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Clinical effectiveness of stress-reduction techniques in patients with hypertension: systematic review and meta-analysis

Nagele, Evaa; Jeitler, Klausb,c; Horvath, Karlb; Semlitsch, Thomasb,d; Posch, Nicoleb; Herrmann, Kirsten H.e,f; Grouven, Ulriche,g; Hermanns, Tatjanae; Hemkens, Lars G.e,h; Siebenhofer, Andreai

doi: 10.1097/HJH.0000000000000298

Objective: A systematic review and meta-analysis focusing on patient-relevant outcomes and blood pressure was conducted to assess the clinical effectiveness of stress-reduction techniques in adults with essential hypertension.

Methods: Systematic reviews and randomized controlled trials (RCTs) were identified as part of a systematic search in six electronic databases ending September 2012. RCTs comparing stress-reduction techniques versus no such techniques with a follow-up of at least 24 weeks and published in English or German were included. Outcomes of interest were death, cardiovascular morbidity/mortality, end-stage renal disease, health-related quality of life, adverse events, changes in blood pressure, and changes in antihypertensive medication. When appropriate, meta-analyses were used to combine data.

Results: Seventeen RCTs analyzing different stress-reduction techniques such as biofeedback, relaxation or combined interventions were identified. Data were not reported for most of the patient-relevant outcomes, and meta-analyses could only be used to evaluate effects on blood pressure. The data indicated a blood pressure-lowering effect, but the studies had methodological shortcomings and heterogeneity between them was high. Mean group differences for DBP ranged from −10 to 1 mmHg and for SBP from −12 to 10 mmHg. In terms of antihypertensive medication, no favorable effects of stress-reduction techniques could be identified.

Conclusions: The available RCTs on stress-reduction techniques used for at least 24 weeks appeared to indicate a blood pressure-lowering effect in patients with essential hypertension, but this should be interpreted with caution because of major methodological limitations. A benefit of specific stress-reduction techniques in hypertensive patients remains unproven.

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aDepartment of Medical Psychology and Psychotherapy, Medical University of Graz

bEBM Review Center, Department of Internal Medicine, Medical University of Graz

cInstitute for Medical Informatics, Statistics and Documentation, Medical University of Graz

dHEALTH-Institute for Biomedicine and Health Sciences, Joanneum Research, Graz, Austria

eInstitute for Quality and Efficiency in Healthcare (IQWiG), Cologne

fBristol-Meyers Squibb GmbH&Co, KGaA, Munich

gHannover Medical School, Hannover, Germany

hBasel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Switzerland

iInstitute of General Practice, Goethe University Frankfurt, Germany

Correspondence to Eva Nagele, PhD, MA, Department of Medical Psychology and Psychotherapy, Medical University of Graz, Auenbruggerplatz 2/8, 8036 Graz, Austria. Tel: +43 316 385 13039; e-mail:

Abbreviations: CARDIA, Coronary Artery Risk Development in Young Adults; EMG, electromyography; HTA, health technology assessment; IQWiG, Institute for Quality and Efficiency in Healthcare; JNC, Joint National Committee; NICE, National Institute for Health and Clinical Excellence; PMR, progressive muscle relaxation; RCT, randomized controlled trial; SF-36, Medical Outcome Study Short Form-36

Received 27 January, 2014

Revised 5 June, 2014

Accepted 5 June, 2014

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