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Blood Pressure

ISSN: 0803-7051 (Print) 1651-1999 (Online) Journal homepage: http://www.tandfonline.com/loi/iblo20

Blood pressure and heart rate of students


undergoing a medical licensing examination

Andreas Zeller, Daniel Handschin, Niklaus Gyr, Benedict Martina & Edouard
Battegay

To cite this article: Andreas Zeller, Daniel Handschin, Niklaus Gyr, Benedict Martina & Edouard
Battegay (2004) Blood pressure and heart rate of students undergoing a medical licensing
examination, Blood Pressure, 13:1, 20-24, DOI: 10.1080/08037050310025645

To link to this article: http://dx.doi.org/10.1080/08037050310025645

Published online: 08 Jul 2009.

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BLOOD PRESSURE 2004; 13: 20±24

Blood Pressure and Heart Rate of Students Undergoing a Medical Licensing


Examination

ANDREAS ZELLER, DANIEL HANDSCHIN, NIKLAUS GYR, BENEDICT MARTINA AND


EDOUARD BATTEGAY
From the Medical Outpatient Department and Hypertension Clinic, Department of Internal Medicine, University Hospital, Basel,
Switzerland

Zeller A, Handschin D, Gyr N, Martina B, Battegay E. Blood pressure and heart rate of students
undergoing a medical licensing examination. Blood Pressure 2004; 13: 20–24.
Aims: To assess the effect of a real life mental stress situation on blood pressure (BP) and heart rate (HR)
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in students undergoing a medical licensing examination. Method: Prospective observational study of 121
medical students taking the final licensing exam. BP and HR were taken before and after the exam.
Additionally, BP was measured by ambulatory BP monitoring device and HR was recorded continuously
by an HR monitor belt in 25 students throughout the examination. Major findings: Diastolic BP (DBP)
increased from 81  10 mmHg before the exam to 86  9 mmHg (p = 0.008) during the exam and to
88  11 mmHg, (p = 0.007) 15 min after the exam. Systolic BP (SBP) did not increase significantly
during (from 131  14 before the exam to 136  18 mmHg) and after the exam (135  16 mmHg). HR
decreased during (to 100  18 beats/min, p < 0.001), and after the exam (to 95  19 beats/min,
p < 0.001) compared to values before the exam (114  19 beats/min). SBP was higher in male students
compared to female students before (138  10 vs 125  18 mmHg) and after (126  18 vs
115  17 mmHg) the exam (p < 0.01). Conclusion: Only DBP increased during medical licensing
examination, albeit within a small range. SBP did not change significantly and HR decreased during the
exam. Male students showed a higher SBP compared to female students. Key words: blood pressure,
cardiovascular reactivity, medical education, medical examination, mental stress.

INTRODUCTION MATERIALS AND METHODS


Between 120 and 140 medical students take their final
Psychological stimuli influence cardiovascular reactivity medical exam each year at the Medical School of the
[1], and mental activity can induce blood pressure (BP) University of Basel, Switzerland. The final exam consists
changes [2]. In animal models, mental stress raises arterial of more than a dozen partial exam sessions in the different
BP and heart rate (HR) due to increased sympathetic realms of clinical medicine. One of these exams, the exam
activity [3]. Of course, real life stress conditions also alter in ambulatory general internal medicine, takes place at
cardiovascular response in doctors. Increased HR in- the Medical Outpatient Department. The exam is divided
dicates psychological stress in cardio-thoracic surgeons into three parts; an initial part with 10 min of observed
[4] and anesthesiologists during anesthesia [5]. Further- history-taking, 60 min of unobserved data gathering and
more, BP is significantly elevated in physicians on call clinical examination, and a final 20 min of oral presenta-
[6–9]. tion and discussion of the patient’s problems and potential
A decisive and stressful situation in every doctor’s management with the examiner.
career is the final medical licensing examination. All 121 students taking the final exam in November
Interestingly, only few studies have assessed the cardio- 2002 were asked to participate in the study during the
vascular response during medical examinations [10, 11]. above-mentioned exam. All students were different from
This study aimed at evaluating HR and BP throughout a the students who had taken the exam a year before and
medical licensing examination. Furthermore, we at- had been investigated in another study [12]. Written
tempted to explore the influence of gender, family history informed consent was obtained from all subjects. The
of hypertension and medication on the above-mentioned study was approved by the Ethical Committee of the
parameters. We also assessed student’s subjective percep- Cantons of Basel-Stadt and Basel-Land. Students formed
tion of cardiovascular parameters, i.e. BP and HR, as 25 groups, each including four or five individuals. In each
compared to the actually measured values before and after group, one student was selected by dice and asked for
the exam. non-invasive ambulatory BP monitoring (ABPM; Space-
 2004 Taylor & Francis on licence from Blood Pressure. ISSN 0803-7051
DOI 10.1080/08037050310025645 BLOOD PRESSURE 2004
Blood pressure during medical school examination 21

Table I. Blood pressure (BP) and heart rate in all students RESULTS
(n = 121) before the examination measured by sphygmo-
manometry (mean  standard deviation) Of 121 students enrolled, 57 (47.1%) were men and 64
(52.9%) were women, aged 25–29 years. All 121 students
Characteristics of students before the examination (n = 121) had BP readings by sphygmomanometry before the exam.
Systolic BP 132  17 mmHg Characteristics of the all studied subjects are summarized
Diastolic BP 81  8 mmHg in Table I. There was no difference of SBP and DBP in
Heart rate 112  18 beats/min students with positive or negative family history of
History of hypertension None of the students hypertension.
Family history of hypertension 36/121 (29.8%) Eight (32%) of 25 students investigated by ABPM had
BP values >140 and/or 90 mmHg before the exam.
Nineteen students (76%) showed an initial HR > 100
beats/min (highest measured HR 153 beats/min). Mean
SBP and DBP, and HR before, during and after the exam
Labs1) and asked to wear an HR monitoring belt
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are shown in Table II.


(POLAR S610 1) during the exam. This latter device Five of 25 students measured by ABPM came to the
permits the recording of heartbeats every 15 s. None of follow-up visit. Approximately 1 month after the
the 25 students that were asked rejected inclusion into the examination, mean SBP and DBP were significantly
study. Systolic BP (SBP), diastolic BP (DBP) and HR lower compared to values throughout the examination
were taken 5 min before, three times during and 5 min (SBP: 115  9 mmHg vs 126  6 mmHg, p = 0.001;
after the exam. In all 121 students, BP was taken 15 min DBP: 72  9 mmHg vs 81  7 mmHg, p < 0.001).
before and immediately after the exam using a standard SBP before the exam was significantly higher in male
sphygmomanometer. HR was measured by taking the students than in female students (138  10 mmHg vs
radial pulse. BP readings were taken according to current 125  18 mmHg, p = 0.003). DBP was slightly, but not
guidelines [13]. significantly, higher in males compared to females
For analysis, SBP and DBP readings during the exam (85  7 mmHg vs 81  9 mmHg) (Fig. 1). After the
are expressed as the average value of the three readings exam, both SBP (126  18 mmHg vs 115  17 mmHg,
during the exam. Students wearing the ABPM device p = 0.008) and DBP (80  7 mmHg vs 75  8 mmHg,
during the exam were requested to return for follow-up p = 0.001) remained higher in men than in women.
BP monitoring 1 month after the examination. SBP and DBP estimated by all students before the
In addition, all participants filled a questionnaire about exam were comparable with effectively measured BP
personal or family history of hypertension, regular intake values (Table III). SBP and DBP were overestimated after
of medication and drugs taken within 12 h before the the exam (p < 0.001). Pulse rate was underestimated
exam. Furthermore, students were asked to record their before the exam (p < 0.001).
own estimated BP and HR before and after the exam Sixteen of the 121 students (13.2%) reported having
without knowing their measured values. taken drugs within 12 h before the exam. Two students
Results are expressed as means  standard deviation (1.7%) regularly took antidepressants (fluoxetin and St.
(SD). Qualitative parameters are given as a proportion John’s wort). Six students (5%) took beta-blocking agents
(percentage). Differences were calculated by Student’s t- (propranolol) at a maximum dosage of 10 mg within 2 h
test and correlations by Pearson Product Moment before the exam and one student took lorazepam 12 h
Correlation. Statistical tests were performed with GB- before the examination. BP and pulse rates were not
STAT1 for Windows, Version V6.0, Dynamic Micro- significantly influenced in these students (data not
systems Inc. (Silver Spring, Maryland, USA). shown). Four students (3.3%) took over-the-counter drugs

Table II. Blood pressure (BP) and heart rate (HR) during a medical licensing examination in 25 students measured by
ambulatory BP monitoring device

Systolic BPa (mean  SD) (mmHg) Diastolic BPb (mean  SD) (mmHg) HRb (mean  SD) (beats/min)
Before oral exam 131  14 81  10 114  19
During oral exam 136  18 86  9 100  18
After oral exam 135  16 88  11 95  19

SD, standard deviation. aNo significant changes in SBP. bSignificant increase in DPB (p < 0.0001), significant decrease in HR
(p > 0.0007).

BLOOD PRESSURE 2004


22 A. Zeller et al.

during acute mental stress might be the young age of the


examinees. Age appears to be an important determinant of
the magnitude of cardiovascular adjustment during
mental stress [15, 16]. HR seemed to be a more sensitive
indicator of stress and cardiovascular reactivity. Similarly
to another study [17], we found a high peak in HR shortly
before the exam, followed by a significant decline briefly
during the exam. The initial peak in HR is compatible
with a substantial increase of sympathetic activity.
A positive family history of hypertension had no
influence on BP and HR throughout the examination. Our
findings are in concordance with a review of several
studies showing no consistent association of positive
family history of hypertension and cardiovascular reac-
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tivity [18]. However, some authors have assumed that a


positive family history of hypertension tends to be
associated with increased cardiovascular response to of
Fig. 1. Difference between systolic blood pressure (SBP) and mental stress [6, 19, 20]. This inconsistency of observa-
diastolic blood pressure (DBP) regarding males versus females tions may be due to the heterogeneity of study popula-
in all students (n = 121) before the examination measured by tions, distinct stressors and the variable inheritance of risk
sphygmomanometry.
for hypertension.
Male students showed higher BP levels than female
containing valerian extracts, vitamins and ginkgo biloba students. These findings were significant, except for DBP
preparations. before the exam, and may indicate an increased
sympathetic response to mental stress in men compared
to women. Thus, mental stress tests elicited different BPs
DISCUSSION in healthy men compared to healthy women [20].
Stressful real-life situations influence arterial BP and HR Examinations produced higher values of stress hormones
also in medical doctors, e.g. all parameters of ABPM such as adrenaline, noradrenaline or cortisol in men
increased in young physicians on call [6]. Similarly, compared to women [21]. Mental stress situations
anesthesiologists showed a significantly transient increase increased blood viscosity more in men than in women
of HR and arterial BP during anesthesia compared with [22]. Hypothetically, such gender differences in the
normal morning baseline values [5]. response to stress may contribute to higher cardiovascular
Our study investigated BP and HR in students under- risk in men.
going a medical licensing examination. Only DBP To our knowledge, no data are published on the
increased during the examination, whereas SBP did not percentage of students taking “calming” medication
change significantly. A very similar BP response occurred before an examination. Beta-blockers are widely used as
in medical students during a written medical examination tranquilizing agents for acute stress situations [23–25],
[14]. The increase of BP in our study was small in range, performance [26, 27] or anxiety [28], although the
and BP values were in the low hypertensive levels. A efficacy of beta-blockers in this indication is poorly
possible explanation for the only moderate changes in BP documented [29]. The six students taking beta-blockers in

Table III. Blood pressure and heart rate estimated by students and effectively measured before and after exam in all
students (n = 121)

Estimated by students Effectively measured p-valuea


SBP before exam 129  12 132  17 ns
DBP before exam 83  7 81  8 ns
HR before exam 84  11 102  17 p < 0.001
SBP after exam 126  11 119  19 p < 0.001
DBP after exam 80  7 77  7 p < 0.001
HR after exam 82  16 84  14 ns

SBP, systolic blood pressure in mmHg; DBP, diastolic blood pressure in mmHg; HR, heart rate in beats per minute; ns, not
significant. Blood pressure measurement by mercury sphygmomanometry. aStudents t-test.

BLOOD PRESSURE 2004


Blood pressure during medical school examination 23

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