Psychological stress and diastolic blood pressure in cardiology outpatients: a multicenter cross-sectional study (from the ABC2X-2026 study)

Background Psychological stress is increasingly recognized as an independent cardiovascular risk factor, yet its hemodynamic correlates in routine cardiology practice remain little characterized. In particular, the clinical implications of distinguishing between ongoing and previous stress have been seldom explored. Methods This multicenter cross-sectional study was conducted across three cardiology outpatient clinics in Northern Italy. Between 2019 and 2025, a total of 675 consecutive adult patients undergoing their first outpatient evaluation were enrolled. Psychological stress was assessed through a structured physician-guided clinical interview and categorized as no stress, present stress, or previous stress. Blood pressure (BP), heart rate (HR), clinical characteristics, and lifestyle factors were recorded during the visit. Multinomial logistic regressions were used to identify determinants of stress timing and stressors, while linear regression models were used to evaluate associations between stress (present and previous) and cardiovascular parameters. Results Overall, 373 patients (55%) reported psychological stress: 264 (39%) had present and 109 (16%) previous stress. Present stress was independently associated with younger age, female sex, lower physical activity, and anxiolytic treatment, whereas previous stress was independently associated with post-COVID enrollment. In multivariable linear regression models, present stress was independently associated with higher diastolic blood pressure (DBP) ( β = 3.0 ± 0.9 mmHg, p = 0.001), whereas previous stress was not. Neither present nor previous stress was significantly associated with systolic BP or HR. Interaction analyses showed that the association between present stress and DBP became more evident with increasing age (β = 0.15 ± 0.06 mmHg, p = 0.007) and was significantly much stronger in patients with coronary artery disease (CAD) (β = 5.9 ± 2.4 mmHg, p = 0.01). Conclusions In cardiology outpatients, psychological stress is highly prevalent and shows distinct hemodynamic correlates according to its timing. Ongoing, but not previous, stress is independently associated with higher DBP, particularly among elderly, and patients with CAD. Routine assessment of psychological stress may improve cardiovascular risk stratification in outpatient practice.