Individuals with high scores of perceived stress (PS) are more likely to develop arterial hypertension (AH) than those with low levels of stress (Hamer and Steptoe, 2012; Lu et al., 2019). Furthermore, hypertensive patients generally report feeling more stressed than individuals without the diagnosis of AH (Footman et al., 2013; Liu et al., 2017).

In addition to being associated with stress (Höfelmann et al., 2018; Khayyat et al., 2019; Samiei Siboni et al., 2019), AH can impact cognition in multiple domains (Gifford et al., 2013; Muela et al., 2017). There is evidence that hypertensive individuals perform worse in tests that assess executive functions (EF) compared to healthy individuals (Moraes et al., 2020, 2019). Souza-Talarico et al. (2020) also found that work-related stress was associated with lower performance on delayed recall, verbal fluency, and EF tests in middle-aged adults (Souza-Talarico et al., 2020). Therefore, AH and stress can be both independent risk factors for cognitive impairment.

Arterial hypertension and stress can also impact the quality of life (QoL) (Ames et al., 2001; Carvalho et al., 2013). Individuals with hypertension seem to have a worse QoL compared to a non-hypertensive group (Carvalho et al., 2013; Cao et al., 2018). In the same way, evidence showed that major or minor stressors events have a significant impact on the QoL of low-income patients with hypertension (Ames et al., 2001). In another sample, composed of 348 dental faculty members from master’s and doctoral programs in Brazil, Meira et al. (2020) found a negative correlation between PS and all QoL domains: physical, psychological, social, and environmental (Meira et al., 2020). However, data about the relationship between PS and QoL in hypertensive individuals is still scarce.

Because of all these deleterious effects of stress on cognition and QoL, strategies to control and deal with emotional stress are of paramount importance. The management of emotional stress can be combined with other pharmacological and non-pharmacological interventions to achieve better results, especially in individuals with AH (Issa et al., 2020).

Studies with other populations indicate that the performance of EF may be associated with the way the subject deals with stress. Lower EF performance in stroke subjects predicted more frequent use of avoidant coping (Kegel et al., 2014). In subjects who suffered from a traumatic brain injury, lower EF performance correlated with greater use of emotion-focused coping (Krpan et al., 2007). A better EF performance, in turn, was related to greater use of problem-focused coping (Krpan et al., 2007). Concerning hypertensive individuals, the instrumental dimension of the coping questionnaire, which refers to being active and task-oriented, such as searching for medical information or taking the prescribed drugs at the right moment, was positively associated with QoL (Rueda and Pérez-García, 2013). However, less is known about how the level of PS can impact the choices of coping strategies, especially in hypertensive patients.

Considering that emotional stress, besides hypertension, can impact a huge number of functions important for daily life, this study aimed to examine the association between PS and EF performance, coping strategies, and QoL in a group of hypertensive individuals. We hypothesize that PS is negatively associated with EF performance, positively associated with dysfunctional coping, negatively associated with the problem and emotion-focused coping strategies, and negatively associated with QoL domains.

Of the 48 participants who had complete data on the PS scale, we excluded one that presented an IQ less than 80, one that had a previous diagnosis of head trauma, and one with the diagnosis of epilepsy. Forty-five patients met the eligibility criteria and were included in the analysis of this cross-sectional study. The clinical and sociodemographic profile of the sample is described in Table 1. The mean age of the sample was 58.42 years (SD ± 8.9). Besides this, 32 of the subjects were female (71.11%) and the mean duration devoted to education was 12.13 years (SD ± 3.7). As for the clinical characteristics, the time of hypertension since diagnosis was 18.03 years (SD ± 11.07), and the systolic blood pressure (SBP) mean of the evaluated patients was 141.7 mmHg (SD ± 11.07), and the diastolic blood pressure (DBP) was 73.05 mmHg (SD ± 8.97). The mean number of medications in use was 4.37 (SD ± 1.95). As seen in Table 1, 17.77% of the sample presented moderate or severe depression symptoms, and the mean IQ was 96.4. The mean scores of the main coping responses and of all domains of the QoL are displayed in Supplementary Tables 1, 2, respectively. The mean scores of each EF test are also individually presented in Supplementary Table 3.

The purpose of this cross-sectional study, was to examine the association of PS with EF performance, coping strategies, and QoL in a group of hypertensive individuals. We found that higher scores of PS were related to lower scores of emotion-focused coping strategies. However, we did not find a significant association of PS with EF, QoL, and problem-focused and dysfunctional coping strategies.

These data are in agreement with other studies that used the same methods to measure PS and coping strategies in other populations. Saczuk et al. (2019) observed that the clinical group of adults diagnosed with clinical bruxism symptoms had a significantly higher percentage of individuals with high PS than the control group (28.6 vs. 4.0%). Besides this, the control group chose more often the acceptance and the religion as strategies to deal with stress in comparison with the study group. That is, positive coping strategies, mainly emotion-focused strategies, were chosen most frequently in the control group. Altunan et al. (2021) found similar results. In their study with individuals diagnosed with multiple sclerosis, patients with low PS levels used the acceptance strategy more than the ones with high PS.

Chronic high levels of distress may be indicative of poorly emotional regulation (Kubzansky et al., 2011). A study that assessed psychological measures such as social support, emotional regulation, and cognitive appraisal of the stressful situation showed that cortisol reactivity and norepinephrine secretion were highest in hypertensive men with poorer hedonistic emotional regulation (Wirtz et al., 2006).

During their lives, every people faces difficult and stressful situations capable to induce a variety of emotions. The emotions generate a disequilibrium that naturally demands an adaptation of the organism. This adaptation occurs through emotion regulation strategies. In this way, the balance is restored, and also the feeling of physical and psychological well-being. Therefore, emotion regulation can be characterized by these processes involved in the way of dealing with high levels of positive and negative emotions (McRae, 2016).

On the other hand, we did not find an association of PS with EF and QoL, although there was a tendency for the PS to predict the overall perception of QoL (β = −0.10; p = 0.06). Korten et al. (2017) also examined the association between PS (PSS-10) and EF (digit span and phonemic and semantic fluency), but in a bigger sample of 1,099 older adults. They observed a negative association between the general score of the PSS-10 and digit span backward in models adjusted for age, sex, education, function limitations, depression, and mastery (Korten et al., 2017). However, the authors did not include hypertension as a possible confounder variable, although it is a well-known risk factor for executive impairment (Iadecola et al., 2016). In this study, we found that the association between PS and EF was not independent of systolic blood pressure.

Evidence from longitudinal studies also showed associations between PS and cerebrovascular disease markers in an elderly cohort (Aggarwal et al., 2014). Aggarwal et al. (2014) found that each one-point increase in the PSS-4 score was associated with lower total brain volume and 7% greater odds of infarction after adjusting for history of hypertension and other covariables (Aggarwal et al., 2014). Another recent longitudinal research that evaluated the association of PSS-4 and executive functioning in old age showed that greater PS in the first wave of data collection predicted a steeper subsequent decline in executive functioning (Ihle et al., 2020). Moreover, the authors examined whether this longitudinal relationship differed by markers of cognitive reserve taking into account sociodemographic and clinical covariates. They verified the longitudinal relationship between PS and subsequent decline in executive functioning might be attenuated in individuals who have accumulated greater cognitive reserve through an engaged lifestyle (Ihle et al., 2020).

Regarding the association between PS and QoL, our results differ from others found in the literature. Meira et al. (2020) found a negative correlation between PS and all QoL domains: physical, psychological, social, and environmental in undergraduate students. They also found that higher PS was associated with less sleep duration and leisure time. According to the authors, these factors can negatively impact their social relationships and, consequently, worsen their health and QoL (Meira et al., 2020). Undergraduate students are exposed to different types of emotional stressors. In addition to this, they can deal differently with stressful situations. Factors that may help explain the difference between our findings.

Nevertheless, our results demonstrated that the expansion of the cognitive and behavioral repertoire to deal with stressful situations, with a focus on increasing the use of emotion-focused coping strategies, could be important psychological strategies for hypertensive patients with high levels of PS. In this sense, future research should focus on developing interventions for hypertensive patients to be fully assisted through programs aimed at emotional regulation, and adaptive coping strategies learning for the effective reduction of stress.

Finally, it is important to consider some of our study limitations. In the first place, this is a cross-sectional study design. In this way, we can not assume causality. Furthermore, the small sample size also could impact the effect size. This is an important issue that will be solved by larger further studies. Despite that, it was the first study that verified the relationship between PS and EF, coping strategies, and QoL in hypertensive patients, adjusting for sociodemographic and clinical control variables. Our results will be helpful for further investigations. Besides that, we included a variety of methods to assess EF that are extensively used in literature (Ferreira and Cunha, 2015; Moraes et al., 2019; Paradela et al., 2021), although they have low ecological validity. That is, they did not evaluate the emotional/motivational component of the EF. Furthermore, although we adjusted our analyses for some demographic and clinical variables, it is possible that unmeasured confounders were present, such as mental disorders or other clinical conditions.

We found that higher scores of perceived stress were associated with lower scores of emotional-focused positive coping responses. However, perceived stress was not related to problem-focused and dysfunctional coping, executive function performance, or any domain of quality of life.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Comitê de ética do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. The patients/participants provided their written informed consent to participate in this study.

LT, RP, and MI: conception and design of the work. LT, RP, and LM: acquisition, analysis, or interpretation of data for the work. DC, RP, and MI: drafting the work or revising it critically for important intellectual content. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.