European Journal of Cardiovascular Medicine

Exam stress can significantly affect cardiac autonomic functions, leading to notable physiological changes. Research indicates that stress responses can alter heart rate variability (HRV) and blood pressure, reflecting the autonomic nervous systems (ANS) activity during stressful situations. For instance, a study found that adolescent’s exhibit marked changes in cardiac autonomic balance during acute stress, which can affect their overall cardiovascular health [1]. Additionally, psychological interventions aimed at managing stress have shown improvements in cardiac autonomic control, suggesting that stress management can mitigate adverse effects on heart function [2]. Furthermore, understanding the mechanisms behind these stress responses is crucial for developing effective interventions, as chronic stress can lead to long-term cardiovascular issues [3]. Overall, recognizing the influence of exam-related stress on cardiac functions is essential for promoting better health outcomes in adolescents.

Medical students are very vulnerable to stress, particularly during exams time. The present study is carried out on medical students to assess the effect of exam stress on cardiovascular autonomic functions.

A total of 33 first-year M.B.B.S. students participated in the study, with the first-term internal examination serving as the stress trigger. All participants were free from any illnesses, and written informed consent was obtained. A detailed history was collected, including age, sleeping, and reading habits over the past week. Based on their sleeping hours, the students were divided into two groups: Group I consisted of students who did not take afternoon naps and group II consisted of students who did take afternoon naps. Resting pulse rate (PR) and blood pressure (BP) were recorded after 5 minutes of rest in a seated position, as well as during handgrip and the Valsalva maneuver, with at least a 5-minute interval between measurements.

All recordings were taken one hour prior to the exam and immediately after it. Blood pressure was measured using the mercury sphygmomanometer. Mean and standard deviation values for age, sleep duration, pulse rate, and blood pressure were calculated.  Statistical significance of the data was measured by applying paired & unpaired t test appropriately. The statistical significance of the data was evaluated using paired and unpaired t-tests, with p < 0.05 considered statistically significant.

Table 1: Age & sleeping time

*p<0.05

Table 1 demonstrate the results of Age: Both groups are similar in age, with Group I averaging 17.71 years and Group II averaging 17.73 years, total Sleep: Group I has significantly less sleep (4.85 hours) compared to Group II (6.3 hours), indicated by the asterisk (*), suggesting a statistically significant difference.

Table 2: Comparison of PR & BP before & after exam in group I

*p<0.05 PR-pulse rate SBP&DBP-systolic &diastolic blood pressure.

The data examines cardiovascular responses in adolescents before and after an exam across three conditions: Resting, Hand Grip, and Valsalva. Key findings reveal that: Resting: Pulse Rate (PR) significantly decreased from 88 bpm to 78 bpm post-exam. Systolic Blood Pressure (SBP) slightly increased from 114 mmHg to 117 mmHg, while Diastolic Blood Pressure (DBP) remained stable around 74 mmHg. Hand Grip: PR significantly dropped from 95.71 bpm to 82.28 bpm. SBP increased slightly from 121.42 mmHg to 123.14 mmHg, and DBP rose significantly from 77.71 mmHg to 82 mmHg. Valsalva: PR decreased significantly from 85.14 bpm to 72 bpm. SBP increased significantly from 120.5 mmHg to 130 mmHg, while DBP showed a slight increase from 77.42 mmHg to 79.14 mmHg. Overall, these results indicate a notable cardiovascular stress response during exams, characterized by decreased heart rates and variations in blood pressure [Table 2, Fig. 1 & 2].

Table 3: Comparison of PR & BP before & after exam in group II

***p<0.001  **p< 0.01  *p<0.05

The data presents cardiovascular responses before and after an exam across three conditions: Resting, Hand Grip, and Valsalva. Key findings include: Resting: Pulse Rate (PR) significantly decreased from 83.26 bpm to 75.26 bpm. Systolic Blood Pressure (SBP) dropped significantly from 118 mmHg to 110 mmHg. Diastolic Blood Pressure (DBP) decreased significantly from 77.89 mmHg to 72.1 mmHg. Hand Grip: PR decreased from 87.57 bpm to 81.57 bpm. SBP declined from 121.15 mmHg to 114.94 mmHg. DBP decreased from 80 mmHg to 76.2 mmHg. Valsalva: PR significantly dropped from 78.31 bpm to 70.73 bpm. SBP decreased from 128.73 mmHg to 118.84 mmHg. DBP remained relatively stable, changing slightly from 79.57 mmHg to 77.57 mmHg. Overall, significant decreases in pulse rate and blood pressure were observed after the exam across all conditions, highlighting the physiological impact of exam stress [Table 3, Fig. 1 & 2].

The findings of the study indicate that both groups of adolescents are comparable in age, with Group I averaging 17.71 years and Group II at 17.73 years. This similarity in age helps to control for potential age-related confounding variables that could influence physiological responses. However, the most striking difference lies in the total sleep hours reported by the two groups. The implications of these findings extend beyond immediate academic performance; chronic sleep deprivation can have long-term effects on mental health, including increased risks for anxiety disorders and depression. It is essential for educational institutions and caregivers to recognize the importance of adequate sleep for adolescents, particularly during high-stress periods like exams. All these findings are supported by various study conducted in the past; Walker in 2006 discusses the critical role of sleep in cognitive function and memory consolidation, highlighting its importance during stress periods like exams [4]. Review of Dewald-Kaufmann examines how sleep quality and duration affect academic performance, emphasizing the significance of adequate sleep for adolescents [5]. The article published by Becker explores the relationship between sleep patterns and cardiovascular health, particularly in young populations [6]. The study conducted by Lund, H. G analyzes sleep patterns in adolescents and identifies factors that contribute to sleep disturbances, with implications for stress management [7].

In resting condition, for both groups PR decreased significantly, indicating a common response to exam stress. However, while the first group shows a slight increase in SBP, the second group indicates a significant decrease in both SBP and DBP, suggesting a more pronounced cardiovascular response in the second group. In the Hand Grip exercise, both groups show a decrease in PR, but the first group indicates an increase in SBP, while the second group shows a significant decrease in both SBP and DBP. This suggests that the Hand Grip exercise may provoke different cardiovascular responses depending on the group. In the Valsalva maneuver, Again, both groups show a significant drop in PR. However, the first group indicates an increase in SBP, contrasting with the second group, which shows a decrease. This divergence highlights different physiological responses to the Valsalva maneuver between the two groups. Both groups reveal significant decreases in pulse rates and variations in blood pressure after the exam, indicating a cardiovascular stress response. However, the differences in SBP and DBP responses suggest that individual factors or group characteristics may influence physiological reactions to exam-related stress. Further investigation into these factors could enhance understanding of how stress affects cardiovascular health in adolescents.

The study by Toivonen, E, et al. explores the relationship between perceived stress and cardiovascular health in adolescents, providing insights into individual factors influencing stress responses [8]. Wang et al. discusses how different perceptions of stress can affect mental health and physiological responses, relevant to understanding variability in stress reactions [9]. Editorial by Jalaludin, J outlines how unmanaged stress can have detrimental effects on cardiovascular health, emphasizing the importance of understanding stress responses in different populations, including adolescents [10].

The significant difference in PR in both groups & BP in group II before & after the exam across all the conditions occurs possibly because of sympathetic activation. The raised cortisol levels may contribute to increased alertness that reflects in decreased hours of sleep before exam especially in Group I. Persistent raised BP after the exam in group I may be due to an abnormal sympathetic nerve activity at rest & in response to stressors.

LIMITATONS OF THE STUDY

We cannot overlook the impact of reduced sleep on autonomic functions, which would necessitate a controlled trial focused on sleep reduction without the presence of other stressors. A study involving a larger sample size and measuring heart rate variability as an indicator of autonomic function would provide conclusions that are more definitive.

The analysis of cardiovascular responses in adolescents during exam-related stress reveals significant decreases in pulse rates and notable variations in blood pressure across both groups. These findings underscore a clear physiological stress response associated with academic pressures. However, the observed differences in systolic and diastolic blood pressure indicate that individual characteristics or group dynamics may play a crucial role in shaping physiological reactions to stress. Understanding these variations is essential for developing targeted interventions to mitigate stress and its potential adverse effects on cardiovascular health in adolescents. Future research should focus on identifying the underlying factors that contribute to these differences, thereby enhancing our comprehension of the complex relationship between stress and cardiovascular function in this vulnerable population.

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