Influence of stress induced by the first announced state of emergency due to coronavirus disease 2019 on outpatient blood pressure management in Japan

The COVID-19 pandemic led Japan to declare a nationwide state of emergency on April 7, 2020, encouraging people to stay home and socially distance. Such measures were expected to elevate daily stress, especially among patients with chronic illnesses. Prior disaster experiences in Japan (earthquakes, typhoons) have shown stress-related cardiovascular effects, including elevations in blood pressure and increased cardiovascular events. Given the high prevalence of hypertension in Japan, understanding how stress from the COVID-19 state of emergency affects blood pressure profiles is clinically important. The study hypothesized that the state of emergency would induce stress, alter BP profiles (e.g., increase office BP, affect home BP), and potentially increase health risks. The aim was to evaluate patients’ stress during the state of emergency and clarify its influence on BP management.

The introduction references disaster-related cardiovascular responses in Japan. After the 1995 Hanshin-Awaji earthquake, white coat hypertension converted to sustained hypertension in some patients, and heart disease events increased (Kario et al.). Following the 2011 East Japan Earthquake, patients living near the disaster area experienced worsened home BP (Miyakawa et al.). These observations established the concept of disaster-related diseases (e.g., stress cardiomyopathy, sudden death, thromboembolism) and underscored prioritizing hypertension-related care during and after disasters. While the COVID-19 state of emergency differs from acute natural disasters, similar stress-related impacts on BP were anticipated, yet evidence specific to the pandemic and emergency declaration remained limited prior to this study.

Design and setting: Retrospective observational analysis across member facilities of the Sagamihara Physicians Association during Japan’s first COVID-19 state of emergency (April 7–May 31, 2020). Participants: 919 outpatients were screened; inclusion criteria: age >20 years; regular clinic visits for chronic/lifestyle-related diseases; available office BP data prior to the emergency (Jan–Mar 2020) and at the time of survey; completion of a stress-related questionnaire. Exclusions: acute/emergency visits; opt-out; insufficient data. Final analyzed cohort: 748 patients. Among these, 535 had early morning home BP data for Jan–Mar 2020; comparisons across three periods (Apr–Jun 2019; Jan–Mar 2020; during emergency) were performed in 567 patients for office BP and 347 for home BP. BP measurements: Office BP measured with validated oscillometric devices per JSH 2019 (seated, rested; average of two readings 1–2 minutes apart). Home BP measured with upper-arm oscillometric devices per JSH 2019; patients measured every morning; weekly average before clinic visit used. Target BP thresholds followed JSH 2019, with stricter targets for patients with DM, cardio-/cerebrovascular disease, CKD with proteinuria, or age <75 years; thresholds increased by 10 mmHg for others. Patients were categorized as controlled, masked, white coat, or sustained hypertension based on office and home BP relative to targets. Clinical data: Collected before and during the emergency: age, sex, body weight, serum creatinine, HbA1c, urine protein (ACR or qualitative converted to albuminuria via Sumida et al.), NT-proBNP, estimated salt intake (Tanaka’s spot urine formula). eGFR calculated using Japanese equation: eGFR = 194 × age^-0.287 × Scr^-1.094 × 0.739 (if female). Stress questionnaire: Developed referencing disaster cardiovascular prevention literature (DCAP). Nine domains potentially impacted by COVID-19/emergency: fear about COVID-19–hypertension relationship, daily stress, diet, salt intake, frequency of meals at home, exercise amount, alcohol intake, sleep quality, medication adherence. Responses on a 5-point scale (much worse to much improved), converted to scores from −2 to +2; summed to a total stress score. Purpose was to guide clinical advice/medication adjustments during limited consultation time. Statistics: Normal data as mean±SD; skewed as median (IQR). Paired t-test for two time-point parametric comparisons; Wilcoxon for nonparametric; McNemar for nominal. For three serial time points: repeated-measures ANOVA (continuous) and Cochran’s Q (nominal); significant results (p<0.05) followed by Bonferroni-corrected post hoc tests. Chi-square to compare BP distribution categories (controlled/masked/white coat/sustained) between pre-emergency (Jan–Mar 2020) and during emergency. Multivariable linear regression: Outcomes were changes in office or home mean arterial pressure (MAP = (SBP−DBP)/3 + DBP). Covariates included demographics, baseline BW, baseline MAP (Jan–Mar 2020), eGFR, estimated salt intake, DM, antihypertensive medication classes, and discrete questionnaire responses. ROC analysis: Assessed predictive accuracy of total stress score for increase in MAP; area under the curve (AUC) reported; cutoff for total stress score selected from ROC. Binary grouping and ANCOVA: Patients divided by total stress score cutoff; ANCOVA compared clinical parameters between groups, with pre-emergency values as covariates and emergency-period values as dependent variables. Ethics: Conducted per Declaration of Helsinki; approved by Special Ethics Committee of the Kanagawa Medical Association (Japan Physicians Association of Internal Medicine 028-2008-001, Dec 4, 2020).

Sample characteristics: 748 patients analyzed; mean age 67.3±12.3 years (22–97); 424 males, 324 females. Hypertension in 96% (714/748); diabetes in 57% (423/748). Blood pressure changes: - Office BP increased during the state of emergency compared with Jan–Mar 2020: SBP/DBP from 136.5±17.5/78.2±12.0 to 138.6±18.6/79.0±12.2 mmHg (p<0.001 and p=0.03). - Home BP decreased: SBP/DBP from 128.2±10.3/75.8±8.8 to 126.9±10.2/75.2±9.0 mmHg (p<0.001 and p=0.01). - BP category distribution shifted significantly (chi-square p<0.001), with an increased prevalence of white coat hypertension during the emergency (p<0.001 by McNemar); no significant changes in sustained (p=0.11), masked (p=0.12), or controlled hypertension (p=0.57). - Three-period comparison (Apr–Jun 2019; Jan–Mar 2020; during emergency) confirmed office SBP rose and home SBP fell during the emergency (p<0.001 for both, by ANOVA). Other clinical changes: - eGFR decreased (p=0.003) and NT-proBNP increased (p=0.01) during/after the emergency. Stress and behaviors: - 58% worried about hypertension worsening COVID-19 severity/prognosis. - 39% reported decreased exercise; 17% reported worsened diet composition. Multivariable regression: - Change in office MAP: independent factors were baseline office MAP (β −0.42, 95% CI −0.50 to −0.35, p<0.001), mineralocorticoid receptor antagonist use (β +4.30, 95% CI 0.95–7.65, p=0.01), worsened dietary intake (β +1.68, 95% CI 0.25–3.10, p=0.02), and worsened medication adherence (β +2.48, 95% CI 0.15–4.81, p=0.04). - Change in home MAP: independent factors included baseline home MAP (β −0.11, 95% CI −0.16 to −0.06, p<0.001), baseline body weight (β +0.05, 95% CI 0.02–0.09, p=0.002), and worsened sleep quality (β +0.82, 95% CI 0.15–1.50, p=0.02); an additional reported coefficient was 0.20 (95% CI 0.003–0.40, p=0.047). Stress score and BP: - ROC-derived cutoff for total stress score predicting office MAP increase: 3.0 (sensitivity 27.3%, specificity 78.2%). - Patients with total stress score ≥3 had higher adjusted office SBP (p=0.04), office MAP (p=0.048), home DBP (p=0.01), and home MAP (p=0.02) versus those with score <3 by ANCOVA. The <3 group had a higher proportion of males (63% vs 44%, p<0.001); other baseline clinical findings did not differ significantly.

The study demonstrated that during Japan’s first COVID-19 state of emergency, office BP increased while home BP decreased among chronic disease outpatients. The divergence suggests a stress-related white coat phenomenon in clinical settings despite potentially improved or stable home conditions. The significant rise in white coat hypertension prevalence supports that acute psychosocial stress associated with the emergency (fear regarding COVID-19 and hypertension, lifestyle disruptions) influenced clinic BP measurements. Behavioral changes (reduced exercise, worsened diet) and patient-reported stress domains were associated with unfavorable BP changes. Multivariable analyses linked higher office MAP increases to poorer diet and reduced medication adherence, and higher home MAP increases to greater baseline body weight and worsened sleep, emphasizing modifiable behaviors. The findings address the research question by confirming an association between heightened stress during the emergency and altered BP profiles, highlighting the need for vigilant BP management and attention to lifestyle and adherence during societal stressors. Clinically, reliance solely on office BP during such periods may overestimate BP control due to white coat effects; incorporating home BP and stress assessment can guide more accurate management.

During the COVID-19 state of emergency in Japan, office BP rose and home BP fell, with an increased prevalence of white coat hypertension, in the context of elevated patient stress and lifestyle disruptions. Stress-related factors, diet, medication adherence, sleep quality, and body weight were associated with changes in BP. General practitioners should intensify BP monitoring (including home BP), assess stress and lifestyle, and support adherence during widespread stressful events to prevent cardiovascular complications.