{"paper_id":"0087ee94-b15f-4380-a63a-b729679f7fa8","body_text":"Hypertension but Not Heart Failure or Coronary Artery Disease is Associated With Mental Disorders | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Hypertension but Not Heart Failure or Coronary Artery Disease is Associated With Mental Disorders Hossein Namdar, Fatemeh Jamshidi, Davoud Ezzati, raana Zakeri, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-33844/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Previous studies have emphasized the significant association between depression, anxiety, and stress and hypertension (HTN), heart failure (HF), and coronary artery disease (CAD). However, among included patients with HF or CAD in those studies, there were considerable proportions of patients with concomitant HTN and vice versa leading to some possible bias in final estimations. Therefore, we aimed to exclude those patients with concomitant diseases and reassess the association between these three prevalent cardiovascular diseases with three important psychological disorders. Methods In this cross-sectional study, 300 patients were evaluated, including 100 with HTN (without a history or concomitant HF or CAD), 100 with HF (without HTN or CAD), and 100 with CAD (without HTN or HF). Moreover, 100 healthy volunteers were considered as the control group. Depression Anxiety Stress Scale 21 was used to measure the magnitude of depression, anxiety, and stress. Result The average scores of 4.6, 9.1, 3.7, and 4.4 for depression, 3.9, 11.1, 4.1, and 3.6 for anxiety and 6.5, 13.6, 5.2, and 5.4 for stress were detected in control, HTN, CAD, and HF groups, respectively. The depression, anxiety, and stress scores of HTN group were significantly higher than the control (p < 0.05), CAD (p < 0.05) and HF (p < 0.05) groups; this is while these scores were not significantly different between other study groups (p > 0.05). Conclusion Our study demonstrated a significantly higher magnitude of psychological disorders in patients with HTN. However, their magnitude in patients with HF and CAD without concomitant HTN were similar to those in healthy participants. Cardiac & Cardiovascular Systems Figures Figure 1 Introduction: Despite promising advances in healthcare and therapeutics, Cardiovascular Diseases (CVDs) remain the leading cause of mortality and disability worldwide ( 1 , 2 ). It has been reported that CVDs cause a number of over 18 million mortalities per year, which will rise up to 23.3 million till 2030 ( 3 ). CVDs impose a heavy social and financial burden on the global economy particularly in low- and middle-income countries ( 4 ). Aging, obesity, inadequate preventive strategies, and suboptimal management of risk factors increase the burden of CVDs ( 4 ). However, it is noteworthy that classical cardiac risk factors such as aging and obesity can explain only a half of the clinical CVDs ( 5 ). A growing number of studies have emphasized the significant role of psychological disorders especially depression, anxiety states including panic disorder, post-traumatic psychological symptoms, and mental stress in development of CVDs ( 6 – 9 ). The relatively poorer outcomes of patients with CVDs and concomitant psychological diseases have made them the subjects of many recent studies ( 10 , 11 ). Depression in patients with congestive Heart Failure (HF) has an independent prognostic role in patients’ outcome and can bring about 2 to 3-fold higher rates of rehospitalization and mortality ( 10 , 11 ). Also, anxiety is reported to be significantly associated with mortality in patients with Coronary Artery Disease (CAD) ( 12 ). Likewise, higher states of psychological stress such as social-isolation or work-related stress can bring about poorer prognosis in patients with established CAD ( 13 ). Although the mechanisms are not well-defined, studies using both electrophysiological and neurochemical techniques, demonstrated that the sympathetic nervous system activation in psychological disorders seems to have an important role in development of CVDs ( 5 ). A high prevalence of psychological disorders is reported among hypertensive patients and the numbers vary greatly among previous studies ( 14 – 17 ). In addition, the proportions of patients with HF or CAD suffering from concomitant psychological disorders have been variedly reported. However, it should be noted that among included patients with HF or CAD in those studies, there were considerable proportions of patients with concomitant Hypertension (HTN) ( 18 – 20 ). Considering that HTN patients have high rate of psychological disorders ( 21 , 22 ), the possibility of this bias exists that due to presence of HTN patients in the study samples, the prevalence of psychological disorders of patients with HF and CAD has been intrusively reported higher than normal ( 23 , 24 ). Therefore, we aimed to exclude those patients with HF and CAD that have a history of or concomitant HTN and reassess the association between these three prevalent CVDs with three important psychological disorders. Patients And Methods: This study was designed as a cross-sectional study on patients with the age of 18 years and above, who were referred to the outpatient clinics of university hospitals of ( the name of the city was blinded for double blinded peer review ), from January 2018 to January 2019. An overall number of 100 healthy volunteers were considered as the control group and 300 patients were consecutively included, of whom 100 patients had HTN (without a history or concomitant HF or CAD), 100 patients had HF (without a history or concomitant HTN or CAD), and 100 patients had CAD (without a history or concomitant HTN or HF). Informed consent for participation was obtained and the study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a priori approval by the institution's human research committee. The diagnosis of HF, HTN, and CAD was assigned by an attending cardiologist. HF was diagnosed based on Framingham criteria and if the patients meet at least two major criteria or one major and two minor criteria and ejection fraction was below 40 percent were included in the HF group ( 25 ). Patients whose blood pressures were consistently ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic or were under treatment with antihypertensive drugs were considered hypertensive according to the Eighth Joint National Committee (JNC 8) guideline ( 26 ). CAD was diagnosed based on a history of confirmed myocardial infraction or a previous angiography report demonstrating more than 50 percent luminal narrowing of coronary arteries ( 25 ). Demographic data including age, sex, marital status, place of residence, education, number of children, and occupation status were recorded for each study sample. The average amount sleeping hours, self-reported sleep disorders and incidence of spontaneous cry were asked from each sample as well. Depression Anxiety Stress Scale 21 (DASS-21) was used as a measure of the magnitude of the three traits of depression, anxiety, and stress. DASS-21 scale consists 21 questions, each question needs to be answered on a 4-point scale by the patient rating the extent of each 21 statements applied over the past week. The Internal consistency scores for this scale in terms of Cronbach's alpha scores rate are high (of 0.96 to 0.97 for Depression, 0.84 to 0.92 for Anxiety, and 0.90 to 0.95 for Stress) ( 27 – 31 ). Interpretation of the patients’ scores was performed by converting them to z-scores and comparing them to the normative values contained in the DASS manual. The scores from this version of DASS (DASS-21) were converted to the DASS normative data by multiplying the scores by two. A z-score of 0.5 was considered as normal, 0.5 to 1.0 was mild, 1.0 to 2.0 was moderate, 2.0 to 3.0 was severe, and z-scores over 3 were considered as extremely severe depression, anxiety, or stress. The validity and reliability of Persian translation of DASS-21 have also been verified by Sahebi et al. (Cronbach Alphas of 0.77, 0.79 and 0.78 for the depression, anxiety and stress subscales, respectively). Also, a significant correlation of DASS-21 with well-known measures such as Beck's Depression Inventory (r = 0.70), Zung's Anxiety Inventory (r = 0.67) and Perceived Stress Inventory (r = 0.49) have been demonstrated. Normal distribution of all variables was tested by the Kolmogorov-Smirnov test. Mean and standard deviation or median and interquartile range of quantitative variables and frequency and percentage of qualitative variables were calculated. Student’s t-test or Mann-Whitney U were used to compare quantitative variables between two groups and one-way ANOVA or the Kruskal-Wallis to compare means of more than two groups. Chi-square test was used for qualitative variables. SPSS version 24 was used for all analyses. A P-value of less than 0.05 was considered significant. Results: An overall 400 participants including 213 women (53.2%) and 187 men (46.8%), with a mean age of 55.1 ± 14.1 years old were included. The majority of the participants were married (95.8%) illiterate (34.7%), urban residences (80.5%) and employed (77%). Also, the participants had a median number of 3 children (0–11). The demographic characteristics of participants within each study group are summarized in Table 1 ; regarding the demographic characteristics, the study groups were significantly different in age (p < 0.05), gender (p < 0.05), marriage status (p < 0.05), children number (p < 0.05), education (p < 0.05), residence place (p < 0.05) and occupation (p < 0.05). Table 1 The demographics of participants (n = 400) Study Groups P-value Control (n = 100) HF (n = 100) HTN (n = 100) CAD (n = 100) Age (years)* 43.5 (13.0) 62.8 (11.5) 55.8 (12.3) 58.3 (12.3) 0.000 ≠ Sex ¥ Male 37 (37.0) 66 (66.0) 21 (21.0) 63 (63.0) 0.000 ∂ Female 63 (63.0) 34 (34.0) 79 (79.0) 37 (37.0) Marriage Status ¥ Married 89 (89.0) 100 (100) 95 (95.0) 99 (99.0) 0.000 ∂ Unmarried 11 (11.0) 0 5 (5.0) 1 (1.0) Children (number) § 2 (0–8) 4 (1–11) 3 (0–10) 3 (0–9) 0.000 ¤ Education ¥ Illiterate 13 (13.0) 59 (59.0) 31 (31.0) 36 (36.0) 0.000 ∂ Middle School 22 (22.0) 35 (35.0) 35 (35.0) 34 (34.0) Diploma 24 (24.0) 6 (6.0) 15 (15.0) 16 (16.0) University Degree 41 (41.0) 0 19 (19.0) 14 (14.0) Residence Place ¥ Urban 90 (90.0) 61 (61.0) 90 (90.0) 81 (81.0) 0.000 ∂ Rural 10 (10.0) 39 (39.0) 10 (10.0) 19 (19.0) Occupation ¥ Unemployed 6 (6.0) 28 (28.0) 5 (5.0) 7 (7.0) 0.000 ∂ Employee 21 (21.0) 0 11 (11.0) 12 (12.0) Businessman 25 (25.0) 34 (34.0) 9 (9.0) 29 (29.0) Retired 10 (10.0) 6 (6.0) 11 (11.0) 19 (19.0) Housekeeper 38 (38.0) 32 (32.0) 64 (64.0) 33 (33.0) *Data are presented as Mean (SD) ¥Data are presented as n (%) §Data are presented as Median (min-max) ≠Analysis of variance (ANOVA) ∂Fisher's exact test ¤Kruskal-Wallis test Following the findings in Table 2 , the study groups were significantly different in sleep duration (p < 0.05) and sleep disorder (p < 0.05). While 70% of participants in the control group reported having an adequate daily sleep (defined as 6–8 hours of sleep), respectively 49%, 63%, and 62% of patients in HTN, CAD, and HF groups reported having an adequate daily sleep (Table 2 ). Although only 38% of participants in control were suffering from sleep disorder, the disorder was as frequents as 71% in HTN group, 43% in CAD group, and 57% in HF group (Table 2 ). In addition, the status of spontaneous crying was significantly different between the groups (p < 0.05), as 12% control participants, 53% HTN patients, 20% CAD patients, and 10% HF patients reported to have spontaneous crying (Table 2 ). In general, insufficient daily sleep, sleep disorder, and spontaneous crying were more common among HTN patients compared to other participants. Table 2 The sleeping and crying status of participants (n = 400) Study Groups P-value ≠ Control (n = 100) HF (n = 100) HTN (n = 100) CAD (n = 100) Sleep Duration (hour)* 6–8 70 (70.0) 62 (62.0) 49 (49.0) 63 (63.0) 0.035 3–6 28 (28.0) 38 (38.0) 48 (48.0) 35 (35.0) < 3 2 (2.0) 0 3 (3.0) 2 (2.0) Sleep Disorder* 38 (38.0) 57 (57.0) 71 (71.0) 43 (43.0) 0.000 Spontaneous Crying* 12 (12.0) 10 (10.0) 53 (53.0) 20 (20.0) 0.000 *Data are presented as N (%) ≠Fisher's exact test The individuals’ scores of depression, anxiety and stress were classified by the normative values contained in the DASS manual. Regarding the depression levels, the frequency of normal versus (vs) severe levels in control, HTN, CAD, and HF groups were 90% vs 1%, 43% vs 9%, 91% vs 1%, and 94% vs 2%, respectively. The prevalence of normal vs severe levels of anxiety in control, HTN, CAD, and HF groups were 86% vs 1%, 24% vs 44%, 85% vs 2%, and 92% vs 2%, respectively. Finally, the prevalence of normal vs severe levels of stress in control, HTN, CAD, and HF groups were 92% vs 2%, 54% vs 10%, 94% vs 1%, and 96% vs 2%, respectively (Table 3 ). Table 3 The levels of depression, anxiety and stress in study groups (n = 400) Study Groups Control (n = 100) HF (n = 100) HTN (n = 100) CAD (n = 100) Depression Level Normal 90 (90.0) 94 (94.0) 43 (43.0) 91 (91.0) Mild 8 (8.0) 4 (4.0) 28 (28.0) 5 (5.0) Moderate 1 (1.0) 0 20 (20.0) 3 (3.0) Severe 1 (1.0) 0 7 (7.0) 1 (1.0) Very Severe 0 2 (2.0) 2 (2.0) 0 Anxiety Level Normal 86 (86.0) 92 (92.0) 24 (24.0) 85 (85.0) Mild 7 (7.0) 2 (2.0) 7 (7.0) 6 (6.0) Moderate 6 (6.0) 4 (4.0) 25 (25.0) 7 (7.0) Severe 1 (1.0) 0 25 (25.0) 1 (1.0) Very Severe 0 2 (2.0) 19 (19.0) 1 (1.0) Stress Level Normal 92 (92.0) 96 (96.0) 54 (54.0) 94 (94.0) Mild 4 (4.0) 2 (2.0) 16 (16.0) 1 (1.0) Moderate 2 (2.0) 0 20 (20.0) 4 (4.00 Severe 2 (2.0) 2 (2.0) 9 (9.0) 1 (1.0) Very Severe 0 0 1 (1.0) 0 Data are presented as N (%) The overall scores of depressions in study groups had an average of 4.6 in the control group, 9.1 in HTN group, 3.7 in CAD group, and 4.4 in HF group (Table 4 , Fig. 1 ). The depression scores between the study groups were significantly different (p < 0.05, Table 4 ), as the depression scores of HTN patients were significantly higher than the control participants (p < 0.05), CAD patients (p < 0.05) and HF patients (p < 0.05); this is while the depression scores were not significantly different between other study groups (Table 5 ). Table 4 The comparison of depression, anxiety and stress scores between study groups (n = 400) Study Groups Control (n = 100) HF (n = 100) HTN (n = 100) CAD (n = 100) P-value ≠ Depression Score* 4.6 (4.0–5.4) 4.4 (3.5–5.3) 9.1 (7.8–10.5) 3.7 (3.1–4.5) 0.000 Anxiety Score* 3.9 (3.3–4.6) 3.6 (3.0–4.2) 11.1 (9.6–12.8) 4.1 (3.5–4.8) 0.000 Stress Score* 6.5 (5.5–7.6) 5.4 (4.7–6.2) 13.6 (12.2–15.1) 5.2 (4.5–6.0) 0.000 *Data are presented as Geometric Mean (95% Confidence Interval) ≠Adjusted for patients’ demographics, sleep duration, sleep disorder, spontaneous crying with analysis of covariance (after logarithmic transformation) Table 5 The post-hoc differences of depression, anxiety and stress scores among the study groups (n = 400) Variable Study Groups MD (95% CI) ¥ P-value ≠ Depression Score HF vs Control 0.5 (-1.7–2.7) 0.935 HTN vs Control 5.7 (3.7–7.7) 0.000 CAD vs Control 0.3 (-1.6–2.3) 0.967 HTN vs HF 5.2 (3.1–7.3) 0.000 CAD vs HF -0.1 (-2.0–1.7) 0.997 CAD vs HTN -5.3 (-7.3 – -3.4) 0.000 Anxiety Score HF vs Control 1.2 (-0.9–3.3) 0.466 HTN vs Control 8.7 (6.8–10.6) 0.000 CAD vs Control 1.5 (-0.4–3.4) 0.171 HTN vs HF 7.5 (5.5–9.5) 0.000 CAD vs HF 0.3 (-1.4–2.1) 0.966 CAD vs HTN -7.2 (-9.0 – -5.3) 0.000 Stress Score HF vs Control 1.6 (-0.9–4.1) 0.362 HTN vs Control 7.9 (5.6–10.1) 0.000 CAD vs Control 1.0 (-1.3–3.3) 0.675 HTN vs HF 6.3 (3.8–8.7) 0.000 CAD vs HF -0.6 (-2.7–1.5) 0.888 CAD vs HTN -6.9 (-9.1 – -4.6) 0.000 ¥MD (95% CI): Mean Difference (95% Confidence Interval) ≠ The post-hoc Tukey test ≠The significant comparisons are reported only The estimations for scores of anxiety revealed overall averages of 3.9, 11.1, 4.1, and 3.6 for control, HTN, CAD, and HF groups, respectively (Table 4 ). The study groups were significantly different in anxiety score (p < 0.05, Table 4 ); the significant differences of anxiety scores were among the HTN patients vs the patients in other groups (all: p < 0.05, Table 5 ), as HTN patients showed higher anxiety scores than others. Regarding the overall scores of stress in study groups, which was significantly different between the groups (p < 0.05), the overall averages of 6.5, 13.6, 5.2, and 5.4 were estimated for control, HTN CAD, and HF groups, respectively (Table 4 ). Similar to depression and anxiety scores, the stress scores of HTN patients were significantly higher than the ones in other groups (p < 0.05), while the other inter-groups scores were not significantly different (Table 5 ). Discussion: Our results demonstrated a significantly higher prevalence of psychological problems including anxiety, depression, and stress among HTN patients. Also, a great proportion of HTN patients had sleeping disorders and spontaneous crying and few had enough sleep. However, HF and CAD patients’ results were similar to the results of healthy participants in terms of status of anxiety, stress, sleep duration, sleep disorders, and spontaneous crying except for depression which was even lower in HF patients as compared to control group. Our study confirms and extends the findings of previous studies that demonstrated a significant association between psychological disorders and HTN ( 14 – 17 ). Ginty et al. revealed a significant association between symptoms of depression and anxiety and a diagnosis of hypertension assessed 5 years later ( 9 ). Maatouk et al. in a recent study, have also confirmed the relationship between depression and a higher risk of HTN ( 14 ). However, some other studies have recently questioned these findings, proposing that, depression and anxiety can even lead to lower BP ( 16 , 17 , 32 ). Thus, two other studies tried to explain these discrepancies and suggested that this association have an age-related pattern as it is more evident in middle-aged patients, but not in young or elderly patient ( 6 , 33 ). HTN group in our study mostly consisted of middle-aged patients (half of the patients aged between 48 to 65 years). The underlying mechanism of this age-related pattern of this association remains to be determined. However, different possible explanations of the mechanism underlying the association between psychological disorders and HTN have been proposed. Both unhealthy behaviors and physiological dysregulation in patients with psychological disorders are imagined to contribute to development of HTN. Some of the possible physiological dysregulations that are previously suggested include altered hypothalamic–pituitary–adrenal axis ( 34 ), deregulated autonomic function ( 35 ), altered brain activity (i.e. hypometabolism of dorsal cortical regions and ventral limbic structures) ( 36 ). An increased postganglionic sympathetic fibers activation passing to blood vessels of skeletal muscle results in vasoconstriction and increased blood pressure in patients with borderline or established hypertension ( 5 , 37 , 38 ). Previous studies postulated that there are associations between HF and CAD with psychological disorders but we found no such association ( 18 – 20 ). One possible explanation could be that the association between HF and CAD with psychological disorders in previous studies is due to the inclusion of HF/CAD patients with concomitant HTN. Garfield et al. reported significant association of anxiety disorders and depression with incident heart failure. Although the results of this study was adjusted to HTN at baseline, HTN due to depression/anxiety disorders over the course of study were not considered in final analysis as a confounding factor ( 18 ). Also, some other studies did not consider controlling the confounding effect of HTN in the evaluation of depression in HF patients ( 19 , 39 ). Abramson et al. revealed that depression can lead to two-fold higher rate of heart failure in patients with HTN ( 24 ). Therefore, HTN may play a role in this association. Thus, it can be imagined that although the prevalence of depression is high among HF patients, this phenomenon is not related to the pathophysiology of HF, instead, it is related to HTN. Accordingly, when we excluded HTN patients from HF patients, no higher rate of depression was found. Similar bias can be found within those studies evaluating the association of anxiety and stress and heart failure ( 18 , 39 , 40 ). Although the cross-sectional design of current study may prevent us to argue about causation relationship between psychological disorders and HTN, low rate of psychological disorders among HF and CAD patient without concomitant HTN leads us to suppose that it is unlikely that psychological disorders in HTN be merely an emotional response to having HTN, instead it is more likely that HTN is a physical response to these damaging psychological disorders. However, this issue needs to be confirmed by future longitudinal and preventive interventional studies. Our study had some limitations that worth mentioning. First, this study was designed as a cross-sectional study rather than a cohort study. Yet, we included a control group in order to be able to compare the results. Second, analysis of demographic characteristics demonstrated significant differences among study groups that was due to consecutive inclusion of patients without considering their demographic characteristics. A previous study in Iran demonstrated that there was no significant associations between DASS-21 scale scores and demographic variables (i.e. age, gender, education, and marital status) ( 41 ). Therefore, differences in demographic characteristics may not prevent us to use our data for comparing the results of DASS-21 between HTN, HF, and CAD patients. Moreover, possible confounding effects of these variables were controlled in final analysis. Conclusion: Our study demonstrated a significantly higher rate of psychological disorders (including stress, anxiety, and depression) among patients with HTN. However, the rate of psychological disorders in patients with HF and CAD without concomitant HTN were similar to those in healthy participants. Therefore, we can conclude that first, the confounding effect of HTN needs to be considered in future studies that evaluate association of psychological disorders and HF and CAD. Second, due to higher rate of psychological disorders among HTN patients and their negative consequences, more attention should be paid on psychological disorders in these patients. Third, considering that we found higher rates of psychological disorders among HTN patients but not among HF and CAD patients, it can be imagined that, these psychological disorders may have a role in pathophysiology of HTN, rather than being an emotional response to a distressing and unwell physical condition. However, this issue needs to be confirmed by future longitudinal studies. Declarations Ethics approval : The protocol of this study was approved by medical ethics committee of our institution. Consent to participate Informed consent was obtained from the participants. Consent for publication : Consent for publication was granted. Availability of data and materials: All Data and material collected during this study are available from the corresponding author upon reasonable request. Conflicts of interest/Competing interests None declared. Funding: This study was supported by a fund from the Tabriz University of Medical Sciences. Authors' contributions: Conceptualization: HN, SRSE; Methodology: HN, FJ, DE; Formal analysis and investigation: RZ, SRSE; Writing - original draft preparation: SRSE; Writing - review and editing: HN, RZ, SRSE; Funding acquisition: HN; Resources: FJ, DE, Supervision: HN Acknowledgements: None. References Smith SC, Collins A, Ferrari R, Holmes DR, Logstrup S, McGhie DV, et al. Our time: a call to save preventable death from cardiovascular disease (heart disease and stroke). J Am Coll Cardiol. 2012;60(22):2343–8. Bansilal S, Castellano JM, Fuster V. Global burden of CVD: focus on secondary prevention of cardiovascular disease. Int J Cardiol. 2015;201(Suppl 1):1–7. World Health Organization. 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Correlates of cognitive impairment among patients with heart failure: results of a multicenter survey. Am J Med. 2005;118(5):496–502. Serafini G, Pompili M, Innamorati M, Iacorossi G, Cuomo I, Della Vista M, et al. The impact of anxiety, depression, and suicidality on quality of life and functional status of patients with congestive heart failure and hypertension: an observational cross-sectional study. Prim Care Companion J Clin Psychiatry. 2010;12(6):PCC..09 m00916. Abramson J, Berger A, Krumholz HM, Vaccarino V. Depression and risk of heart failure among older persons with isolated systolic hypertension. Arch Intern Med. 2001;161(14):1725–30. Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF. Braunwald's Heart Disease A Textbook of Cardiovascular Medicine: Elsevier Health Sciences; 2018. 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Confirmatory factor analysis of the Depression–Anxiety–Stress Scales in depressed and anxious patients. Journal of psychopathology behavioral assessment. 2001;23(1):61–7. Page AC, Hooke GR, Morrison DL. Psychometric properties of the Depression Anxiety Stress Scales (DASS) in depressed clinical samples. Br J Clin Psychol. 2007;46(Pt 3):283–97. Hildrum B, Romild U, Holmen J. Anxiety and depression lowers blood pressure: 22-year follow-up of the population based HUNT study, Norway. BMC Public Health. 2011;11(1):601. Nabi H, Chastang J-F, Lefèvre T, Dugravot A, Melchior M, Marmot MG, et al. Trajectories of depressive episodes and hypertension over 24 years: the Whitehall II prospective cohort study. Hypertension. 2011;57(4):710–6. Brown ES, Varghese FP, McEwen BS. Association of depression with medical illness: does cortisol play a role? Biol Psychiatry. 2004;55(1):1–9. Kibler JL, Ma M. Depressive symptoms and cardiovascular reactivity to laboratory behavioral stress. Int J Behav Med. 2004;11(2):81–7. Taylor WD, Aizenstein HJ, Alexopoulos GS. The vascular depression hypothesis: mechanisms linking vascular disease with depression. Mol Psychiatry. 2013;18(9):963–74. Esler M. Sympathetic activity in experimental and human hypertension. Handbook of hypertension. 1997;17:628–73. Julius S. Changing role of the autonomic nervous system in human hypertension. J Hypertens Suppl. 1990;8(7):59–65. Haworth JE, Moniz-Cook E, Clark AL, Wang M, Waddington R, Cleland JG. Prevalence and predictors of anxiety and depression in a sample of chronic heart failure patients with left ventricular systolic dysfunction. Eur J Heart Fail. 2005;7(5):803–8. Jiang W, Babyak M, Krantz DS, Waugh RA, Coleman RE, Hanson MM, et al. Mental stress–induced myocardial ischemia and cardiac events. JAMA. 1996;275(21):1651–6. Asghari A, Saed F, Dibajnia P. Psychometric properties of the Depression Anxiety Stress Scales-21 (DASS-21) in a non-clinical Iranian sample. Int J Psychol. 2008;2(2):82–102. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-33844\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research\",\"associatedPublications\":[],\"authors\":[{\"id\":671618,\"identity\":\"16c16638-d639-4ffa-b576-bb91988565a2\",\"order_by\":0,\"name\":\"Hossein Namdar\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Tabriz University of Medical Sciences\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Hossein\",\"middleName\":\"\",\"lastName\":\"Namdar\",\"suffix\":\"\"},{\"id\":671619,\"identity\":\"a85e3a3d-c287-4ea8-b8bf-6d16d0a2d009\",\"order_by\":1,\"name\":\"Fatemeh Jamshidi\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Tabriz University of Medical Sciences\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Fatemeh\",\"middleName\":\"\",\"lastName\":\"Jamshidi\",\"suffix\":\"\"},{\"id\":671620,\"identity\":\"ab16e629-6458-4580-b8e8-78fb2caaecf1\",\"order_by\":2,\"name\":\"Davoud Ezzati\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Tabriz University of Medical Sciences\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Davoud\",\"middleName\":\"\",\"lastName\":\"Ezzati\",\"suffix\":\"\"},{\"id\":671621,\"identity\":\"0617dc78-9a2f-4093-916a-ef478ba67394\",\"order_by\":3,\"name\":\"raana Zakeri\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Tabriz University of Medical Sciences\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"raana\",\"middleName\":\"\",\"lastName\":\"Zakeri\",\"suffix\":\"\"},{\"id\":671622,\"identity\":\"9c3fde5c-8cf1-40c9-83f1-25efbf831b81\",\"order_by\":4,\"name\":\"Seyyed-Reza Sadat-Ebrahimi\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYBAC+QYGAyBlAyYZeEAEMwEtBgeAig8wpEmQoIUBrOUwkhZCwID98MbPH/ecrzPnP5344A2DnTwDO+8DvFrke9KKJQ48uy1h2XB2s+EchmTDBmZ2A/zWHMgxkDhw4LaEwcHebdI8DMwJDMxsBFx2/o3xjwMHzkkYHObd/puHoZ4ILTdyzIC2HJAwOMa7jZmH4TBhLQY3npVZnDmQLLmzh3ez5ByD44ZthLTI9ydvvlFxwI7fnP/sxg9vKqrl+fmPEXAYmqUMDIR8MgpGwSgYBaOACAAAtMNCT3PRTU8AAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"Tabriz University of Medical Sciences\",\"correspondingAuthor\":true,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Seyyed-Reza\",\"middleName\":\"\",\"lastName\":\"Sadat-Ebrahimi\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2020-06-05 15:25:00\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-33844/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-33844/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":1352629,\"identity\":\"6e5209c0-721d-434a-9e31-831eec6a045c\",\"added_by\":\"auto\",\"created_at\":\"2020-06-17 17:02:01\",\"extension\":\"jpg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":306778,\"visible\":true,\"origin\":\"\",\"legend\":\"The results of three dimensions of DASS-21 including depression, anxiety, and stress in four study groups (HTN, hypertension; HF, heart failure; CAD, coronary artery disease; and control groups).\",\"description\":\"\",\"filename\":\"Figure1.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-33844/v1/Figure1.jpg\"},{\"id\":13542270,\"identity\":\"3e09bbe3-6141-4236-bd48-6c1363c97098\",\"added_by\":\"auto\",\"created_at\":\"2021-09-17 01:53:51\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":373001,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-33844/v1/c6a7bfeb-7b7d-4d29-ab99-0758fe882ecd.pdf\"}],\"financialInterests\":\"\",\"formattedTitle\":\"\\u003cp\\u003eHypertension but Not Heart Failure or Coronary Artery Disease is Associated With Mental Disorders\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"Introduction:\",\"content\":\" \\u003cp\\u003eDespite promising advances in healthcare and therapeutics, Cardiovascular Diseases (CVDs) remain the leading cause of mortality and disability worldwide (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e). It has been reported that CVDs cause a number of over 18\\u0026nbsp;million mortalities per year, which will rise up to 23.3\\u0026nbsp;million till 2030 (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). CVDs impose a heavy social and financial burden on the global economy particularly in low- and middle-income countries (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e). Aging, obesity, inadequate preventive strategies, and suboptimal management of risk factors increase the burden of CVDs (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e). However, it is noteworthy that classical cardiac risk factors such as aging and obesity can explain only a half of the clinical CVDs (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e). A growing number of studies have emphasized the significant role of psychological disorders especially depression, anxiety states including panic disorder, post-traumatic psychological symptoms, and mental stress in development of CVDs (\\u003cspan additionalcitationids=\\\"CR7 CR8\\\" citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). The relatively poorer outcomes of patients with CVDs and concomitant psychological diseases have made them the subjects of many recent studies (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e). Depression in patients with congestive Heart Failure (HF) has an independent prognostic role in patients\\u0026rsquo; outcome and can bring about 2 to 3-fold higher rates of rehospitalization and mortality (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e). Also, anxiety is reported to be significantly associated with mortality in patients with Coronary Artery Disease (CAD) (\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). Likewise, higher states of psychological stress such as social-isolation or work-related stress can bring about poorer prognosis in patients with established CAD (\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e). Although the mechanisms are not well-defined, studies using both electrophysiological and neurochemical techniques, demonstrated that the sympathetic nervous system activation in psychological disorders seems to have an important role in development of CVDs (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eA high prevalence of psychological disorders is reported among hypertensive patients and the numbers vary greatly among previous studies (\\u003cspan additionalcitationids=\\\"CR15 CR16\\\" citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e). In addition, the proportions of patients with HF or CAD suffering from concomitant psychological disorders have been variedly reported. However, it should be noted that among included patients with HF or CAD in those studies, there were considerable proportions of patients with concomitant Hypertension (HTN) (\\u003cspan additionalcitationids=\\\"CR19\\\" citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e). Considering that HTN patients have high rate of psychological disorders (\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e), the possibility of this bias exists that due to presence of HTN patients in the study samples, the prevalence of psychological disorders of patients with HF and CAD has been intrusively reported higher than normal (\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e). Therefore, we aimed to exclude those patients with HF and CAD that have a history of or concomitant HTN and reassess the association between these three prevalent CVDs with three important psychological disorders.\\u003c/p\\u003e \"},{\"header\":\"Patients And Methods:\",\"content\":\" \\u003cp\\u003eThis study was designed as a cross-sectional study on patients with the age of 18\\u0026nbsp;years and above, who were referred to the outpatient clinics of university hospitals of (\\u003cspan type=\\\"BoldItalic\\\" class=\\\"BoldItalic\\\" name=\\\"Emphasis\\\"\\u003ethe name of the city was blinded for double blinded peer review\\u003c/span\\u003e), from January 2018 to January 2019. An overall number of 100 healthy volunteers were considered as the control group and 300 patients were consecutively included, of whom 100 patients had HTN (without a history or concomitant HF or CAD), 100 patients had HF (without a history or concomitant HTN or CAD), and 100 patients had CAD (without a history or concomitant HTN or HF). Informed consent for participation was obtained and the study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a priori approval by the institution's human research committee.\\u003c/p\\u003e \\u003cp\\u003eThe diagnosis of HF, HTN, and CAD was assigned by an attending cardiologist. HF was diagnosed based on Framingham criteria and if the patients meet at least two major criteria or one major and two minor criteria and ejection fraction was below 40 percent were included in the HF group (\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e). Patients whose blood pressures were consistently\\u0026thinsp;\\u0026ge;\\u0026thinsp;140\\u0026nbsp;mm Hg systolic or \\u0026ge;\\u0026thinsp;90\\u0026nbsp;mm Hg diastolic or were under treatment with antihypertensive drugs were considered hypertensive according to the Eighth Joint National Committee (JNC 8) guideline (\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e). CAD was diagnosed based on a history of confirmed myocardial infraction or a previous angiography report demonstrating more than 50 percent luminal narrowing of coronary arteries (\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eDemographic data including age, sex, marital status, place of residence, education, number of children, and occupation status were recorded for each study sample. The average amount sleeping hours, self-reported sleep disorders and incidence of spontaneous cry were asked from each sample as well. \\u003cem\\u003eDepression Anxiety Stress Scale 21\\u003c/em\\u003e (DASS-21) was used as a measure of the magnitude of the three traits of depression, anxiety, and stress. DASS-21 scale consists 21 questions, each question needs to be answered on a 4-point scale by the patient rating the extent of each 21 statements applied over the past week. The Internal consistency scores for this scale in terms of Cronbach's alpha scores rate are high (of 0.96 to 0.97 for Depression, 0.84 to 0.92 for Anxiety, and 0.90 to 0.95 for Stress) (\\u003cspan additionalcitationids=\\\"CR28 CR29 CR30\\\" citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eInterpretation of the patients\\u0026rsquo; scores was performed by converting them to z-scores and comparing them to the normative values contained in the DASS manual. The scores from this version of DASS (DASS-21) were converted to the DASS normative data by multiplying the scores by two. A z-score of 0.5 was considered as normal, 0.5 to 1.0 was mild, 1.0 to 2.0 was moderate, 2.0 to 3.0 was severe, and z-scores over 3 were considered as extremely severe depression, anxiety, or stress. The validity and reliability of Persian translation of DASS-21 have also been verified by Sahebi et al. (Cronbach Alphas of 0.77, 0.79 and 0.78 for the depression, anxiety and stress subscales, respectively). Also, a significant correlation of DASS-21 with well-known measures such as Beck's Depression Inventory (r\\u0026thinsp;=\\u0026thinsp;0.70), Zung's Anxiety Inventory (r\\u0026thinsp;=\\u0026thinsp;0.67) and Perceived Stress Inventory (r\\u0026thinsp;=\\u0026thinsp;0.49) have been demonstrated.\\u003c/p\\u003e \\u003cp\\u003eNormal distribution of all variables was tested by the Kolmogorov-Smirnov test. Mean and standard deviation or median and interquartile range of quantitative variables and frequency and percentage of qualitative variables were calculated. Student\\u0026rsquo;s t-test or Mann-Whitney U were used to compare quantitative variables between two groups and one-way ANOVA or the Kruskal-Wallis to compare means of more than two groups. Chi-square test was used for qualitative variables.\\u003c/p\\u003e \\u003cp\\u003eSPSS version 24 was used for all analyses. A P-value of less than 0.05 was considered significant.\\u003c/p\\u003e \"},{\"header\":\"Results:\",\"content\":\" \\u003cp\\u003eAn overall 400 participants including 213 women (53.2%) and 187 men (46.8%), with a mean age of 55.1\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;14.1\\u0026nbsp;years old were included. The majority of the participants were married (95.8%) illiterate (34.7%), urban residences (80.5%) and employed (77%). Also, the participants had a median number of 3 children (0\\u0026ndash;11). The demographic characteristics of participants within each study group are summarized in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e; regarding the demographic characteristics, the study groups were significantly different in age (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05), gender (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05), marriage status (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05), children number (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05), education (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05), residence place (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05) and occupation (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eThe demographics of participants (n\\u0026thinsp;=\\u0026thinsp;400)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"7\\\"\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" morerows=\\\"1\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\" rowspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c6\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003eStudy Groups\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eP-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eControl (n\\u0026thinsp;=\\u0026thinsp;100)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eHF\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;100)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eHTN (n\\u0026thinsp;=\\u0026thinsp;100)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eCAD\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;100)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eAge (years)*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e43.5 (13.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e62.8 (11.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e55.8 (12.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e58.3 (12.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.000\\u003csup\\u003e\\u0026ne;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"7\\\" nameend=\\\"c7\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eSex \\u003csup\\u003e\\u0026yen;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e37 (37.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e66 (66.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e21 (21.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e63 (63.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003e0.000\\u003csup\\u003e\\u0026part;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eFemale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e63 (63.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e34 (34.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e79 (79.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e37 (37.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"7\\\" nameend=\\\"c7\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eMarriage Status \\u003csup\\u003e\\u0026yen;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMarried\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e89 (89.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e100 (100)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e95 (95.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e99 (99.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003e0.000\\u003csup\\u003e\\u0026part;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUnmarried\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e11 (11.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e5 (5.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1 (1.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eChildren (number) \\u003csup\\u003e\\u0026sect;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2 (0\\u0026ndash;8)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4 (1\\u0026ndash;11)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3 (0\\u0026ndash;10)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e3 (0\\u0026ndash;9)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.000\\u003csup\\u003e\\u0026curren;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"7\\\" nameend=\\\"c7\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eEducation \\u003csup\\u003e\\u0026yen;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eIlliterate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e13 (13.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e59 (59.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e31 (31.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e36 (36.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\" morerows=\\\"3\\\" rowspan=\\\"4\\\"\\u003e \\u003cp\\u003e0.000\\u003csup\\u003e\\u0026part;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMiddle School\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e22 (22.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e35 (35.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e35 (35.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e34 (34.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eDiploma\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e24 (24.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e6 (6.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e15 (15.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e16 (16.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUniversity Degree\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e41 (41.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e19 (19.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e14 (14.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"7\\\" nameend=\\\"c7\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eResidence Place \\u003csup\\u003e\\u0026yen;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUrban\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e90 (90.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e61 (61.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e90 (90.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e81 (81.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003e0.000\\u003csup\\u003e\\u0026part;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRural\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e10 (10.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e39 (39.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e10 (10.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e19 (19.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"7\\\" nameend=\\\"c7\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eOccupation \\u003csup\\u003e\\u0026yen;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUnemployed\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e6 (6.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e28 (28.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e5 (5.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e7 (7.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\" morerows=\\\"4\\\" rowspan=\\\"5\\\"\\u003e \\u003cp\\u003e0.000\\u003csup\\u003e\\u0026part;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eEmployee\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e21 (21.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e11 (11.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e12 (12.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eBusinessman\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e25 (25.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e34 (34.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e9 (9.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e29 (29.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRetired\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e10 (10.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e6 (6.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e11 (11.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e19 (19.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHousekeeper\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e38 (38.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e32 (32.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e64 (64.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e33 (33.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"7\\\" nameend=\\\"c7\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003e*Data are presented as Mean (SD)\\u003c/p\\u003e \\u003cp\\u003e\\u0026yen;Data are presented as n (%)\\u003c/p\\u003e \\u003cp\\u003e\\u0026sect;Data are presented as Median (min-max)\\u003c/p\\u003e \\u003cp\\u003e\\u0026ne;Analysis of variance (ANOVA)\\u003c/p\\u003e \\u003cp\\u003e\\u0026part;Fisher's exact test\\u003c/p\\u003e \\u003cp\\u003e\\u0026curren;Kruskal-Wallis test\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eFollowing the findings in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e, the study groups were significantly different in sleep duration (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05) and sleep disorder (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05). While 70% of participants in the control group reported having an adequate daily sleep (defined as 6\\u0026ndash;8 hours of sleep), respectively 49%, 63%, and 62% of patients in HTN, CAD, and HF groups reported having an adequate daily sleep (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). Although only 38% of participants in control were suffering from sleep disorder, the disorder was as frequents as 71% in HTN group, 43% in CAD group, and 57% in HF group (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). In addition, the status of spontaneous crying was significantly different between the groups (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05), as 12% control participants, 53% HTN patients, 20% CAD patients, and 10% HF patients reported to have spontaneous crying (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). In general, insufficient daily sleep, sleep disorder, and spontaneous crying were more common among HTN patients compared to other participants.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eThe sleeping and crying status of participants (n\\u0026thinsp;=\\u0026thinsp;400)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"7\\\"\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" morerows=\\\"1\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\" rowspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c6\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003eStudy Groups\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eP-value\\u003csup\\u003e\\u0026ne;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eControl (n\\u0026thinsp;=\\u0026thinsp;100)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eHF\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;100)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eHTN (n\\u0026thinsp;=\\u0026thinsp;100)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eCAD\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;100)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"6\\\" nameend=\\\"c6\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eSleep Duration (hour)*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e6\\u0026ndash;8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e70 (70.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e62 (62.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e49 (49.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e63 (63.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003e0.035\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3\\u0026ndash;6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e28 (28.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e38 (38.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e48 (48.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e35 (35.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2 (2.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3 (3.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2 (2.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eSleep Disorder*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e38 (38.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e57 (57.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e71 (71.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e43 (43.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eSpontaneous Crying*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e12 (12.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e10 (10.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e53 (53.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e20 (20.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"7\\\" nameend=\\\"c7\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003e*Data are presented as N (%)\\u003c/p\\u003e \\u003cp\\u003e\\u0026ne;Fisher's exact test\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe individuals\\u0026rsquo; scores of depression, anxiety and stress were classified by the normative values contained in the DASS manual. Regarding the depression levels, the frequency of normal versus (vs) severe levels in control, HTN, CAD, and HF groups were 90% vs 1%, 43% vs 9%, 91% vs 1%, and 94% vs 2%, respectively. The prevalence of normal vs severe levels of anxiety in control, HTN, CAD, and HF groups were 86% vs 1%, 24% vs 44%, 85% vs 2%, and 92% vs 2%, respectively. Finally, the prevalence of normal vs severe levels of stress in control, HTN, CAD, and HF groups were 92% vs 2%, 54% vs 10%, 94% vs 1%, and 96% vs 2%, respectively (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eThe levels of depression, anxiety and stress in study groups (n\\u0026thinsp;=\\u0026thinsp;400)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"6\\\"\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" morerows=\\\"1\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\" rowspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c6\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003eStudy Groups\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eControl (n\\u0026thinsp;=\\u0026thinsp;100)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eHF\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;100)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eHTN (n\\u0026thinsp;=\\u0026thinsp;100)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eCAD\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;100)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"6\\\" nameend=\\\"c6\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eDepression Level\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNormal\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e90 (90.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e94 (94.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e43 (43.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e91 (91.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMild\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8 (8.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4 (4.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e28 (28.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e5 (5.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eModerate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1 (1.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e20 (20.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e3 (3.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSevere\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1 (1.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e7 (7.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1 (1.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eVery Severe\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2 (2.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e2 (2.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"6\\\" nameend=\\\"c6\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eAnxiety Level\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNormal\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e86 (86.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e92 (92.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e24 (24.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e85 (85.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMild\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7 (7.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2 (2.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e7 (7.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e6 (6.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eModerate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e6 (6.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4 (4.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e25 (25.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e7 (7.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSevere\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1 (1.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e25 (25.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1 (1.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eVery Severe\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2 (2.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e19 (19.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1 (1.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"6\\\" nameend=\\\"c6\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eStress Level\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNormal\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e92 (92.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e96 (96.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e54 (54.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e94 (94.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMild\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4 (4.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2 (2.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e16 (16.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1 (1.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eModerate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2 (2.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e20 (20.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e4 (4.00\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSevere\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2 (2.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2 (2.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e9 (9.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1 (1.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eVery Severe\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1 (1.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"6\\\" nameend=\\\"c6\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eData are presented as N (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe overall scores of depressions in study groups had an average of 4.6 in the control group, 9.1 in HTN group, 3.7 in CAD group, and 4.4 in HF group (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e, Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). The depression scores between the study groups were significantly different (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05, Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e), as the depression scores of HTN patients were significantly higher than the control participants (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05), CAD patients (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05) and HF patients (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05); this is while the depression scores were not significantly different between other study groups (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab5\\\" class=\\\"InternalRef\\\"\\u003e5\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eThe comparison of depression, anxiety and stress scores between study groups (n\\u0026thinsp;=\\u0026thinsp;400)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"6\\\"\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c5\\\" namest=\\\"c2\\\"\\u003e \\u003cp\\u003eStudy Groups\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eControl\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;100)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eHF\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;100)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eHTN\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;100)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eCAD\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;100)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eP-value\\u003csup\\u003e\\u0026ne;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDepression Score*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4.6 (4.0\\u0026ndash;5.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4.4 (3.5\\u0026ndash;5.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e9.1 (7.8\\u0026ndash;10.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.7 (3.1\\u0026ndash;4.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAnxiety Score*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3.9 (3.3\\u0026ndash;4.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3.6 (3.0\\u0026ndash;4.2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e11.1 (9.6\\u0026ndash;12.8)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e4.1 (3.5\\u0026ndash;4.8)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eStress Score*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e6.5 (5.5\\u0026ndash;7.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5.4 (4.7\\u0026ndash;6.2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e13.6 (12.2\\u0026ndash;15.1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e5.2 (4.5\\u0026ndash;6.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"6\\\" nameend=\\\"c6\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003e*Data are presented as Geometric Mean (95% Confidence Interval)\\u003c/p\\u003e \\u003cp\\u003e\\u0026ne;Adjusted for patients\\u0026rsquo; demographics, sleep duration, sleep disorder, spontaneous crying with analysis of covariance (after logarithmic transformation)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab5\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 5\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eThe post-hoc differences of depression, anxiety and stress scores among the study groups (n\\u0026thinsp;=\\u0026thinsp;400)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVariable\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eStudy Groups\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eMD (95% CI)\\u003csup\\u003e\\u0026yen;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eP-value\\u003csup\\u003e\\u0026ne;\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eDepression Score\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHF vs Control\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.5 (-1.7\\u0026ndash;2.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.935\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHTN vs Control\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5.7 (3.7\\u0026ndash;7.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCAD vs Control\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.3 (-1.6\\u0026ndash;2.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.967\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHTN vs HF\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5.2 (3.1\\u0026ndash;7.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCAD vs HF\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-0.1 (-2.0\\u0026ndash;1.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.997\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCAD vs HTN\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-5.3 (-7.3 \\u0026ndash; -3.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eAnxiety Score\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHF vs Control\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.2 (-0.9\\u0026ndash;3.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.466\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHTN vs Control\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8.7 (6.8\\u0026ndash;10.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCAD vs Control\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.5 (-0.4\\u0026ndash;3.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.171\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHTN vs HF\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7.5 (5.5\\u0026ndash;9.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCAD vs HF\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.3 (-1.4\\u0026ndash;2.1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.966\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCAD vs HTN\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-7.2 (-9.0 \\u0026ndash; -5.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eStress Score\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHF vs Control\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.6 (-0.9\\u0026ndash;4.1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.362\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHTN vs Control\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7.9 (5.6\\u0026ndash;10.1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCAD vs Control\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.0 (-1.3\\u0026ndash;3.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.675\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHTN vs HF\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e6.3 (3.8\\u0026ndash;8.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCAD vs HF\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-0.6 (-2.7\\u0026ndash;1.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.888\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCAD vs HTN\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-6.9 (-9.1 \\u0026ndash; -4.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u0026yen;MD (95% CI): Mean Difference (95% Confidence Interval)\\u003c/p\\u003e \\u003cp\\u003e\\u0026ne; The post-hoc Tukey test\\u003c/p\\u003e \\u003cp\\u003e\\u0026ne;The significant comparisons are reported only\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe estimations for scores of anxiety revealed overall averages of 3.9, 11.1, 4.1, and 3.6 for control, HTN, CAD, and HF groups, respectively (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e). The study groups were significantly different in anxiety score (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05, Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e); the significant differences of anxiety scores were among the HTN patients vs the patients in other groups (all: p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05, Table\\u0026nbsp;\\u003cspan refid=\\\"Tab5\\\" class=\\\"InternalRef\\\"\\u003e5\\u003c/span\\u003e), as HTN patients showed higher anxiety scores than others.\\u003c/p\\u003e \\u003cp\\u003eRegarding the overall scores of stress in study groups, which was significantly different between the groups (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05), the overall averages of 6.5, 13.6, 5.2, and 5.4 were estimated for control, HTN CAD, and HF groups, respectively (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e). Similar to depression and anxiety scores, the stress scores of HTN patients were significantly higher than the ones in other groups (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05), while the other inter-groups scores were not significantly different (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab5\\\" class=\\\"InternalRef\\\"\\u003e5\\u003c/span\\u003e).\\u003c/p\\u003e \"},{\"header\":\"Discussion:\",\"content\":\" \\u003cp\\u003eOur results demonstrated a significantly higher prevalence of psychological problems including anxiety, depression, and stress among HTN patients. Also, a great proportion of HTN patients had sleeping disorders and spontaneous crying and few had enough sleep. However, HF and CAD patients\\u0026rsquo; results were similar to the results of healthy participants in terms of status of anxiety, stress, sleep duration, sleep disorders, and spontaneous crying except for depression which was even lower in HF patients as compared to control group.\\u003c/p\\u003e \\u003cp\\u003eOur study confirms and extends the findings of previous studies that demonstrated a significant association between psychological disorders and HTN (\\u003cspan additionalcitationids=\\\"CR15 CR16\\\" citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e). Ginty et al. revealed a significant association between symptoms of depression and anxiety and a diagnosis of hypertension assessed 5\\u0026nbsp;years later (\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). Maatouk et al. in a recent study, have also confirmed the relationship between depression and a higher risk of HTN (\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e). However, some other studies have recently questioned these findings, proposing that, depression and anxiety can even lead to lower BP (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e). Thus, two other studies tried to explain these discrepancies and suggested that this association have an age-related pattern as it is more evident in middle-aged patients, but not in young or elderly patient (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e). HTN group in our study mostly consisted of middle-aged patients (half of the patients aged between 48 to 65\\u0026nbsp;years). The underlying mechanism of this age-related pattern of this association remains to be determined. However, different possible explanations of the mechanism underlying the association between psychological disorders and HTN have been proposed. Both unhealthy behaviors and physiological dysregulation in patients with psychological disorders are imagined to contribute to development of HTN. Some of the possible physiological dysregulations that are previously suggested include altered hypothalamic\\u0026ndash;pituitary\\u0026ndash;adrenal axis (\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e), deregulated autonomic function (\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e), altered brain activity (i.e. hypometabolism of dorsal cortical regions and ventral limbic structures) (\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e). An increased postganglionic sympathetic fibers activation passing to blood vessels of skeletal muscle results in vasoconstriction and increased blood pressure in patients with borderline or established hypertension (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003ePrevious studies postulated that there are associations between HF and CAD with psychological disorders but we found no such association (\\u003cspan additionalcitationids=\\\"CR19\\\" citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e). One possible explanation could be that the association between HF and CAD with psychological disorders in previous studies is due to the inclusion of HF/CAD patients with concomitant HTN. Garfield et al. reported significant association of anxiety disorders and depression with incident heart failure. Although the results of this study was adjusted to HTN at baseline, HTN due to depression/anxiety disorders over the course of study were not considered in final analysis as a confounding factor (\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e). Also, some other studies did not consider controlling the confounding effect of HTN in the evaluation of depression in HF patients (\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e). Abramson et al. revealed that depression can lead to two-fold higher rate of heart failure in patients with HTN (\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e). Therefore, HTN may play a role in this association. Thus, it can be imagined that although the prevalence of depression is high among HF patients, this phenomenon is not related to the pathophysiology of HF, instead, it is related to HTN. Accordingly, when we excluded HTN patients from HF patients, no higher rate of depression was found. Similar bias can be found within those studies evaluating the association of anxiety and stress and heart failure (\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eAlthough the cross-sectional design of current study may prevent us to argue about causation relationship between psychological disorders and HTN, low rate of psychological disorders among HF and CAD patient without concomitant HTN leads us to suppose that it is unlikely that psychological disorders in HTN be merely an emotional response to having HTN, instead it is more likely that HTN is a physical response to these damaging psychological disorders. However, this issue needs to be confirmed by future longitudinal and preventive interventional studies.\\u003c/p\\u003e \\u003cp\\u003eOur study had some limitations that worth mentioning. First, this study was designed as a cross-sectional study rather than a cohort study. Yet, we included a control group in order to be able to compare the results. Second, analysis of demographic characteristics demonstrated significant differences among study groups that was due to consecutive inclusion of patients without considering their demographic characteristics. A previous study in Iran demonstrated that there was no significant associations between DASS-21 scale scores and demographic variables (i.e. age, gender, education, and marital status) (\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e). Therefore, differences in demographic characteristics may not prevent us to use our data for comparing the results of DASS-21 between HTN, HF, and CAD patients. Moreover, possible confounding effects of these variables were controlled in final analysis.\\u003c/p\\u003e \"},{\"header\":\"Conclusion:\",\"content\":\" \\u003cp\\u003eOur study demonstrated a significantly higher rate of psychological disorders (including stress, anxiety, and depression) among patients with HTN. However, the rate of psychological disorders in patients with HF and CAD without concomitant HTN were similar to those in healthy participants. Therefore, we can conclude that first, the confounding effect of HTN needs to be considered in future studies that evaluate association of psychological disorders and HF and CAD. Second, due to higher rate of psychological disorders among HTN patients and their negative consequences, more attention should be paid on psychological disorders in these patients. Third, considering that we found higher rates of psychological disorders among HTN patients but not among HF and CAD patients, it can be imagined that, these psychological disorders may have a role in pathophysiology of HTN, rather than being an emotional response to a distressing and unwell physical condition. However, this issue needs to be confirmed by future longitudinal studies.\\u003c/p\\u003e \"},{\"header\":\"Declarations\",\"content\":\" \\u003cp\\u003e \\u003ch2\\u003e\\u003cb\\u003eEthics approval\\u003c/b\\u003e:\\u003c/h2\\u003e \\u003cp\\u003eThe protocol of this study was approved by medical ethics committee of our institution.\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eConsent to participate\\u003c/strong\\u003e \\u003cp\\u003eInformed consent was obtained from the participants.\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003e\\u003cb\\u003eConsent for publication\\u003c/b\\u003e:\\u003c/strong\\u003e \\u003cp\\u003eConsent for publication was granted.\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eAvailability of data and materials:\\u003c/strong\\u003e \\u003cp\\u003eAll Data and material collected during this study are available from the corresponding author upon reasonable request.\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eConflicts of interest/Competing interests\\u003c/strong\\u003e \\u003cp\\u003eNone declared.\\u003c/p\\u003e \\u003c/p\\u003e \\u003ch2\\u003eFunding:\\u003c/h2\\u003e \\u003cp\\u003eThis study was supported by a fund from the Tabriz University of Medical Sciences.\\u003c/p\\u003e \\u003ch2\\u003eAuthors' contributions:\\u003c/h2\\u003e \\u003cp\\u003eConceptualization: HN, SRSE; Methodology: HN, FJ, DE; Formal analysis and investigation: RZ, SRSE; Writing - original draft preparation: SRSE; Writing - review and editing: HN, RZ, SRSE; Funding acquisition: HN; Resources: FJ, DE, Supervision: HN\\u003c/p\\u003e \\u003ch2\\u003eAcknowledgements:\\u003c/h2\\u003e \\u003cp\\u003eNone.\\u003c/p\\u003e \"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e \\u003cspan\\u003eSmith SC, Collins A, Ferrari R, Holmes DR, Logstrup S, McGhie DV, et al. Our time: a call to save preventable death from cardiovascular disease (heart disease and stroke). J Am Coll Cardiol. 2012;60(22):2343\\u0026ndash;8.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eBansilal S, Castellano JM, Fuster V. Global burden of CVD: focus on secondary prevention of cardiovascular disease. Int J Cardiol. 2015;201(Suppl 1):1\\u0026ndash;7.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eWorld Health Organization. Cardiovascular diseases (CVDs): World Health Organization; 2017 [Available from: \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds\\u003c/span\\u003e\\u003c/span\\u003e).\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eMensah GA, Brown DW. An overview of cardiovascular disease burden in the United States. Health Aff (Millwood). 2007;26(1):38\\u0026ndash;48.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eEsler M, Kaye D. Sympathetic nervous system activation in essential hypertension, cardiac failure and psychosomatic heart disease. J Cardiovasc Pharmacol. 2000;35(7 Suppl 4):1\\u0026ndash;7.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eGangwisch JE, Malaspina D, Posner K, Babiss LA, Heymsfield SB, Turner JB, et al. Insomnia and sleep duration as mediators of the relationship between depression and hypertension incidence. Am J Hypertens. 2010;23(1):62\\u0026ndash;9.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eChaudieu I, Norton J, Ritchie K, Birmes P, Vaiva G, Ancelin ML. Late-life health consequences of exposure to trauma in a general elderly population: the mediating role of reexperiencing posttraumatic symptoms. 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Arch Intern Med. 2001;161(15):1849\\u0026ndash;56.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eFreedland KE, Carney RM, Rich MW. Effect of depression on prognosis in heart failure. Heart Fail Clin. 2011;7(1):11\\u0026ndash;21.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eEaker ED, Sullivan LM, Kelly-Hayes M, D'Agostino RB, Sr., Benjamin EJ. Tension and anxiety and the prediction of the 10-year incidence of coronary heart disease, atrial fibrillation, and total mortality: the Framingham Offspring Study. Psychosom Med. 2005;67(5):692\\u0026ndash;6.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eSteptoe A, Kivimaki M. Stress and cardiovascular disease. Nat Rev Cardiol. 2012;9(6):360\\u0026ndash;70.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eMaatouk I, Herzog W, Bohlen F, Quinzler R, Lowe B, Saum KU, et al. 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J Hypertens. 2017;35(10):1983\\u0026ndash;91.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eGarfield LD, Scherrer JF, Hauptman PJ, Freedland KE, Chrusciel T, Balasubramanian S, et al. Association of anxiety disorders and depression with incident heart failure. Psychosom Med. 2014;76(2):128\\u0026ndash;36.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eJani BD, Mair FS, Roger VL, Weston SA, Jiang R, Chamberlain AM. Comorbid Depression and Heart Failure: A Community Cohort Study. PLoS One. 2016;11(6):e0158570.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eRosenman RH, Brand RJ, Jenkins D, Friedman M, Straus R, Wurm M. Coronary heart disease in Western Collaborative Group Study. Final follow-up experience of 8 1/2 years. JAMA. 1975;233(8):872\\u0026ndash;7.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eTaraghi Z, Akbari Kamrani AA, Foroughan M, Yazdani J, Mahdavi A, Baghernejad SK. Cognitive Impairment Among Elderly Patients With Chronic Heart Failure and Related Factors. Iran J Psychiatry Behav Sci. 2016;10(2):e4500.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eZuccala G, Marzetti E, Cesari M, Lo Monaco MR, Antonica L, Cocchi A, et al. Correlates of cognitive impairment among patients with heart failure: results of a multicenter survey. Am J Med. 2005;118(5):496\\u0026ndash;502.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eSerafini G, Pompili M, Innamorati M, Iacorossi G, Cuomo I, Della Vista M, et al. The impact of anxiety, depression, and suicidality on quality of life and functional status of patients with congestive heart failure and hypertension: an observational cross-sectional study. Prim Care Companion J Clin Psychiatry. 2010;12(6):PCC..09 m00916.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eAbramson J, Berger A, Krumholz HM, Vaccarino V. Depression and risk of heart failure among older persons with isolated systolic hypertension. Arch Intern Med. 2001;161(14):1725\\u0026ndash;30.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eZipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF. Braunwald's Heart Disease A Textbook of Cardiovascular Medicine: Elsevier Health Sciences; 2018.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eJames PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507\\u0026ndash;20.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eLovibond PF, Lovibond SH. The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther. 1995;33(3):335\\u0026ndash;43.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eBrown TA, Chorpita BF, Korotitsch W, Barlow DH. Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples. Behav Res Ther. 1997;35(1):79\\u0026ndash;89.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eAntony MM, Bieling PJ, Cox BJ, Enns MW, Swinson RP. Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychol Assess. 1998;10(2):176.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eClara IP, Cox BJ, Enns MW. Confirmatory factor analysis of the Depression\\u0026ndash;Anxiety\\u0026ndash;Stress Scales in depressed and anxious patients. Journal of psychopathology behavioral assessment. 2001;23(1):61\\u0026ndash;7.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003ePage AC, Hooke GR, Morrison DL. Psychometric properties of the Depression Anxiety Stress Scales (DASS) in depressed clinical samples. Br J Clin Psychol. 2007;46(Pt 3):283\\u0026ndash;97.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eHildrum B, Romild U, Holmen J. Anxiety and depression lowers blood pressure: 22-year follow-up of the population based HUNT study, Norway. BMC Public Health. 2011;11(1):601.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eNabi H, Chastang J-F, Lef\\u0026egrave;vre T, Dugravot A, Melchior M, Marmot MG, et al. Trajectories of depressive episodes and hypertension over 24 years: the Whitehall II prospective cohort study. Hypertension. 2011;57(4):710\\u0026ndash;6.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eBrown ES, Varghese FP, McEwen BS. Association of depression with medical illness: does cortisol play a role? Biol Psychiatry. 2004;55(1):1\\u0026ndash;9.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eKibler JL, Ma M. Depressive symptoms and cardiovascular reactivity to laboratory behavioral stress. Int J Behav Med. 2004;11(2):81\\u0026ndash;7.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eTaylor WD, Aizenstein HJ, Alexopoulos GS. The vascular depression hypothesis: mechanisms linking vascular disease with depression. Mol Psychiatry. 2013;18(9):963\\u0026ndash;74.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eEsler M. Sympathetic activity in experimental and human hypertension. Handbook of hypertension. 1997;17:628\\u0026ndash;73.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eJulius S. Changing role of the autonomic nervous system in human hypertension. J Hypertens Suppl. 1990;8(7):59\\u0026ndash;65.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eHaworth JE, Moniz-Cook E, Clark AL, Wang M, Waddington R, Cleland JG. Prevalence and predictors of anxiety and depression in a sample of chronic heart failure patients with left ventricular systolic dysfunction. Eur J Heart Fail. 2005;7(5):803\\u0026ndash;8.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eJiang W, Babyak M, Krantz DS, Waugh RA, Coleman RE, Hanson MM, et al. Mental stress\\u0026ndash;induced myocardial ischemia and cardiac events. JAMA. 1996;275(21):1651\\u0026ndash;6.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eAsghari A, Saed F, Dibajnia P. Psychometric properties of the Depression Anxiety Stress Scales-21 (DASS-21) in a non-clinical Iranian sample. Int J Psychol. 2008;2(2):82\\u0026ndash;102.\\u003c/span\\u003e \\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-33844/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-33844/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003ePrevious studies have emphasized the significant association between depression, anxiety, and stress and hypertension (HTN), heart failure (HF), and coronary artery disease (CAD). However, among included patients with HF or CAD in those studies, there were considerable proportions of patients with concomitant HTN and vice versa leading to some possible bias in final estimations. Therefore, we aimed to exclude those patients with concomitant diseases and reassess the association between these three prevalent cardiovascular diseases with three important psychological disorders.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eIn this cross-sectional study, 300 patients were evaluated, including 100 with HTN (without a history or concomitant HF or CAD), 100 with HF (without HTN or CAD), and 100 with CAD (without HTN or HF). Moreover, 100 healthy volunteers were considered as the control group. Depression Anxiety Stress Scale 21 was used to measure the magnitude of depression, anxiety, and stress.\\u003c/p\\u003e\\u003ch2\\u003eResult\\u003c/h2\\u003e \\u003cp\\u003eThe average scores of 4.6, 9.1, 3.7, and 4.4 for depression, 3.9, 11.1, 4.1, and 3.6 for anxiety and 6.5, 13.6, 5.2, and 5.4 for stress were detected in control, HTN, CAD, and HF groups, respectively. The depression, anxiety, and stress scores of HTN group were significantly higher than the control (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05), CAD (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05) and HF (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05) groups; this is while these scores were not significantly different between other study groups (p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05).\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003eOur study demonstrated a significantly higher magnitude of psychological disorders in patients with HTN. However, their magnitude in patients with HF and CAD without concomitant HTN were similar to those in healthy participants.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Hypertension but Not Heart Failure or Coronary Artery Disease is Associated With Mental Disorders\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2020-06-17 17:01:59\",\"doi\":\"10.21203/rs.3.rs-33844/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"99df22bb-5591-4bed-8af0-4b49f82f918b\",\"owner\":[],\"postedDate\":\"June 17th, 2020\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[{\"id\":122369,\"name\":\"Cardiac \\u0026 Cardiovascular Systems\"}],\"tags\":[],\"updatedAt\":\"2020-06-17T17:02:00+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2020-06-17 17:01:59\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-33844\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-33844\",\"identity\":\"rs-33844\",\"version\":[\"v1\"]},\"buildId\":\"7rjqhiLT3MXkJMwkYKINL\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}