The effect of mental arithmetic in normotensive and hypertensive subjects, and its modification by beta-adrenergic receptor blockade

Physiological reactivity to acute mental stress in essential hypertension-a systematic review

Objective

Exaggerated physiological reactions to acute mental stress (AMS) are associated with hypertension (development) and have been proposed to play an important role in mediating the cardiovascular disease risk with hypertension. A variety of studies compared physiological reactivity to AMS between essential hypertensive (HT) and normotensive (NT) individuals. However, a systematic review of studies across stress-reactive physiological systems including intermediate biological risk factors for cardiovascular diseases is lacking.

Methods

We conducted a systematic literature search (PubMed) for original articles and short reports, published in English language in peer-reviewed journals in November and December 2022. We targeted studies comparing the reactivity between essential HT and NT to AMS in terms of cognitive tasks, public speaking tasks, or the combination of both, in at least one of the predefined stress-reactive physiological systems.

Results

We included a total of 58 publications. The majority of studies investigated physiological reactivity to mental stressors of mild or moderate intensity. Whereas HT seem to exhibit increased reactivity in response to mild or moderate AMS only under certain conditions (i.e., in response to mild mental stressors with specific characteristics, in an early hyperkinetic stage of HT, or with respect to certain stress systems), increased physiological reactivity in HT as compared to NT to AMS of strong intensity was observed across all investigated stress-reactive physiological systems.

Conclusion

Overall, this systematic review supports the proposed and expected generalized physiological hyperreactivity to AMS with essential hypertension, in particular to strong mental stress. Moreover, we discuss potential underlying mechanisms and highlight open questions for future research of importance for the comprehensive understanding of the observed hyperreactivity to AMS in essential hypertension.

Cholinergic stimulation with pyridostigmine blunts the cardiac responses to mental stress

Mental stress may induce myocardial ischemia and ventricular arrhythmia in patients with coronary artery disease, and cholinergic stimulation is a potential protective mechanism. The purpose of this study was to determine the effect of pyridostigmine bromide (PYR), a reversible cholinesterase inhibitor, on the cardiac responses to a mental stress challenge. Twelve healthy young volunteers were submitted to a mental stress test (arithmetic test) 2 hours after the oral administration of either placebo or PYR (45 mg) on two separate days, following a randomized crossover double-blind protocol. Heart rate was reduced after both placebo and PYR (p < 0.05), but the cardiac responses to the mental stress were lower with PYR (p < 0.05): mean RR interval (mean +/- SE)-placebo: 730 +/- 19 msec; PYR: 769 +/- 21 msec; Peak systolic pressure-placebo: 129 +/- 4 mmHg; PYR: 124 +/- 3 mmHg; Peak diastolic pressure-placebo: 92 +/- 3 mmHg; PYR: 89 +/- 4 mmHg; Mean rate-pressure product-placebo: 10,496 +/- 412 bpm x mmHg; PYR: 9,746 +/- 383 bpm x mmHg. In conclusion, 45 mg of pyridostigmine blunted the pressor and chronotropic responses to mental stress in healthy young subjects.

Comparison of the effects of terazosin and enalapril on laboratory stress testing blood pressure in patients with essential hypertension

It is the current opinion that an ideal antihypertensive drug should reduce blood pressure (BP) not only at rest but also during stressful situations. The current study was aimed to compare the effects of the selective alpha 1-adrenergic blocker terazosin (5 mg once daily) and of the angiotensin-converting enzyme inhibitor enalapril (20 mg once daily) on cardiovascular response to a set of standardized laboratory stressors, such as mental arithmetic, handgrip test and cycle ergometry, in a group of 16 essential hypertensive patients. The study was a randomized, double-blind, cross-over trial preceded by a placebo run-in period. Terazosin and enalapril had a comparable effect on resting BP, reducing systolic (SBP) and diastolic (DBP) blood pressure from 159.5 +/- 13.9/101.6 +/- 8.8 mm Hg during placebo by 7.8%/6.7% and by 11.3%/10.2%, respectively. The "response" rate to the two treatments was approximately the same, being 69% and 75% after terazosin and enalapril, respectively. During mental arithmetic, from an average of 181.6 +/- 17.8/118.6 +/- 11.5 mm Hg during placebo, BP was reduced by 11.5%/7.9% after terazosin and by 13.6%/8.5% after enalapril; during handgrip test, BP decreased from 207.2 +/- 22.2/142.2 +/- 13.6 mm Hg by 7.3%/8.4% after terazosin and by 7.7%/7.1% after enalapril; finally, during cycle ergometry, terazosin and enalapril lowered BP by 5.4%/6.7% and 7%/3.1%, respectively, from a placebo value of 215.5 +/- 17.3/127.6 +/- 11.2. No significant difference in antihypertensive efficacy was observed between the two drugs, either at rest and during stress testing.(ABSTRACT TRUNCATED AT 250 WORDS)

Sympathetic activity is influenced by task difficulty and stress perception during mental challenge in humans

1. Our aim was to determine the influence of the type of task, the absolute and relative difficulty of the task, and the perceived stress associated with performance of the task on sympathetic circulatory regulation during cognitive challenge in humans. 2. Sympathetic nerve activity to skeletal muscle (MSNA) determined from peroneal microneurography, heart rate and arterial blood pressure were recorded continuously in twelve subjects during a modified Stroop colour word test (CWT) and mental arithmetic (MA), each performed over six levels of increasing absolute task difficulty. Performance (percentage correct) on each task was assessed and ratings of perceived stress obtained. Responses to CWT and MA were compared at similar levels of performance and perceived stress. 3. MSNA decreased at task onset, remained below baseline levels at low levels of difficulty which were not perceived as stressful, increased above baseline levels at higher levels of difficulty which were perceived as stressful, and increased further during recovery. Thus, the regulation of MSNA was stress dependent. At similar levels of stress perception there were no differences in MSNA between CWT and MA. Although performance declined as task difficulty increased, there was no particular 'threshold' level of performance associated with the stimulation of MSNA. 4. Arterial pressure and heart rate were elevated above baseline levels throughout the mental tasks. Arterial pressure increased over the first 3-4 levels of each task and then plateaued whereas heart rate did not vary across increasing levels of task difficulty. Heart rate and arterial pressure responses to CWT were higher than those to MA. 5. These data demonstrate that during cognitive challenge the stimulation of MSNA is governed primarily by perceived stress which is dependent, in part, on the absolute level of task difficulty. In contrast, neither performance nor the type of cognitive task appear to be important determinants of MSNA. Arterial pressure is influenced by the task and level of difficulty. Heart rate is independent of task difficulty but may be task dependent.

Cardiovascular reactivity to psychosocial stressors. A review of the effects of beta-blockade

Fifty-nine studies examining the effects of beta-blockers on cardiovascular reactivity to psychosocial stressors are reviewed. Across all classifications of beta-blockers, heart rate reactivity was reduced (p less than 0.0001), while there were no significant changes in either systolic or diastolic blood pressure reactivity. Nonselective beta-blockers were more often associated with a reduction in heart rate reactivity than selective blockers (p less than 0.05). There was no evidence that drug lipophilicity or intrinsic sympathomimetic activity differentially affected blood pressure or heart rate reactivity; nor was there evidence that the reactivity of hypertensive subjects was differentially affected by blockade compared to the reactivity of normotensive subjects. While beta-blockers are effective in reducing resting blood pressure, they are not effective agents in reducing blood pressure reactivity to mild psychosocial stressors.

Brain and the regulation of blood pressure: a hemodynamic perspective

The central nervous system subserves the homeostasis of the circulation and is organized as a negative feedback system. The following properties of such a feedback system are of interest: a) the setting; b) the range of the regulation; and c) the nature of the feedback (regulated) variable. In this review we show that in hypertension blood pressure is set at a higher level, but regulation of blood pressure in hypertension is normal. The central nervous system is involved in maintaining a higher set point in early human hypertension as well as in many forms of experimental hypertension. Results from trials of antihypertensive drugs suggest that setting of the baseline level of blood pressure and regulation of blood pressure variability are independent properties and are probably regulated by different areas of the central nervous system. It is, therefore, unlikely that research on blood pressure "reactivity" will elucidate the pathophysiology of the central resetting of baseline blood pressure level in hypertension. We present evidence that in subserving the circulation, the central nervous system regulates and senses blood pressure and not flow. Pathophysiologic implications of this concept are discussed particularly in regards to the apparent decrease of sympathetic tone during the evolution of hypertension.

Responses to mental stress and physical provocations before and during long term treatment of hypertensive patients with beta-adrenoceptor blockers or hydrochlorothiazide

1 Cardiovascular and sympatho-adrenal responsiveness to mental stress (CWT; a colour word test), orthostatic testing (ORT) and a cold pressor test (CPT) were examined in three groups of hypertensive patients (n = 14-16) before and after 6 months treatment with metoprolol (243 +/- 26 mg daily), propranolol (149 +/- 16 mg daily) or hydrochlorothiazide (50 +/- 8 mg daily) in an open trial design. 2 Treatment reduced outpatient blood pressures in the three groups similarly (from approximately 155/102 to 135/90 mm Hg). During treatment resting blood pressures in the laboratory were clearly reduced by beta-adrenoceptor blockade but not by thiazide treatment. Metoprolol and propranolol caused similar reductions of basal heart rates and plasma glycerol levels, whereas only propranolol reduced cyclic AMP concentrations in plasma. 3 Before treatment CWT and CPT increased systolic and diastolic blood pressures by about 30%. Heart rate increased by about 30 beats min-1 during CWT and 10-15 beats min-1 during CPT and ORT. Small venous plasma adrenaline responses were evoked by all tests, whereas noradrenaline was elevated mainly by CPT and ORT. Dopamine levels did not change. 4 Heart rate responses to all stressors were markedly and similarly reduced, whereas blood pressure responses were essentially unchanged during metoprolol or propranolol treatment. In the thiazide group circulatory responses to CWT were slightly attenuated, whereas responses to ORT and CPT were unchanged. 5 The systolic blood pressure levels were reduced throughout the test session in all three groups, although less so in the hydrochlorothiazide group. Both beta-adrenoceptor antagonists clearly reduced diastolic blood pressure and heart rate levels at rest and during stress, whereas thiazide treatment caused no significant changes in these respects. 6 The rate pressure product, which increased by 80-100% in response to CWT before treatment, was more markedly reduced by beta-adrenoceptor blockade than by thiazide treatment both at rest and during stress. 7 Self ratings (visual analogue scales) of stress and irritation were increased by CWT in a similar fashion before and during treatment in all groups. beta-adrenoceptor blockade was associated with higher subjective ratings of tiredness at rest, but not after CWT. Performance in the CWT increased slightly more in the thiazide group. The physiological responses to CWT were not correlated to the subjective responses.(ABSTRACT TRUNCATED AT 400 WORDS)

Disparate hemodynamic responses to mental challenge after antihypertensive therapy with beta blockers and calcium entry blockers

The hemodynamic response to mental challenge was studied in 40 male outpatients with mild essential hypertension. The patients were treated randomly either with a beta adrenoreceptor blocker (oxprenolol) or with a calcium entry blocker (nitrendipine). Cardiovascular reactivity was evaluated with two different mental arithmetic tasks before and six months after treatment by continuously measuring systolic and diastolic pressure (ultrasonic Doppler device), heart rate (electrocardiography), and stoke volume (impedance cardiography). Patients in both treatment groups had equal decreases in arterial pressure and the same pressures at rest. In patients receiving calcium entry blockers, mental challenge provoked an increase in stroke volume and a decrease in total peripheral resistance similar to results in the pretreatment phase. In contrast, beta adrenoreceptor blockade reversed the hemodynamic response pattern to a distinct decrease in stroke volume (p less than or equal to 0.05) and an increase in total peripheral resistance (p less than or equal to 0.05). In addition, an attenuated heart rate response (p less than or equal to 0.01) and a larger increase in diastolic pressure (p less than or equal to 0.01) were found in the beta blocker group compared with the calcium entry blocker group. Although beta blockers and calcium blockers produce equal decreases in arterial pressure, beta blockers evoke an abnormal hemodynamic response to mental challenge, whereas calcium entry blockers preserve the physiologic reactivity pattern of the untreated state.

Cardioselective and nonselective beta-adrenoceptor blocking drugs in hypertension: a comparison of their effect on blood pressure during mental and physical activity

The ability of cardioselective and nonselective beta-adrenoceptor blocking drugs, with and without partial agonist activity, to control increases in blood pressure associated with mental and physical activity was compared in 35 subjects with hypertension. Direct measurements of blood pressure and radioenzymatic determinations of plasma norepinephrine were obtained before, during and after four activities, and were repeated after random allocation to treatment with atenolol, metoprolol, pindolol or propranolol. Cardioselective and nonselective drugs modestly reduced the pressor response to reaction time testing, but not to mental arithmetic or isometric exercise. The increase in systolic blood pressure during bicycling was attenuated significantly by the cardioselective drugs atenolol (by 23 mm Hg, or 38%) and metoprolol (21 mm Hg, or 41%), but not by the nonselective agents pindolol (with partial agonist activity) (13 mm Hg, or 20%) and propranolol (10 mm Hg, or 17%) (p less than 0.02 cardioselective versus nonselective; p = NS pindolol versus propranolol). Only bicycle exercise increased plasma norepinephrine concentrations (by 80%). These results suggest that beta-adrenoceptor blocking drugs will not attenuate increases in blood pressure during mental or physical activities unless intense sympathoadrenal activation also occurs. Marked elevations in circulating epinephrine, with or without norepinephrine, and peripheral beta 2-blockade appear necessary for alpha-mediated vasoconstriction to predominate and for the contrasting effects of cardioselective and nonselective drugs to be appreciated.

Psychopharmacological effects of vinpocetine in normal healthy volunteers

Twelve healthy female volunteers received pre-treatments with vinpocetine 10, 20, 40 mg and placebo (t.d.s.) for two days according to a randomised, double-blind crossover design. On the third day of treatment and 1 h following morning dosage, subjects completed a battery of psychological tests including Critical Flicker Fusion (CFF), Choice Reaction Time (CRT), Subjective Ratings of Drug Effects (LARS) and a Sternberg Memory Scanning Test. No statistically significant changes from placebo were observed on CFF, CRT or subjective ratings of drug effects. However, memory as assessed using the Sternberg technique was found to be significantly improved following treatment with vinpocetine 40 mg when compared to placebo and results suggested a localised effect of the drug on the serial comparison stage of the reaction process.

Effect of cardioselective beta-blockers on the heart rate and arterial pressure responses to laryngoscopy

The effects of the cardioselective beta-blockers practolol (Eraldin, ICI) and metoprolol (Seloken, Hässle) were studied during microlaryngoscopy. I. v. practolol (0.4 mg/kg before and 0.2 mg/kg during anaesthesia) did not protect against increases in arterial pressure, although heart rate was reduced. Oral metoprolol (0.2 g for 4 days) reduced the level of arterial pressure both before and during anaesthesia. Variations in arterial pressure were not attenuated. Very low levels of arterial pressure were seen, and variations in arterial pressures were attenuated when metoprolol was combined with fentanyl.

Effects of moderate salt restriction on intralymphocytic sodium and pressor response to stress in borderline hypertension

The effects of a moderate dietary salt restriction on intralymphocytic sodium content and pressor response to stress (mental arithmetic, handgrip, and bicycle exercise) were tested in 25 young subjects with borderline hypertension. The study was performed by a randomized, cross-over, within-patient, experimental design. Diet did not significantly reduce blood pressure at rest but did so significantly in both systolic and diastolic blood pressure during stress and exercise. Variations in diastolic blood pressure induced by stimulation correlated significantly with intralymphocytic sodium content both before and during low-salt diet whereas no correlation was found in the case of systolic blood pressure and heart rate variations. These findings suggest that in young subjects with borderline hypertension, sodium homeostasis and blood pressure regulation are somehow interrelated, and that a moderate dietary salt restriction reduces both intralymphocytic sodium content and pressor response to adrenergic stimulation. This could be useful in preventing the development of sustained hypertension.

Propranolol in experimentally induced stress

The influence of beta-adrenoceptor antagonism on the effects of a single experimental stress was investigated in 12 healthy volunteers, using a double-blind protocol. A single oral dose of 80 mg propranolol reduced the stress-induced increase in heart rate and systolic blood pressure to 49.9 per cent and 8.3 per cent respectively compared to 61.0 per cent and 17.4 per cent with placebo. The rise in diastolic blood pressure was small and unaffected by beta-adrenoceptor blockade. The rise in temperature of the skin of the trunk was significantly reduced by propranolol. The self-rating of anxiety, alertness and concentration by the subjects was unaffected by propranolol.

Effects of chronic beta-blockade on intra-arterial blood pressure during motor car driving

Continuous intra-arterial blood pressure recordings during motor car driving were performed in 15 patients with untreated essential hypertension, using the "Oxford" recording technique. Each subject was an experienced driver who used his car every day, and for the study drove from his work place to the hospital during the later afternoon. This drive took place in urban traffic and the average duration was 20.9 minutes. Blood pressure during car driving was remarkably stable, and the average systolic and diastolic pressures were similar to the mean daytime pressure. After 16 weeks of treatment with oxprenolol each patient was restudied. Blood pressure during driving had dropped from 176/107 to 160/93 mmHg, but the blood pressure response to driving and blood pressure variation during driving (expressed as the coefficient of variation) were unchanged. After treatment, the mean daytime systolic pressure was lower than the mean pressure during driving, but the relative antihypertensive effect during driving was similar to that observed in the same patients during dynamic exercise on a bicycle ergometer. No drug-induced side effects occurred and there were no apparent effects on driving ability. Chronic treatment with oxprenolol reduced blood pressure during car driving without affecting the normal blood pressure response to driving.

Intralymphocytic sodium concentration: a sensitive index to identify young subjects at risk of hypertension

In subjects with borderline (BL) hypertension and in normal subjects with familial hypertension (FH), the increase in diastolic blood pressure (DBP) induced by mental arithmetic, handgrip and bicycle exercise strongly correlates with intralymphocytic sodium concentration (ILSC). In BL subjects with high or normal ILSC basal BP values are identical, but the increase in DBP during stress is significantly greater in BL subjects with high ILSC. The same phenomenon can be found in normal subjects with FH. Four hours after acute salt loading urinary Na+ is significantly higher in BL subjects with high ILSC. ILSC is a test by which one can identify BL and normal subjects with abnormal responsiveness to stimuli and who probably are fated to develop sustained hypertension.

Atenolol and chlorthalidone in combination for hypertension

1 The hypotensive effect of single daily dosing with atenolol 100 mg and chlorthalidone 25 mg given alone or in combination has been assessed in a double-blind, crossover, placebo controlled trial in fifteen hypertensive patients. 2 Average lying blood pressures were: Placebo 155.4/103.9 mm Hg, atenolol 134.6/85.8 mm Hg, chlorthalidone 139.5/90.1 mm Hg, combination 127.7/82.5 mm Hg. 3 The effect of the combination therapy in reducing lying diastolic pressure compared with placebo (a fall of 21.4 mm Hg) was significantly less than the 31.9 mm Hg fall predicted from the sum of the individual effects (P = 0.01). 4 Observations on blood pressure at rest and under mental, isometric and bicycle ergometer stress were made pre-dose and post-dose for a 12 h period at the end of the last treatment period. 5 Lying blood pressure declined from the zero hour (pre-dose) reading on all treatments to a low at 15.00--18.00 h and then rose again. 6 The rise in systolic blood pressure after isometric exercise and mental stress was of a similar magnitude with all four treatment regimes. 7 Atenolol, alone and in combination with chlorthalidone, reduced the blood pressure and the pulse rate increase on exercise 2 h post-dose when compared with readings 24 h post-dose. 8 Once daily dosing with a combination of atenolol and chlorthalidone produced a fall in supine blood pressure over a 24 h period but the effect on exercise induced changes was not uniform over this period.

Possible significance of the pharmacological differentiation of beta-blockers for therapy of hypertension

1 Cardioselective and non-selective beta-blockers affect to a different degree several aspects of the circulatory homeostasis. The evidence available in this regard has been evaluated and the possible clinical importance of these differences has been discussed. 2 Venous return in partly regulated by beta-receptors (possibly of the beta 2 type) in the venous resistance vessels. Differences in blockade of venous return by the two classes of beta-blockers may, therefore, influence the degree of increase in left ventricular size, left ventricular end diastolic BPs and stroke volume during beta-blockade. 3 At the first part of the dose-reponse curve, non-selective beta-blockers seem to block more effectively renin release than cardioselective beta-blockers. 4 The direction and the extent to which beta-blockers 'directly' affect total peripheral resistance (TPR), is determined by the resultant of the degree of decrease in TPR by blockade of renin release and the extent of the increase in TPR by blockade of the beta 2-receptors in the arteriolar wall. 5 The clinical relevance of these differences could be that--especially in the low doses range--non-selective beta-blockers may be more 'safe' in patients with compromised cardiac function and may be more appropriate for the therapy of high renin hypertension than cardioselective blockers, whereas the latter may be more appropriate for the majority of hypertensive patients who have low to normal renin hypertension.

The second Lilly Prize Lecture, University of Newcastle, July 1977. beta-Adrenergic receptor blockade in hypertension, past, present and future

All beta-adrenoceptor blocking drugs that have been described share the common property of being competitive inhibitors. They differ in their associated properties, the presence or absence of cardioselectivity, membrane stabilizing activity, and partial agonist activity. Recently some beta-adrenoceptor blocking drugs have been reported which also possess alpha-adrenoceptor blocking activity. The associated properties have been used as a basis for classifying beta-adrenoceptor blocking drugs (Fitzgerald, 1969, 1972). The presence or absence of cardioselectivity is most useful for dividing beta-adrenoceptor blocking drugs. The non-selective drugs (Division I) can be further divided according to the presence or absence of intrinsic sympathomimetic activity (ISA) and membrane stabilizing activity (Fitzgerald's groups I-IV). Group I possess both membrane activity and ISA, e.g. alprenolol, oxprenolol, group II just membrane action, e.g. propanolol, group III ISA but no membrane action, e.g. pindolol. Fitzgerald placed pindolol in group I but should be placed in group III as it possesses a high degree of beta-adrenoceptor blocking potency in relation to its membrane activity (Prichard, 1974). Finally drugs in group IV have neither ISA nor membrane action, e.g. sotalol, timolol. The cardioselective drugs (Division II) can be similarly sub-divided into groups I-IV according to the presence or absence of ISA or membrane action (Fitzgerald grouped all these together as group V). Lastly there are new beta-adrenergic receptor blocking drugs which in addition have alpha- adrenergic receptor blocking properties (Division III).