple studies confirm the association between anxiety and obesity in adolescent children and adults [44–46]. Obesity can cause low self-esteem and body dissatisfaction predisposing to anxiety [47] whereas anxiety can result in unhealthy eating and lack of exercise predisposing to obesity [48].
Anxiety might increase blood pressure through multiple mechanisms, including sympathetic activity, plasma renin activity, abnormal lipid metabolism, hypothalamic–pituitary–adrenal dysfunction, and others [49–52]. Anxiety can increase blood pressure in the short-term as commonly seen in a white coat hypertension (WCH) in children [18,53,54]. Increased sympathetic activation in this setting increases peripheral vascular resistance and leads to elevated BP [19]. Long-term anxiety may decrease vascular variability, damage endothelial cells, increase the risk of atherosclerosis, and cause hypothalamic–pituitary–adrenal dysfunction [51,55,56]. The latter increases steroid hormone secretion leading to water and sodium retention, which results in elevated blood pressure. Another factor is an unhealthy lifestyle, which is common among anxious people, such as unhealthy eating, smoking, alcohol use, and lack of exercise [48]. The role of those factors and mechanisms in children with anxiety has not been studied.
We did not perform ambulatory blood pressure monitoring (ABPM) in our patients; therefore, in some patients, WCH might be the cause of observed elevated BP. Recent studies confirm that WCH is a risk factor for hypertension and overall cardiovascular morbidity and mortality [57]; therefore, we propose that anxiety may predispose to WCH and later in life to HTN in some patients. WCH might be an initial presentation of anxiety related HTN.
Our study further emphasizes the importance of screening for anxiety as part of the routine evaluation of adolescent children. In our study, we used SCARED, which is a simple tool, widely used as initial screen for anxiety in children [21,29]. Although other questionnaires might be more sensitive, they are more time-consuming.
Limitations of our study include the relatively small size of the population of children evaluated in a single subspecialty clinic, which may not adequately represent children in primary pediatric settings. Data regarding lifestyle preferences including physical activity, sedentary behavior, use of alcohol was not collected in this study. These factors are associated with both anxiety and elevated BPs. We also based the diagnosis of elevated BP on blood pressure measurements on the day of the clinic visit; therefore, we cannot assert that these patients fulfilled the criteria of HTN according to the American Board of Pediatrics guidelines [5]. In our study, we used automatic blood pressure measurements, which tend to underestimate DBPs [58,59]. We cannot rule out WCH in our cohort as ABPM was not performed in this study. Future studies should include a larger cohort size, the use of ABPM, a more robust assessment of anxiety and patients in general pediatric practices.
In conclusion, our results demonstrate an association between anxiety and elevated DBP in adolescent children. These findings support recommendations for anxiety screening as a part of routine evaluation of adolescent children and screening for anxiety of adolescent children with hypertension.
ACKNOWLEDGEMENTSThe authors acknowledge Dr Robert A. Weiss for helping with the concept of the study and reviewing the manuscript.
Previous presentations of this work: ‘Association Between Anxiety and Hypertension in Adolescent Patients: A Single Center Cross-Sectional Study’ presented as Poster at ASN 2022
Funding/Support: No funding was received for this study.
Conflicts of interestThere are no conflicts of interest.
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