Clinical and Experimental Hypertension, 33(5):281–286, (2011)

Copyright © Informa Healthcare USA, Inc.

ISSN 1064-1963 print /1525-6006 online
DOI: 10.3109/10641963.2010.531850

Exam Anxiety Induces Significant Blood Pressure and Heart Rate

Increase in College Students

Zhihong Zhang, Hai Su, Qiang Peng, Qing Yang, Xiaoshu Cheng
Department of Cardiology, Second Affiliated Hospital, Medical College of Nanchang University, Nanchang, China

Abstract
To investigate the relationship between the anxiety and blood pressure (BP) and heart rate (HR) increase in peri-exam
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period. Sixty-four college students(20.0 ± 0.1 year old) were included in this study. The BP and HR were measured in
the morning and in the evening for 3 days during the prereview (ba), review, and exam periods. The BP and HR increase
amplitudes (HRIA) of review and exam periods were from the difference of corresponding values and basic values, and
the BPIA/baBP and HRIA/baHR were calculated. All of the students completed the Self-Rating Anxiety score (SAS)
questionnaire the first day of the exam period. Scores over 50 points were used as the standard for anxiety. From the
prereview to exam periods, the BP and HR increased gradually. The exam SBPIA (4.3 ± 1.3 vs. 0.3 ± 0.5 mmHg, P
< 0.05) and DBPIA (4.4 ± 1.5 vs. 1.0 ± 0.5 mmHg, P < 0.05) were significantly higher in the anxiety group than in
the no-anxiety group. The SBPIA/DBPIA and HRIA showed a similar profile also(9.7 ± 2.1 vs. 1.9 ± 0.9 bpm, P <
0.05). Strong positive correlations were found between the SAS score and BPIA and HRIA both in the review and exam
period. The smoking group and family hypertension group had higher anxiety score; meanwhile, their exam BPIAs
and HRIAs were significantly higher than their corresponding group. The BP and HR increase in the review and exam
period, anxiety is an important factor of BP and HR increase.
For personal use only.

Keywords: exam stress, anxiety, blood pressure, heart rate, student

20 INTRODUCTION
Anxiety is a general term for several disorders that
causes nervousness, fear, apprehension, and worry.
Mild anxiety is vague and unsettling, while severe
anxiety can negatively impact daily life. Anxiety has
25 been demonstrated as an independent factor for
hypertension (1, 2). Students may experience different
levels of anxiety in the duration of a certain exam,
i.e., the exam anxiety which is considered as a
situation-specific trait accounting for individual differ-
30 ences in the extent to which people find examinations
threatening (3).
However, at present, little is known about the
potential links between the exam anxiety and blood
pressure (BP) profile of college students in the
35 peri-exam period. This study was designed to eval-
uate the relationship between the extent of exam
anxiety and the change of BP and heart rate (HR)
in 64 medical students in our college, and the
relevant influencing factors for exam-associated BP
40 change.
METHODS
Subjects and Methods
Sixty-four normotensive college students with a mean
age of 20.0 ± 0.1 years old were enrolled. Their height
and weigh were recorded to calculate body mass index 45
(BMI). Students with one or two parents diagnosed
with hypertension were considered to have family
hypertensive history (FHH). Students with smoking
or passive smoking history in the past half year were
included in the smoking group. 50
This study was approved by the Ethics Committee of
the Second Affiliated Hospital of Nanchang University
and the subjects offered informed consent.
BP Measurement
Auscultatory BP measurement was applied in this study. 55
The key points for BP taking include: the subjects were
given at least a 10-min rest before BP measurement in
the sitting position; the empty cuff was appropriately
fastened around the right upper arm, and the cuff
60

Address correspondence to Hai Su, Department of Cardiology, Second Affiliated Hospital, Medical College of Nanchang University,
No. 1 Mingde Road, Nanchang, 330006 China. E-mail: suyihappy@sohu.com
Received 29 April 2010; revised 13 June 2010; accepted 25 June 2010.

281
 282 Z. Zhang et al.
was initially inflated to at least 30 mmHg above the
point at which the radial pulse disappears; the rate of
deflation was 2 mmHg per second (mm/s); the first and
fifth audible sound of artery pulsation should be taken
65 as systolic blood pressure (SBP) and diastolic blood
pressure (DBP); the second measurements of BP were
performed 2 min later.
Two BP readings were taken both in the morning
(6:00–7:00) and in the evening (18:00–19:00) for 3
70 days in prereview, review, and exam period, respectively.
The exam period lasted for 3 days. Four days without
class before the exam period, when students prepare
for the exam, were identified as the review period. And
3 days just before the review period were identified
75 as the prereview period. The BP in the review period
was measured in the last 3 days. The average of
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the 12 BP readings of each period were calculated
as the prereview, review, and exam BP. All BP
readings were taken with the same newly calibrated
80 mercurial sphygmomanometer and by the same doctor.
Measuring time and calculating methods of the HR and
BP were the same.
The BP and HR in the prereview were considered
as the basic values (baBP and ba HR). The differences
85 of review and exam values of BP and HR to the basic
value were used as the increase amplitudes (IA), i.e.,
For personal use only.
BPIA and HRIA, and the ratios of BPIA/baBP and
HRIA/baHR were calculated from BPIA and HRIA and
their basic values.
90 In this study, the Zung Self-Rating Anxiety Scale
(SAS) questionnaire was used to measure anxiety on
the first day of the exam period. The self-administered
test has 20 questions. Each question is scored on a scale
of 1–4 (none or a little of the time, some of the time,
95 good part of the time, most of the time). There are 15
questions worded toward increasing anxiety levels and
five questions worded toward decreasing anxiety levels.
The score range is from 20–80 and the SAS score being
more than 50 points was considered as anxiety in this
100 study.
Statistical Analysis
All data are presented as mean ± standard error
(M ± SE). The SPSS 10.0 statistical package (SPSS
Company, Chicago, IL, USA) was used for the
105 analysis of variation (ANOVA) and student’s t-test.
Logistic regression analysis (forward stepwise) was
used for evaluating the effects of age, BMI, sex
(male:1, female: 0), smoking (yes:1, no: 0), family
history of hypertension (having: 1,not having: 0) on
110 anxiety. Multifactor analysis of variance (MNOVA) was
used for identifying the interaction between different
factors. The relationship among the BP and HR
changes and other factors were analyzed with linear
correlation analysis and multiple linear regression
115 analysis respectively. Statistical significance was defined
as P < 0.05.
RESULTS
This study included 31 male and 33 female subjects.
Smoking and non-smoking groups had 20 and 44
students, respectively. Fifteen students had a family 120
history of hypertension and 49 did not. The ages
were similar between the two groups, smoking and
non-smoking groups, and with and without a family
history of hypertension groups. In this study, eight
students were found to have both a smoking history and 125
a family history of hypertension.
The Change of BP and HR in the Peri-Exam Period
The SBP, DBP, and HR increased gradually from the
basic period to the exam period. A significant increase
of DBP occurred in the review period (Table 1). 130
The Relationship of BP and HR Change to Anxiety
In this study, 20 students (31.25%) were considered
as having anxiety. The SBP, DBP, and HR increase
amplitudes, as well as the BPIA/baBP and HRIA/baHR,
and were significantly higher in the anxiety group than 135
in the non-anxiety group in both review and exam
periods (Table 2). These results indicate that anxiety
is an independent factor for a BP increase beyond the
basic level, although the basic BP was somewhat higher
in the anxiety group than in the non-anxiety group. 140
The line analysis showed a strong positive correlation
between SAS scores and the SBPIA, DBPIA, and HRIA
with the correlation coefficient (R) of 0.30, 0.38, and
0.32, respectively, in the review period. In the exam
period, the correlation was stronger proven by the R of 145
0.36, 0.45, and 0.44, respectively (Figure 1).
The Influencing Factors for Anxiety and BP, HR
The SAS scores of male and female subjects were
similar. The groups with family hypertensive history
(FHH) or smoking history had higher SAS scores 150
than their corresponding group, respectively. However,
logistic regression analysis showed that smoking was a
single influencing factor for anxiety or anxiety score,
but family history of hypertension was not. Multifactor
analysis of variance (MNOVA) demonstrated that no 155
interaction was found between smoking and family
history of hypertension.
The group with FHH had a higher BP increase
amplitude in the review and exam periods. These results
indicate that the students with FHH are susceptible 160
Table 1. The changes of BP and HR in the periexam period
(M±SE)
Period SBP (mmHg) DBP (mmHg) HR (bpm)
Basic 108.9 ± 1.0 71.8 ± 0.7 71.2 ± 0.7
Review 109.3 ± 1.1 72.8 ± 0.9∗ 73.9 ± 1.0∗
Exam 110.4 ± 1.1∗# 73.9 ± 0.8∗# 75.6 ± 1.1∗#
*Comparison with pre review. P < 0.05; # Comparison with
review. P < 0.05.
Clinical and Experimental Hypertension
 Exam Anxiety and Blood Pressure 283

Table 2. The BP and HR parameters between the groups with and without anxiety (M±SE)
Anxiety baSBP SBP IA (mmHg) baDBP DBP IA (mmHg) ba HR HRIA (bpm)
(N) (mmHg) Review Exam (mmHg) Review Exam (bpm) Review Exam
Non(44) 108.3 ± 1.2 −0.4 ± 0.4 0.3 ± 0.5 71.3 ± 0.9 0.2 ± 0.4 1.0 ± 0.5 71.4 ± 0.9 1.0 ± 0.9 1.9 ± 0.9
Y(20) 110.0 ± 1.6 2.4 ± 0.8∗ 4.3 ± 1.3∗ 72.9 ± 1.2 2.8 ± 1.0∗ 4.4 ± 1.5∗ 71.0 ± 0.9 6.1 ± 2.1∗ 9.7 ± 2.1∗
*Comparison with non-anxiety. P < 0.05.

review period to anxiety and a higher BP and HR in the peri-exam

period. The smoking group had higher systolic BPIA
20 and diastolic BPIA in both the review and exam period.
exam period
The HR change was similar to the BP change (Table 3).
The comparison of BP and HR increase amplitudes 165
SBPIA (mmHg)

10 in the exam period between different conditions is

R Sq Linear = 0.126
shown in Figure 2. The BPIA/baBP and HRIA/baHR
of the three subgroups with anxiety, FHH, or smoking
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R Sq Linear = 0.088
0 were higher than the corresponding group both in the
review and exam period. 170
The multiple linear regression analysis showed that
–10 anxiety was the strongest influencing factor for the
BP and HR increase in the review and exam periods.
30 40 50 60 70
Smoking was a weak factor for a DBP increase in only
SAS score the review period. The family history of hypertension 175
was not an influencing factor.
20
For personal use only.

DISCUSSION
DBPIA (mmHg)

The BP and HR in the Peri-Exam Period

10 R Sq Linear = 0.201 Some researches evaluated the BP change during exam
time. A prospective observational study of 121 medical 180
students taking the final licensing exam found that
R Sq Linear = 0.146
their DBP, measured by an ambulatory BP monitoring
device, increased significantly from 81 +/- 10 mmHg
0 before the exam to 86 +/- 9 mmHg (p = 0.008)
during the exam, and the DBP was still higher 15 185
min after the exam (88 +/- 11 mmHg), but their
30 40 50 60 70 SBP did not increase significantly during (131 +/- 14
SAS score vs. 136 +/- 18 mmHg) the whole process (4). In 22
medical residents, Italy scholars found that SBP and
30
HR increased significantly when subjects sitting before 190
an examination, as compared to a calm situation (5).
These results demonstrated that BP and HR increased
20 significantly within the duration of an exam.
R Sq Linear = 0.192 In this study, we evaluated the BP and HR change
HRIA (bpm)

in the peri-exam period. A significant increase of SBP 195

10 (from 108.9 to 110.4 mmHg) and DBP (from 71.8 to
R Sq Linear = 0.101 73.9mmHg) from the basic period to the exam period
was found in the 64 college students. These results
0 demonstrate that a BP increase occurs not only during
the exam time and in the exam room, but also in the 200
time and place beyond the exam.
–10 A significant increase of DBP in the review period
30 40 50 60 70 demonstrated that the preparation for exam could
SAS score induce a BP increase and that a DBP increase occurred
earlier than a SBP increase. Picot et al. (6) found that 205
Figure 1. The relationship of the SAS scores and BPIA and
HRIA in review and exam periods.
lowered anger was associated with significant increases
of DBP in black females with ambulatory BPs during
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 Clin Exp Hypertens Downloaded from informahealthcare.com by Kainan University on 04/18/15
For personal use only.

284 Z. Zhang et al.

Table 3. The BP and HR parameters between groups with and without FHH or smoking (M±SE)
baSBP SBPIA (mmHg) baDBP DBPIA (mmHg) HRIA (bpm)
Grouping(n) SAS score (mmHg) Review Exam (mmHg) Review Exam Basic (bpm) Review Exam
FHH No (49) 45.9 ± 1.0 107.5 ± 1.1 −0.1 ± 0.4 1.4 ± 0.5 71.0 ± 0.9 0.5 ± 0.4 1.7 ± 0.6 70.5 ± 0.8 2.0 ± 1.0 3.2 ± 1.1
Y (15) 51.0 ± 2.4∗ 113.3 ± 1.9∗ 2.4 ± 1.2∗ 2.0 ± 1.9 74.5 ± 1.1∗ 2.8 ± 1.1∗ 3.5 ± 1.6 73.8 ± 1.3∗ 4.7 ± 2.0 8.0 ± 2.2∗
Smoking Non (44) 108.5 ± 1.2 −0.3 ± 0.4 0.4 ± 0.6 71.1 ± 0.8 0.1 ± 0.4 1.1 ± 0.5 70.8 ± 0.9 1.8 ± 0.9 2.6 ± 1.0 108.5 ± 1.2
Y (20) 109.6 ± 1.7 2.2 ± 0.9∗ 4.0 ± 1.3* 73.4 ± 1.4 2.9 ± 1.0∗ 4.3 ± 1.5∗ 72.1 ± 1.0 4.4 ± 2.1 8.1 ± 2.2∗ 109.6 ± 1.7
Abbreviation: FHH - family hypertensive history. *Comparison with no FHH or no smoking P < 0.05.

C
B
A

IA/base IA/base IA/base

–0.05
0.00
0.05
0.10
0.15

–0.05
0.00
0.05
0.10
0.15
–0.05
0.00
0.05
0.10
0.15

SBP

*P < 0.05
SBP

SBP
*P < 0.05

smoke (n = 20)
anxiety (n = 20)

no smoke (n = 44)
no anxiety (n = 44)

DBP
*P < 0.05

DBP

DBP
*P < 0.05
family hypertension (n = 15)
no family hypertension (n = 49)
HR

HR

HR
*P < 0.05

*P < 0.05

*P < 0.05

non-smoking groups. IA/base: BPIA/baBP or HRIA/baHR.

Figure 2. The comparison of BP and HR increase amplitudes

Clinical and Experimental Hypertension

without family hypertensive history; (C) between the smoking and
anxiety and non-anxiety groups; (B) between the groups with and
in exam period between different conditions. (A) between the

a 12-h period. The reason for the more obvious DBP
increase may be the increased arterial tendency induced
210 by the anxiety. At the same time, the HR increased
gradually from 71.2 bpm in the preview period to 75.6
bpm in the exam period.
Anxiety and BP and HR Profile in Exam Period
In this study, we found that 31.25% of the students
215 experienced anxiety in the exam period. Appropriate
anxiety in the peri-exam period is normal; however,
excessive or intensive exam anxiety may induce a lot
of psychological and physiological disorders (3, 7).
At present, there is little research on the relationship
220 between exam anxiety and BP. Although less sleeping
and exercise time in the peri-exam period may be
one reason for increased BP, our results demonstrated
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that anxiety is an important factor for an exam BP
increase.
225 At first, in the non-anxiety group, the BP and HR
did not increase in the review period; even in the
exam period the SBPIA and DBPIA were small. But
in the anxiety group, the mean SBPIA and DBPIA
in the exam period were 4.3 mmHg and 4.4 mmHg,
230 respectively. Secondly, the BP and HR increase in the
anxiety group was independent on the basic BP and
HR, as the BPIA/baBP and HRIA/baHR were higher
For personal use only.
in the anxiety group than in the non-anxiety group.
Thirdly, the SAS score was positively correlated with
235 the BPIA and HRIA, either in the review period or
in the exam period. Scholars in Italy found that SBP
and HR increases in the exam was paralleled with
the increase in the HRSA total score in 22 medical
residents (5). In addition, multiple linear regression
240 analysis demonstrated that anxiety was the strongest
influencing factor for the BP and HR increase in the
peri-exam period.
It is accepted that the sympathetic overactivation
is the key point of anxiety-induced hypertension.
245 Meanwhile, stress may also activate the brain and the
peripheral rennin-angiotensin-system (RAS). Activation
of brain RAS may induce hormone secretion, including
corticortropin-releasing hormone, adrenocorticotripic
hormone, corticoids, vasopressin, and neuropeptide
250 Y (8–10). Lambert (11) results suggest that chronic
mental stress modulates the pattern of sympathetic
activity, which in turn, may confer greater cardiovascu-
lar risks on individuals with metabolic syndrome and
elevated BP.
255 Family Hypertensive History and Anxiety
Many studies pointed out that a higher ratio of anxiety
was found in the hypertensive patients in comparison
with normotensive ones. But it is still unclear whether
the exam anxiety is higher in normotensive youngsters
260 with FHH. In this study, 15 students with FHH
were found to have higher anxiety scores than those
without FHH, which suggested that the students from
a hypertensive family were more vulnerable to exam
© 2011 Informa Healthcare USA, Inc.
Exam Anxiety and Blood Pressure 285
anxiety. This result is similar to a study in 4048
seafarers, which showed a positive relationship between 265
anxiety and hypertensive family history.
Compared to the non-FHH group, the group with
FHH not only had higher basic SBP, DBP, and HR,
but they had higher SBP, DBP, and HR increase
amplitudes in the review period and exam period. These 270
results indicated that stress can induce an earlier and
stronger BP increase in the students with FHH. As
SBPIA/baSBP and DBPIA/baDBP of the FHH group
were about twice as those in the non-FHH group,
even with no significant difference, it may indicate 275
that the higher BP increase in the peri-exam period is
independent on the basic BP level.
Smoking and Anxiety
Our results showed that the smoking group had a
higher anxiety score than the non-smoking group. 280
The SBP and DBP increase amplitude, as well as
the HR increase amplitude, in the smoking group
were significantly higher compared to the non-smoking
group, which demonstrated that there is a positive
relationship between smoking and anxiety, and that 285
smoking may enhance the BP and HR reaction in the
peri-exam period.
Many studies showed a positive relationship between
smoking and anxiety or other psychological disorders.
Celikel, Celikel, and Erkorkmaz found higher levels of 290
depressive symptoms and hopelessness in the students
with smoking behavior in 1870 Turkish students (21.2
± 2.0 y) (12). A study, including 60,814 participants
from Norway, showed a strong association of smoking
with co-morbid anxiety depression, especially in females 295
and younger participants (13). In this study, the logistic
regression analysis showed that smoking was also a
single influencing factor for anxiety or anxiety scores,
but no interaction was found between smoking and a
family history of hypertension. Cosci et al.pointed out 300
that panic and cigarette smoking each appear to have
the capacity to serve as a causal factor/facilitator in the
development of the other (14).
The limitation of this study was the small number of
investigated students, and a larger sample is needed for 305
more convincing results.
Clinical Applications
Anxiety is recognized as a precursor to hypertension
development and an increased risk of fatal coronary
heart disease, as indicated by many studies (2, 15, 310
16). Sarason et al. (17) pointed out that we live in a
test-conscious, test-giving culture in which the lives of
people are in part determined by their test performance.
It is well known that the mental workers are more
likely to have hypertension. Our study demonstrated 315
that even common tests can induce BP increase, and
the BP increase amplitude is connected with the extent
of anxiety in the young students. An environment full of
various and endless tests may be one responsive factor
 286 Z. Zhang et al.
320 for higher hypertension incidence in mental workers. To
reduce and avoid test anxiety is an important way to
prevent hypertension.
CONCLUSIONS
The BP and HR increase in the peri-exam period in
325 young medical students, and their increase amplitudes
are positively connected with the extent of anxiety.
Smoking is a responsible factor for exam anxiety.
ACKNOWLEDGMENT
This study was supported by a grant from the
330 Chinese National Science and Technology Plan
(2008 BAI68B02).
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Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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Clinical and Experimental Hypertension