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Stress May Increase the Risk for Stroke in Patients Treated for Hypertension

Updated: Feb 18

By Melissa Kluczynski, MS

The definition of stress is twofold: it is a feeling of emotional or physical tension usually caused by a stressor (e.g., job-related stress), and also refers to the body’s response to a challenge or demand. We all get stressed from time to time, but have you ever wondered how it is affecting your health? Dr. Huan Li and colleagues examined the relationship between psychological stress and risk of first stroke in adults with hypertension in a new study titled, ‘Self-Perceived Psychological Stress and Risk of First Stroke in Treated Hypertensive Patients.’ Previous research has found that stress increases the risk for cardiovascular disease and hypertension; however, less is known about the relationship between stress and the risk for stroke.

The China Stroke Primary Prevention Trial (CSPPT) was a randomized, double-blind trial conducted from May 2008 to August 2013 in China; and was designed to investigate how effective enalapril (an ACE inhibitor used to treat hypertension) plus folic acid (B vitamin) was for reducing the risk of first stroke in adults with hypertension compared to enalapril alone. Patients were included in the CSPPT if they were between the ages of 45 and 75 years and had hypertension defined as either 1) blood pressure greater than or equal to 140/90 mmHg or 2) taking antihypertensive medication. Any patients with a history of cardiovascular disease, including stroke, were excluded. The current study included 20,688 patients who reported their level of stress by answering a single question, “How would you describe your psychological stress in daily life or work (high, medium or low)?” Stress was defined as “persistent daily worries in one’s life or work status.” The primary outcome of this study was first fatal or nonfatal stroke. Fatal stroke was defined as death within 28 days of stroke due to the stroke itself or related complications.

Over 4.5 years, 30.7% (636 of 20,688) of CSPPT participants experienced a first stroke, of which 80.8% were ischemic strokes and 18.9% were hemorrhagic strokes. A total of 28 participants (4.4%) experienced a fatal stroke. Most participants rated their stress level as low (60.8%), followed by medium (33.5%) and high (5.7%) levels of stress. Participants with high levels of stress had 40% higher risk for first stroke (either ischemic or hemorrhagic) and 45% higher risk for first ischemic stroke compared to patients with low levels of stress. There was no relationship between stress and risk of hemorrhagic stroke. Additionally, participants with mean arterial pressure (MAP) less than 101 mmHg had almost three times the risk of first stroke compared to MAP greater than or equal to 101 mmHg. Previous research has found that increased MAP is a risk factor for cardiovascular events, which is the opposite of what Dr. Li and colleagues found, so further research is needed to better understand the effects of MAP on stroke risk.

It is not certain how exactly stress contributes to stroke risk. Some research has shown that stress may slow fibrinolysis (a natural process of the body that prevents blood clots from forming) or stress might cause arterial inflammation. Limitations of this study include only being conducted in China, as the results may differ for other racial and ethnic groups. For example, there may be cultural differences in self-perceived stress. Also, stress was self-reported by participants and may be subject to errors in memory or reporting. The authors also did not distinguish between acute (short-term) and chronic (long-term) stress which may have different effects on stroke risk. Additionally, the authors did not report how well patients adhered to taking antihypertensive medication and how many patients were successful at getting their blood pressure under control.

The authors of this study concluded that “higher psychological stress was associated with an increased risk of first stroke among treated hypertensive patients, especially in those with lower mean arterial pressure during the treatment period.” Further research is needed to confirm the results of this study.

Bottom line: Stress might increase the risk of first stroke in patients treated for hypertension. Further research is needed to better understand whether a combination of stress management techniques and antihypertensive medication is more effective at reducing stroke risk in hypertensive patients than medication alone.

How Can I Manage Daily Stress? Here are a few suggestions for managing stress:

  • Breathing exercises

  • Meditation

  • Journaling

  • Take a walk in nature

  • Meet with a friend for coffee or a meal



American Heart Association. Three Tips to Manage Stress. October 4, 2021. Accessed March 7, 2022.


Melissa Kluczynski holds a Master of Science degree in Epidemiology from the University at Buffalo and she is currently working as a Research Associate in the Department of Cancer Prevention and Control at Roswell Park Comprehensive Cancer Center in Buffalo, NY. Her research interests include chronic disease prevention and women's health.

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