Clinical and Experimental Hypertension

ISSN: (Print) (Online) Journal homepage: www.tandfonline.com/journals/iceh20

The effect of auricular acupuncture on

preoperative blood pressure across age groups: a
prospective randomized controlled trial

Jingjing Ma, Yiqing Zhang, Qingqing Ge & Keer Wu

To cite this article: Jingjing Ma, Yiqing Zhang, Qingqing Ge & Keer Wu (2023) The effect of
auricular acupuncture on preoperative blood pressure across age groups: a prospective
randomized controlled trial, Clinical and Experimental Hypertension, 45:1, 2169452, DOI:
10.1080/10641963.2023.2169452

To link to this article: https://doi.org/10.1080/10641963.2023.2169452

© 2023 The Author(s). Published with

license by Taylor & Francis Group, LLC.

Published online: 22 Jan 2023.

Submit your article to this journal

Article views: 3148

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=iceh20
CLINICAL AND EXPERIMENTAL HYPERTENSION
2023, VOL. 45, NO. 1, 2169452
https://doi.org/10.1080/10641963.2023.2169452

The effect of auricular acupuncture on preoperative blood pressure across age

groups: a prospective randomized controlled trial
Jingjing Ma, Yiqing Zhang, Qingqing Ge, and Keer Wu
Department of Nursing, Ningbo Medical Center LiHuili Hospital, Ningbo, China

ABSTRACT ARTICLE HISTORY

Purpose: To determine the effect of auricular acupuncture on preoperative blood pressure (BP) elevation Received 12 August 2022
in different age groups. Revised 31 October 2022
Materials and methods: Auricular acupuncture treats elevated BP among patients before surgery. This Accepted 11 January 2023
prospective, randomized clinical trial was performed at Li Huili Hospital of Ningbo Medical Center, China, KEYWORDS
from January to June 2021. We prospectively enrolled 120 patients with elevated BP aged 45 to 75 and Auricular acupuncture; Blood
observed them in the inpatient department. Patients were randomly assigned in a 1:1 ratio to undergo pressure; Randomized
auricular acupuncture or sham control groups. In addition to usual care, the study group underwent controlled trial; Preoperative;
auricular acupuncture bilaterally at HX6 7i–Ear apex, TF4–Shen men, TF1–Superior triangular fossa, and Hypertension
CO15–Heart.
Results: A total of 120 patients completed the study, 60 in the study group and 60 in the control group. Of
these, 76 (63.3%) were men, and the mean (standard deviation) was 64.55 (9.48) years. The differences in
systolic BP comparisons after intervention were significant (7.88 mmHg; 95% confidence interval [CI], 2.94
to 12.81; P = .002). Diastolic BP also showed statistical significance (5.85 mmHg; 95% CI, 3.05 to 8.64; P <
.01. Neither AA-related adverse events nor serious adverse events occurred. Stratified by age, the
differences comparisons of systolic BP (−10.13 mmHg; 95% confidence interval [CI], −16.69 to −3.57;
P < .01) and diastolic BP (−7.65 mmHg; 95% confidence interval [CI], −11.17 to −4.14; P < .01) were
statistically significant for participants aged 60–75 years; The differences comparison of systolic BP
(−2.37 mmHg; 95% confidence interval [CI], −8.04 to 3.31; P = .40) and diastolic BP (−1.46 mmHg; 95%
confidence interval [CI], −5.68 to 2.76; P = .48) were not significant aged 45–59.
Conclusion: Auricular acupuncture can reduce BP before procedures. However, further research is needed
on the antihypertensive effect on people aged 45–59. These findings provide clinicians with evidence of
auricular acupuncture as a standard adjunctive therapy targeting this patient population.

Introduction Talk and relaxation therapies reduce BP and relieve anxiety;

however, their effects need more research (6).
Preoperative hypertension is a complex problem, encom­
AA is a non-pharmacological treatment that is safe and
passing patients with essential hypertension and those with
effective in clinical practice (7–10). AA can stabilize the auto­
elevated blood pressure (BP) related to surgical stress.
nomic nervous system and reduce BP by activating and sup­
Several studies suggested that preoperative hypertension is
pressing the parasympathetic and sympathetic nervous systems
associated with increased perioperative risk (1,2). The sur­
(11). Several well-designed randomized controlled trials of AA
gery is a severe stressor that can cause vasovagal responses
treating hypertension have been published (12,13). AA has
and unnecessary allostatic loads (3). Preoperative patients
a mild antihypertensive effect and does not cause sharp drops
often produce hypertension via sympathetic nerve excita­
in blood pressure. Nevertheless, there is little evidence of the
tion due to anxiety. Minimizing stressful stimuli accompa­
ability of AA to reduce BP elevated due to the stress surround­
nying procedures is critical but often neglected in hospital
ing surgery. There are few studies on the effect of AA on
routines (4). Preoperative hypertension is a common reason
hypertensive people or in specific age groups. Therefore, we
to cancel or postpone surgery, which will bring quantifiable
designed this study to determine the preoperative pressure
losses of resources and unquantifiable, significant psycho­
effect of AA on patients of different ages.
logical, social, and financial implications for patients and
families (3). Therefore, we focused on preoperative hyper­
tension generated by surgery-related stress that requires Methods/design
immediate resolution.
Design
Medications are used to reduce BP; however, they can cause
unsafe drops in BP, especially in elderly patients. Substantial This study was a randomized trial of AA to treat preoperative
BP variability was significantly associated with coronary ather­ hypertension. The trial was conducted at Li Huili Hospital of
oma progression and major adverse cardiovascular events (5). Ningbo Medical Center from January to June 2021. All patients

CONTACT Jingjing Ma shelleymjj2004@hotmail.com Master, Department of Nursing, Ningbo Medical Center LiHuili Hospital, Ningbo 315000, China

© 2023 The Author(s). Published with license by Taylor & Francis Group, LLC.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits
unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
2 J. MA ET AL.

provided written, informed consent prior to randomization. Recruitment procedures

The Ethics Committee of the Li Huili Hospital of Ningbo
We recruited participants using advertisements for the hospi­
Medical Center approved the trial protocol. Trial registration:
tal. All participants were informed that there were two study
Clinical Trials gov MR-33-20-005594.
groups, i.e., an AA group and a sham control group, with 50%
of the allocation. If patients were taking antihypertensive med­
Participants ications, they were instructed to continue them. All were
informed of their right to withdraw from the trial (Figure 1).
We prospectively enrolled 130 patients from the Li Huili
Hospital of Ningbo Medical Center. Finally, 120 patients
were randomized into two groups (Table 1). Randomization
One appointed investigator was responsible for the randomiza­
tion. Complete randomization was performed using the random
Inclusion criteria
number generator in SPSS 23.0 (IBM Corp, Armonk, NY). After
1. Scheduled for nasopharyngeal surgery under general establishing selection criteria, the recruiters obtained numbers
anesthesia. from the assigning investigator and randomly assigned patients
2. American Society of Anesthesiologists physical status classi­ to the study or control groups. The groups were assigned to
fication of I or II. separate wards to prevent communication.
3. Systolic BP (SBP) ≥ 130 mmHg or diastolic BP (DBP) >
80 mmHg on the day of surgery morning (14).
4. Age 45–75 years. Interventions and comparison
5.Willingness to participate and signed an informed consent Study group
form. In addition to usual care(disease awareness, dietary gui­
dance, exercise, and psychological care), the participants
received AA treatment based on the theory of neuroanatomy
Exclusion criteria
(16), the literature (17,18), and a textbook (19). We chose the
1. Hypertensive crisis (220/140 mm Hg) and DBP 120 to following auricular points(Figure 2): HX6 7i–Ear apex, TF4–
130 mm Hg (15). Shen men, TF1–Superior triangular fossa, and CO15–Heart.
2. History of syncope resulting from applying needles or con­ The licensed acupuncturist had more than 5 years of experi­
traindications to using needles. ence in AA. When the patients were relaxed and prone, the
3. Previous use of opioid or psychotropic medication. acupuncturist held the upper posterior corner of the helix with
4. Canceled surgery. one hand and located sensitive points with an auricular point
5. Complications during treatment (e.g., auricular skin infec­ detector using the other hand. The acupuncturist used 75%
tion or pain). alcohol pads to sterilize the area, then inserted needles

Table 1. Baseline demographic and clinical characteristics.

Mean (SD)
Study group Control group
Characteristic (n = 60) (n = 60) P value
Age, y 63.55(9.82) 65.55(9.10) .25
Body mass indexa 24.59(1.23) 24.74(1.79) .58
Male, No. (%) 37(61.7) 39(65) .70
Medical history, No. (%)
Hypertension 22(36.7) 20(33.3) .70
Diabetes 8(13.3) 4(6.7) .22
Medication, No. (%)
Antihypertensive drugs 22(36.7) 20(33.3) .70
Controlled BP on ≥2drugs 12 (21.7) 11 (18.3) .65
ACE inhibitors/angiotensin receptor antagonists 15 (25.0) 14 (23.3) .83
Calcium channel blockers 7 (11.7) 6 (10.0) .77
Diuretics 12 (20.0) 11 (19.2) .82
Aldosterone antagonist 5 (8.3) 3 (5.0) .71
oral antidiabetics 8(13.3) 4(6.7) .22
Surgical classification 11 (%)
Two-level 25(41.7) 28(46.7) 0.63
three-level 28(46.7) 23(38.3)
four-level 7(11.7) 9(15.0)

1
Surgical classification: In order to ensure the safety of patients, Chinese Ministry of Health issued the “Surgical Classification Catalog” in 2011. According to the risk and
difficulty of the operation, the operation is divided into four grades.

Figure 1. Flow diagram depicting the study design.
Figure 2. Auricular acupuncture used in the study group.
(Figure 3) (length 1.5 mm, diameter 0.22 mm; Seirin Corp,
Shizuoka City, Japan) into the four auricular points bilaterally.
The needles remained in situ. Subsequently, the acupuncturist
instructed the patient to stimulate the auricular needles for 10s,
with a 3-s pause between the two pressings (20). Optimal
stimulation was achieved when the subject felt localized tin­
gling pain. Auricular needles were removed before sending the
patient to the operating room. The patient would enter the
operating room accompanied by transport staff and wait about
15 minutes for anesthesia and surgery.
Control group
The control group received sham acupuncture. Acupuncture
points and manipulation methods of sham acupuncture were
CLINICAL AND EXPERIMENTAL HYPERTENSION 3
Figure 3. Baseline BP was measured the day after admission, BP before AA was
measured at 6:00 on the day of the procedure, and BP after AA was measured
30 min before surgery. BPs between 45 and 75 years old include SBP and DBP.
*P < .05 BP after AA for study group vs control group.
the same as the study group. The fake needle is made of round
tape with a diameter of 1 cm and no sharp needle. Its appear­
ance, color, and shape were identical to the AA needle. Each
acupuncture point received the same twirling motion as the
acupuncture group.
BP measurement
The BP measurement device was validated. We had the patient
relax and sit comfortably in a quiet room at a controlled
temperature of 18–22°C. Neither the patient nor the observer
4 J. MA ET AL.
talked during the measurement. We used the average of two
readings obtained twice to estimate an individual’s BP level.
The measurement interval was 10 minutes. All BP measure­
ments were performed by nurses using the same training
techniques.
Outcome
The primary outcome measure was a change in systolic BP,
measured after AA intervention and immediately before sur­
gery. Secondary outcomes were changes in diastolic BP after
AA intervention and immediately before surgery and adverse
events (i.e., pain, hematomas, skin damage, bleeding, and local
infections) (Figure 3).
Safety and quality control
Adverse events were appropriately assessed and recorded by
the observers. Severe adverse events would have resulted in
stopping the trial. Two investigators independently collected
and recorded the data in a computer to ensure safety and
reliability.
Sample size calculation
The study was powered for a primary outcome measure of the
difference in systolic BP in two groups before and after the
ðZα þZβ Þ�2σ 2
intervention. We used the formula n ¼ δ2
. the study group had no difference in SBP and DBP after the
N represents the sample size in each group, ϭ represents the
standard deviation, and δ represents the between-group differ­
ence with clinical significance. At an α value of 0.05, we
obtained Z scores of Za = 1.28 and Zβ = 0.84 from the
Z score table. The sample size calculation was based on Tu
et al., who showed a decrease of – 8.53 ± 13.50 mmHg in
systolic BP in the control group (13). SBP was expected to
decrease by 8.5 mmHg. A one-sided 0.05 level of significance
provided 80% statistical power. To accommodate a 10% attri­
tion rate, we needed to recruit at least 80 patients.
Statistical analysis
The data were analyzed using SPSS 23.0. Shapiro-Wilk tests
were performed to determine the normality of data distri­
bution. Continuous variables were expressed as means with
standard deviations (SDs), and mean differences were
expressed with two-sided 95% CIs. Between-group differ­
ences at baseline and changes from baseline to the end of
the study were tested using independent t-tests. Paired
t-tests were performed for within-group comparisons from
baseline to the end of the study. Socio-demographic char­
acteristics, disease-related characteristics, and homogeneity
of dependent variables were analyzed using the chi-squared
(χ2) test. The level of significance was a two-sided P-value
less than 0.05.
Results
Recruitment and retention
All of the 120 patients who met the enrollment criteria agreed
to participate. No patient terminated the study prematurely; all
completed the follow-up assessments and were included in the
analysis (Figure 1). Of the total, 76 (63.3%) were men, the mean
(SD) age was 64.64 (10.9) years, and 35 (29.1%) were aged 45–
59 years. Baseline demographic, clinical characteristics and
surgery classification are displayed in Table.
Outcomes
The primary outcome (SBP after intervention) was more sig­
nificant in the study group (mean 9.91 mmHg) than in the
control group (mean 2.03 mmHg), with a mean difference of
7.88 mmHg (95% CI, 2.94 to 12.81; P = .002). The reduction in
DBP after the intervention was more significant in the study
group (mean, 6.30 mmHg) than in the control group
(0.45 mmHg), with a mean difference of 5.85 mmHg (95%
CI, 3.05 to 8.64; P < .01). There were no AA-related or severe
adverse events (Figure 3).
Stratified by age, participants aged 60–75 years (SBP after
intervention) in the study group (mean −10.83 mmHg) was
more significant than the control group (mean 0.69 mmHg),
with a mean difference of −10.13 mmHg (95% CI, −16.69 to
−3.57; P = .003), the reduction in DBP (mean −7.19 mmHg)
was more significant than the control group (0.46 mmHg),
with a mean difference of −7.65 mmHg (95% CI, −11.17 to
−4.14; P < .01). (Figure 4) However, participants aged 45–59 in
intervention compared with the control group. The reduction
in SBP (mean −2.37 mmHg, 95% CI, −8.04 to 3.31; P =.40) and
DBP (mean −1.46 mmHg, 95% CI, −5.68 to 2.76; P =.48) were
not different from the control group.
Discussion
Auricular therapy treats physical and psychosomatic diseases
by stimulating specific points in the ears; it is a fundamental
method in traditional Chinese medicine for returning the body
to a harmonized, balanced state (21). Western investigators
have also studied auricular points. In 1957, Paul Nogier pro­
posed an inverted fetal image to describe the holographic
theory. The manipulation of auricular therapy is based on the
holographic theory, a sort of assumption that information
regarding a part of the entire organism could be retrieved
from the corresponding point of the ear, so that stimulation
to a specific point of ear could ameliorate the function of the
corresponding visceral organ or other part of the body (22).
Preoperative elevated BP is a frequent complication (23). In
this trial, we aimed to clarify the efficacy and safety of AA for
preoperative BP elevation. We found that AA reduced preo­
perative SBP and DBP. This phenomenon may involve baror­
eceptor responses and cardiovascular inhibition induced by
auricular acupuncture (24). Hypertension is due to sympa­
thetic nerve activity increased or vagally-mediated cardiac

Figure 4. Stratified by age, the chart shows the change in BP between 60 and 75 years old. BPs include SBP and DBP. *P < .05 BP after AA for study group vs. control
group.
tone reduction (25). The auricular conchae are innervated by
the auricular branch of the vagus nerve, and acupuncture at
a concha can induce afferent projection through the vagus
nerve to the nucleus of the solitary tract (11). Acupuncture
has been used to treat high BP in China (26–28). Auricular
acupuncture evokes cardiovascular inhibition similar to the
baroreceptor in regulating cardiovascular function.
Hypertension maintains optimal levels and achieves less
BP variability (19). BP changes even if patients are not
diagnosed with hypertension (27). Medications may reduce
BP too quickly and increase the risk of hypotension perio­
peratively. In our trial, AA safely altered BP, particularly
systolic BP.
However, age is an influencing factor of BP in the guide­
lines, especially after age 60; the range of BP has changed. The
population in our study was 45–75 years old, and the BP
analysis was carried out according to the age factor, with
60 years old as the cutoff line. It is concluded that AA sig­
nificantly affects preoperative BP control in 60–75-year-olds
but not in 45–59- year-olds. This may be related to the small
sample size of 45–59-year-olds; only 35 (29.1%) were aged
45–59 in this trial. This could be attributed to the individuals’
perceptions of the controllability of the stressor. Stress-
induced increases or decreases in dopamine secretion in the
nucleus accumbens depend on many factors (28). Stress-
Figure 5. Auricular acupuncture.
CLINICAL AND EXPERIMENTAL HYPERTENSION 5
induced BP increases within a very short period in young
individuals (29).
The acupuncture points we chose are unique; they stimulate
cranial nerves that modulate stress-related brain areas (30). In
a previous trial, five or more acupoints were used to lower BP.
In our trial, we used only four points to simplify the treatment
in the perioperative setting.
Surgery is a stressful event for most patients (31). BP can be
reduced once sympathetic nerve excitation is relieved. When
general anesthesia begins, the sympathetic nerve excitement is
relieved. Therefore, we removed the needles at the beginning of
the procedure and only studied patients with elevated BP
preoperatively.
It is worth mentioning that the safety of AA should draw
our attention, as it is a kind of traumatic intervention. We
recorded no AA-related adverse events or severe adverse
events. Our subcuticular needle (Figure 5) method circumvents
the limitations of conventional acupuncture (fixed treatment
and time, inconvenience of other medical operations during
needle retention, and patient aversion to needles). In addition,
we designed sham acupuncture. The fake needle is made of
round tape with a diameter of 1 cm and has no sharp needle. Its
appearance, color, and shape are identical to the AA needle.
Most of the participants could hardly distinguish this device
from real acupuncture.
6 J. MA ET AL.
Limitation
Our findings suggest the safety and efficacy of AA as adjunctive
therapy in patients with perioperative hypertension.
Nevertheless, this study has several limitations. First, the study
was the unblended single center. Second, the study lacked more
extensive age stratification, there were no individuals under the
age of 45, and there was an insufficient sample size for 45–59-
year-olds. Further research is needed to address this issue.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
This work was supported by the Zhejiang Provincial Medical and Health
Technology Project [2021KY1042].
References
1. Abbott TEF, Pearse RM, Archbold RA, Wragg A, Kam E,
Ahmad T, Khan AW, Niebrzegowska E, Rodseth RN,
Devereaux PJ, et al. Association between preoperative pulse pres­
sure and perioperative myocardial injury: an international obser­
vational cohort study of patients undergoing non-cardiac surgery.
Br J Anaesth. 2017;119:78–86.
2. Oprea AD, Lombard FW, Liu WW, White WD, Karhausen JA,
Li Y-J, Miller TE, Aronson S, Gan TJ, Fontes ML, et al. Baseline
pulse pressure, acute kidney injury, and mortality after noncardiac
surgery. Anesth Analg. 2016;123(6):1480–89.doi:10.1213/ANE.
0000000000001557.
3. Hartle A, McCormack T, Carlisle J, Anderson S, Pichel A,
Beckett N, Woodcock T, Heagerty A. The measurement of adult
blood pressure and management of hypertension before elective
surgery: joint guidelines from the association of anaesthetists of
Great Britain and Ireland and the British hypertension society.
Anaesthesia. 2016;71(3):326–37.doi:10.1111/anae.13348.
4. Ayyadhah Alanazi A. Reducing anxiety in preoperative patients:
a systematic review. Br J Nurs. 2014;23:387–93.doi:10.12968/bjon.
2014.23.7.387.
5. Clark D 3rd, Sj N, St John J, MB E, HM A, Khraishah H, SE N,
Puri R. Visit-to-visit blood pressure variability, coronary atheroma
progression, and clinical outcomes. JAMA Cardiol. 2019 May 1;4
(5):437–43. doi: 10.1001/jamacardio.2019.0751.
6. Ruiz Hernández C, Gómez-Urquiza JL, Pradas-Hernández L,
Vargas Roman K, Suleiman-Martos N, Albendín-García L.
Cañadas-De la Fuente GA Effectiveness of Nursing Interventions
for Preoperative Anxiety in Adults: A Systematic Review with
meta-analysis. J Adv Nurs. 2021 Aug;77(8):3274–85.
7. Wunsch JK, Klausenitz C, Janner H, Hesse T, Mustea A,
Hahnenkamp K, Petersmann A, Usichenko TI. Auricular acupunc­
ture for treatment of preoperative anxiety in patients scheduled for
ambulatory gynaecological surgery: a prospective controlled inves­
tigation with a non-randomised arm. Acupunct Med. 2018;36
(4):222–27.doi:10.1136/acupmed-2017-011456.
8. Ruela LO, Iunes DH, Nogueira DA, Stefanello J, Gradim CVC.
Effectiveness of auricular acupuncture in the treatment of cancer
pain: randomized clinical trial. Rev Esc Enferm USP. 2018;52:
e03402.doi:10.1590/S1980-220X2017040503402.
9. Ahlberg R, Skårberg K, Brus O, Kjellin L. Auricular acupuncture
for substance use: a randomized controlled trial of effects on
anxiety, sleep, drug use and use of addiction treatment services.
Subst Abuse Treat Prev Policy. 2016;11(1):24.doi:10.1186/s13011-
016-0068-z.
10. Lv JQ, Wang C, Yang Y, Li Y, Xu TH, Jian LQ. Intradermal
thumbtack needle buried Neiguan (P6) point for prevention of
postoperative nausea and vomiting in patients undergoing craniot­
omy: study protocol for a randomised controlled trial. BMJ Open.
2019;9(11):e032417.doi:10.1136/bmjopen-2019-032417.
11. Thi Mai Nguyen H, Lee DY, Wu HM, Hsieh CL, Zhu G. Auricular
acupuncture to lower blood pressure involves the adrenal gland in
spontaneously hypertensive rats. Evid Based Complement Alternat
Med. 2020;2020:3720184.
12. Liu Y, Park JE, Shin KM, Lee M, Jung HJ, Kim AR, Jung SY,
Yoo HR, Sang KO, Choi SM. Acupuncture lowers blood pressure
in mild hypertension patients: a randomized, controlled,
assessor-blinded pilot trial. Complement Ther Med. 2015;23
(5):658–65.doi:10.1016/j.ctim.2015.06.014.
13. Tu JF, Wang LQ, Liu JH, Qi YS, Tian ZX, Wang Y, Yang JW,
Shi GX, Kang SB, Liu CZ. Home-based transcutaneous electrical
acupoint stimulation for hypertension: a randomized controlled
pilot trial. Hypertens Res. 2021;44(10):1300–06.doi:10.1038/
s41440-021-00702-5.
14. 2017ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/
NMA/PCNA guideline for the prevention, detection, evaluation,
and management of high blood pressure in adults.
15. Cherney D, Straus S. Management of patients with hypertensive
urgencies and emergencies: a systematic review of the literature.
J Gen Intern Med. 2002;17(12):937–45.doi:10.1046/j.1525-1497.
2002.20389.x.
16. Nguyen H, Lee DY, Wu HM, Hsieh CL. Auricular acupuncture to
lower blood pressure involves the adrenal gland in spontaneously
hypertensive rats. Evid Based Complement Alternat Med.
2020;2020:3720184.doi:10.1155/2020/3720184.
17. Wu YW. Study of auricular acupressure on hypertension. Master‘s
thesis. Beijing University of Chinese Medicine, China, 2008.
18. Gao J, Chen G, He H, Liu C, He Q, Li J, Wang J. The effect of
auricular therapy on blood pressure: a systematic review and
meta-analysis. Eur J Cardiovasc Nurs. 2020;19(1):20–30.doi:10.
1177/1474515119876778.
19. Minji W, Jiang Z, Yongqing Y, et al. The complete book of Chinese
acupuncture and moxibustion. [M].1nd. Henan Province, China:
Henan Science and Technology Press; 2012. p. 490–92.
20. Tan Y, Zhao Y, He T, Ma Y, Cai W, Wang Y. Efficacy and safety of
auricular point acupressure treatment for gastrointestinal dysfunction
after laparoscopic cholecystectomy: study protocol for a randomized
controlled trial. Trials. 2016;17(1):280.doi:10.1186/s13063-016-1404-3.
21. Hou PW, Hsu HC, Lin YW, et al. The history, mechanism, and
clinical application of auricular therapy in traditional Chinese
medicine. Evid Based Complement Alternat Med. 2015. p. 495684.
22. Tan Y, Zhao Y Lin YW, Tang NY, Cheng CY, Hsieh CL. The
History, Mechanism, and Clinical Application of Auricular
Therapy in Traditional Chinese Medicine. Evid Based Comp
Alternat Med. 2015;2015:495684.
23. Erdoğan G, Arslan U, Yenerçağ M, Şahin O, Arslan H, Yavuz MB,
Karagöz A, Şahin İ. The association between nondipper pattern
and perioperative hypertension in patients with controlled
hypertension. Blood Press Monit. 2021 Dec:1.
24. Gao XY, Li YH, Liu K, Rong PJ, Ben H, Li L, Zhu B, Zhang SP.
Acupuncture-like stimulation at auricular point Heart evokes car­
diovascular inhibition via activating the cardiac-related neurons in
the nucleus tractus solitarius. Brain Res. 2011 Jun;23(1397):19–27.
doi:10.1016/j.brainres.2011.04.034.
25. Mancia G, Grassi G. E autonomic nervous system and
hypertension. Circ Res. 2014;114(11):1804–14.doi:10.1161/
CIRCRESAHA.114.302524.
26. Abdi H, Tayefi M, Moallem SR, Zhao B, Fayaz M, Ardabili HM,
Razavi AA, Darbandi M, Darbandi S, Abbasi P, et al. Abdominal
and auricular acupuncture reduces blood pressure in hypertensive
patients. Complement Ther Med. 2017 Apr;31:20–26. doi:10.1016/
j.ctim.2017.01.003.
27. Kim JH, Jung HJ, Kim TH, Lee S, Kim JE, Kang KW, Jung SY,
Kim AR, Park HJ, Shin MS, et al. Auricular acupuncture for
prehypertension and stage 1 hypertension: study protocol for
a pilot multicentre randomised controlled trial. Trials. 2013 Sep
22;14:303. doi:10.1186/1745-6215-14-303.

28. Oei NYL, Both S, van Heemst D, van der Grond J, van der Grond J.
Acute stress-induced cortisol elevations mediate reward system activ­
ity during subconscious processing of sexual stimuli.
Psychoneuroendocrinology. 2014 Jan;39:111–20. doi:10.1016/j.psy
neuen.2013.10.005.
29. Hada S, Amatya S, Shrestha RK. Cold pressor test in borderline
hypertensive university students. Kathmandu Univ Med J (KUMJ).
2016 Oct-Dec;14(56):337–41.
CLINICAL AND EXPERIMENTAL HYPERTENSION 7
30. Usichenko T, Hacker H, Lotze M. Transcutaneous auricular
vagal nerve stimulation (taVNS) might be a mechanism behind
the analgesic effects of auricular acupuncture. Brain Stimul.
2017 Nov-Dec;10(6):1042–44. doi:10.1016/j.brs.2017.07.013.
31. Farbood A, Sahmeddini MA, Bayat S, Karami N. The effect of
preoperative depression and anxiety on heart rate variability in
women with breast cancer. Breast Cancer. 2020 Sep;27(5):912–18.
doi:10.1007/s12282-020-01087-y.