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Aims We evaluated the incidence and relative risk of major post-acute cardiovascular consequences of SARS-CoV-2 infection in a large real-world population from a primary care database in a region at moderate cardiovascular risk followed up in the period 2020–22. Methods and results This is a retrospective cohort analysis using data from a cooperative of general practitioners in Italy. Individuals aged >18 affected by COVID-19 starting from January 2020 have been followed up for 3 years. Anonymized data from 228 266 patients in the period 2020–22 were considered for statistical analysis and included 31 764 subjects with a diagnosis of COVID-19. An equal group of subjects recorded in the same database in the period 2017–19 was used as propensity score-matched comparison as an unquestionable COVID-19-free population. Out of the 228 266 individuals included in the COMEGEN database during 2020–22, 31 764 (13.9%) were ascertained positive with SARS-CoV-2 infection by a molecular test reported to general practitioners. The proportion of individuals with a new diagnosis of major adverse cardiovascular and cerebrovascular events was higher in the 2020–22 COVID-19 group than in the 2017–19 COMEGEN propensity score-matched comparator, with an odds ratio of 1.73 (95% confidence interval: 1.53–1.94; P < 0.001). All major adverse cardiovascular and cerebrovascular events considered showed a significantly higher risk in COVID-19 individuals. Incidence calculated for each 6-month period after the diagnosis of COVID-19 in our population was the highest in the first year (1.39% and 1.45%, respectively), although it remained significantly higher than in the COVID-19-free patients throughout the 3 years. Conclusion The increase of cardiovascular risk associated with COVID-19 might be extended for years and not limited to the acute phase of the infection. This should promote the planning of longer follow-up for COVID-19 patients to prevent and promptly manage the potential occurrence of major adverse cardiovascular and cerebrovascular events. [ABSTRACT FROM AUTHOR]

Renal denervation is a device-based procedure for hypertension for which safety and efficacy has been demonstrated. At present, its clinical use is still matter of debate, despite the most recent clinical trials have shown promising results with new-generation devices in various hypertensive populations. This position paper was deemed necessary by the Italian Society of Arterial Hypertension, in order to provide indications about the applications of renal denervation in the clinical setting. A state-of-the art review of the literature, focusing on safety and efficacy data, is provided. Furthermore, based on current evidence and expert consensus, clinical profiles of possible candidates for renal denervation are proposed. The selection process should take into account not only blood pressure values, global cardiovascular risk profile, but also drug adherence and tolerability and patient preferences. This position paper also defines minimum requirements for renal denervation selection centers and a flowchart for the difficult-to-treat hypertensive patient. Further studies are needed to support these preliminary indications, which are based on expert-consensus only. [ABSTRACT FROM AUTHOR]

The 'Campania Salute' (CS) is a network system aimed at improving the management of essential hypertension by integrating the activity of general practitioners (GPs) with that of the hypertension specialists. It involves 23 outpatient hypertensive clinics distributed in different community hospitals of the Napoli's metropolitan area, 60 randomly selected GPs homogeneously distributed in the same area, and the Hypertension Clinic of the Federico II University in Naples (co-ordinating centre). Through the CS system it is possible to share clinical data collected during each visit at peripheral units (general practitioners and community hospitals hypertensive clinics), which manage low-risk hypertensive patients, and the co-ordinating centre, which mainly manages high-risk hypertensive patients. The co-ordinating centre works in co-operation with the peripheral units in the treatment and follow-up of all hypertensive patients. Since the first reports on the CS network activity, it has been evident the effectiveness of this network in ameliorating the clinical management of the hypertensive disease. CS network is also a large prospective registry that generated several scientific reports based on the longitudinal assessment of hypertensive patients during their treatment. Nowadays, as observed in the Health Search Database, the rate of BP control in Campania was 69.5%, almost reaching the 'Objective 70%', a result that could be in part linked to the activity of the CS network. [ABSTRACT FROM AUTHOR]

Background Mucopolysaccharidoses ( MPS) are inherited lysosomal storage disorders caused by deficiency of required glycosaminoglycans breakdown enzymes, inducing cardiac involvement. Little is known about myocardial deformation involvement in MPS. Our aim was to assess biventricular structure and function in asymptomatic children with MPS using standard echo Doppler and 2D speckle tracking ( STE). Methods Fifteen MPS children (one type I, six type II, three type III A, one III B, three IV A, one VI), asymptomatic for cardiac symptoms, and 15 age and sex-matched healthy controls underwent echo Doppler and STE. Left ventricular ( LV) wall thicknesses, diameters, and mass were normalized by z-score. LV global longitudinal strain ( GLS), global circumferential strain ( GCS), global radial strain ( GRS) at papillary muscles, LV twisting, and right ventricular ( RV) GLS were measured. Results The two groups were comparable for body mass index, heart rate, and blood pressure. LV mass index and relative wall thickness were higher in MPS. Ejection fraction (EF), and s′ velocity did not differ between the two groups. E/A ratio was lower and E/e′ higher in MPS. Tricuspid annular plane systolic excursion, RV s′ and e′ were lower in MPS. LV GLS did not differ between the two groups, but GCS ( P=.014), GRS ( P=.023), twisting ( P=.012), and RV GLS ( P<.001) were lower in the MPS group. Conclusions LV strain abnormalities are detectable in MPS pediatric patients, independently of MPS type, when EF is still normal. RV GLS is also involved consensually with TAPSE reduction. STE can be useful for detection of subclinical myocardial damage in MPS. [ABSTRACT FROM AUTHOR]

Background Longitudinal strain is an early marker of left ventricular ( LV) dysfunction in several cardiac diseases. Our aim was to differentiate cardiac amyloidosis ( CA) at diagnosis from hypertensive LV hypertrophy ( LVH) by analysis of longitudinal myocardial deformation. Methods Thirty healthy controls (C), 30 newly diagnosed, never treated hypertensives with LVH ( H- LVH), and 33 patients with CA at diagnosis underwent echo Doppler including speckle tracking-based automated function imaging ( AFI). Averaged peak systolic global longitudinal strain ( GLS, 18 segments) and basal, middle, and apical longitudinal strain ( BLS, MLS, and ALS, respectively, six segments each) were calculated. Results Left ventricular mass index, relative wall thickness, and ejection fraction did not differ between H- LVH and CA. E/ e′ ratio was higher in CA than in H- LVH (P<.001) and C (P<.0001). GLS was lower in CA than in C (P<.0001), without difference with H- LVH. ALS did not differ among the three groups, MLS was significantly lower in both CA and H- LVH than in C but BLS was lower in CA compared to both H- LVH and C (both P<.0001). In the pooled population, E/ e′ was independently associated with BLS (β=−0.54, P<.0001). At receiver operating curve analysis, CA was predicted by BLS≤−11.3% (sensitivity=63.3%, specificity=100%) and E/ e′≥12.3 (sensitivity=69.7%, specificity=83.3%). The best AUC (=0.819) was obtained by the combination E/ e′+ BLS. Conclusions Our findings highlight a real difference of E/ e′ ratio and longitudinal strain of LV basal segments between hypertensive LVH and CA, which could be used to differentiate the two diseases. [ABSTRACT FROM AUTHOR]

Purpose: Atherosclerosis is a systemic disease and coronary artery disease is frequently associated with peripheral artery disease. As aortic and mitral valvular calcification (VC) share some etiopathogenetic mechanisms with atherosclerosis, we analyzed the risk profile and the echocardiographic characteristics of patients admitted for first acute coronary syndrome (ACS) to investigate whether the presence of VC could be a marker of asymptomatic hemodynamically significant peripheral atherosclerosis. Methods: A total of 151 patients admitted for ACS without previous history of cardiovascular disease were consecutively enrolled. The presence of VC was identified by echocardiography; a carotid stenosis >50% by ultrasound identified carotid artery disease (CarAD); an ankle-brachial index <0.9 or >1.4 identified lower extremity artery disease (LEAD). Significant peripheral atherosclerosis was defined by the presence of CarAD and/or LEAD. Results: Peripheral atherosclerosis was diagnosed in 82 (54.3%) patients; isolated CarAD in 24, isolated LEAD in 20, both diseases in 38 patients. VC was present in 103 (68.2%) patients. By multivariate analysis, age (OR = 1.059, 95% CI 1.007-1.11 3, P = 0.025), diabetes mellitus (OR = 5.068, 95% CI 1.480-1 7.351, P = 0.010), VC (OR = 7.422, 95% CI 2.421-22.880, P < 0.001), and multivessel CAD (OR = 3.31 7, 95% CI 1.281-8.586, P = 0.01 3) were the only independent predictors of having peripheral atherosclerosis. C-statistic for VC was not inferior to that obtained by age (0.728, 95% CI 0.649-0.797 vs. 0.800, 95% CI 0.727-0.861, P = 0.101) and to that obtained by the combination of multivessel CAD with diabetes (0.750; 95% CI 0.673-0.817, P = 0.635), and, furthermore, it was higher than that obtained by diabetes alone (0.620, 95% CI 0.538-0.698, P = 0.036). Conclusion: Ruling out the presence of significant peripheral atherosclerosis should be routinely considered in patients with ACS showing VC at echocardiography. [ABSTRACT FROM AUTHOR]

Observational clinical studies have demonstrated that only 30-40 % of patients with arterial hypertension achieve the recommended blood pressure goals (below 140/90 mmHg). In contrast, interventional trials consistently showed that it is possible to achieve effective blood pressure targets in about 70 % of treated hypertensive patients with different cardiovascular risk profiles, especially through the use of rational, effective and well tolerated combination therapies. In order to bridge the gap between current and desired blood pressure control and to achieve more effective prevention of cardiovascular diseases, the Italian Society of Hypertension (SIIA) has developed an interventional strategy aimed at reaching nearly 70 % of treated controlled hypertensive patients by 2015. This ambitious goal can be realistically achieved by a more rational use of modern tools and supports, and also through the use of combination therapy in hypertension in daily clinical practice, especially if this approach can be simplified into a single pill (fixed combination therapy), which is a therapeutic option now also available in Italy. Since about 70-80 % of treated hypertensive patients require a combination therapy based on at least two classes of drugs in order to achieve the recommended blood pressure goals, it is of key importance to implement this strategy in routine clinical practice. Amongst the various combination therapies currently available for hypertension treatment and control, the use of those strategies based on drugs that antagonize the renin-angiotensin system, such as angiotensin II type 1 receptor antagonists (angiotensin receptor blockers) and ACE inhibitors, in combination with diuretics and/or calcium channel blockers, has been shown to significantly reduce the risk of major cardiovascular events and to improve patient compliance to treatment, resulting in a greater antihypertensive efficacy and better tolerability compared with monotherapy. The present document of the Italian Society of Arterial Hypertension (SIIA) aims to gather the main indications for the implementation of combination therapy in the treatment of hypertension, in order to improve blood pressure control in Italy. [ABSTRACT FROM AUTHOR]

Fixed combinations of antihypertensive drugs have the potentiality to improve blood pressure (BP) control. However, when pharmacokinetic parameters of the two drugs are different, both method and time of administration of the two drugs may modify the antihypertensive response. In an open-label, single-blind, randomized study we compared antihypertensive effect of four administration schemes of a combination therapy of olmesartan and amlodipine in the same group of hypertensive patients, using ambulatory blood pressure monitoring (ABPM). The olmesartan + amlodipine combination has demonstrated to provide a good control of BP, with systolic and diastolic BP constantly below 130 and 85 mmHg over the 24 h. The simultaneous or separate administration of the 2 drugs fully overlapped, suggesting that the fixed combination and the separate administration induce a similar and sustained BP control. [ABSTRACT FROM AUTHOR]

Introduction: The prevalence of patients with 'borderline' levels of cardiovascular risk factors has been rarely investigated, being often reported in studies evaluating abnormal values of these parameters. The BORDERLINE study represents a pilot experience to primarily identify the prevalence of 'high-normal' conditions, such as pre-hypertension, lipid and glucose levels in the upper range of normality in the setting of general practice in Italy. Aim: The aim of this study was to evaluate the prevalence of patients with 'borderline' values of cardiovascular risk factors in Italy. Methods: Involved physicians were asked to evaluate the first 20 outpatients, consecutively seen in June 2009. Data were collected in a study-designed case-report form, in which physicians identified thresholds rather than reported absolute values of several clinical parameters. High-normal values were defined as follows: blood pressure (BP) 130-140/85-90 mmHg; total cholesterol 180-200 mg/dL; low-density lipoprotein cholesterol (LDL-C) 130-150 mg/dL; high-density lipoprotein cholesterol (HDL-C) 30-40 mg/dL in males and 40-50 mg/dL in females; triglycerides 130-150 mg/dL and fasting glucose 100-110 mg/dL. Results: Fifty-three Italian physicians provided valuable clinical data on 826 individual outpatients, among which 692 (83.7%, 377 women, mean age 60.9 ± 13.2 years, body mass index 26.6 ± 5.0 kg/m2) were included in the present analysis. Prevalence of borderline values of systolic BP and total cholesterol levels were at least comparable with those in the normal limits of the corresponding parameters, whereas prevalence of borderline diastolic BP, LDL-C, HDL-C, triglycerides and fasting glucose levels was significantly lower than that of normal values, but higher than that of abnormal values of the corresponding parameters. Conclusions: Using this sample of healthy subjects in the setting of general practice in Italy, our results demonstrated a relatively high prevalence of borderline values of cardiovascular risk factors, which was at least comparable with that of normal, but significantly higher than that of abnormal thresholds. These preliminary findings may prompt more extensive investigations in the area of 'borderline' cardiovascular risk. This information may, in fact, potentially enable the design of more effective prevention strategies in the future to limit the burden of cardiovascular disease in the general population in Italy. [ABSTRACT FROM AUTHOR]

Introduction: The increase of cardiovascular risk in women coincides with the onset of menopause. Left ventricular hypertrophy (LVH), carotid atherosclerosis (CA) and chronic kidney disease are expressions of target organ damage in hypertension. This study evaluated whether menopause affects the development of target organ damage in hypertension. Methods: We retrospectively analysed 963 hypertensive women referred to the Hypertension Clinic of the ''Federico II'' University, Naples, Italy, from October 1998 to July 2007. Results: Postmenopausal women (n = 399) were older, had higher systolic blood pressure and worse metabolic profile compared with premenopausal women (n = 564). In postmenopausal women, prevalence of target organ damage was higher compared with premenopausal women. In particular, in premenopausal and postmenopausal patients, prevalence of LVH was 27% and 49% (p < 0.001), and of chronic kidney disease was 7% and 10% (p < 0.05), respectively. Similarly, prevalence of carotid thickening and carotid plaque was 34% and 28% in premenopausal women, and 37% and 48% (both p < 0.001) in postmenopausal women, respectively. Multiple stepwise regression analysis showed that menopause (adjusted odds ratio [OR] 2.14; 95% CI 1.13, 4.06; p = 0.02) and hypercholesterolaemia (adjusted OR 2.3; 95% CI 1.03, 5.17; p = 0.04) were independent predictors of CA. Conclusions: Our results show that in hypertensive women menopause increases the risk of CA. [ABSTRACT FROM AUTHOR]

Background and objectives: Left ventricular hypertrophy, carotid atherosclerosis and renal dysfunction are indicators of target organ damage in hypertension, and independent risk factors for both fatal and non-fatal cardio- and cerebrovascular events. In the general population, smoking is associated with increases in left ventricular mass and carotid intima-media thickness (IMT), and impaired renal function. The aim of the present study was to evaluate whether smoking affects the development of target organ damage in patients with arterial hypertension. Methods: 3192 hypertensive patients referred to the Hypertension Clinic of the "Federico II" University of Naples from January 2000 to July 2006 were retrospectively analysed. Subjects were aged from 18 to 75 years. Among these patients, 1391 were smokers and 1801 non-smokers. Results: The duration and severity of hypertension was significantly shorter in smokers when compared with non-smokers. The maximum arterial IMT was significantly higher in smokers compared with non-smokers (1.7 ± 0.1 mm vs 1.5 ± 0.1, p < 0.0001), while left ventricular mass index was comparable between the two groups. In contrast, glomerular filtration rate was observed to be higher in smokers compared with non-smokers. Logistic regression analysis showed that smoking, age, sex, duration of hypertension, systolic blood pressure and diastolic blood pressure were significantly correlated with IMT. Furthermore, a strong correlation was found between the number of cigarettes smoked per day and IMT. Conclusions: Together, these data indicate that in hypertensive patients who have a high risk of developing atherosclerosis, smoking could potentiate the development of atherosclerotic plaques. [ABSTRACT FROM AUTHOR]

Arterial hypertension still represents the most common preventable cause of morbidity and mortality, worldwide, and the WHO states that high blood pressure levels are responsible for 62% of cerebrovascular events and 49% of ischaemic heart diseases globally. Effective antihypertensive treatment significantly reduces individual total cardiovascular risk. Both cardiac and vascular consequences of arterial hypertension derive from structural and functional abnormalities of peripheral arteries, and these clinical conditions strongly predispose to developing major hypertension-related cardiovascular events. Due to the asymptomatic or oligo-symptomatic course, before being clinically evident, of hypertensive cardiopathy (e.g. hypertensive disease), the appropriate and periodic evaluation of structural and functional cardiac damage represents an important diagnostic and prognostic outcome for driving therapeutic strategy in the clinical management of hypertension. The present guidelines, endorsed by the Joint Committee of the Italian Society of Hypertension, the Italian Society of Cardiology, and the Associazione Nazionale Medici Cardiologi Ospedalieri, are aimed to help physicians to choose the best diagnostic and therapeutic approach in the clinical management of any individual hypertensive patient. [ABSTRACT FROM AUTHOR]

BACKGROUND. Recent studies conducted in individuals who survived COVID-19 suggest that SARS-CoV-2 infection is associated with an increased risk of dyslipidemia. However, it remains unclear whether this augmented risk is confirmed in the general population and how this phenomenon is affecting the overall burden of cardiometabolic diseases. METHODS. To address these aspects, we conducted a 6-year longitudinal study to examine the broader effects of COVID-19 on dyslipidemia incidence in a real-world population (228,266 individuals) residing in Naples in southern Italy. The pre-COVID-19 and COVID-19 groups were balanced for demographic and clinical factors using propensity score matching. RESULTS. Our analysis spans a period of 3 years during the COVID-19 pandemic (2020-2022), comparing dyslipidemia incidence with pre-pandemic data (2017-2019), with a follow-up of at least 1,095 days corresponding to 21,349,215 person- years. During the COVID-19 period, we detected an increased risk of developing any dyslipidemia when compared with the pre-COVID-19 triennium (OR = 1.29; 95% CI, 1.19-1.39). Importantly, these estimates were adjusted for comorbidities by a multivariate analysis. CONCLUSIONS. Taken together, our data reveal a notable rise in dyslipidemia incidence during the COVID-19 pandemic, suggesting the utility of establishing specialized clinical monitoring protocols for patients who survive COVID-19 to mitigate the risk of developing dyslipidemia. [ABSTRACT FROM AUTHOR]

Background Cardiovascular diseases (CVD) are the first cause of death and disability in western countries. Despite therapeutic advances, their prevalence is constantly increasing. Detailed assessment of modifiable CV risk factors could improve CVD prevention and management. Methods to assess CV risk and hypertension control in a sample of the Italian population, individuals participating to the 2015 “World Hypertension Day” were interviewed in 62sites all over Italy. Blood pressure was measured with a validated auscultatory or oscillometric device and information on demography and prevalence of CVD risk factors was collected by an anonymous questionnaire. An ad-hoc modified version of the Systematic COronary Risk Evaluation (SCORE) system was then applied. Results 8657 recruited individuals (43%women, aged 56.68 ± 16 years) were subdivided into 3 age groups (40–49 y, 50–59 y, 60–69 y) for analysis. CV risk was low in 62.4%, 18.0% and 0%; moderate in 26.0%, 66.0% and 62.5%; high/very high in 11.6%, 16% and 37.4%, respectively. Smoking was mainly responsible for increased CV risk among those aged 40–49 y (26%smokers), while hypertension was the main factor in the whole sample and in subjects over 50y (36% and 42% respectively). Overall, BP control was unsatisfactory in 36% of individuals (28%, 48% and 31% of those who declared to be normotensive, hypertensive on treatment or unaware of their BP condition, respectively). Conclusions In this sample of the Italian population, CV risk was alarmingly high, irrespectively of age, mostly due to presence of modifiable risk factors, including hypertension, which should thus be better addressed, especially in the youngsters. [ABSTRACT FROM AUTHOR]

This multicenter experience sought to investigate the feasibility and safety of BVS for the treatment of ISR. From April 2012 to June 2014, a total of 315 patients (334 lesions) underwent PCI for ISR at the participating centers. Of those, 83 patients (90 lesions) received BVS. Procedural success was achieved in all patients. At a median of 7 (IQR 3–18) months follow-up, MACCE rate was 12%, TLR 7.7%, while one (1.1%) definite BVS-in-stent thrombosis was reported. The results of this multicenter experience suggest that BVS implantation for the treatment of coronary ISR is technically feasible and associated with favorable mid-term clinical results. These data could be considered hypothesis generating for a future randomized clinical trial. [ABSTRACT FROM AUTHOR]

Background/purpose: Coronary in-stent restenosis (ISR) is a clinical problem for which a satisfactory solution has not been found yet. Bioabsorbable drug eluting vascular scaffolds (BVSs) provide transient vessel scaffolding combined with prolonged drug delivery capability. The aim of this study was to investigate the safety of BVS for the treatment of coronary ISR.Methods/materials: Between January 2013 and June 2013, 27 patients (31 lesions), presenting with either stable or unstable angina due to coronary ISR, were enrolled in a single arm, prospective, open label registry. Primary end point was the occurrence of target vessel revascularization (TVR) at 12 months. Secondary end point was the composite of death, myocardial infarction and TVR at 12 months.Results: A diffuse ISR pattern was present in 70% of the lesions; mean lesion length was 34.6±15. BVS was successfully implanted in all patients with no in hospital MACE. At twelve months of follow up, MACE rate was 18.5%. One patient died for non-cardiac reason, one patient died due to a possible stent thrombosis and TVR was necessary in 3 patients (11.1%).Conclusions: Our data suggest that BVS is safe and technically feasible for treatment of long and diffuse coronary ISR. These data could be considered hypothesis generator for a randomized clinical trial. [ABSTRACT FROM AUTHOR]

The second half of the last century was characterized by intense research in the field of arterial hypertension and related therapies. These studies showed that the management of arterial hypertension requires a robust coordination with close integration of the "health care systems" and "health care professionals." In 1998, the healthcare organization named "Campania Salute Network" was set up at the Federico II University, Naples, Italy. The Campania Salute Network involves 23 outpatient hypertensive clinics distributed in different community hospitals of the Regione Campania's area, 60 randomly selected general practitioners uniformly distributed in the same area, and the Hypertension Clinic of the Federico II University (coordinating center). Through this network, clinical data collected at each visit are shared (via text messages or e-mails) with peripheral units (general practitioners and community hospital outpatient hypertensive clinics). The coordinating centre works in cooperation with the peripheral units in the treatment and follow-up of all hypertensive patients (i.e. assessing hypertension mediated organ damage and associated diseases). Information about patients are shared through on-line access to the remote web-based database. The integrated approach to the mamangement of hyperetension determined a better control of blood pressure, that was associated with a reduction of hypertension mediated organ damage and decreased incidence of fatal or non-fatal cardiovascular events. Furthermore, this innovative approach improved the adherence and the persistence to the initial pharmacologic treatment. Campania Salute Network is also a powerful tool for the clinical and translational research with more 15,000 hypertensive patients followed for more than 15 years. This database allowed, in prospetic, large scale studies, to identify the hemodiminamic and metabolic determinants of hypertension mediated organ damage and major cardiovascular events. The experience of Campania Salute Netwiork indicates that the creation of large databases from real life experiences becomes an indispensable condition also for artificial intelligence which, in the near future, thanks to scientific knowledge, the availability of particularly advanced hardware and software, will also be able to transform the management of arterial hypertension.

Aims: Adherence to medical therapy following acute coronary syndrome (ACS) affects a patient's prognosis. In this cohort study, we sought to assess the factors that could affect a patient's adherence to therapy after ACS., Methods: We prospectively collected information from patients (N = 964) hospitalized at the coronary care unit of the Federico II University Hospital, from 1 January 2015 to 30 June 2017, for ACS. Adherence to three classes of drugs including statins, antiplatelets [dual or single antiplatelet agent (SAPT)] and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACE-I/ARB) and their composites were assessed at 1 month, 1 and 2 years after discharge., Results: At 30 days adherence to prescribed therapy was 94.4% for dual antiplatelet therapy (DAPT), 78.2% for statins, 92.7% for ACE-I/ARB and 70.7% for multitherapy. At 1 year, it was 91.1% for DAPT, 81.2% for ACE-I/ARB, 84.9% for statins and 71.4% for multitherapy. At 2 years, it was 97.1% for SAPT, 78.1% for ACE-I/ARB, 91.8% for statins, 72.8% for multitherapy. Multivariable logistic analysis demonstrated that at each time point, a telephone follow-up assessment predicts nonadherence to multitherapy and that a percutaneous coronary intervention at the index hospitalization is an independent predictor of adherence to composite therapy at 1 month and 1 year., Conclusion: Up to 2 years after ACS, three out of four patients are adherent to multitherapy prescription; percutaneous coronary intervention during the index hospitalization improves a patient's adherence, whereas telephone follow-up is associated with reduced adherence to multitherapy.Campania Salute Network Registry (Clinical Trials.gov Identifier: NCT02211365)., (Copyright © 2021 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Background: Hypertensive urgencies (HypUrg) are defined as severe elevation in blood pressure (BP) without acute target organ damage. In the office setting, treated asymptomatic patients, with severe BP elevation meeting criteria for urgency are often seen. We evaluate incident Cardiovascular (CV) events (n = 311) during follow-up (FU) in patients with HypUrg at first outpatient visit., Methods: HypUrg was defined by systolic BP ≥180 mm Hg and/or diastolic BP ≥110 mm Hg. Patients were >18 years old, with available ultrasound data, without prevalent CV disease, and no more than stage III Chronic Kidney Disease. BP control was defined as the average BP during FU <140/90 mm Hg., Results: Four hundred and sixty-nine of 6,929 patients presented with HypUrg at first visit. Patients with HypUrg were more likely to be women, obese and diabetic and with higher prevalence of left ventricle (LV) hypertrophy and carotid plaque (all P <  0.05). During FU patients with HypUrg had 5-fold higher risk of uncontrolled BP (95% confidence interval (CI) 4.1-6.8, P < 0.0001). In Cox regression presenting with HypUrg was not associated with increased CV risk after adjusting for significant covariates, including age, sex, BP control, LV hypertrophy, and carotid plaque (hazard ratio (HR) 1.42, 95% CI (0.96-2.11), P = 0.08)., Conclusions: Patients with HypUrg have worst CV risk profile, reduced probability of BP control during FU and greater prevalence of target organ damage, but the excess CV event risk appears to be mediated through BP control, non-BP cardio-vascular disease risk factors, and demographic attributes., Clinicaltrials.gov Identifier: NCT02211365., (© American Journal of Hypertension, Ltd 2020. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: The search for reliable cardiac functional parameters is crucial in patients with mitral regurgitation (MR). In the Italian arm of the European Registry of MR, we compared the ability of global longitudinal strain (GLS) and left ventricular (LV) ejection fraction (LVEF) to detect cardiac damage in MR., Methods: Five hundred four consecutive patients with MR underwent a complete echo-Doppler exam. A total of 431, 53 and 20 patients had degenerative, secondary and mixed MR, respectively. The main echocardiographic parameters, including LV and left atrial (LA) size measurements, pulmonary artery systolic pressure (PASP) and GLS were compared between patients with mild MR (n = 392) vs. moderate to severe MR (n = 112)., Results: LVEF and GLS were related one another in the pooled population, and separately in patients with mild and moderate/severe MR (all p < 0.0001). However, a certain number of patients were above the upper or below the lower limits of the 95% confidence interval (CI) of the normal relation in the pooled population and in patients with mild MR. Only 2 patients were below the 95% CI in moderate to severe MR. After adjusting for confounders by separate multivariate models, LVEF and GLS were independently associated with LV and left atrial size in the pooled population and in mild and moderate/severe MR. GLS, but not LVEF, was also independently associated with PASP in patients with mild and moderate to severe MR., Conclusions: Both LVEF and GLS are independently associated with LV and LA size, but only GLS is related to pulmonary arterial pressure. GLS is a powerful hallmark of cardiac damage in MR.

Arterial hypertension is a leading risk factor for developing atrial fibrillation. CHA 2 DS 2 -VASc score can help to decide if patients with atrial fibrillation need anticoagulation. Whether CHA 2 DS 2 -VASc may predicts incident atrial fibrillation and how it interacts with left atrial dilatation is unknown. We tested this hypothesis in a large registry of treated hypertensive patients. From 12154 hypertensive patients we excluded those with prevalent atrial fibrillation (n 51), without follow-up (n 3496), or carotid ultrasound (n 1891), and low ejection fraction (i.e. <50%, n 119). A CHA 2 DS 2 -VASc score ≥3 was compared with CHA 2 DS 2 -VASc score ≤2. Incident symptomatic or occasionally detected atrial fibrillation was the end-point of the present analysis. At baseline, 956 (15%) patients exhibited high CHA 2 DS 2 -VASc; they were older, most likely to be women, obese and diabetic, with lower glomerular filtration rate, and higher prevalence of left ventricular hypertrophy, left-atrial dilatation and carotid plaque (all p < 0.005). Prevalent Stroke/TIA was found only in the subgroup with high CHA 2 DS 2 -VASc. During follow-up (median = 54 months) atrial fibrillation was identified in 121 patients, 2.57-fold more often in patients with high CHA 2 DS 2 -VASc (95% Cl 1.71-4.86 p < 0.0001). In multivariable Cox analysis, CHA 2 DS 2 -VASc increased incidence of atrial fibrillation by 3-fold, independently of significant effect of left-atrial dilatation (both p < 0.0001) and other markers of organ damage. Incident AF is more than doubled in hypertensive patients with CHA 2 DS 2 -VASc ≥3. Coexisting CHA 2 DS 2 -VASc score >3 and LA dilatation identify high risk subjects potentially needing more aggressive management to prevent AF and associated cerebrovascular ischemic events.

Background Elderly patients have high ischemic and bleeding rates after acute coronary syndrome; however, the occurrence of these complications over time has never been studied. This study sought to characterize average daily ischemic rates ( ADIRs ) and average daily bleeding rates ( ADBRs ) over 1 year in patients aged >74 years with acute coronary syndrome undergoing percutaneous coronary intervention who were randomized in the Elderly ACS 2 trial, comparing low-dose prasugrel (5 mg daily) with clopidogrel (75 mg daily). Methods and Results ADIRs and ADBRs were calculated as the total number of events, including recurrent events, divided by the number of patient-days of follow-up and assessed within different clinical phases: acute (0-3 days), subacute (4-30 days), and late (31-365 days). Generalized estimating equations were used to test the least squares mean differences for the pairwise comparisons of ADIRs and ADBRs and the pairwise comparison of clopidogrel versus prasugrel effects. Globally, ADIRs were 2.6 times (95% CI, 2.4-2.9) higher than ADBRs . ADIRs were significantly higher in the clopidogrel arm than in the low-dose prasugrel arm in the subacute phase ( P adj <0.001) without a difference in ADBRs ( P adj =0.35). In the late phase, ADIRs remained significantly higher with clopidogrel ( P adj <0.001), whereas ADBRs were significantly higher with low-dose prasugrel ( P adj <0.001). Conclusions Ischemic burden was greater than bleeding burden in all clinical phases of 1-year follow-up of elderly patients with acute coronary syndrome treated with percutaneous coronary intervention. Low-dose prasugrel reduced ischemic events in the subacute and chronic phases compared with clopidogrel, whereas bleeding burden was lower with clopidogrel in the late phase. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 01777503.

Background: Aortic root (AR) dimension (ARD) at the Valsalva sinuses has been associated with incident cardiovascular (CV) events in population-based studies, but this effect could be due to the association with increased left ventricular (LV) mass. There is also uncertainty on how to define clear-cut AR dilatation. Thus, we analyzed the Campania Salute Network (CSN) registry to (i) establish criteria for evaluation of ARD, (ii) propose cut-points for AR dilatation, and (iii) determine whether AR dilatation has prognostic value independent of LV hypertrophy (LVH)., Methods: We analyzed hypertensive patients with available follow-up, in sinus rhythm and free of prevalent valvular and CV disease (n = 8,573). AR exceeding the 75th percentile of the AR z-score (Ao-Z) obtained by comparison with the value predicted by age, sex, and height (i.e., Ao-Z > 0.80) was considered dilated., Results: Patients with baseline-dilated ARD by Ao-Z were more likely to be younger, men, and obese and had higher baseline blood pressure (BP; all <0.02) but similar kidney function as those without ARD dilatation. In multivariable Cox regression model, dilated ARD predicted 36% increased rate of CV events, independently of older age, male sex, systolic BP, LVH, and class of antihypertensive medications used during follow-up (95% confidence interval: 1.07-1.71, P = 0.011)., Conclusions: In the context of a population of treated hypertensive patients, ARD defined by z-score of predicted values is an independent predictor of CV events regardless of LVH and other common confounders., Clinical Trials Registration: Trial Number NCT02211365.

Background: Hypertension is a leading cause of chronic kidney disease (CKD) and a decrease in glomerular filtration rate (GFR) is associated with a higher prevalence of hypertension and an increased proportion of suboptimal blood pressure (BP) control., Methods: To investigate characteristics associated with GFR decline, we selected 4539 hypertensive patients from the Campania Salute Network (mean age 53 ± 11 years) with at least 3 years of follow-up (FU) and no more than Stage III CKD. GFR was calculated at baseline and at the last available visit using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. GFR decline was defined as a ≥30% decrease from initial GFR for patients in Stage III CKD or by a composite ≥30% decrease from baseline and a final value of <60 for those < with Stage III or higher CKD., Results: At a mean FU of 7.5 years, 432 patients (10%) presented with GFR decline. Those patients were older, more likely to be diabetic, with lower GFR and ejection fraction, higher systolic and lower diastolic BP and higher left ventricular (LV) mass and relative wall thickness at baseline; during FU, patients with GFR decline exhibited higher systolic BP, took more drugs and developed more atrial fibrillation (all P < 0.02). The probability of GFR decline was independently associated with older age, prevalent diabetes, baseline lower GFR, higher systolic BP during FU, FU duration, increased LV mass and incident AF with no impact from antihypertensive and antiplatelet medications., Conclusions: During antihypertensive therapy, kidney function declines in patients with initially lower GFR, increased LV mass and suboptimal BP control during FU., (© The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

Background Increased pulse pressure is associated with structural target organ damage, especially in elderly patients, increasing cardiovascular risk. Design In this analysis, we investigated whether high pulse pressure retains a prognostic effect also when common markers of target organ damage are taken into account. Methods We analysed an unselected cohort of treated hypertensive patients from the Campania Salute Network registry ( n = 7336). Participants with available cardiac and carotid ultrasound were required to be free of prevalent cardiovascular disease, with ejection fraction ≥50%, and no more than stage III Chronic Kidney Disease. The median follow-up was 41 months and end-point was occurrence of major cardiovascular events (i.e. fatal and non-fatal stroke or myocardial infarction and sudden death). Based on current guidelines, pulse pressure ≥60 mm Hg was classified as high pulse pressure ( n = 2356), at the time of the initial visit, whereas pulse pressure <60 mm Hg was considered normal ( n = 4980). Results High pulse pressure patients were older, more likely to be women and diabetic, while receiving more antihypertensive medications than normal pulse pressure (all p < 0.0001). High pulse pressure exhibited greater prevalence of left ventricular hypertrophy, and carotid plaque than normal pulse pressure (all p < 0.0001). In Cox regression, high pulse pressure patients had 57% increased hazard of major cardiovascular events, compared to normal pulse pressure (hazard ratio = 1.57; 95% confidence interval: 1.12-2.22, p = 0.01), an effect that was independent of significant prognostic impact of older age, male sex, diabetes, left ventricular hypertrophy, carotid plaque and less prescription of anti-renin-angiotensin system therapy. Conclusions High pulse pressure is a functional marker of target organ damage, predicting cardiovascular events in hypertensive patients, even independently of well-known structural markers of target organ damage.

Cardiovascular prevention represents a cornerstone of modern strategies to reduce the burden of cardiovascular disease. It is of key importance to prevent cardiovascular diseases and associated events, not only to reduce morbidity and mortality, but also to increase the years of wellness in the aging population and to make the growing socio-economic burden imposed by cardiovascular events more sustainable.The current approach to prevention is based on an integrated use of effective lifestyle measures and, whenever appropriate, of antihypertensive and antidiabetic drugs, lipid-lowering agents and antiplatelet drugs.Given that population characteristics, in terms of ethnicity, demography and lifestyle habits, and healthcare system organizations differ among countries, international guidelines are not always applicable to specific countries and, often, are difficult to translate into daily clinical practice.In order to afford the specific features of Italy, 10 Scientific Societies and Research Institutions, mostly involved in preventive strategies, contributed to the present Italian consensus document, which includes brief, practical recommendations to support the preventive actions within the physician community and the general practice setting.

Background: Thiazide diuretics have been recommended as a first-line antihypertensive treatment, although the choice of 'the right drug in the individual essential hypertensive patient' remains still empirical. Essential hypertension is a complex, polygenic disease derived from the interaction of patient's genetic background with the environment. Pharmacogenomics could be a useful tool to pinpoint gene variants involved in antihypertensive drug response, thus optimizing therapeutic advantages and minimizing side effects., Methods and Results: We looked for variants associated with blood pressure response to hydrochlorothiazide over an 8-week follow-up by means of a genome-wide association analysis in two Italian cohorts of never-treated essential hypertensive patients: 343 samples from Sardinia and 142 from Milan. TET2 and CSMD1 as plausible candidate genes to affect SBP response to hydrochlorothiazide were identified. The specificity of our findings for hydrochlorothiazide was confirmed in an independent cohort of essential hypertensive patients treated with losartan. Our best findings were also tested for replication in four independent hypertensive samples of European Ancestry, such as GENetics of drug RESponsiveness in essential hypertension, Genetic Epidemiology of Responses to Antihypertensives, NORdic DILtiazem intervention, Pharmacogenomics Evaluation of Antihypertensive Responses, and Campania Salute Network-StayOnDiur. We validated a polymorphism in CSMD1 and UGGT2., Conclusion: This exploratory study reports two plausible loci associated with SBP response to hydrochlorothiazide: TET2, an aldosterone-responsive mediator of αENaC gene transcription; and CSMD1, previously described as associated with hypertension in a case-control study.

We evaluated the prevalence and severity of occult coronary artery disease (CAD) and cerebrovascular disease (CeVD) in patients with abdominal aortic aneurysm (AAA). We studied 100 consecutive patients with no history of CAD, normal electrocardiogram, normal systolic function, and no angina or dyspnea. All patients underwent carotid Doppler study and invasive coronary angiography. Significant CAD was observed in 61% of patients. In all, 51% of patients with significant CAD showed either left main (n = 7), 3-vessel (n = 17), or proximal left anterior descending (n = 7) CAD, corresponding to 31% of the total cohort. Cerebrovascular disease was detected in 53% of patients, and in 38% of them was significant (peak systolic flow velocity ≥125 <230 cm/s). In 36% of patients with CeVD either left main (n = 5), 3-vessel (n = 11), or proximal left anterior descending (n = 3) CAD was observed. Severe asymptomatic CAD is prevalent in AAA, and 31% of patients fulfill indications for coronary revascularization., (© The Author(s) 2014.)

Background: Whether the combination of chronic kidney disease (CKD) and left ventricular hypertrophy (LVH) affects the cardiovascular (CV) risk in patients with uncomplicated hypertension is poorly investigated. The aim of this study was to assess the effects of LVH, CKD, and their combination on CV events in hypertension., Methods: This study analyzed 1,078 patients with essential hypertension., Results: LVH was present in 104 (9.6%) patients, CKD was present in 556 (51.5%) patients, and the combination of LVH and CKD was found in 174 (16.1%) patients. During the follow-up (median = 84 months), 52 CV events were observed (0.64 events/100 patient-years): 6 (2.4%) in patients without target-organ damage (TOD), 6 (5.7%) in patients with LVH, 20 (3.6%) in patients with CKD, and 20 (11.4%) in patients with combined LVH+CKD. Adjusted hazard ratio (HR) for CV events was 1.62 (P = 0.34) for LVH, 0.951 (P = 0.94) for CKD, and 2.45 (P = 0.03) for LVH+CKD. After multivariable Cox proportional hazard analysis, the combination of LVH+CKD was significantly associated with risk of CV events, when the model was adjusted for sex and age (HR = 2.447; P = 0.03) and for the presence of 1 CV risk factor (HR = 3.226; P = 0.02). In contrast, the association of LVH+CKD was no longer significant when the model was adjusted for sex, age, and the presence of ≥ 2 CV risk factors., Conclusions: The results of this study highlight the relevance of the interactions between TODs and hemodynamic, anthropometric, and metabolic abnormalities in the CV risk stratification of patients with essential hypertension., (© American Journal of Hypertension, Ltd 2014. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objectives: The aim of this study was to identify predictors of occlusion intolerance (OI) developing during proximal protected carotid artery stenting (CAS)., Background: The use of proximal embolic protection devices, such as endovascular occlusion, during CAS has been demonstrated to be particularly safe and effective. However, endovascular occlusion can expose the ipsilateral hemisphere to hypoperfusion and produce transient neurological symptoms (OI)., Methods: From March 2010 to March 2012, 605 consecutive patients underwent proximal protected CAS at our institution. To identify independent predictors of OI, a multivariate logistic regression model was developed that included all patients' clinical/angiographic and procedural characteristics., Results: OI developed in a total of 184 patients (30.4%). Compared with patients in whom OI did not develop, those who experienced OI had lower occlusion pressure (OP) (42.3 ± 12.7 mm Hg vs. 61.9 ± 15.4 mm Hg, p < 0.001). Receiver-operating characteristic curve analysis demonstrated that OP was the most consistent predictor of OI with a C-statistic of 0.85 (95% confidence interval [CI]: 0.82 to 0.88) with best cutoff being ≤40 mm Hg (sensitivity, 68.5%; specificity, 93.3%). By logistic regression analysis, the most powerful independent predictor of OI developing was an OP ≤40 mm Hg (odds ratio: 33.2, 95% CI: 19.1 to 57.7) and the most powerful clinical predictor of such OP was the presence of contralateral internal carotid artery occlusion (odds ratio: 3.1, 95% CI: 1.5 to 6.2)., Conclusions: OI may occur in as many as one-third of the patients undergoing proximal protected CAS. This event is more common in those patients with an OP ≤40 mm Hg. Patients presenting with concomitant occlusion of the contralateral internal carotid artery more frequently have an OP ≤40 mm Hg., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Chronic therapy with statins, antihypertensive and antiplatelet drugs is one of the most important interventions for primary and secondary prevention of cardiovascular disease. Adherence to drug treatment is key to successful therapeutic intervention, especially in chronic conditions. This holds particularly true in the setting of cardiovascular diseases, because poor adherence may have serious adverse effects in terms of morbidity and mortality. Many factors may contribute to poor adherence, which can be either patient-related or dependent on the healthcare system, the physician and the environment. The identification and appropriate correction of these factors may result in both clinical and economic benefits. In this setting it is also important to assess the implications of the increasing use of generic or equivalent drugs on adherence to pharmacological therapy.

We evaluated the relation between reperfusion indexes and right ventricular (RV) dysfunction in patients with inferior ST-segment elevation myocardial infarction (STEMI). We included patients with inferior STEMI undergoing percutaneous coronary intervention and right coronary artery as infarct-related artery. Myocardial reperfusion was evaluated by Thrombolysis In Myocardial Infarction (TIMI) flow, TIMI frame count, myocardial blush grade, and ST-segment resolution. RV dysfunction was defined as tricuspid annular plane systolic excursion≤16 mm in M-mode imaging. RV dysfunction was present in 58 of 141 patients (41.1%) and was more frequent in patients achieving suboptimal postprocedural TIMI flow grade (66.7% vs 36.7%, grades 0 to 2 vs 3, p=0.01), TIMI frame count (63.2% vs 37.7%, ≥40 vs <40 frames, p=0.04), and myocardial blush grade (33.3% vs 56.2%, grade 0 or 1 vs 2 or 3, p=0.001). RV dysfunction rates did not differ according to ST-segment resolution. Patients with RV dysfunction had increased rates of cardiac death (13.2% vs 2.6%, p=0.03), reinfarction (24.5% vs 10.3%, p=0.03), and stent thrombosis (22.6% vs 6.4%, p=0.01) at 2-year follow-up. Postprocedural TIMI flow grade 3 (odds ratio 0.25, 95% confidence interval 0.09 to 0.68, p=0.007) was the only reperfusion correlate of RV dysfunction at multivariate analysis. In an independent cohort of 84 patients with STEMI, postprocedural TIMI flow grade 3 had a limited sensitivity (52%), with a high specificity (74.5%) and negative predictive value (71%) for excluding RV dysfunction. In conclusion, in patients with inferior STEMI undergoing coronary revascularization, RV dysfunction is associated with a worse long-term prognosis. Postprocedural TIMI flow grade may be a useful tool to predict RV dysfunction., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The indications for the use of aspirin in primary cardiovascular prevention continue to be a source of intense debate, with major international guidelines providing conflicting advices. This document, written by delegates of the main Italian scientific societies dealing with cardiovascular prevention and modeled on a similar document by the European Society of Cardiology Working Group on Thrombosis, reviews the evidence in favor and against the use of aspirin therapy in primary prevention based on data cumulated so far, including recent data linking aspirin with cancer protection. While awaiting the results of several ongoing studies, this document argues for a pragmatic approach to the use of low-dose aspirin in primary cardiovascular prevention, and suggests its use in patients at high cardiovascular risk, defined as ≥2 major cardiovascular events (death, myocardial infarction, or stroke) projected per 100 person-years, who are not at increased risk of bleeding.

Objectives: The aim of this prospective registry was to evaluate the safety and efficacy at 2-year follow-up of the use of drug-eluting balloons (DEBs) for the treatment of superficial femoral artery (SFA) in-stent restenosis (ISR)., Background: The use of DEBs for the treatment of SFA ISR is associated with a satisfactory primary patency rate at 1 year, but no data are available for longer follow-up. Unfortunately, when DEBs were used to treat SFA de novo lesions, the occurrence of restenosis increased by 50% between the first and the second years of follow-up., Methods: From December 2009 to December 2010, 39 consecutive patients underwent percutaneous transluminal angioplasty of SFA ISR at our institution (Clinica Montevergine, Mercogliano, Italy). All patients underwent conventional SFA percutaneous transluminal angioplasty and final post-dilation with paclitaxel-eluting balloons (IN.PACT, Medtronic Inc., Minneapolis, Minnesota). Patients were evaluated for up to 24 months., Results: During follow-up, 1 patient died of heart failure and another of sudden death, for a 2-years rate of cardiovascular mortality rate of 5.12 %. The primary patency rate at 2 years was 70.3% (11 of 37 patients experienced restenosis recurrence at 2-year follow-up). The treatment of complex ISR lesions (classes II and III) was associated with an increased rate of recurrent restenosis compared with class I (33.3 % and 36.3 % vs. 12.5%; p = 0.05)., Conclusions: The data suggest that adjunctive use of DEBs for the treatment of SFA ISR is a safe and effective therapeutic strategy up to 2 years of follow-up., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: The aim of the study was to assess the age-specific, sex-specific, and region-specific average sodium and potassium intake and its association with anthropometric characteristics in a sample of the Italian adult hypertensive population., Methods: A total of 1232 hypertensive patients were recruited consecutively by 47 centers recognized by the Italian Society of Hypertension. The enrolled participants were on stable antihypertensive treatment. Anthropometric indices, blood pressure, 24-h urinary sodium, and potassium excretion were measured and used as proxy for the average daily sodium and potassium intake., Results: The average sodium intake was 172  mmol (or 10.1  g of salt/day) among men and 138 (or 8.1) among women, with no difference among geographical areas. Over 90% of men and 81% of women had a consumption higher than the recommended standard dietary intake of 5  g/day. The average potassium intake was 63 and 56  mmol, respectively in men and women, again without geographical differences, nearly 92% of men and 95% of women having an intake lower than the recommended intake (100  mmol/day or 3.9  g/day). There was a significant trend to a gradual decrease in sodium intake with age in both sexes (P <0.001). There was also a direct association between BMI and sodium intake in both sexes, this association being independent of age (P < 0.001)., Conclusion: In this national sample of the Italian hypertensive population, dietary sodium intake was largely higher and potassium intake much lower than the recommended intakes, and this was true for all geographical areas. Overweight and obese hypertensive patients had particularly high sodium intakes.

Aim: The aim of this study is to evaluate the differences in the prevalence of chronic kidney disease (CKD) and of cardiovascular risk factors and diseases between men and women participating in the Italy Developing Education and awareness on MicroAlbuminuria in patients with hyperteNsive Disease (I-DEMAND) study., Methods: This is an observational, cross-sectional, multicenter study aimed at assessing prevalence and correlates of CKD among Italian hypertensive patients attending out-patient referral clinics. CKD was defined as glomerular filtration rate (GFR) less than 60 ml/min per 1.73 m(2) [Modification of Diet in Renal Disease (MDRD) study equation and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation] and/or urine albumin-to-creatinine ratio of at least 2.5 mg/mmol in men and of at least 3.5 mg/mmol in women or both. Left-ventricular hypertrophy (LVH) was diagnosed by either ECG or echocardiography., Results: A total of 3558 study patients with renal data available were considered for this analysis: mean age was 61 ± 4 years and 37% had diabetes mellitus. Female patients (n = 1636, 46%) were older, with a greater prevalence of obesity and lower prevalence of smoking. The prevalence of concomitant coronary artery and peripheral artery diseases, but not of hypertension, diabetes mellitus, or heart failure, was lower in women than in men. The overall prevalence of albuminuria (21 vs. 32%; P = 0.001) and of microalbuminuria (16 vs. 23%; P = 0.001) was lower in women than in men. In women the prevalence of a reduced GFR estimated by both MDRD (33 vs. 21%; P = 0.001) and CKD-EPI equations (32 vs. 23%; P = 0.001) was higher than in men. CKD prevalence was similar in women and men (44 vs. 41%; P = 0.095 and 43 vs. 43%; P = 0.475, respectively, when MDRD and CKD-EPI eGFR estimations were used). The prevalence of LVH (diagnosed by either ECG or echocardiography) was similar in men and women (18 vs. 20%; P = 0.12).The main independent determinants of CKD were age, glycemia, uricemia, pulse pressure, hypertension duration, and previous cardiovascular diseases in men, and increasing age, glycemia, uricemia, pulse pressure, and a lower BMI in women., Conclusion: Renal abnormalities are present in a significant number of female hypertensive patients attending hypertension clinics. Prevalence of reduced eGFR and of microalbuminuria, associated risk factors, and clinical conditions are different between men and women, suggesting the need to develop specific therapeutic strategies to prevent renal dysfunction and reduce associated morbidity and mortality.

Observational studies demonstrate that the proportion of treated hypertensive patients who attain the recommended blood pressure goals (140/90 mmHg) does not exceed 30-40%. Conversely, clinical trials have consistently shown that effective blood pressure control within the recommended targets can be achieved in 70-80% of treated hypertensive patients with different cardiovascular risk profile, especially when appropriate, effective and well tolerated combination therapies are used. In order to bridge the gap between current and optimal blood pressure control rates and to achieve a more effective cardiovascular prevention, the Italian Society of Hypertension has recently developed an interventional strategy that aims to approximate 70% of treated controlled patients by 2015. This ambitious goal can be realistically achieved by the appropriate use of modern aids and tools, also including the implementation of combination therapy, especially if this approach can be simplified into a single pill, now available in Italy. At present, 70-80% of hypertensive patients require combination therapies based on at least two classes of antihypertensive drugs to achieve the recommended blood pressure goals. It is therefore of paramount importance to implement this strategy in routine clinical practice. Among the different combination therapies, the use of combination strategies based on drugs inhibiting the renin-angiotensin system, such as angiotensin receptor blockers and angiotensin-converting enzyme inhibitors, combined with diuretics and/or calcium-channel blockers, have demonstrated to significantly reduce the rates of major cardiovascular events and discontinuations from prescribed therapies, resulting in higher antihypertensive efficacy and better tolerability than monotherapy. The present document of the Italian Society of Hypertension aims to provide main indications for implementing combination therapy in the clinical management of hypertension in order to improve blood pressure control in Italy.

Objectives: It is well known that among hypertensive patients, an increased left ventricular mass (LVM) is a powerful predictor of cardiovascular morbidity and mortality. However, the mechanisms underlying LVM in hypertension are not completely understood, as the absolute value of blood pressure and other risk factors associated do not predict alone a definite LVM progression. Recently, the 9p21 chromosomal region has been consistently associated with coronary heart disease., Methods and Results: We examined the association of 384 single nucleotide polymorphisms (SNPs) in the short arm of chromosome 9 with LVM in 821 hypertensive individuals from northern Italy. We identified a SNP (rs894379) in the intronic region of the centlein, centrosomal protein (CNTLN) gene on chromosome 9p22, whose minor allele G is associated with an increased LVM. We performed a follow-up validation analysis for the top SNP in 1038 hypertensive individuals from southern Italy. We then combined the results and found a nominal association for rs894379 (β  =  2.46, P  =  0.0026)., Conclusion: We describe a new variant associated with echocardiography LVM. This result, though it needs to be further investigated, may improve our understanding of the genetic determination of this prognostically relevant trait.

Introduction: Blood pressure (BP) control is poorly achieved in hypertensive patients, worldwide., Aim: We evaluated clinic BP levels and the rate of BP control in hypertensive patients included in observational studies and clinical surveys published between 2005 and 2011 in Italy., Methods: We reviewed the medical literature to identify observational studies and clinical surveys on hypertension between January 2005 and June 2011, which clearly reported information on clinic BP levels, rates of BP control, proportions of treated and untreated patients, who were followed in different clinical settings (mostly in general practice, and also in outpatient clinics and hypertension centres)., Results: The overall sample included 158 876 hypertensive patients (94 907 women, mean age 56.6 ± 9.6 years, BMI 27.2 ± 4.2 kg/m(2), known duration of hypertension 90.2 ± 12.4 months). In the selected studies, average SBP and DBP levels were 145.7 ± 15.9 and 87.5 ± 9.7 mmHg, respectively; BP levels were higher in patients followed in hypertension centres (n = 10 724, 6.7%; 146.5 ± 17.3/88.5 ± 10.3 mmHg) than in those followed by general practitioners (n = 148 152, 93.3%; 143.5 ± 13.9/84.8 ± 8.9 mmHg; P < 0.01). More than half of the patients were treated (n = 91 318, 57.5%); among treated hypertensive patients, only 31 727 (37.0%) had controlled BP levels., Conclusion: The present analysis confirmed inadequate control of BP in Italy, independently of the clinical setting. Although some improvement was noted compared with a similar analysis performed between 1995 and 2005, these findings highlight the need for a more effective clinical management of hypertension.

The kidney has been recognized as a sensor of cardiovascular risk. However, evaluation of urinary albumin excretion and estimated glomerular filtration rate is still too often overlooked in clinical practice. The I-DEMAND (Italy-Developing Education and awareness on MicroAlbuminuria in patients with hyperteNsive Disease) study was designed to assess the prevalence of microalbuminuria and its clinical correlates among Italian hypertensive patients. A total of 4151 patients from 87 specialized care centres were included in the study. Overall, this study demonstrated that approximately one-half of the enrolled patients had chronic kidney disease, with albuminuria being present in one-quarter of the individuals. The presence of renal abnormalities was more prevalent in patients with concomitant cardiovascular risk factors. This article discusses the main results of the study and its potential implications in clinical practice.

Objectives: To estimate the prevalence of hypertension-migraine comorbidity; to determine their demographic and clinical characteristics versus patients with hypertension or migraine alone; and to see whether a history of cerebrovascular events was more common in the comorbidity group., Methods: The MIRACLES, multicenter, cross-sectional, survey included 2973 patients with a known diagnosis of hypertension or migraine in a general practitioner setting in Italy., Results: Five hundred and seventeen patients (17%) suffered from hypertension-migraine comorbidity, whereas 1271 (43%) suffered from hypertension only, and 1185 (40%) from migraine only. In the comorbidity group, the onset of comorbidity occurred at about 45 years of age, with migraine starting significantly later than in the migraine-only group, and hypertension significantly before than in the hypertension-only group; a familial history of both hypertension and migraine had a significantly higher frequency as compared with the hypertension and migraine group. Compared to hypertension (3.1%) and migraine (0.7%), the comorbidity group had a higher prevalence (4.4%) of history of cerebrovascular events, with an odds ratio of a predicted history of stroke/transient ischemic attack (TIA) of 1.76 [95% confidence interval (CI) 1.01-3.07] compared to the hypertension group. In patients without other recognized risk factors for stroke, stroke/TIA occurred more frequently in the comorbidity group, compared to the hypertension group. In the age range 40-49 years, prevalence of history of stroke/TIA was five-fold greater (4.8% in comorbidity vs. 0.9% in hypertension group)., Conclusion: This cross-sectional study indicates that the prevalence of comorbidity hypertension-migraine is substantial and that patients with comorbidity have a higher probability of history of cerebrovascular events, compared to hypertensive patients.

Left ventricular (LV) mass (LVM) is the most important information requested in hypertensive patients referred for echocardiography. However, LV function also predicts cardiovascular (CV) risk independent of LVM. There is no evidence that addition of LV function significantly improves model prediction of CV risk compared with LVM alone. Thus, composite fatal and nonfatal CV or cerebrovascular events were evaluated in 5380 hypertensive outpatients (2336 women, 298 diabetics, and 1315 obese subjects) without prevalent CV disease (follow-up: 3.5+/-2.8 years). We compared 5 risk models using Cox regression and adjusting for age and sex: (1) LV mass normalized for height in meters(2.7) (LVMi); (2) LVMi, concentric LV geometry, by relative wall thickness (>0.43), ejection fraction, and transmitral diastolic pattern (by thirtiles of mitral deceleration index); (3) LVMi, LV geometry, midwall shortening, and mitral deceleration index thirtiles; (4) as No. 2 with the addition of left atrial dilatation (>23 mm); and (5) as No. 3 with the addition of left atrial dilatation. Individual hazard functions were compared using receiving operating characteristic curves and z statistics. Areas under the curves increased from 0.60 in the model with the sole LVMi to 0.62 in the others (all P values for differences were not significant). The additional information on systolic and diastolic function decreased the contribution (Wald statistics) of LVMi in the Cox model without improving the model ability to predict CV risk. We conclude that risk models with inclusion of information on LV geometry and systolic and diastolic function, in addition to LVMi, do not improve the prediction of CV events but rather redistribute the impact of individual predictors within the risk variance.

Objectives: In the past years, several risk charts have been created to increase the accuracy of cardiovascular risk stratification. The most widely used and validated algorithms do not included target organ damage as risk prediction. The aim of the present study was to evaluate whether preclinical renal damage is associated with cardiovascular diseases independently of individual risk profile assessed by risk charts., Methods: The study population was that of Italy-Developing Education and awareness on MicroAlbuminuria in patients with hypertensive Disease, a large observational study conducted on hypertensive patients in Italy. The Framingham Risk Score (FRS), Systematic COronary Risk Estimation (SCORE) and Progetto Cuore Risk Score (Progetto Cuore RS) were computed in each eligible patient. Chronic kidney disease was defined by the presence of albuminuria or by a reduction of glomerular filtration rate., Results: Study participants were categorized to have low, medium and high risk according to the tertiles of the three charts. Prevalence of total cardiovascular diseases progressively and significantly increased according to the degrees of risk assessed by the three charts, the highest prevalence being in participants with a high-risk profile (both high and medium vs. low risk <0.01 for FRS, SCORE and Progetto Cuore RS). The presence of chronic kidney disease was associated with total cardiovascular diseases, independently of FRS (odds ratio 1.64, 95% confidence interval 1.33-2.02, P < 0.001), SCORE (odds ratio 1.55, 95% confidence interval 1.21-1.98, P < 0.001) and Progetto Cuore RS (odds ratio 1.59, 95% confidence interval 1.22-2.07, P < 0.001). Moreover, inclusion of renal damage in the logistic model significantly increased the accuracy of the FRS (P < 0.05), SCORE (P < 0.01) and Progetto Cuore RS (P < 0.01) to identify patients with overt cardiovascular diseases., Conclusion: Identification of patients with preclinical renal damage should be encouraged in the hypertension cardiovascular risk stratification setting in order to achieve a more accurate individual risk computation. The presence of renal damage could improve cardiovascular risk prediction over the widely used risk stratification charts.

Objective and Methods: Italy Developing Education and awareness on MicroAlbuminuria in patients with hyperteNsive Disease is an observational, cross-sectional, multicenter study aimed at determining prevalence and correlates of chronic kidney disease (CKD) among Italian hypertensive patients attending out-patient referral clinics. CKD was defined as glomerular filtration rate (GFR) less than 60 ml/min per 1.73 m (Modification of Diet in Renal Disease equation) or urine albumin to creatinine ratio of at least 2.5 mg/mmol in men and of at least 3.5 mg/mmol in women or both., Results: Among 3534 study patients (mean age 61 years, 54% male patients, 37% diabetic patients), the prevalence of microalbuminuria, reduced GFR, and CKD was 27, 26, and 42%, respectively. Only 11% of patients had concomitant microalbuminuria and reduced GFR. Sex, smoking, systolic blood pressure, glucose, and GFR were the independent predictors of albumin to creatinine ratio, whereas sex, age, history of cardiovascular diseases, uric acid, abdominal obesity, and albumin to creatinine ratio were more closely related to GFR. The presence of CKD was associated with older age, smoking, higher systolic and pulse pressure levels, impaired fasting glucose, hyperuricemia, and previous cardiovascular disease. Furthermore, CKD was not only associated with a greater use of renin-angiotensin system-inhibiting, lipid-lowering and antiplatelet drugs but also with inadequate blood pressure control., Conclusion: Renal abnormalities are found in a significant number of hypertensive patients. CKD occurs more often in older patients and in those with associated metabolic risk factors or clinical conditions. These results suggest the need to improve awareness of the role of renal damage as a component of global risk and to develop appropriate therapeutic strategies to reduce morbidity and mortality in this specific subgroup of patients.

Objective: Incidence of type 2 diabetes might be associated with preexisting hypertension. There is no information on whether incident diabetes is predicted by blood pressure control. We evaluated the hazard of diabetes in relation to blood pressure control in treated hypertensive patients., Research Design and Methods: Nondiabetic, otherwise healthy, hypertensive patients (N = 1,754, mean +/- SD age 52 +/- 11 years, 43% women) participated in a network over 3.4 +/- 1 years of follow-up. Blood pressure was considered uncontrolled if systolic was >or=140 mmHg and/or diastolic was >or=90 mmHg at the last outpatient visit. Diabetes was defined according to American Diabetes Association guidelines., Results: Uncontrolled blood pressure despite antihypertensive treatment was found in 712 patients (41%). At baseline, patients with uncontrolled blood pressure were slightly younger than patients with controlled blood pressure (51 +/- 11 vs. 53 +/- 12 years, P < 0.001), with no differences in sex distribution, BMI, duration of hypertension, baseline blood pressure, fasting glucose, serum creatinine and potassium, lipid profile, or prevalence of metabolic syndrome. During follow-up, 109 subjects developed diabetes. Incidence of diabetes was significantly higher in patients with uncontrolled (8%) than in those with controlled blood pressure (4%, odds ratio 2.08, P < 0.0001). In Cox regression analysis controlling for baseline systolic blood pressure and BMI, family history of diabetes, and physical activity, uncontrolled blood pressure doubled the risk of incident diabetes (hazard ratio [HR] 2.10, P < 0.001), independently of significant effects of age (HR 1.02 per year, P = 0.03) and baseline fasting glucose (HR 1.10 per mg/dl, P < 0.001)., Conclusions: In a large sample of treated nondiabetic hypertensive subjects, uncontrolled blood pressure is associated with twofold increased risk of incident diabetes independently of age, BMI, baseline blood pressure, or fasting glucose.

Objectives: Renal abnormalities are strongly associated with cardiac damage in essential hypertension. Detection of preclinical cardiac and renal abnormalities is a key clinical step in hypertension management. This study investigated the relationship between ECG abnormalities and microalbuminuria (MAU) in hypertensive patients without overt cardiovascular disease. This relationship, in fact, has never been extensively studied., Methods: The study population was that of Italy-Developing Education and awareness on MicroAlbuminuria in patients with hypertensive Disease, a large observational study including 4121 hypertensive patients in Italy. Patients with overt cardiovascular diseases were excluded from the present analysis. ECGs were centrally read and urinary albumin/creatinine ratio was carefully assessed. Chronic kidney disease was defined by the presence of albuminuria or by a reduction of glomerular filtration rate., Results: The presence of ECG abnormalities was significantly and directly associated with chronic kidney disease [odds ratio (OR) 1.66, 95% confidence interval (CI) 1.32-2.07, P<0.001], particularly with MAU (OR 1.81, 95% CI 1.39-2.36, P<0.001). Main selected ECG abnormalities were also significantly associated with MAU [rhythm abnormalities (OR 2.94, 95% CI 1.77-4.88, P<0.001), intraventricular conduction defects (OR 1.95, 95% CI 1.32- 2.87, P<0.01), ventricular repolarization alterations (OR 1.84, 95% CI 1.26-2.70, P<0.01) and left-axis deviation (OR 1.87, 95% CI 1.26-2.79, P<0.01)]. After adjustment for confounders, an abnormal ECG and all the main ECG abnormalities remained significantly associated with MAU., Conclusion: This is the first large and systematic analysis of the relationship between detailed ECG abnormalities and MAU/chronic kidney disease in hypertensive patients without overt cardiovascular diseases. We report a significant and independent relationship between the presence of ECG abnormalities and renal damage in a preclinical stage of hypertension. Identification of ECG abnormalities in hypertension should prompt physicians to careful detection for renal damage, also in order to achieve an accurate risk stratification.

Objective: A previous analysis of the ForLife study demonstrated a high estimated risk of stroke, poor blood pressure control and higher cardiovascular risk. Data from a subsequent visit within 6 months, to evaluate the impact of systematic stroke risk assessment, are reported., Methods: Between February and July 2003, 1800 general practitioners (GPs) recruited a total of 12,792 (7512 untreated and 5280 treated) patients with hypertension. Blood pressure values were assessed in the whole study population, and for different demographic and clinical features in two visits within 6 months. The data were recorded into a Framingham-based stroke risk score and computed using a risk calculator., Results: Between the two visits the percentage of patients with controlled blood pressure (< 140/90 mmHg) increased substantially in all subgroups, being greater in patients who were not treated at baseline. Among initially treated patients, the greater control of blood pressure involved both diastolic and systolic values. The percentage of patients with diabetes whose blood pressure levels were less than 130/80 mmHg also increased at the second visit. Between the two visits the estimated stroke risk score showed a reduction, with a significant shift of patients from high to intermediate and low-risk categories. This reduction involved all subgroups, including patients with diabetes and left ventricular hypertrophy., Conclusion: The present large-scale observational study demonstrates that the assessment of stroke risk and increased awareness of stroke risk factors by GPs is associated with improved blood pressure control, reduced cardiovascular risk profile and a prompt reduction in the 10-year estimated risk of stroke.

Background: A number of patients with chronic heart failure (CHF) have diastolic but not systolic dysfunction. This occurs particularly in the elderly and in hypertension, but the prevalence of diastolic dysfunction in elderly hypertensives without CHF has never been investigated systematically., Methods and Results: The Assessment of PRevalence Observational Study of Diastolic Dysfunction (APROS-diadys) project was a cross-sectional observational study on elderly (age >/= 65 years) hypertensives without systolic dysfunction [left ventricular ejection fraction (LVEF) >/= 45%] consecutively attending hospital outpatient clinics in Italy, in order to establish the prevalence of echocardiographic signs of diastolic dysfunction according to various criteria, and to correlate them with a number of demographic and clinical characteristics. Primary criteria for diastolic dysfunction was an E/A ratio (ratio between transmitral peak velocities of E and A waves) < 0.7 or > 1.5 on echocardiographic Doppler examination. Secondary criteria were: E/A < 0.5 and deceleration time (DT) > 280 ms, or isovolumic relaxation time (IVRT) > 105 ms or pulmonary vein (PV) peak systolic/peak diastolic flow (S/D) ratio > 2.5 or PV atrial retrograde flow (PV A) > 35 cm/s. Throughout Italy, 27 447 patients were screened in 107 clinics, with 24 141 excluded according to protocol. Among the remaining 3336 patients, 754 (22.6%) had signs of CHF. After exclusion of 37 protocol violators, 2545 patients (49.0% men, mean age 70.3 years, 95.4% under antihypertensive treatment) were studied ultrasonographically. Diastolic dysfunction (primary criteria) was found in 649 (25.8%) patients. Multiple logistic regression analysis found age, gender, left ventricular mass, systolic and pulse pressures and midwall shortening fraction as significant covariates. Using secondary criteria, the prevalence of diastolic dysfunction was higher (45.6%), mostly because of IVRT > 105 ms or PVA flow > 35 cm/s., Conclusion: CHF and diastolic dysfunction are highly prevalent in elderly hypertensives attending hospital clinics.

Background: Blood pressure (BP) control is reported to be poor in hypertensive patients worldwide., Objective: BP levels, the rate of BP control, prevalence of risk factors and total cardiovascular risk were assessed in a large cohort of hypertensive patients, derived from recent surveys performed in Italy., Methods: Fifteen studies on hypertension, performed in different clinical settings (general population, general clinical practice, specialist outpatient clinics and hypertension centres) over the past decade were considered., Results: The overall sample included 52 715 hypertensive patients (26 315 men and 26 410 women, mean age 57.3 +/- 6.9 years). Despite the high percentage of patients on stable antihypertensive treatment (n = 36 556, 69%), mean systolic and diastolic BP levels were 147.8 +/- 8.5 and 89.5 +/- 5.2 mmHg, respectively. On the basis of the nature of the study (population surveys or clinical referrals), systolic BP levels were consistently higher than the normality threshold in both settings (142.6 +/- 12.4/84.8 +/- 3.7 mmHg and 150.4 +/- 4.6/91.9 +/- 4.1 mmHg, respectively). The BP stratification could be assessed in 40 829 individuals: 4.5% had optimal, 9.2% normal and 8.3% high-normal BP levels, however, the large majority were in grade 1 (39%) or grades 2-3 (32.6%) hypertension. In the overall sample, 55.9% of hypertensive patients had hypercholesterolemia, 28.7% were smokers, 36.4% were overweight or obese and 15.0% had diabetes mellitus. Cardiovascular risk stratification was assessed in 37 813 hypertensives: 23.2% had low, 33.9% moderate, 30.2% high and 12.7% very high added risk., Conclusion: Our analysis demonstrates the persistence of poor BP control and high prevalence of risk factors, supporting the need for more effective, comprehensive and urgent actions to improve the clinical management of hypertension.