Assessing Anxiety Levels Among Individuals With White Coat Hypertension Using the Beck Anxiety Inventory

Assessing Anxiety Levels Among Individuals With White Coat Hypertension Using the Beck Anxiety Inventory | 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 Article Assessing Anxiety Levels Among Individuals With White Coat Hypertension Using the Beck Anxiety Inventory Muhammad Zohaib Rehman, Khushbakht Noor This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4206523/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 Objectives: To determine the prevalence of white coat hypertension in comparison to home-based blood pressure (BP) and anxiety levels in patients with white coat hypertensionusing the Beck Anxiety Inventory. Methods: An observational cross-sectional study was conducted from March 2021 to April 2022 on people visiting OPDs at Khyber Teaching Hospital, Peshawar. In-hospital and home blood pressure recording with anxiety inventory completion was performed with a sample size of 213 normotensives using a nonprobability convenience sampling technique. The data were recorded on a structured questionnaire with an anxiety scale and analyzed with IBM SPSS version 26 and MS Excel 2019. The data are presented in the form of tables and charts. Results: Among 213 respondents aged 14-67 years [164 (77%) male and 49 (23%) female, 22 (10.3%) had a BP above 140/90 in the OPD, called white coat hypertension, and a BPbelow 140/90 at home. The Beck Anxiety Index (BAI)score was 2 (9.1%) for minimal anxiety, 6 (27.3%) for mild anxiety, 12 (54.5%) for moderate anxiety and 2 (9.1%) for severe anxiety. Conclusion: WCH has profound value due to its high incidenceand ability to predictprehypertension, CVD,and mTOD. This labile BP in the clinical environment can be falsely interpreted as causing unneeded pharmacological interventions to increase thephysical, mental, and financial agony of patients. Therefore, both medical staff and the public should be widely educated. Home-based BP measurements and ambulatory BPs may be preferred over these methods. Cardiac & Cardiovascular Systems Anxiety Hypertension White coat hypertension WCH Blood pressure determination INTRODUCTION White coat hypertension (WCH), characterized by elevated blood pressure readings in a clinical setting despite normal readings in everyday environments, has been a subject of increasing concern in the realm of cardiovascular health. While the phenomenon itself has been recognized, the intricate relationship between WCH and anxiety levels remains understudied. This study aimed to address this gap by examining the prevalence of white-coat hypertension and its association with anxiety. The overarching goal is to unravel the complexities surrounding the interplay between anxiety and WCH, examining contributing factors and potential implications for cardiovascular well-being. As we embarked on this investigation, a deeper understanding of the psychophysiological mechanisms at play may pave the way for more targeted interventions and improved patient care. The term "white coat hypertension" (WCH) was introduced in 1984 by Kleinert and associates to describe a condition in which individuals in a clinical office environment have increased blood pressure (BP) even when their typical daily BP is within acceptable limits. 1 Pickering and his team then published a additional description of this disease, stating that WCH is often characterized as the presence of a blood pressure measurement of ≥ 140 by 90 mmHg in the clinic while maintaining blood pressure readings < 135 by 85 mmHg outside of the clinic. 2 First, this disorder was associated with the stressful aspect of the doctor's appointments, but its precise diagnosis was still few unclear. A specific definition for WCH has been provided by the European Society of Hypertension guidelines, which states that it involves a high office blood pressure of 140/90 mmHg or higher combined with a 24-hour ambulatory blood pressure (ABP) reading of less than 130/80 mmHg (with an awake ABP of less than 135/85 and a sleep ABP of less than 120/70) or a blood pressure reading at home that is less than 135/85. 3 It is crucial to distinguish WCH from the "white coat effect" (WCE), which refers to the brief elevation in blood pressure that takes place in a clinical context, independent of the patient's ambulatory blood pressure or the use of hypertension drugs. 4 According to European criteria, the general incidence of WCH is estimated to be 13%. 5 However, numerous research studies have suggested prevalence rates of 11–39%. 6–8 Mancia et al. (1983) identified WCE as a sudden increase in both systolic and diastolic blood pressure following the entrance of a doctor at the patient's bedside. 9 Research by Grassi et al. has demonstrated that when a healthcare provider takes a patient's blood pressure, skin nerves become stimulated, and sympathetic suppression of muscular nerve activity is triggered concurrently. This reaction is similar to a "defense reaction" controlled by the same diencephalic areas that control the body's reaction to worry and other emotional states. 10–11 Examining the relationship between anxiety and increased clinic blood pressure, Jhalani and colleagues discovered a link between anxiousness during healthcare visits and WCE, a conclusion that has been embarked by several studies. 12–13 Notably, however, certain studies have not been able to definitively prove a link between anxiety and WCE. 14 A number of indicators suggest that untreated persons with simple hypertension are more likely to develop WCH: 2,3,5,8,15–17 clinic systolic blood pressure measurements between 140 and 159 mmHg or diastolic blood pressure measurements between 90 and 99 mmHg; female sex; age; not smoking; recent onset of hypertension; limited number of blood pressure readings in a clinical setting; people without target organ damage; and people with a normal left ventricular mass. Among these variables, age has a significant impact on the occurrence of WCH, with effects that are more noticeable on blood pressure readings taken in clinics than on those taken at home or via ambulatory blood pressure monitoring (ABPM). 18 The Group of Experts on the Prognostic Importance of Ambulatory Blood Pressure Surveillance suggested employing ambulatory monitoring to rule out white coat hypertension in those who are not receiving treatment when: 19 Three separate clinic visits are needed for the blood pressure to be at least 140/90 mmHg. At least two readings obtained outside the clinic, frequently with home blood pressure monitoring, were under 140/90 mmHg, and no convincing evidence of hypertensive damage to target organs was observed. The British National Institute for Clinical and Health Excellence (NICE) released clinical guidelines indicating that if the clinical blood pressure is 140/90 mmHg or above, an ABPM should be performed to verify the diagnosis of hypertension and rule out white coat hypertension. This method can reduce office visits, prevent the negative consequences of incorrect therapy, and is cost-effective because it is carried out before patients begin taking medicine. Accurate WCH diagnosis is crucial for treating these individuals. A misdiagnosis of WCH may result in improper prescription and usage of antihypertensive drugs, which might have negative consequences for elderly people and patients with several comorbidities. Additional costs and expenses for medication and office visits could also result from this. Altogether, combined office and out-of-office BP measurements allowed us to identify four BP phenotypes: True Normotension (i.e., normal office and out-of-office BP), Sustained hypertension (elevated in-office and out-of-office BP), White-coat hypertension (elevated office and normal out-of-office BP) and Masked hypertension (normal office and elevated out-of-office BP). It has been demonstrated that there are significant differences between these blood pressure phenotypes with regard to their prevalence, characteristics, clinical traits, level of extra and subclinical cardiac and heart damage, and risk of incident cardiovascular events. 3,20 It is critical to investigate the impact of anxiety produced by hospitals on blood pressure readings as measured by the Beck Anxiety Index. This is because it has important clinical ramifications for guaranteeing accurate diagnosis, making knowledgeable treatment decisions, improving patient welfare, allocating resources as efficiently as possible, and encouraging patient-centered healthcare. The aforementioned research fills a significant gap in our present understanding and may provide guidance on how to reduce the aberrations in blood pressure measurements that are linked to anxiety. This approach has the potential to provide real advantages to hospital patients as well as healthcare professionals. Our study aimed to use home-based blood pressure monitoring to determine the prevalence of white-coat hypertension and to assess its association with anxiety using the Beck Anxiety Inventory. RESEARCH METHODOLOGY The study was set in the outpatient department (OPD) of Khyber Teaching Hospital and its nearby areas in Peshawar, focusing on adult males and females attending the OPD. Employing an observational cross-sectional study design. The WHO formula was used for sample size calculation, with a confidence interval of 95% and a population proportion of 16.6% . 28 The inclusion criteria involved visiting the OPD and residing nearby, while those with cardiovascular diseases and those receiving long-term treatment were excluded. Various variables were explored, with white-coat hypertension as the dependent variable. The independent variables included anxiety/stress, physician competency, attitude, and the frequency of hospital visits. The confounding (intervening) variables included socioeconomic status, educational background, ailments related to the cardiovascular system, infections, inflammation, and drug history. Gender and age are considered universal variables, while body mass index (BMI) is a composite variable. The data collection involved self-administered questionnaires in the OPD, complemented by home visits and blood pressure recordings. The analysis was conducted using the Statistical Package for Social Students (SPSS) with statistical tests such as the chi-square test, and the results are presented through charts, graphs, and tabulated forms. The study plan included dividing the research team into two groups, each assigned an equal number of questionnaires. The data are recorded in OPDs of KTH, and participants' residences are traced with informed consent. Blood pressure was recorded in the patients’ homes, and both sets of results were compared and analyzed using SPSS. Throughout this process, the confidentiality of each individual was rigorously maintained. This research declares an absence of any conflicts of interest and highlights its self-funded nature, with resources equally distributed among the researchers and no external financial support sought. Ethical considerations were paramount, as evidenced by the ethical approval granted by Institutional Review Board (IRB) No. 582/DME/KMC . The study strongly emphasized maintaining patient confidentiality, ensuring informed consent from every participant, and strictly adhering to voluntary participation. Importantly, the questionnaire employed in the research was carefully crafted to avoid any offensive or intrusive queries or to uphold ethical standards throughout the investigative process. Time Frame March 2021 to April 2022 RESULTS A comparison of hospital and home-based blood pressure readings revealed that 22 (10.3%) out of 213 patients had WCH, while the other patients had a normal blood pressure. Comparative frequencies of WCHs and Non-WCHs in the study: Valid Non-White Coat Hypertensives 191 89.7 89.7 89.7 White Coat Hypertensives 22 10.3 10.3 100.0 Total 213 100.0 100.0 Effect of anxiety on white-coat hypertension: The Beck Anxiety Index (BAI) score was 2 (9.1%) for minimal anxiety, 6 (27.3%) for mild anxiety, 12 (54.5%) for moderate anxiety and 2 (9.1%) for severe anxiety. ANXIETY ANALYSIS OF PERSON WITH WCH USING BAI Beck Anxiety Index Total Minimal (0-7) Mild (8-15) Moderate (16-25) Severe (26-63) White coat hypertension Count 2 a 6 a 12 a 2 a 22 % Within whitecoat hypertension 9.1% 27.3% 54.5% 9.1% 100.0% Total Count 2 6 12 2 22 % Within whitecoat hypertension 9.1% 27.3% 54.5% 9.1% 100.0% Statistical Analysis Value df P value Pearson Chi-Square 79.113 a 3 .0001 P values less than 0.0001. The result was statistically significant. DISCUSSION This research was conducted by a group of students from KMC, Peshawar, to determine the effect of hospital-induced anxiety on a patient’s blood pressure during an OPD visit. A comparative analysis was also performed by recording the BP of the same subject at home. According to our study of 213 respondents aged 14–67 years [164 (77%) male and 49 (23%) female], 22 (10.3%) had a BP above 140/90 in the OPD, which is called white coat hypertension, and a score of 140/90 at home; moreover, the Beck Anxiety Inventory was calculated for 22 white coat hypertensive individuals: 2 (9.1%) had minimal anxiety, 6 (27.3%) had mild anxiety, 12 (54.5%) had moderate anxiety and 2 (9.1%) had severe anxiety. Our research aligns with previous studies on the prevalence of White Coat Hypertension (WCH). In a descriptive cross-sectional study conducted at Aga Khan University Hospital (AKUH) in Karachi, Pakistan, from 2011 to 2014, the authors found that WCH had a prevalence of 16.6% among participants aged > 15 years. 28 These findings closely mirror the results of Dolan and Stanton's extensive study involving 5716 patients, which reported a WCH incidence of 15.4%. 21 Various other studies have also reported similar prevalence rates, ranging from 12–54%. 22,23,24 However, it is worth noting that the incidence of WCH can vary considerably and is influenced by factors such as the selection of patient groups and the specific definitions used to classify hypertension. For instance, a study conducted in Lahore, Pakistan, by Aziz et al. reported a higher prevalence of WCH in their local society (26.6%). 25 This discrepancy may be attributed to the different criteria used in defining hypertension. Our study indicated that hospital anxiety, possibly stemming from environmental stress or physician attitude, played a significant role in the observed increase in blood pressure among patients with white coat hypertension (WCH). A further analysis using the Beck Anxiety Inventory (BAI) demonstrated that most individuals with WCHs exhibited varying degrees of anxiety when visiting the outpatient department (OPD). This observation is noteworthy because, before our research, no study had explored the connection between WCH and anxiety scores. While prior studies had delved into the pathogenesis of WCH, it was in July 1999 that researchers investigated this phenomenon by conducting sympathetic nervous system recordings on 16 patients. Their findings suggested that the white-coat effect is essentially an alerting reaction operating through reflex sympathetic nervous system stimulation. 26,27 The European Society of Hypertension Working Group on Blood Pressure Monitoring gave magnitude patients presenting with an office BP at least 20 mm Hg systolic and/or 10 mm Hg diastolic higher than the awake ambulatory BP. 28 A randomized controlled trial in a kidney center in Sialkot, Pakistan, in 2018 proved that cognitive behavior therapy improves blood pressure-related latrophobia in adults to manage white coat hypertension 28 , which embarks on the anxiety linked to white coat hypertension. CONCLUSION Analysis of our collected data showed that there was a direct association between white coat hypertension and anxiety, with a high prevalence among our population. Anxiety causes sympathoadrenal stimulation, which increases BP. Anxiety is due to fear of the hospital environment, agony, haste, fear of contracting the disease, and, most commonly, attitudes of health professionals; ineffective communication; multiple visits; and stress about health. Therefore, these findings may lead to false-positive results for hypertension, leading to injudicious prescriptions by health care providers and enhancing the physical, mental, and financial detrimental side effects of drugs. For that purpose, the concept of white coat hypertension may be widely considered, and alternatives such as home-based blood pressure monitoring and ambulatory blood pressure monitoring may be promoted; alternatively, patient‒doctor communication may be helpful for eliminating the altruistic response of patients in the form of elevated blood pressure. References Kleinert HD, Harshfield GA, Pickering TG, Devereux RB, Sullivan PA, Marion RM et al (1984) What is the value of home blood pressure measurement in patients with mild hypertension? Hypertension 6(4):574–578 Pickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH (1988) How common is white coat hypertension? JAMA 259(2):225–228 O'Brien E, Parati G, Stergiou G, Asmar R, Beilin L, Bilo G et al (2013) European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens 31(9):1731–1768 Verdecchia P, Schillaci G, Borgioni C, Ciucci A, Zampi I, Gattobigio R et al (1995) White coat hypertension and white coat effect. Similarities and differences. Am J Hypertens 8(8):790–798 Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M et al (2013) 2013 ESH/ESC Guidelines for the management of arterial hypertension. Arterial Hypertens 17(2):69–168 Martínez MA, Moreno A, de Cárcer AA, Cabrera R, Rocha R, Torre A et al (2001) Frequency and determinants of microalbuminuria in mild hypertension: a primary-care-based study. J Hypertens 19(2):319–326 Franklin SS, Thijs L, Asayama K, Li Y, Hansen TW, Boggia J et al (2016) The cardiovascular risk of white-coat hypertension. J Am Coll Cardiol 68(19):2033–2043 Dolan E, Stanton A, Atkins N, Den Hond E, Thijs L, McCormack P et al (2004) Determinants of white-coat hypertension. Blood Press Monit 9(6):307–309 Mancia G, Grassi G, Pomidossi G, Gregorini L, Bertinieri G, Parati G et al (1983) Effects of blood-pressure measurement by the doctor on patient's blood pressure and heart rate. Lancet 322(8352):695–698 Grassi G, Turri C, Vailati S, Dell’Oro R, Mancia G (1999) Muscle and skin sympathetic nerve traffic during the white-coat effect. Circulation 100(3):222–225 Grassi G, Seravalle G, Buzzi S, Magni L, Brambilla G, Quarti-Trevano F et al (2013) Muscle and skin sympathetic nerve traffic during physician and nurse blood pressure measurement. J Hypertens 31(6):1131–1135 Jhalani J, Goyal T, Clemow L, Schwartz JE, Pickering TG, Gerin W (2005) Anxiety and outcome expectations predict the white-coat effect. Blood Press Monit 10(6):317–319 Spruill TM, Pickering TG, Schwartz JE, Mostofsky E, Ogedegbe G, Clemow L et al (2007) The impact of perceived hypertension status on anxiety and the white coat effect. Ann Behav Med 34(1):1–9 Siegel WC, Blumenthal JA, Divine GW (1990) Physiological, psychological, and behavioral factors and white coat hypertension. Hypertension 16(2):140–146 Verdecchia P, Palatini P, Schillaci G, Mormino P, Porcellati C, Pessina AC (2001) Independent predictors of isolated clinic (white-coat') hypertension. J Hypertens 19(6):1015–1020 Manios ED, Koroboki EA, Tsivgoulis GK, Spengos KM, Spiliopoulou IK, Brodie FG et al (2008) Factors influencing white-coat effect. Am J Hypertens 21(2):153–158 Fisher M, Blackwell J, Saseen J (2005) Clinical inquiries. What is the best way to identify patients with white-coat hypertension? J Fam Pract 54(6):549–550 Sega R, Cesana G, Milesi C, Grassi G, Zanchetti A, Mancia G (1997) Ambulatory and home blood pressure normality in elderly individuals: data from the PAMELA population. Hypertension 30(1):1–6 Staessen JA, Asmar R, De Buyzere M, Imai Y, Parati G, Shimada K et al (2001) Task Force II: Blood pressure measurement and cardiovacular outcome. Blood Press Monit 6(6):355–370 Archbold RA (2016) Comparison between National Institute for Health and Care Excellence (NICE) and European Society of Cardiology (ESC) guidelines for the diagnosis and management of stable angina: implications for clinical practice. Open Heart 3(1):e000406 Dolan E, Stanton A, Atkins N, Den Hond E, Thijs L, McCormack P et al (2004) Determinants of white-coat hypertension. Blood Press Monit 9(6):307–309 Pickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH (1988) How common is white coat hypertension? JAMA 259(2):225–228 Gustavsen PH, Høegholm A, Bang LE, Kristensen KS (2003) White coat hypertension is a cardiovascular risk factor: a 10-year follow-up study. J Hum Hypertens 17(12):811–817 Aguirre-Ramos R, Trujillo-Hernández B, Huerta M, Trujillo X, Vásquez C, Millán-Guerrero RO (2002) White-Coat Hypertension and Risk Factors in Recently, Diagnosed Hypertensive Patients. Gac Med Mex 138(4):319 Aziz NR, Ubaidullah S, Zaheer J, Khan JA, Hassan M (1999) Role of Ambulatory Blood Pressure Monitoring in Diagnosing White Coat Hypertension. Ann King Edw Med Coll 5:266–269 Grassi G, Turri C, Vailati S, Dell’Oro R, Mancia G (1999) Muscle and skin sympathetic nerve traffic during the white-coat effect. Circulation 100(3):222–225 O’Brien E, Parati G, Stergiou G, Asmar R, Beilin L, Bilo G et al (2013) European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens 31(9):1731–1768 Godil SS, Tabani H, Khan AH, Almas A (2011) White coat hypertension is not a benign entity: a cross-sectional study at a tertiary care hospital in Pakistan. J Pak Med Assoc 61(9):938 Shafique MN, RM SK, Razi MS, Muhammad S, Akhtar SH, Hussain M (2020) Cognitive behavior therapy for white coat hypertension-causing latrophobia in adults: randomized controlled trial. J Pak Med Assoc 70(9):1523–1526 Additional Declarations The authors declare no competing interests. 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. 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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-4206523","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":286613819,"identity":"d7143213-d649-420e-bf5d-a6fad854b63a","order_by":0,"name":"Muhammad Zohaib Rehman","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYFACHgaGxAYgLQHiVCSAxUBsAyK1nCFWCyNMC2MbEVrk23sPfni4gyGfX7o78XPhvLRo/gbmg7d5GO4Y49LC2HMuWSLxDIPlzDlnN0vP3JaTO+MAW7I1D8MzM1xamCVyDCQS2xgMDG7kbpDm3VaRu4GBx0yah+GwDS4tbBI5xj9AWuxv5G7+zTsHpIX/G14tPBI5ZhBbJHK3SfM25IBsYQNpwekwCZ4zZhaJZyQMJG7kbrPmOZaWO+Mwm7HlHINnOL0v395jfPPnDhsD/hm5m2/z1CTn9rc3P7zxpuKOYQMuPVDLkEMERBgcwK8BGyBDyygYBaNgFAxXAAAjDFHE2eTQMQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0009-0004-6615-7593","institution":"Khyber Medical College, Peshawar","correspondingAuthor":true,"prefix":"","firstName":"Muhammad","middleName":"Zohaib","lastName":"Rehman","suffix":""},{"id":286613820,"identity":"bb3a4990-61c5-430d-b94e-829818da818e","order_by":1,"name":"Khushbakht Noor","email":"","orcid":"","institution":"Khyber Medical College, Peshawar","correspondingAuthor":false,"prefix":"","firstName":"Khushbakht","middleName":"","lastName":"Noor","suffix":""}],"badges":[],"createdAt":"2024-04-02 11:59:28","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4206523/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4206523/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53990310,"identity":"1a18504d-d2cb-43a0-a595-147475a0d52d","added_by":"auto","created_at":"2024-04-03 05:34:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":233344,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4206523/v1/893b7442-0bdc-4052-9a26-8152e0c572b1.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eAssessing Anxiety Levels Among Individuals With White Coat Hypertension Using the Beck Anxiety Inventory\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eWhite coat hypertension (WCH), characterized by elevated blood pressure readings in a clinical setting despite normal readings in everyday environments, has been a subject of increasing concern in the realm of cardiovascular health. While the phenomenon itself has been recognized, the intricate relationship between WCH and anxiety levels remains understudied. This study aimed to address this gap by examining the prevalence of white-coat hypertension and its association with anxiety. The overarching goal is to unravel the complexities surrounding the interplay between anxiety and WCH, examining contributing factors and potential implications for cardiovascular well-being. As we embarked on this investigation, a deeper understanding of the psychophysiological mechanisms at play may pave the way for more targeted interventions and improved patient care.\u003c/p\u003e \u003cp\u003eThe term \"white coat hypertension\" (WCH) was introduced in 1984 by Kleinert and associates to describe a condition in which individuals in a clinical office environment have increased blood pressure (BP) even when their typical daily BP is within acceptable limits.\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePickering and his team then published a additional description of this disease, stating that WCH is often characterized as the presence of a blood pressure measurement of \u0026ge;\u0026thinsp;140 by 90 mmHg in the clinic while maintaining blood pressure readings\u0026thinsp;\u0026lt;\u0026thinsp;135 by 85 mmHg outside of the clinic.\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFirst, this disorder was associated with the stressful aspect of the doctor's appointments, but its precise diagnosis was still few unclear.\u003c/p\u003e \u003cp\u003eA specific definition for WCH has been provided by the European Society of Hypertension guidelines, which states that it involves a high office blood pressure of 140/90 mmHg or higher combined with a 24-hour ambulatory blood pressure (ABP) reading of less than 130/80 mmHg (with an awake ABP of less than 135/85 and a sleep ABP of less than 120/70) or a blood pressure reading at home that is less than 135/85.\u003csup\u003e\u003cb\u003e3\u003c/b\u003e\u003c/sup\u003e It is crucial to distinguish WCH from the \"white coat effect\" (WCE), which refers to the brief elevation in blood pressure that takes place in a clinical context, independent of the patient's ambulatory blood pressure or the use of hypertension drugs.\u003csup\u003e\u003cb\u003e4\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAccording to European criteria, the general incidence of WCH is estimated to be 13%.\u003csup\u003e\u003cb\u003e5\u003c/b\u003e\u003c/sup\u003e However, numerous research studies have suggested prevalence rates of 11\u0026ndash;39%.\u003csup\u003e\u003cb\u003e6\u0026ndash;8\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMancia et al. (1983) identified WCE as a sudden increase in both systolic and diastolic blood pressure following the entrance of a doctor at the patient's bedside.\u003csup\u003e\u003cb\u003e9\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eResearch by Grassi et al. has demonstrated that when a healthcare provider takes a patient's blood pressure, skin nerves become stimulated, and sympathetic suppression of muscular nerve activity is triggered concurrently. This reaction is similar to a \"defense reaction\" controlled by the same diencephalic areas that control the body's reaction to worry and other emotional states.\u003csup\u003e\u003cb\u003e10\u0026ndash;11\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eExamining the relationship between anxiety and increased clinic blood pressure, Jhalani and colleagues discovered a link between anxiousness during healthcare visits and WCE, a conclusion that has been embarked by several studies.\u003csup\u003e\u003cb\u003e12\u0026ndash;13\u003c/b\u003e\u003c/sup\u003e Notably, however, certain studies have not been able to definitively prove a link between anxiety and WCE.\u003csup\u003e\u003cb\u003e14\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA number of indicators suggest that untreated persons with simple hypertension are more likely to develop WCH: \u003csup\u003e\u003cb\u003e2,3,5,8,15\u0026ndash;17\u003c/b\u003e\u003c/sup\u003e clinic systolic blood pressure measurements between 140 and 159 mmHg or diastolic blood pressure measurements between 90 and 99 mmHg; female sex; age; not smoking; recent onset of hypertension; limited number of blood pressure readings in a clinical setting; people without target organ damage; and people with a normal left ventricular mass. Among these variables, age has a significant impact on the occurrence of WCH, with effects that are more noticeable on blood pressure readings taken in clinics than on those taken at home or via ambulatory blood pressure monitoring (ABPM). \u003csup\u003e\u003cb\u003e18\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe Group of Experts on the Prognostic Importance of Ambulatory Blood Pressure Surveillance suggested employing ambulatory monitoring to rule out white coat hypertension in those who are not receiving treatment when:\u003csup\u003e\u003cb\u003e19\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThree separate clinic visits are needed for the blood pressure to be at least 140/90 mmHg.\u003c/p\u003e \u003cp\u003eAt least two readings obtained outside the clinic, frequently with home blood pressure monitoring, were under 140/90 mmHg, and no convincing evidence of hypertensive damage to target organs was observed.\u003c/p\u003e \u003cp\u003e The British National Institute for Clinical and Health Excellence (NICE) released clinical guidelines indicating that if the clinical blood pressure is 140/90 mmHg or above, an ABPM should be performed to verify the diagnosis of hypertension and rule out white coat hypertension.\u003c/p\u003e \u003cp\u003eThis method can reduce office visits, prevent the negative consequences of incorrect therapy, and is cost-effective because it is carried out before patients begin taking medicine. Accurate WCH diagnosis is crucial for treating these individuals. A misdiagnosis of WCH may result in improper prescription and usage of antihypertensive drugs, which might have negative consequences for elderly people and patients with several comorbidities. Additional costs and expenses for medication and office visits could also result from this. Altogether, combined office and out-of-office BP measurements allowed us to identify four BP phenotypes:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eTrue Normotension (i.e., normal office and out-of-office BP),\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSustained hypertension (elevated in-office and out-of-office BP),\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWhite-coat hypertension (elevated office and normal out-of-office BP) and\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMasked hypertension (normal office and elevated out-of-office BP).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eIt has been demonstrated that there are significant differences between these blood pressure phenotypes with regard to their prevalence, characteristics, clinical traits, level of extra and subclinical cardiac and heart damage, and risk of incident cardiovascular events.\u003csup\u003e\u003cb\u003e3,20\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIt is critical to investigate the impact of anxiety produced by hospitals on blood pressure readings as measured by the Beck Anxiety Index. This is because it has important clinical ramifications for guaranteeing accurate diagnosis, making knowledgeable treatment decisions, improving patient welfare, allocating resources as efficiently as possible, and encouraging patient-centered healthcare. The aforementioned research fills a significant gap in our present understanding and may provide guidance on how to reduce the aberrations in blood pressure measurements that are linked to anxiety. This approach has the potential to provide real advantages to hospital patients as well as healthcare professionals.\u003c/p\u003e \u003cp\u003eOur study aimed to use home-based blood pressure monitoring to determine the prevalence of white-coat hypertension and to assess its association with anxiety using the Beck Anxiety Inventory.\u003c/p\u003e"},{"header":"RESEARCH METHODOLOGY","content":"\u003cp\u003eThe study was set in the outpatient department (OPD) of Khyber Teaching Hospital and its nearby areas in Peshawar, focusing on adult males and females attending the OPD. Employing an observational cross-sectional study design.\u003c/p\u003e \u003cp\u003eThe WHO formula was used for sample size calculation, with a confidence interval of 95% and a population proportion of \u003cb\u003e16.6%\u003c/b\u003e.\u003csup\u003e28\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe inclusion criteria involved visiting the OPD and residing nearby, while those with cardiovascular diseases and those receiving long-term treatment were excluded.\u003c/p\u003e \u003cp\u003eVarious variables were explored, with white-coat hypertension as the dependent variable. The independent variables included anxiety/stress, physician competency, attitude, and the frequency of hospital visits. The confounding (intervening) variables included socioeconomic status, educational background, ailments related to the cardiovascular system, infections, inflammation, and drug history. Gender and age are considered universal variables, while body mass index (BMI) is a composite variable.\u003c/p\u003e \u003cp\u003eThe data collection involved self-administered questionnaires in the OPD, complemented by home visits and blood pressure recordings. The analysis was conducted using the Statistical Package for Social Students (SPSS) with statistical tests such as the chi-square test, and the results are presented through charts, graphs, and tabulated forms. The study plan included dividing the research team into two groups, each assigned an equal number of questionnaires. The data are recorded in OPDs of KTH, and participants' residences are traced with informed consent. Blood pressure was recorded in the patients\u0026rsquo; homes, and both sets of results were compared and analyzed using SPSS. Throughout this process, the confidentiality of each individual was rigorously maintained.\u003c/p\u003e \u003cp\u003eThis research declares an absence of any conflicts of interest and highlights its self-funded nature, with resources equally distributed among the researchers and no external financial support sought. Ethical considerations were paramount, as evidenced by the ethical approval granted by Institutional Review Board (IRB) \u003cb\u003eNo. 582/DME/KMC\u003c/b\u003e. The study strongly emphasized maintaining patient confidentiality, ensuring informed consent from every participant, and strictly adhering to voluntary participation. Importantly, the questionnaire employed in the research was carefully crafted to avoid any offensive or intrusive queries or to uphold ethical standards throughout the investigative process.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTime Frame\u003c/strong\u003e \u003cp\u003eMarch 2021 to April 2022\u003c/p\u003e \u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA comparison of hospital and home-based blood pressure readings revealed that 22 (10.3%) out of 213 patients had WCH, while the other patients had a normal blood pressure.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eComparative frequencies of WCHs and Non-WCHs in the study:\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eValid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-White Coat Hypertensives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e89.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e89.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e89.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhite Coat Hypertensives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e22\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e10.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e213\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eEffect of anxiety on white-coat hypertension:\u003c/h2\u003e \u003cp\u003e \u003cb\u003eThe\u003c/b\u003e Beck Anxiety Index (BAI) score was 2 (9.1%) for minimal anxiety, 6 (27.3%) for mild anxiety, 12 (54.5%) for moderate anxiety and 2 (9.1%) for severe anxiety.\u003c/p\u003e \n\u003cp\u003e\u003cstrong\u003eANXIETY ANALYSIS OF PERSON WITH WCH USING BAI\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"675\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.103857566765576%\" colspan=\"3\" rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.29080118694362%\" colspan=\"4\" valign=\"bottom\"\u003e\n \u003cp\u003eBeck Anxiety Index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.6053412462908%\" rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.32051282051282%\" valign=\"bottom\"\u003e\n \u003cp\u003eMinimal (0-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.474358974358974%\" valign=\"bottom\"\u003e\n \u003cp\u003eMild (8-15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.602564102564102%\" valign=\"bottom\"\u003e\n \u003cp\u003eModerate (16-25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.602564102564102%\" valign=\"bottom\"\u003e\n \u003cp\u003eSevere (26-63)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.24925816023739%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eWhite coat hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.231454005934718%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.623145400593472%\" valign=\"top\"\u003e\n \u003cp\u003eCount\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.72106824925816%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.940652818991097%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.31454005934718%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.31454005934718%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.6053412462908%\" valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.308447937131632%\" valign=\"top\"\u003e\n \u003cp\u003e% Within whitecoat hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.520628683693516%\" valign=\"top\"\u003e\n \u003cp\u003e9.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.163064833005894%\" valign=\"top\"\u003e\n \u003cp\u003e27.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.30648330058939%\" valign=\"top\"\u003e\n \u003cp\u003e54.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.30648330058939%\" valign=\"top\"\u003e\n \u003cp\u003e9.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.394891944990176%\" valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.480712166172108%\" colspan=\"2\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.623145400593472%\" valign=\"top\"\u003e\n \u003cp\u003eCount\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.72106824925816%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.940652818991097%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.31454005934718%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.31454005934718%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.6053412462908%\" valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.308447937131632%\" valign=\"top\"\u003e\n \u003cp\u003e% Within whitecoat hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.520628683693516%\" valign=\"top\"\u003e\n \u003cp\u003e9.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.163064833005894%\" valign=\"top\"\u003e\n \u003cp\u003e27.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.30648330058939%\" valign=\"top\"\u003e\n \u003cp\u003e54.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.30648330058939%\" valign=\"top\"\u003e\n \u003cp\u003e9.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.394891944990176%\" valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"371\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.38814016172507%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.598382749326145%\" valign=\"bottom\"\u003e\n \u003cp\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.598382749326145%\" valign=\"bottom\"\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.41509433962264%\" valign=\"bottom\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.38814016172507%\" valign=\"top\"\u003e\n \u003cp\u003ePearson Chi-Square\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.598382749326145%\" valign=\"top\"\u003e\n \u003cp\u003e79.113\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.598382749326145%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.41509433962264%\" valign=\"top\"\u003e\n \u003cp\u003e.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eP values less than 0.0001. The result was statistically significant.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis research was conducted by a group of students from KMC, Peshawar, to determine the effect of hospital-induced anxiety on a patient\u0026rsquo;s blood pressure during an OPD visit. A comparative analysis was also performed by recording the BP of the same subject at home.\u003c/p\u003e \u003cp\u003eAccording to our study of 213 respondents aged 14\u0026ndash;67 years [164 (77%) male and 49 (23%) female], 22 (10.3%) had a BP above 140/90 in the OPD, which is called white coat hypertension, and a score of 140/90 at home; moreover, the Beck Anxiety Inventory was calculated for 22 white coat hypertensive individuals: 2 (9.1%) had minimal anxiety, 6 (27.3%) had mild anxiety, 12 (54.5%) had moderate anxiety and 2 (9.1%) had severe anxiety.\u003c/p\u003e \u003cp\u003eOur research aligns with previous studies on the prevalence of White Coat Hypertension (WCH). In a descriptive cross-sectional study conducted at Aga Khan University Hospital (AKUH) in Karachi, Pakistan, from 2011 to 2014, the authors found that WCH had a prevalence of 16.6% among participants aged\u0026thinsp;\u0026gt;\u0026thinsp;15 years.\u003csup\u003e\u003cb\u003e28\u003c/b\u003e\u003c/sup\u003e These findings closely mirror the results of Dolan and Stanton's extensive study involving 5716 patients, which reported a WCH incidence of 15.4%.\u003csup\u003e\u003cb\u003e21\u003c/b\u003e\u003c/sup\u003e Various other studies have also reported similar prevalence rates, ranging from 12\u0026ndash;54%.\u003csup\u003e\u003cb\u003e22,23,24\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHowever, it is worth noting that the incidence of WCH can vary considerably and is influenced by factors such as the selection of patient groups and the specific definitions used to classify hypertension. For instance, a study conducted in Lahore, Pakistan, by Aziz et al. reported a higher prevalence of WCH in their local society (26.6%).\u003csup\u003e\u003cb\u003e25\u003c/b\u003e\u003c/sup\u003e This discrepancy may be attributed to the different criteria used in defining hypertension.\u003c/p\u003e \u003cp\u003eOur study indicated that hospital anxiety, possibly stemming from environmental stress or physician attitude, played a significant role in the observed increase in blood pressure among patients with white coat hypertension (WCH). A further analysis using the Beck Anxiety Inventory (BAI) demonstrated that most individuals with WCHs exhibited varying degrees of anxiety when visiting the outpatient department (OPD). This observation is noteworthy because, before our research, no study had explored the connection between WCH and anxiety scores.\u003c/p\u003e \u003cp\u003eWhile prior studies had delved into the pathogenesis of WCH, it was in July 1999 that researchers investigated this phenomenon by conducting sympathetic nervous system recordings on 16 patients. Their findings suggested that the white-coat effect is essentially an alerting reaction operating through reflex sympathetic nervous system stimulation.\u003csup\u003e\u003cb\u003e26,27\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe European Society of Hypertension Working Group on Blood Pressure Monitoring gave magnitude patients presenting with an office BP at least 20 mm Hg systolic and/or 10 mm Hg diastolic higher than the awake ambulatory BP.\u003csup\u003e\u003cb\u003e28\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA randomized controlled trial in a kidney center in Sialkot, Pakistan, in 2018 proved that cognitive behavior therapy improves blood pressure-related latrophobia in adults to manage white coat hypertension\u003csup\u003e\u003cb\u003e28\u003c/b\u003e,\u003c/sup\u003e which embarks on the anxiety linked to white coat hypertension.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eAnalysis of our collected data showed that there was a direct association between white coat hypertension and anxiety, with a high prevalence among our population. Anxiety causes sympathoadrenal stimulation, which increases BP.\u003c/p\u003e \u003cp\u003eAnxiety is due to fear of the hospital environment, agony, haste, fear of contracting the disease, and, most commonly, attitudes of health professionals; ineffective communication; multiple visits; and stress about health.\u003c/p\u003e \u003cp\u003eTherefore, these findings may lead to false-positive results for hypertension, leading to injudicious prescriptions by health care providers and enhancing the physical, mental, and financial detrimental side effects of drugs.\u003c/p\u003e \u003cp\u003eFor that purpose, the concept of white coat hypertension may be widely considered, and alternatives such as home-based blood pressure monitoring and ambulatory blood pressure monitoring may be promoted; alternatively, patient‒doctor communication may be helpful for eliminating the altruistic response of patients in the form of elevated blood pressure.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKleinert HD, Harshfield GA, Pickering TG, Devereux RB, Sullivan PA, Marion RM et al (1984) What is the value of home blood pressure measurement in patients with mild hypertension? Hypertension 6(4):574\u0026ndash;578\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH (1988) How common is white coat hypertension? JAMA 259(2):225\u0026ndash;228\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO'Brien E, Parati G, Stergiou G, Asmar R, Beilin L, Bilo G et al (2013) European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens 31(9):1731\u0026ndash;1768\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerdecchia P, Schillaci G, Borgioni C, Ciucci A, Zampi I, Gattobigio R et al (1995) White coat hypertension and white coat effect. Similarities and differences. Am J Hypertens 8(8):790\u0026ndash;798\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, B\u0026ouml;hm M et al (2013) 2013 ESH/ESC Guidelines for the management of arterial hypertension. Arterial Hypertens 17(2):69\u0026ndash;168\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMart\u0026iacute;nez MA, Moreno A, de C\u0026aacute;rcer AA, Cabrera R, Rocha R, Torre A et al (2001) Frequency and determinants of microalbuminuria in mild hypertension: a primary-care-based study. J Hypertens 19(2):319\u0026ndash;326\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFranklin SS, Thijs L, Asayama K, Li Y, Hansen TW, Boggia J et al (2016) The cardiovascular risk of white-coat hypertension. J Am Coll Cardiol 68(19):2033\u0026ndash;2043\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDolan E, Stanton A, Atkins N, Den Hond E, Thijs L, McCormack P et al (2004) Determinants of white-coat hypertension. Blood Press Monit 9(6):307\u0026ndash;309\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMancia G, Grassi G, Pomidossi G, Gregorini L, Bertinieri G, Parati G et al (1983) Effects of blood-pressure measurement by the doctor on patient's blood pressure and heart rate. Lancet 322(8352):695\u0026ndash;698\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrassi G, Turri C, Vailati S, Dell\u0026rsquo;Oro R, Mancia G (1999) Muscle and skin sympathetic nerve traffic during the white-coat effect. Circulation 100(3):222\u0026ndash;225\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrassi G, Seravalle G, Buzzi S, Magni L, Brambilla G, Quarti-Trevano F et al (2013) Muscle and skin sympathetic nerve traffic during physician and nurse blood pressure measurement. J Hypertens 31(6):1131\u0026ndash;1135\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJhalani J, Goyal T, Clemow L, Schwartz JE, Pickering TG, Gerin W (2005) Anxiety and outcome expectations predict the white-coat effect. Blood Press Monit 10(6):317\u0026ndash;319\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpruill TM, Pickering TG, Schwartz JE, Mostofsky E, Ogedegbe G, Clemow L et al (2007) The impact of perceived hypertension status on anxiety and the white coat effect. Ann Behav Med 34(1):1\u0026ndash;9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiegel WC, Blumenthal JA, Divine GW (1990) Physiological, psychological, and behavioral factors and white coat hypertension. Hypertension 16(2):140\u0026ndash;146\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerdecchia P, Palatini P, Schillaci G, Mormino P, Porcellati C, Pessina AC (2001) Independent predictors of isolated clinic (white-coat') hypertension. J Hypertens 19(6):1015\u0026ndash;1020\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManios ED, Koroboki EA, Tsivgoulis GK, Spengos KM, Spiliopoulou IK, Brodie FG et al (2008) Factors influencing white-coat effect. Am J Hypertens 21(2):153\u0026ndash;158\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFisher M, Blackwell J, Saseen J (2005) Clinical inquiries. What is the best way to identify patients with white-coat hypertension? J Fam Pract 54(6):549\u0026ndash;550\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSega R, Cesana G, Milesi C, Grassi G, Zanchetti A, Mancia G (1997) Ambulatory and home blood pressure normality in elderly individuals: data from the PAMELA population. Hypertension 30(1):1\u0026ndash;6\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStaessen JA, Asmar R, De Buyzere M, Imai Y, Parati G, Shimada K et al (2001) Task Force II: Blood pressure measurement and cardiovacular outcome. Blood Press Monit 6(6):355\u0026ndash;370\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArchbold RA (2016) Comparison between National Institute for Health and Care Excellence (NICE) and European Society of Cardiology (ESC) guidelines for the diagnosis and management of stable angina: implications for clinical practice. Open Heart 3(1):e000406\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDolan E, Stanton A, Atkins N, Den Hond E, Thijs L, McCormack P et al (2004) Determinants of white-coat hypertension. Blood Press Monit 9(6):307\u0026ndash;309\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH (1988) How common is white coat hypertension? JAMA 259(2):225\u0026ndash;228\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGustavsen PH, H\u0026oslash;egholm A, Bang LE, Kristensen KS (2003) White coat hypertension is a cardiovascular risk factor: a 10-year follow-up study. J Hum Hypertens 17(12):811\u0026ndash;817\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAguirre-Ramos R, Trujillo-Hern\u0026aacute;ndez B, Huerta M, Trujillo X, V\u0026aacute;squez C, Mill\u0026aacute;n-Guerrero RO (2002) White-Coat Hypertension and Risk Factors in Recently, Diagnosed Hypertensive Patients. Gac Med Mex 138(4):319\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAziz NR, Ubaidullah S, Zaheer J, Khan JA, Hassan M (1999) Role of Ambulatory Blood Pressure Monitoring in Diagnosing White Coat Hypertension. Ann King Edw Med Coll 5:266\u0026ndash;269\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrassi G, Turri C, Vailati S, Dell\u0026rsquo;Oro R, Mancia G (1999) Muscle and skin sympathetic nerve traffic during the white-coat effect. Circulation 100(3):222\u0026ndash;225\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Brien E, Parati G, Stergiou G, Asmar R, Beilin L, Bilo G et al (2013) European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens 31(9):1731\u0026ndash;1768\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGodil SS, Tabani H, Khan AH, Almas A (2011) White coat hypertension is not a benign entity: a cross-sectional study at a tertiary care hospital in Pakistan. J Pak Med Assoc 61(9):938\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShafique MN, RM SK, Razi MS, Muhammad S, Akhtar SH, Hussain M (2020) Cognitive behavior therapy for white coat hypertension-causing latrophobia in adults: randomized controlled trial. J Pak Med Assoc 70(9):1523\u0026ndash;1526\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"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":"[email protected]","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":"Anxiety, Hypertension, White coat hypertension, WCH, Blood pressure determination","lastPublishedDoi":"10.21203/rs.3.rs-4206523/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4206523/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eTo determine the prevalence of white coat hypertension in comparison to home-based blood pressure (BP) and anxiety levels in patients with white coat hypertensionusing the Beck Anxiety Inventory.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eAn observational cross-sectional study was conducted from March 2021 to April 2022 on people visiting OPDs at Khyber Teaching Hospital, Peshawar. In-hospital and home blood pressure recording with anxiety inventory completion was performed with a sample size of 213 normotensives using a nonprobability convenience sampling technique. The data were recorded on a structured questionnaire with an anxiety scale and analyzed with IBM SPSS version 26 and MS Excel 2019. The data are presented in the form of tables and charts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAmong 213 respondents aged 14-67 years [164 (77%) male and 49 (23%) female, 22 (10.3%) had a BP above 140/90 in the OPD, called white coat hypertension, and a BPbelow 140/90 at home.\u003c/p\u003e\n\u003cp\u003eThe Beck Anxiety Index (BAI)score was 2 (9.1%) for minimal anxiety, 6 (27.3%) for mild anxiety, 12 (54.5%) for moderate anxiety and 2 (9.1%) for severe anxiety.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eWCH has profound value due to its high incidenceand ability to predictprehypertension, CVD,and mTOD. This labile BP in the clinical environment can be falsely interpreted as causing unneeded pharmacological interventions to increase thephysical, mental, and financial agony of patients. Therefore, both medical staff and the public should be widely educated. Home-based BP measurements and ambulatory BPs may be preferred over these methods.\u003c/p\u003e","manuscriptTitle":"Assessing Anxiety Levels Among Individuals With White Coat Hypertension Using the Beck Anxiety Inventory","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-03 05:26:36","doi":"10.21203/rs.3.rs-4206523/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","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":"59076fc1-f8a9-4ed3-a485-4b45d4f32f4b","owner":[],"postedDate":"April 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":30200333,"name":"Cardiac \u0026 Cardiovascular Systems"}],"tags":[],"updatedAt":"2024-04-03T05:26:36+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-03 05:26:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4206523","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4206523","identity":"rs-4206523","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}