Hypertension is a chronic cardiovascular disorder characterized by persistently elevated arterial blood pressure. It is a major public health problem and an important risk factor for coronary artery disease, stroke, heart failure, chronic kidney disease and premature mortality. Although pharmacological treatment and lifestyle modifications are effective in controlling blood pressure, a considerable proportion of hypertensive individuals fail to achieve recommended blood pressure targets [1].

The development and progression of hypertension are influenced by multiple factors, including genetic predisposition, dietary habits, obesity, physical inactivity, excessive sodium consumption, smoking and psychological factors. Among these, psychological stress has received increasing attention because of its potential effects on cardiovascular regulation and blood pressure control [1,2].

Psychological stress refers to the emotional and physiological response that occurs when individuals perceive that environmental or personal demands exceed their available coping resources. Stress may arise from occupational pressures, financial difficulties, family conflicts, interpersonal relationships, social responsibilities and chronic illness. Persistent exposure to stressful situations may influence cardiovascular function through several neuroendocrine mechanisms.

The physiological response to stress involves activation of the sympathetic nervous system and hypothalamic-pituitary-adrenal axis. Increased sympathetic activity results in the release of catecholamines, including adrenaline and noradrenaline, which increase heart rate, myocardial contractility and peripheral vascular resistance. Activation of the hypothalamic-pituitary-adrenal axis stimulates cortisol secretion, which may contribute to metabolic and cardiovascular changes. These mechanisms can produce temporary elevations in blood pressure [2,3].

The relationship between chronic psychological stress and sustained hypertension is complex. Acute stress-related blood pressure elevation does not necessarily indicate chronic hypertension. However, repeated or prolonged stress exposure may contribute to adverse cardiovascular effects through autonomic dysregulation, sleep disturbances, unhealthy dietary practices, reduced physical activity and increased tobacco or alcohol consumption [3].

Psychological stress may also influence blood pressure control indirectly through behavioural pathways. Patients experiencing substantial stress may demonstrate poor adherence to prescribed antihypertensive medication, irregular follow-up, inadequate dietary control and reduced participation in physical activity. These behaviours may contribute to inadequate blood pressure control despite receiving appropriate treatment.

The Perceived Stress Scale (PSS-10), developed by Cohen and colleagues, is a commonly used instrument for evaluating the degree to which individuals perceive their lives as stressful during the previous month [4]. It provides a standardized method of assessing perceived psychological stress in clinical and research settings.

Blood pressure measurement is essential for evaluating hypertension control. Standardized measurement procedures, including appropriate cuff size, adequate rest before measurement and repeated readings, are necessary to improve accuracy. Ambulatory or home blood pressure monitoring may provide additional information regarding blood pressure variations outside the clinical environment [1].

Understanding the relationship between psychological stress and blood pressure control may help improve the comprehensive management of hypertensive patients. The present study aims to assess perceived psychological stress among individuals with essential hypertension and determine whether stress levels are associated with controlled or uncontrolled blood pressure.

Aim: To assess the association between psychological stress and blood pressure control in patients with hypertension.

A hospital-based cross-sectional observational study will be conducted in the Department of General Medicine in collaboration with the Department of Psychiatry at a tertiary care teaching hospital. Study duration The proposed duration of the study will be six months following Institutional Ethics Committee approval. Study population The study will include 150 patients diagnosed with essential hypertension attending the General Medicine outpatient department and inpatient services. Inclusion criteria • Patients aged 30–70 years. • Diagnosed with essential hypertension. • Duration of hypertension of at least six months. • Patients receiving antihypertensive treatment or undergoing regular clinical follow-up. • Individuals willing to participate and provide written informed consent. Exclusion criteria • Patients with secondary hypertension. • Patients with hypertensive emergencies. • Patients with acute myocardial infarction or acute stroke. • Patients with severe psychiatric disorders that interfere with participation. • Patients with severe cognitive impairment. • Pregnant women. • Individuals unwilling to provide informed consent. Sociodemographic and clinical assessment A structured questionnaire will be used to collect demographic and clinical information, including age, sex, occupation, education, socioeconomic status, marital status, duration of hypertension, family history and current antihypertensive medication. Additional information will be collected regarding diabetes mellitus, obesity, dyslipidaemia, chronic kidney disease, smoking, dietary habits, physical activity and sleep patterns. Assessment of psychological stress Psychological stress will be assessed using the 10-item Perceived Stress Scale (PSS-10), developed by Cohen et al. [4]. The questionnaire measures the extent to which participants perceive their lives as unpredictable, uncontrollable and overloaded during the preceding month. Each item is scored from 0 to 4, producing a total score ranging from 0 to 40. Four positively worded items are reverse-scored. For descriptive purposes, the following categories may be used: PSS-10 score Stress category 0–13 Low perceived stress 14–26 Moderate perceived stress 27–40 High perceived stress These categories are commonly used descriptive groupings rather than universally validated diagnostic cut-offs. Assessment of blood pressure Blood pressure will be measured using a validated automated sphygmomanometer or calibrated manual sphygmomanometer. Participants will be instructed to avoid smoking, caffeine and strenuous physical activity for at least 30 minutes before measurement. They will rest in a seated position for approximately five minutes before blood pressure assessment. At least two readings will be obtained at appropriate intervals, and the average will be recorded. The same arm should preferably be used for subsequent readings. For the primary analysis, blood pressure control will be classified using a prespecified target. For example, controlled blood pressure may be defined as systolic BP below 140 mmHg and diastolic BP below 90 mmHg, while uncontrolled blood pressure will be defined as systolic BP of 140 mmHg or above and/or diastolic BP of 90 mmHg or above. The selected threshold must be justified according to the applicable clinical guideline and study protocol. Statistical analysis Data will be entered into Microsoft Excel and analysed using SPSS or equivalent statistical software. Continuous variables will be expressed as mean ± standard deviation, while categorical variables will be presented as frequencies and percentages. The independent Student's t-test or Mann–Whitney U test will be used to compare stress scores between controlled and uncontrolled hypertensive groups. Pearson's or Spearman's correlation will be used to assess the relationship between PSS-10 scores and systolic and diastolic blood pressure. Chi-square testing will be used to evaluate associations between categorical stress levels and blood pressure control. Multivariable logistic regression will be performed to identify independent factors associated with uncontrolled hypertension. A p-value below 0.05 will be considered statistically significant.

Table 1. Sociodemographic characteristics

The study population consisted of 150 hypertensive patients, with males representing 58% and females 42%. Most participants belonged to the 51–60-year age group.

Table 2. Distribution according to perceived stress levels

Moderate perceived stress was the most frequent category, affecting 54% of participants. High stress was identified in 26%, while 20% reported low perceived stress.

Table 3. Distribution according to blood pressure control

In this illustrative population, 58% of participants had uncontrolled hypertension according to the study threshold of systolic BP below 140 mmHg and diastolic BP below 90 mmHg for controlled BP.

Table 4. Association between perceived stress and blood pressure control

Illustrative chi-square test: χ² = 22.57; df = 2; p = 0.00001.

Uncontrolled hypertension was observed in 30% of patients with low stress, 55.6% with moderate stress and 84.6% with high stress. This demonstrates a progressive increase in the proportion of uncontrolled hypertension across increasing stress categories.

Table 5. Comparison of PSS-10 scores between controlled and uncontrolled hypertensive patients

Hypertension is a multifactorial cardiovascular disorder influenced by genetic, metabolic, behavioural and environmental factors. Psychological stress has received increasing attention as a potential contributor to blood pressure elevation and inadequate hypertension control. Understanding the relationship between psychological stress and blood pressure may help improve the comprehensive management of hypertensive patients. The present study is designed to evaluate perceived psychological stress among patients with essential hypertension and investigate its association with blood pressure control. The Perceived Stress Scale provides a standardized assessment of an individual's subjective experience of stress and is suitable for use in clinical research [4]. Psychological stress activates the sympathetic nervous system, resulting in increased catecholamine secretion, elevated heart rate, increased cardiac output and peripheral vasoconstriction. These physiological changes contribute to transient elevations in blood pressure. Repeated activation of these pathways may influence cardiovascular regulation, although the relationship between chronic psychological stress and sustained hypertension is complex [2,3]. Sparrenberger et al. conducted a systematic review examining the association between psychosocial stress and hypertension. Their findings suggested that chronic stress and maladaptive responses to stress may be associated with an increased risk of hypertension, although the evidence was not uniform across all studies [3]. Another important mechanism involves activation of the hypothalamic-pituitary-adrenal axis. Stress-related cortisol secretion may influence metabolic activity, vascular function and sympathetic regulation. Chronic exposure to psychological stress may also contribute to sleep disturbances, obesity, unhealthy eating habits and reduced physical activity, all of which can adversely affect cardiovascular health. Psychological stress may influence blood pressure control through behavioural pathways as well. Patients experiencing high stress may forget medications, miss medical appointments, consume excessive dietary sodium and experience difficulties maintaining regular physical activity. Therefore, medication adherence and lifestyle practices should be considered when evaluating the relationship between stress and hypertension. The 2023 American College of Cardiology and American Heart Association hypertension guideline recognizes stress management as an important component of lifestyle-based blood pressure management. It also discusses evidence supporting certain stress-reduction approaches, including meditation and controlled breathing, as complementary strategies for lowering blood pressure [1]. The clinical implications of the present study are particularly relevant to General Medicine and Psychiatry departments. Routine assessment of psychological stress may help identify patients who experience substantial emotional distress alongside hypertension. Appropriate interventions, including psychological counselling, relaxation techniques, sleep improvement and lifestyle modification, may complement standard antihypertensive treatment. However, several limitations must be considered. The cross-sectional design cannot establish a causal relationship between psychological stress and blood pressure control. Blood pressure measurements obtained during a single clinical visit may be influenced by temporary stress, white-coat effects and measurement variability. Furthermore, factors such as medication adherence, dietary sodium intake, obesity, physical activity and socioeconomic status may act as confounders. Overall, assessing psychological stress alongside conventional cardiovascular risk factors may contribute to a more comprehensive understanding of blood pressure control and support an integrated approach involving both General Medicine and Psychiatry.

Routine assessment of psychological well-being may help identify hypertensive patients who require additional psychological support. Integrating stress management, counselling and lifestyle modification with standard antihypertensive treatment may improve comprehensive cardiovascular care. However, longitudinal studies are required to establish whether chronic psychological stress independently predicts poor blood pressure control.