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Clinical and Experimental Hypertension, 33(5):281–286, (2011)

Copyright © Informa Healthcare USA, Inc.


ISSN 1064-1963 print /1525-6006 online
DOI: 10.3109/10641963.2010.531850

Exam Anxiety Induces Significant Blood Pressure and Heart Rate


Increase in College Students

Zhihong Zhang, Hai Su, Qiang Peng, Qing Yang, Xiaoshu Cheng
Department of Cardiology, Second Affiliated Hospital, Medical College of Nanchang University, Nanchang, China

Abstract
To investigate the relationship between the anxiety and blood pressure (BP) and heart rate (HR) increase in peri-exam
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period. Sixty-four college students(20.0 ± 0.1 year old) were included in this study. The BP and HR were measured in
the morning and in the evening for 3 days during the prereview (ba), review, and exam periods. The BP and HR increase
amplitudes (HRIA) of review and exam periods were from the difference of corresponding values and basic values, and
the BPIA/baBP and HRIA/baHR were calculated. All of the students completed the Self-Rating Anxiety score (SAS)
questionnaire the first day of the exam period. Scores over 50 points were used as the standard for anxiety. From the
prereview to exam periods, the BP and HR increased gradually. The exam SBPIA (4.3 ± 1.3 vs. 0.3 ± 0.5 mmHg, P
< 0.05) and DBPIA (4.4 ± 1.5 vs. 1.0 ± 0.5 mmHg, P < 0.05) were significantly higher in the anxiety group than in
the no-anxiety group. The SBPIA/DBPIA and HRIA showed a similar profile also(9.7 ± 2.1 vs. 1.9 ± 0.9 bpm, P <
0.05). Strong positive correlations were found between the SAS score and BPIA and HRIA both in the review and exam
period. The smoking group and family hypertension group had higher anxiety score; meanwhile, their exam BPIAs
and HRIAs were significantly higher than their corresponding group. The BP and HR increase in the review and exam
period, anxiety is an important factor of BP and HR increase.
For personal use only.

Keywords: exam stress, anxiety, blood pressure, heart rate, student

20 INTRODUCTION METHODS
Anxiety is a general term for several disorders that Subjects and Methods
causes nervousness, fear, apprehension, and worry. Sixty-four normotensive college students with a mean
Mild anxiety is vague and unsettling, while severe age of 20.0 ± 0.1 years old were enrolled. Their height
anxiety can negatively impact daily life. Anxiety has and weigh were recorded to calculate body mass index 45
25 been demonstrated as an independent factor for (BMI). Students with one or two parents diagnosed
hypertension (1, 2). Students may experience different with hypertension were considered to have family
levels of anxiety in the duration of a certain exam, hypertensive history (FHH). Students with smoking
i.e., the exam anxiety which is considered as a or passive smoking history in the past half year were
situation-specific trait accounting for individual differ- included in the smoking group. 50
30 ences in the extent to which people find examinations This study was approved by the Ethics Committee of
threatening (3). the Second Affiliated Hospital of Nanchang University
However, at present, little is known about the and the subjects offered informed consent.
potential links between the exam anxiety and blood
pressure (BP) profile of college students in the
35 peri-exam period. This study was designed to eval- BP Measurement
uate the relationship between the extent of exam Auscultatory BP measurement was applied in this study. 55
anxiety and the change of BP and heart rate (HR) The key points for BP taking include: the subjects were
in 64 medical students in our college, and the given at least a 10-min rest before BP measurement in
relevant influencing factors for exam-associated BP the sitting position; the empty cuff was appropriately
40 change. fastened around the right upper arm, and the cuff
60

Address correspondence to Hai Su, Department of Cardiology, Second Affiliated Hospital, Medical College of Nanchang University,
No. 1 Mingde Road, Nanchang, 330006 China. E-mail: suyihappy@sohu.com
Received 29 April 2010; revised 13 June 2010; accepted 25 June 2010.

281
282 Z. Zhang et al.

was initially inflated to at least 30 mmHg above the RESULTS


point at which the radial pulse disappears; the rate of
This study included 31 male and 33 female subjects.
deflation was 2 mmHg per second (mm/s); the first and
Smoking and non-smoking groups had 20 and 44
fifth audible sound of artery pulsation should be taken
students, respectively. Fifteen students had a family 120
65 as systolic blood pressure (SBP) and diastolic blood
history of hypertension and 49 did not. The ages
pressure (DBP); the second measurements of BP were
were similar between the two groups, smoking and
performed 2 min later.
non-smoking groups, and with and without a family
Two BP readings were taken both in the morning
history of hypertension groups. In this study, eight
(6:00–7:00) and in the evening (18:00–19:00) for 3
students were found to have both a smoking history and 125
70 days in prereview, review, and exam period, respectively.
a family history of hypertension.
The exam period lasted for 3 days. Four days without
class before the exam period, when students prepare
for the exam, were identified as the review period. And The Change of BP and HR in the Peri-Exam Period
3 days just before the review period were identified The SBP, DBP, and HR increased gradually from the
75 as the prereview period. The BP in the review period basic period to the exam period. A significant increase
was measured in the last 3 days. The average of of DBP occurred in the review period (Table 1). 130
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the 12 BP readings of each period were calculated


as the prereview, review, and exam BP. All BP The Relationship of BP and HR Change to Anxiety
readings were taken with the same newly calibrated In this study, 20 students (31.25%) were considered
80 mercurial sphygmomanometer and by the same doctor. as having anxiety. The SBP, DBP, and HR increase
Measuring time and calculating methods of the HR and amplitudes, as well as the BPIA/baBP and HRIA/baHR,
BP were the same. and were significantly higher in the anxiety group than 135
The BP and HR in the prereview were considered in the non-anxiety group in both review and exam
as the basic values (baBP and ba HR). The differences periods (Table 2). These results indicate that anxiety
85 of review and exam values of BP and HR to the basic is an independent factor for a BP increase beyond the
value were used as the increase amplitudes (IA), i.e., basic level, although the basic BP was somewhat higher
For personal use only.

BPIA and HRIA, and the ratios of BPIA/baBP and in the anxiety group than in the non-anxiety group. 140
HRIA/baHR were calculated from BPIA and HRIA and The line analysis showed a strong positive correlation
their basic values. between SAS scores and the SBPIA, DBPIA, and HRIA
90 In this study, the Zung Self-Rating Anxiety Scale with the correlation coefficient (R) of 0.30, 0.38, and
(SAS) questionnaire was used to measure anxiety on 0.32, respectively, in the review period. In the exam
the first day of the exam period. The self-administered period, the correlation was stronger proven by the R of 145
test has 20 questions. Each question is scored on a scale 0.36, 0.45, and 0.44, respectively (Figure 1).
of 1–4 (none or a little of the time, some of the time,
95 good part of the time, most of the time). There are 15 The Influencing Factors for Anxiety and BP, HR
questions worded toward increasing anxiety levels and The SAS scores of male and female subjects were
five questions worded toward decreasing anxiety levels. similar. The groups with family hypertensive history
The score range is from 20–80 and the SAS score being (FHH) or smoking history had higher SAS scores 150
more than 50 points was considered as anxiety in this than their corresponding group, respectively. However,
100 study. logistic regression analysis showed that smoking was a
single influencing factor for anxiety or anxiety score,
but family history of hypertension was not. Multifactor
Statistical Analysis analysis of variance (MNOVA) demonstrated that no 155
All data are presented as mean ± standard error interaction was found between smoking and family
(M ± SE). The SPSS 10.0 statistical package (SPSS history of hypertension.
Company, Chicago, IL, USA) was used for the The group with FHH had a higher BP increase
105 analysis of variation (ANOVA) and student’s t-test. amplitude in the review and exam periods. These results
Logistic regression analysis (forward stepwise) was indicate that the students with FHH are susceptible 160
used for evaluating the effects of age, BMI, sex
(male:1, female: 0), smoking (yes:1, no: 0), family
Table 1. The changes of BP and HR in the periexam period
history of hypertension (having: 1,not having: 0) on (M±SE)
110 anxiety. Multifactor analysis of variance (MNOVA) was
used for identifying the interaction between different Period SBP (mmHg) DBP (mmHg) HR (bpm)
factors. The relationship among the BP and HR Basic 108.9 ± 1.0 71.8 ± 0.7 71.2 ± 0.7
changes and other factors were analyzed with linear Review 109.3 ± 1.1 72.8 ± 0.9∗ 73.9 ± 1.0∗
correlation analysis and multiple linear regression Exam 110.4 ± 1.1∗# 73.9 ± 0.8∗# 75.6 ± 1.1∗#
115 analysis respectively. Statistical significance was defined *Comparison with pre review. P < 0.05; # Comparison with
as P < 0.05. review. P < 0.05.

Clinical and Experimental Hypertension


Exam Anxiety and Blood Pressure 283

Table 2. The BP and HR parameters between the groups with and without anxiety (M±SE)
Anxiety baSBP SBP IA (mmHg) baDBP DBP IA (mmHg) ba HR HRIA (bpm)
(N) (mmHg) Review Exam (mmHg) Review Exam (bpm) Review Exam
Non(44) 108.3 ± 1.2 −0.4 ± 0.4 0.3 ± 0.5 71.3 ± 0.9 0.2 ± 0.4 1.0 ± 0.5 71.4 ± 0.9 1.0 ± 0.9 1.9 ± 0.9
Y(20) 110.0 ± 1.6 2.4 ± 0.8∗ 4.3 ± 1.3∗ 72.9 ± 1.2 2.8 ± 1.0∗ 4.4 ± 1.5∗ 71.0 ± 0.9 6.1 ± 2.1∗ 9.7 ± 2.1∗
*Comparison with non-anxiety. P < 0.05.

review period to anxiety and a higher BP and HR in the peri-exam


period. The smoking group had higher systolic BPIA
20 and diastolic BPIA in both the review and exam period.
exam period
The HR change was similar to the BP change (Table 3).
The comparison of BP and HR increase amplitudes 165
SBPIA (mmHg)

10 in the exam period between different conditions is


R Sq Linear = 0.126
shown in Figure 2. The BPIA/baBP and HRIA/baHR
of the three subgroups with anxiety, FHH, or smoking
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R Sq Linear = 0.088
0 were higher than the corresponding group both in the
review and exam period. 170
The multiple linear regression analysis showed that
–10 anxiety was the strongest influencing factor for the
BP and HR increase in the review and exam periods.
30 40 50 60 70
Smoking was a weak factor for a DBP increase in only
SAS score the review period. The family history of hypertension 175
was not an influencing factor.
20
For personal use only.

DISCUSSION
DBPIA (mmHg)

The BP and HR in the Peri-Exam Period


10 R Sq Linear = 0.201 Some researches evaluated the BP change during exam
time. A prospective observational study of 121 medical 180
students taking the final licensing exam found that
R Sq Linear = 0.146
their DBP, measured by an ambulatory BP monitoring
device, increased significantly from 81 +/- 10 mmHg
0 before the exam to 86 +/- 9 mmHg (p = 0.008)
during the exam, and the DBP was still higher 15 185
min after the exam (88 +/- 11 mmHg), but their
30 40 50 60 70 SBP did not increase significantly during (131 +/- 14
SAS score vs. 136 +/- 18 mmHg) the whole process (4). In 22
medical residents, Italy scholars found that SBP and
30
HR increased significantly when subjects sitting before 190
an examination, as compared to a calm situation (5).
These results demonstrated that BP and HR increased
20 significantly within the duration of an exam.
R Sq Linear = 0.192 In this study, we evaluated the BP and HR change
HRIA (bpm)

in the peri-exam period. A significant increase of SBP 195


10 (from 108.9 to 110.4 mmHg) and DBP (from 71.8 to
R Sq Linear = 0.101 73.9mmHg) from the basic period to the exam period
was found in the 64 college students. These results
0 demonstrate that a BP increase occurs not only during
the exam time and in the exam room, but also in the 200
time and place beyond the exam.
–10 A significant increase of DBP in the review period
30 40 50 60 70 demonstrated that the preparation for exam could
SAS score induce a BP increase and that a DBP increase occurred
earlier than a SBP increase. Picot et al. (6) found that 205
Figure 1. The relationship of the SAS scores and BPIA and
HRIA in review and exam periods.
lowered anger was associated with significant increases
of DBP in black females with ambulatory BPs during
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For personal use only.

284 Z. Zhang et al.

Table 3. The BP and HR parameters between groups with and without FHH or smoking (M±SE)
baSBP SBPIA (mmHg) baDBP DBPIA (mmHg) HRIA (bpm)
Grouping(n) SAS score (mmHg) Review Exam (mmHg) Review Exam Basic (bpm) Review Exam
FHH No (49) 45.9 ± 1.0 107.5 ± 1.1 −0.1 ± 0.4 1.4 ± 0.5 71.0 ± 0.9 0.5 ± 0.4 1.7 ± 0.6 70.5 ± 0.8 2.0 ± 1.0 3.2 ± 1.1
Y (15) 51.0 ± 2.4∗ 113.3 ± 1.9∗ 2.4 ± 1.2∗ 2.0 ± 1.9 74.5 ± 1.1∗ 2.8 ± 1.1∗ 3.5 ± 1.6 73.8 ± 1.3∗ 4.7 ± 2.0 8.0 ± 2.2∗
Smoking Non (44) 108.5 ± 1.2 −0.3 ± 0.4 0.4 ± 0.6 71.1 ± 0.8 0.1 ± 0.4 1.1 ± 0.5 70.8 ± 0.9 1.8 ± 0.9 2.6 ± 1.0 108.5 ± 1.2
Y (20) 109.6 ± 1.7 2.2 ± 0.9∗ 4.0 ± 1.3* 73.4 ± 1.4 2.9 ± 1.0∗ 4.3 ± 1.5∗ 72.1 ± 1.0 4.4 ± 2.1 8.1 ± 2.2∗ 109.6 ± 1.7
Abbreviation: FHH - family hypertensive history. *Comparison with no FHH or no smoking P < 0.05.

C
B
A

IA/base IA/base IA/base

–0.05
0.00
0.05
0.10
0.15

–0.05
0.00
0.05
0.10
0.15
–0.05
0.00
0.05
0.10
0.15

SBP

*P < 0.05
SBP

SBP
*P < 0.05

smoke (n = 20)
anxiety (n = 20)

no smoke (n = 44)
no anxiety (n = 44)

DBP
*P < 0.05

DBP

DBP
*P < 0.05
family hypertension (n = 15)
no family hypertension (n = 49)
HR

HR

HR
*P < 0.05

*P < 0.05

*P < 0.05

non-smoking groups. IA/base: BPIA/baBP or HRIA/baHR.


Figure 2. The comparison of BP and HR increase amplitudes

Clinical and Experimental Hypertension


without family hypertensive history; (C) between the smoking and
anxiety and non-anxiety groups; (B) between the groups with and
in exam period between different conditions. (A) between the
Exam Anxiety and Blood Pressure 285

a 12-h period. The reason for the more obvious DBP anxiety. This result is similar to a study in 4048
increase may be the increased arterial tendency induced seafarers, which showed a positive relationship between 265
210 by the anxiety. At the same time, the HR increased anxiety and hypertensive family history.
gradually from 71.2 bpm in the preview period to 75.6 Compared to the non-FHH group, the group with
bpm in the exam period. FHH not only had higher basic SBP, DBP, and HR,
but they had higher SBP, DBP, and HR increase
Anxiety and BP and HR Profile in Exam Period amplitudes in the review period and exam period. These 270
In this study, we found that 31.25% of the students results indicated that stress can induce an earlier and
215 experienced anxiety in the exam period. Appropriate stronger BP increase in the students with FHH. As
anxiety in the peri-exam period is normal; however, SBPIA/baSBP and DBPIA/baDBP of the FHH group
excessive or intensive exam anxiety may induce a lot were about twice as those in the non-FHH group,
of psychological and physiological disorders (3, 7). even with no significant difference, it may indicate 275
At present, there is little research on the relationship that the higher BP increase in the peri-exam period is
220 between exam anxiety and BP. Although less sleeping independent on the basic BP level.
and exercise time in the peri-exam period may be
one reason for increased BP, our results demonstrated Smoking and Anxiety
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that anxiety is an important factor for an exam BP Our results showed that the smoking group had a
increase. higher anxiety score than the non-smoking group. 280
225 At first, in the non-anxiety group, the BP and HR The SBP and DBP increase amplitude, as well as
did not increase in the review period; even in the the HR increase amplitude, in the smoking group
exam period the SBPIA and DBPIA were small. But were significantly higher compared to the non-smoking
in the anxiety group, the mean SBPIA and DBPIA group, which demonstrated that there is a positive
in the exam period were 4.3 mmHg and 4.4 mmHg, relationship between smoking and anxiety, and that 285
230 respectively. Secondly, the BP and HR increase in the smoking may enhance the BP and HR reaction in the
anxiety group was independent on the basic BP and peri-exam period.
HR, as the BPIA/baBP and HRIA/baHR were higher Many studies showed a positive relationship between
For personal use only.

in the anxiety group than in the non-anxiety group. smoking and anxiety or other psychological disorders.
Thirdly, the SAS score was positively correlated with Celikel, Celikel, and Erkorkmaz found higher levels of 290
235 the BPIA and HRIA, either in the review period or depressive symptoms and hopelessness in the students
in the exam period. Scholars in Italy found that SBP with smoking behavior in 1870 Turkish students (21.2
and HR increases in the exam was paralleled with ± 2.0 y) (12). A study, including 60,814 participants
the increase in the HRSA total score in 22 medical from Norway, showed a strong association of smoking
residents (5). In addition, multiple linear regression with co-morbid anxiety depression, especially in females 295
240 analysis demonstrated that anxiety was the strongest and younger participants (13). In this study, the logistic
influencing factor for the BP and HR increase in the regression analysis showed that smoking was also a
peri-exam period. single influencing factor for anxiety or anxiety scores,
It is accepted that the sympathetic overactivation but no interaction was found between smoking and a
is the key point of anxiety-induced hypertension. family history of hypertension. Cosci et al.pointed out 300
245 Meanwhile, stress may also activate the brain and the that panic and cigarette smoking each appear to have
peripheral rennin-angiotensin-system (RAS). Activation the capacity to serve as a causal factor/facilitator in the
of brain RAS may induce hormone secretion, including development of the other (14).
corticortropin-releasing hormone, adrenocorticotripic The limitation of this study was the small number of
hormone, corticoids, vasopressin, and neuropeptide investigated students, and a larger sample is needed for 305
250 Y (8–10). Lambert (11) results suggest that chronic more convincing results.
mental stress modulates the pattern of sympathetic
activity, which in turn, may confer greater cardiovascu- Clinical Applications
lar risks on individuals with metabolic syndrome and Anxiety is recognized as a precursor to hypertension
elevated BP. development and an increased risk of fatal coronary
heart disease, as indicated by many studies (2, 15, 310
255 Family Hypertensive History and Anxiety 16). Sarason et al. (17) pointed out that we live in a
Many studies pointed out that a higher ratio of anxiety test-conscious, test-giving culture in which the lives of
was found in the hypertensive patients in comparison people are in part determined by their test performance.
with normotensive ones. But it is still unclear whether It is well known that the mental workers are more
the exam anxiety is higher in normotensive youngsters likely to have hypertension. Our study demonstrated 315
260 with FHH. In this study, 15 students with FHH that even common tests can induce BP increase, and
were found to have higher anxiety scores than those the BP increase amplitude is connected with the extent
without FHH, which suggested that the students from of anxiety in the young students. An environment full of
a hypertensive family were more vulnerable to exam various and endless tests may be one responsive factor
© 2011 Informa Healthcare USA, Inc.
286 Z. Zhang et al.

320 for higher hypertension incidence in mental workers. To [6] Picot ST, Zauszniewsk JA, Debanne SM, Holston EC. Mood
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ACKNOWLEDGMENT C, Ruskoaho H, Koulu M, Pesonen U. Stress-induced 365
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This study was supported by a grant from the overexpressing neuropeptide Y in noradrenergic neurons.
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Declaration of interest: The authors report no
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conflicts of interest. The authors alone are respon- (3):543–550.
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Clinical and Experimental Hypertension