ANXIETY MAY MODULATE CARDIAC AUTONOMIC MODULATION AND BLOOD PRESSURE LEVELS IN HYPERTENSIVE OLDER WOMEN

Correspondence: Carlos José M. Dias, Physical Education Course, Federal University of Maranhão (UFMA), Pinheiro - MA, BRAZIL. Email: [email protected]. 99 ANXIETY MAY MODULATE CARDIAC AUTONOMIC MODULATION AND BLOOD PRESSURE LEVELS IN HYPERTENSIVE OLDER WOMEN LUCAS MIQUEIAS SILVA ABREU1,3; FELIPE BISPO RIBEIRO JÚNIOR1,3; MICHELE BRITO CORREIA1; MANUELLY ESTEFANNY VIEIRA PEREIRA1; AUGUSTO RIBEIRO DE OLIVEIRA2; JAMES CARLOS PEREIRA GOMES1; VALDIRA CARVALHO GOMES CONCEIÇÃO1; KARINA HELLEN DE SOUZA DE OLIVEIRA1,3; HERIKSON ARAÚJO COSTA3,5; CRISTIANO T. MOSTARDA2,3,4; CARLOS ALBERTO ALVES DIAS-FILHO1; CARLOS BENJAMIM LINO MORAES DIAS1; CARLOS JOSÉ MORAES DIAS1,3* 1Laboratory of Cardiorenal Adaptations to Physical Exercise (LACE), Federal University of Maranhão (UFMA), Pinheiro - MA, BRAZIL. *Email: [email protected]. 2Laboratory of Cardiovascular Adaptations to Exercise, Federal University of Maranhão, São Luis-MA, BRAZIL. 3Postgraduate Program in Physical Education, Universidade Federal do Maranhão, São Luís, MA, BRAZIL. 4Postgraduate Program in Adult Health, Federal University of Maranhão, São Luís-MA, BRAZIL. 5Center for Studies and Research in Physical Activity (NAFS), Federal University of Maranhão (UFMA), Pinheiro - MA, BRAZIL. How to cite this article: Abreu, L.M.S., Junior, F.B.R., Correia, M.B., Pereira, M.E.V., DeOliveira, A.R., Gomes, J.C.P., Conceicao, V.C.G., DeOliveira, K.H.D.S., Costa, H.A., Mostarda, C.T., Dias-Filho, C.A.A., Dias, C.B.L.M, & Dias, C.J.M. (September 2025). Anxiety may modulate cardiac autonomic modulation and blood pressure levels in hypertensive older women. Journal of Physical Education Research, Volume 12, Issue III, 01-07. Received: July 16, 2025 Accepted: September 09, 2025 ABSTRACT Arterial hypertension is highly prevalent among older women, particularly due to hormonal changes following menopause. This condition may lead to cardiac autonomic dysfunction, which is often exacerbated by mental health disorders such as anxiety and depression—both commonly found in this population. The present study aimed to analyze the effects of anxiety levels on cardiac autonomic modulation and depression levels in hypertensive older women. This crosssectional study involved 44 hypertensive women aged 60 years or older, who were divided into three groups according to their anxiety levels based on the Beck Anxiety Inventory: minimal (n=20), mild (n=10), and moderate (n=14). The study assessed anthropometric variables, body composition, blood pressure, heart rate variability (HRV), sleep quality, and depressive symptoms. Statistical analysis included ANOVA, the Kruskal–Wallis test, and correlation analyses. The results showed that the group with moderate anxiety presented higher sympathetic activity (LF), reduced parasympathetic modulation (HF), worse autonomic balance indicated by a higher LF/HF ratio, and increased depression levels when compared to the group with minimal anxiety. Additionally, a positive correlation was observed between anxiety and depression, while a negative correlation was found between anxiety and HF, suggesting an influence of anxiety on autonomic imbalance. In conclusion, higher levels of anxiety are associated with greater cardiac autonomic dysfunction and more severe depressive symptoms in hypertensive older women. These findings underscore the importance of addressing mental health as part of the multidisciplinary clinical care provided to this vulnerable population. Keywords: Anxiety, hypertension, older women, cardiac autonomic modulation, depression. Journal of Physical Education Research, Volume 12, Issue III, September 2025, pp.01-07 ISSN: Print-2394 4048, Online-2394 4056 Abreu, L.M.S. et al. (September 2025). Anxiety may modulate cardiac autonomic modulation and blood pressure levels in hypertensive older women. Journal of Physical Education Research, Volume 12, Issue III, 0107. JOPER® www.joper.org JOPER 2 1. INTRODUCTION According to the guidelines of the World Health Organization (WHO), any individual aged 60 years or older is considered elderly (Travassos, Coelho, & Arends-Kuenning, 2020). This population presents greater healthcare needs, and, as a result, managing the health of older adults becomes more complex (Veras, Oliveira, & Coletiva, 2018). These complications may increase the likelihood of developing cardiovascular diseases, such as arterial hypertension (Oliveros et al., 2020), especially in older women due to postmenopausal changes, such as the decline in estrogen levels (Gao, Chen, Sun, & Deng, 2019). This condition may facilitate the emergence of health complications in these elderly women. One of the main causes of health impairment in older women is arterial hypertension, which is currently one of the most prevalent cardiovascular diseases in the country, especially among elderly populations (Oliveira et al., 2022). The higher prevalence of hypertension in older women may result from physiological changes associated with aging, such as worsened endothelial function and increased arterial stiffness (Kim, 2023). In addition, older individuals tend to exhibit poorer cardiac autonomic modulation. The so-called cardiac autonomic dysfunction is directly associated with arterial hypertension, in which this dysfunction is characterized by an exacerbated activation of the sympathetic component (Seravalle & Grassi, 2022). This leads to autonomic imbalance, thus resulting in a poor prognosis for the individual's cardiovascular health. In addition to cardiovascular complications, arterial hypertension has been shown to be associated with the onset and worsening of anxiety disorders (Santos-Veloso et al., 2019), which are characterized by symptoms such as persistent worry, social and performancerelated phobias, among others (Szuhany & Simon, 2022). Moreover, the prevalence of anxiety tends to increase with age, which may result from the influence of social, economic, and health-related conditions (Jalali et al., 2024). Elderly populations also present a higher prevalence of depression, which may be explained by psychological factors such as changes in self-image, perceived uselessness, and low self-esteem (Hu et al., 2022). In addition, the prevalence of depression is associated with cardiovascular diseases such as hypertension (Krittanawong et al., 2023). It is also observed that both anxiety disorders and depression are more prevalent in elderly and hypertensive populations. Moreover, both conditions are associated with worsening cardiovascular health (Turana et al., 2021), which further highlights the need for research investigating the possible effects of interactions between these health conditions in hypertensive older women, who are already naturally more exposed to these and other health risk factors. To analyze the effects of anxiety levels on cardiac autonomic modulation and depression levels in hypertensive older women. 1. MATERIAL AND METHODS 2.1 Experimental Design This is a cross-sectional study in which the sample was divided into groups. According to the classification of anxiety levels from the Beck Anxiety Inventory, three groups were formed: Minimal Anxiety Group (MAG), Mild Anxiety Group (MiAG), and Moderate Anxiety Group (MoAG). 2.2 Study Location The study was conducted in Basic Health Units (BHUs) in the municipality of Pinheiro, Maranhão, Brazil. Abreu, L.M.S. et al. (September 2025). Anxiety may modulate cardiac autonomic modulation and blood pressure levels in hypertensive older women. Journal of Physical Education Research, Volume 12, Issue III, 0107. JOPER® www.joper.org JOPER 3 2.3 Sample The sample consisted of hypertensive older women who met the inclusion criteria, and were divided into three groups based on the anxiety level identified by the Beck Anxiety Inventory. The groups were: MAG, with n = 20; MiAG, with n = 10; and MoAG, with n = 14. 2.4 Inclusion Criteria Older women with hypertension were included if they had sufficient cognitive capacity to understand the research process, sign the Informed Consent Form, and voluntarily agree to participate in the study. 2.5 NonInclusion Criteria Participants were not included if they had communication impairments that prevented the application of questionnaires; lacked the cognitive capacity to understand the research process and sign the Informed Consent Form; or declared that they were not taking their prescribed antihypertensive medication. 2.6 INSTRUMENTS AND PROCEDURE The volunteers underwent a sequence that included anamnesis, followed by the completion of anxiety, depression, and sleep quality questionnaires. They also underwent an electrocardiogram and blood pressure measurement. 2.7 Anamnesis The selected individuals were informed about the risks and benefits of the study and signed the Informed Consent Form. Subsequently, they completed a sample characterization questionnaire, which included information on personal, sociodemographic, and socioeconomic characteristics, as well as current health history. 2.8 Questionnaire Administration The assessments were carried out after the completion of the anamnesis. These included the Beck Anxiety Inventory and the Beck Depression Inventory. 2.9 Beck Anxiety Inventory (BAI) The BAI assesses the intensity of anxiety symptoms through self-report. This scale contains 21 items that describe various anxiety symptoms. Participants are asked to indicate how much they have been bothered by each symptom over the past week. Each item is rated on a 4-point scale, ranging from 0 (not at all) to 3 (severely). The total score is calculated by summing the responses, resulting in a score ranging from 0 to 63 (Cunha, 2001). The BAI classifies anxiety levels based on the total score obtained, as follows: 0–10 indicates minimal anxiety; 11–19, mild anxiety; 20–30, moderate anxiety; and 31–63, severe anxiety. 2.10 Beck Depression Inventory (BDI-II) The BDI-II, presented in Appendix 4, is a scale that measures the severity of depressive symptoms through 21 items, each with four response options ranging from 0 to 3 (16). The sum of all item scores results in a maximum possible score of 63. Scores of ≤9 indicate absence of depression; 10–18, mild depression; 19–29, moderate depression; and 30–63, severe depression (Gomes-Oliveira, Gorenstein, Lotufo Neto, Andrade, & Wang, 2012). 2.11 Body Composition Assessment Three measurements were taken for each participant using anthropometric procedures, including weight and height measurements with a scale and a stadiometer, followed by the calculation of Body Mass Index (BMI). Prior to the assessment, participants were instructed regarding appropriate clothing and other precautions for the evaluation day. 2.12 Assessment of Cardiac Autonomic Modulation Heart Rate Variability (HRV) was recorded using a 12-lead electrocardiograph (Wincardio, Micromed) in conjunction with the KUBIOS HRV Scientific software, version 4.1.0. All volunteers were taken to a quiet environment and remained in the supine position for 10 minutes. During this period, the periodic fluctuation of heart rate and the minute-by-minute intervals of cardiac beats (RR intervals) were recorded (Ernst, 2017). Abreu, L.M.S. et al. (September 2025). Anxiety may modulate cardiac autonomic modulation and blood pressure levels in hypertensive older women. Journal of Physical Education Research, Volume 12, Issue III, 0107. JOPER® www.joper.org JOPER 4 2.13 Blood Pressure Measurement Blood pressure was measured by a trained member of the research team. Participants were required to rest for at least 5 minutes while seated, after which blood pressure was measured three times at 1-minute intervals. This procedure was standardized, and the same automatic blood pressure monitor (Omron HEM-7320-BR) was used for all participants during all evaluations (Zhang et al., 2021). 2.14 Ethical Considerations This study is part of a larger project entitled: Effects of Aerobic Training on Cardiorenal Adaptations and Cardiac Autonomic Modulation in Hypertensive Individuals, which was submitted on July 21, 2020, at 11:32 a.m. to the Ethics Committee of the Federal University of Maranhão and approved under opinion number: 4.284.220. The research was based on ethical principles involving human subjects and followed the guidelines of Resolution 466/12 of the Brazilian National Health Council (CNS), which outlines the principles of autonomy, non-maleficence, beneficence, and justice, while ensuring data confidentiality and privacy. 2.15 STATISTICAL ANALYSIS Data processing and statistical analysis were performed using GraphPad Prism software, version 9.0.0. Initially, descriptive statistics were conducted using graphs and frequency tables of the analyzed variables, as well as estimates of mean, standard deviation, median, and interquartile ranges. For numerical variables, the Shapiro–Wilk test was applied to assess normality. Levene’s test was used to evaluate sample homogeneity. For variables with homogeneous distribution, a one-way Welch’s ANOVA was conducted, while for variables with non-normal data distribution, the Kruskal–Wallis test was applied. Regarding the post hoc tests: for variables with homogeneous variances, Tukey’s test was used; for those with heterogeneous variances, the Games–Howell test was applied. To test correlations, Pearson’s test was used for variables with normal distribution, and Spearman’s test was applied for non-normally distributed variables. Cohen's f effect size analysis was also performed. The significance level for rejecting the null hypothesis was set at 5%, meaning that p < 0.05 was considered statistically significant. 3. RESULTS Table 1: Characterization of anxiety-related groups based on anthropometric variables, sleep quality, depression, and hemodynamic parameters in hypertensive women Minimal Anxiety (N= 20) Mild Anxiety (N=10) Moderate Anxiety (N=14) P ES Anxiety BAI 4,15±2,56 10,60±2,45 19,14±2,93 <0,001 2,44 Antrhropometry and Body Composition Age (years) 68,70±6,37 71,60±9,53 70,57±7,84 0,6 0,15 Height (m) 1,49±0,04 1,49±0,04 1,46±0,05 0,19 0,3 Weight (Kg) 59,40±6,99 58,85±11,10 59,65±8,03 0,98 0,03 BMI 29,68±3,36 26,42± 5,58 27,99±4,13 0,59 0,14 Depression (BDI-II) 5,50 (0-22) 11,50 (10-13) 14,50 (6-36) * <0,001 0,78 Hemodynamics SBP (mmHg) 145,05±22,70 138,50±23,06 145,92±24,56 0,50 0,12 DBP (mmHg) 81,55±10,05 80,70±10,61 86,21±13,77 0,71 0.20 HR (bpm) 70,32±10,55 75,90±15,29 73,28±7,71 0,49 0,08 The results are presented as mean ± standard deviation for parametric variables and as median with interquartile range for non-parametric variables. One-way ANOVA was used for parametric variables, while the Kruskal–Wallis test was applied to non-parametric variables. A significance level of p ≤ 0.05 was considered statistically significant when compared to the minimal anxiety group. Abbreviations: BAI – Beck Anxiety Inventory; PSQI – Pittsburgh Sleep Quality Index; BDI-II – Beck Depression Inventory-II; ES – Effect Size. Abreu, L.M.S. et al. (September 2025). Anxiety may modulate cardiac autonomic modulation and blood pressure levels in hypertensive older women. Journal of Physical Education Research, Volume 12, Issue III, 0107. JOPER® www.joper.org JOPER 5 Table 1 No statistically significant differences were found in anthropometric, body composition, or hemodynamic variables. However, we observed that the moderate anxiety group presented higher levels of depression compared to the minimal anxiety group, which may be related to the commonly reported association between anxiety and depression in older adults. Table 2: Characterization of anxiety groups based on heart rate variability Minimal Anxiety (N= 20) Mild Anxiety (N=10) Moderate Anxiety (N=14) P ES Mean RR 855,50 (688-1231) 769,50 (673-1390) 842,50 (644-1010) 0,44 0,17 LF (NU) 35,74±12,39 32,49±9,35# 68,78±9,60* <0,001 1,51 HF (NU) 63,91±12,71 65,12±12,97# 31,17±9,61* <0,001 1.30 LF/HF 0,61 (0,08-1,32) 0,49 (0,20-3,02) # 2,12 (0,96-5,19) * <0,0001 0,98 The results are presented as mean ± standard deviation for parametric variables and as median with interquartile range for non-parametric variables. One-way ANOVA was used for parametric variables, and the Kruskal–Wallis test was applied for non-parametric variables. A significance level of p ≤ 0.05 was considered for comparisons: * indicates a significant difference versus the minimal anxiety group, and # indicates a significant difference versus the moderate anxiety group. LF (NU) refers to low-frequency normalized units, HF (NU) to high-frequency normalized units, and ES to effect size. Table 2 The moderate anxiety group showed higher LF (NU) values compared to the mild and minimal anxiety groups, indicating greater sympathetic activation in this group, which may be induced by the higher level of anxiety. This group also presented lower HF (NU) values and higher LF/HF ratios compared to the other groups, suggesting impaired cardiac autonomic modulation. The variables mentioned also showed large effect sizes, indicating a strong influence of group classification on the analysis. In other words, anxiety levels affected the results. Figure 1 a negative correlation was observed between BAI and HF (NU), which may indicate that higher anxiety scores are associated with lower parasympathetic activation in cardiac autonomic modulation. A positive correlation was also observed between anxiety and depression, a relationship that is well described in the existing literature. Abreu, L.M.S. et al. (September 2025). Anxiety may modulate cardiac autonomic modulation and blood pressure levels in hypertensive older women. Journal of Physical Education Research, Volume 12, Issue III, 0107. JOPER® www.joper.org JOPER 6 Figure 2: Correlation plots. Figure A: Pearson correlation between anxiety (BAI) and the parasympathetic component of cardiac autonomic modulation, HF (NU). Figure B: Spearman correlation between anxiety (BAI) and depression (BDI-II). 4. DISCUSSION This study aimed to analyze the effects of anxiety levels on depression and cardiac autonomic modulation in hypertensive older women. The findings indicate that anxiety levels are correlated with increased depression and impaired autonomic regulation in this population. Anxiety levels may influence depression levels in individuals with hypertension (Polishchuk et al., 2021), and this effect was observed in the present study, in which anxiety levels showed a positive correlation with depression levels. This scenario raises concern, as depression is known to be associated with worsening cardiovascular health (Krittanawong et al., 2023). Factors such as anxiety and depression are also associated with worsening cardiovascular health (Patterson, Marcus, Goetz, Vaccarino, & Gooding, 2022), and this condition requires even greater attention in older women, who are naturally more predisposed to developing poorer cardiovascular outcomes (Rodgers et al., 2019). This decline in cardiovascular health among older women occurs as a result of the aging process and is further intensified by the loss of hormonal protection following menopause (Maas et al., 2021). In addition to the hormonal decline that occurs in older women, this population, when affected by hypertension, is also commonly subject to impaired cardiac autonomic modulation, characterized by an exaggerated activation of the sympathetic component (Miller & Arnold, 2022). Moreover, anxiety levels may influence both the prevalence and severity of hypertension in this population (Turana et al., 2021). In line with the literature, our study observed a negative correlation between anxiety levels and HF (NU), indicating reduced parasympathetic activation. In addition, the groups with higher anxiety levels presented increased LF (NU) values, suggesting greater sympathetic activation and a worse sympathovagal balance as indicated by the LF/HF ratio. These factors point to a deterioration in cardiac autonomic modulation (Vanderlei, Pastre, Hoshi, Carvalho, & Godoy, 2009). Regarding blood pressure, our study did not observe significant differences between the groups. However, the association between anxiety and blood pressure remains a subject of debate in the literature. A meta-analysis investigating the relationship between anxiety and hypertension reported that while some studies identified a positive association, others did not, revealing considerable heterogeneity in the findings (Lim, Solmi, Cortese, & Reviews, 2021). Our findings lead us to conclude that anxiety levels are associated with impaired cardiac autonomic regulation (Tomasi, Zai, Pouget, Tiwari, & Kennedy, 2024). This conclusion is further supported by our correlation results, which showed that higher anxiety levels were related to lower vagal autonomic cardiac modulation. This correlation reinforces the influence of anxiety levels on cardiac autonomic dysregulation (Tomasi et al., 2024). 5. 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