Concluding Remarks

The next decade promises to bring us closer to a more definitive understanding of the link between stress and essential hypertension. It is already certain that the relation between stress and essential hypertension is not simple or direct, and that multiple etiologic factors need to be considered when explaining how a psychological construct like stress can result in the disturbed blood pressure regulation seen in essential hypertension. Optimal assessment strategies aimed at identifying the unique predictors of increased risk for hypertension on a case-by-case basis need to be devised and tested so they may be applied in clinical settings to facilitate the accurate diagnosis of hypertension as well as effective treatment planning. The literature examined in this book suggests that at least some essential hypertensive patients develop blood pressure regulation problems based upon exposure to environmental stressors and the patterning of their associated acute stress responses. Increased efforts should be made to improve identification of these individuals so that lifestyle and psychosocial prevention programs that target the unique behaviors associated with risk for hypertension can be tested and implemented. With this type of data, we will be much closer to being able to state that stress causes essential hypertension.

So, where might that leave us with our patient, Franklin? Although Franklin, in many ways, was a typical hypertensive patient, his case was also unique. In contrast to hundreds of thousands of patients currently being evaluated and treated for essential hypertension, Franklin participated in a few ongoing clinical research projects during which he was provided access to state-of-the-art ambulatory blood pressure monitoring as well as an individually tailored anger management intervention trial. For Franklin, data from the ambulatory blood pressure monitoring period confirmed that he indeed exhibited high blood pressures throughout the day and most of the night and was not simply showing an isolated clinic hypertensive profile. The monitoring record also yielded information regarding the extreme lability of Franklin's blood pressure and his propensity to exhibit elevated pressures during periods of stress, particularly those involving the experience and expression of anger. Once he reviewed these records, Franklin began to see the seriousness of his blood pressure problem and was motivated to participate more actively in his treatment program. In this regard, ambulatory monitoring of blood pressure was useful in enlisting Franklin's participation in treatment planning and improving his motivation to work with his medical team to regulate his blood pressure better.

As noted in Chapter 8, Franklin's blood pressures declined somewhat following his participation in the anger management training program. Unfortunately, most physicians rely solely on pharmacologic interventions for regulating blood pressure, and the opportunity to participate in this type of intervention trial is not available in most primary care settings. In Franklin's case, this non-pharmacologic approach clearly served as a helpful adjunctive treatment. Certainly, not all patients with essential hypertension would benefit from this type of stress management intervention, but with continued research, it is likely that we will be able to better elucidate the characteristics of patients for whom such an approach would be worthwhile. In this regard, patients like Franklin will be able to lower their blood pressures using lower doses of antihypertensive medications, if any are used at all.

Patients like Franklin deserve health care providers who are fully informed about the latest advances in the assessment, treatment, and prevention of essential hypertension. I hope that the information presented in this book represents one step in this direction. As empirical work continues to accumulate in this area, we hope to see continued exploration of the utility of ambulatory monitoring of blood pressure for ascertaining diagnoses of high blood pressure and monitoring treatment effectiveness, the development of more sensitive measures of vulnerability to stress associated with hypertension, and a greater use of individual difference variables in identifying optimal treatment choices. As we move in this direction, patients like Franklin will be better treated and hypertension will be less of the public health problem that it is today.

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