Prevalence of hypertension and associated cardiovascular risk factors among pharmacies customers: an Italian nationwide epidemiological survey

Hypertension and other modifiable cardiovascular (CV) risk factors are the leading causes of avoidable mortality and disability.1,2 On the occasion of the World Hypertension Day in 2018, the Italian Society of Hypertension and the National Federation of Italian Pharmacies (Federfarma) co-sponsored a cross-sectional, nationwide epidemiological survey (Abbasso la Pressione!, 17–20 May 2018), aimed at evaluating the prevalence and awareness of modifiable/non-modifiable CV risk factors, with focus on hypertension, among Italian pharmacy customers, in conformity with the Helsinki Declaration. Self-presented individuals entering the participating pharmacies (n = 3956, 21% of all Italian pharmacies) during the survey period and who provided written informed consent were consecutively enrolled. Blood pressure (BP) was measured by trained pharmacists with a standard protocol (average of the second and third BP readings taken with validated, automated oscillometric devices after 2 minutes rest). Information on concomitant modifiable (smoking, physical inactivity, dietary salt, fruit and vegetables, obesity, personal history of hypertension, diabetes mellitus, dyslipidemia, CV disease [CVD] and chronic kidney disease [CKD]) and unmodifiable (age, gender and CVD family history) CV risk factors was self-reported as categorical data (except for age, weight and height). Geographic information was collected automatically. Statistical analyses were performed using R (v3.5.1). Unpaired Student’s t test and χ2 test were used to detect differences in quantitative (mean ± standard deviation [SD]) and qualitative (N, %) data, respectively (statistical significance: p < 0.05). BP was used as a continuous (mmHg) and categorical (normal BP, hypertension; controlled/uncontrolled hypertension) variable. Hypertension was defined as mean BP ≥ 140 and/or 90 mmHg if untreated, or as being on antihypertensive drugs. Uncontrolled hypertension was defined as BP ≥130/80 mmHg in treated participants <65 years and with normal renal function and ≥140/80 mmHg if ≥65 years.3 Overall and age-/gender-stratified prevalence of diagnosed/undiagnosed/uncontrolled hypertension and associated CV risk factors was calculated. The 10-year CV risk was estimated by guidelines.4 Data were analysed as recorded, without imputation for missing data. Of 48,229 participants recruited, 47,217 (60.6% women; mean age 59.2 ± 15.3 years; 25.3% smokers; mean BP 129.2 ± 18.0/76.7 ± 10.8 mmHg; mean body mass index [BMI] 26.0 ± 4.6; 40.9% with moderate–very high CV risk) had complete data. Self-reported hypertensive participants were 22,935 (48.6%; 93.1% treated). Based on their actual BP values, 9.2% self-declared normotensive participants were reclassified as hypertensive (grade 1, 2 or 3). Hypertensive participants (N = 27,289, 57.8%) were older, overweight/obese, sedentary men (p < 0.001) from Northern Italy (p = 0.009), with greater prevalence of family/personal history of CVD/CKD, diabetes and dyslipidemia (p < 0.001); 63.1% had moderate–very high CV risk. No difference in salt (p = 0.908) and vegetables (p = 0.318) use was recorded between normotensive and hypertensive participants. Among newly detected hypertensive participants, significant differences in age (p < 0.001), BMI (p < 0.001), CV risk (p < 0.001), use of salt (p = 0.004) and vegetables (p = 0.02), but not in gender, physical activity, smoking, comorbidities or family history of CVD/CKD were detected across hypertension grades. The majority of new diagnoses occurred between 45 and 64 years of age. The prevalence of hypertension, overweight/obesity, dyslipidemia and diabetes increased with age. Conversely, use of salt, smoking and scarce vegetable consumption were more frequent at younger ages. Sedentary lifestyle was epidemic at all age ranges (44.3% among men <35 years; 58.3% among women ≥65 years). All risk factors, except for physical inactivity, were more prevalent among men. According to 2018 European Society of Hypertension/European Society of Cardiology (ESC/ESH) hypertension guidelines,3 only 38.9% of treated hypertensive participants were at goal (–28.9% compared with 2013 guidelines;4 Supplementary Figure). They were older women, non-smokers, non-diabetic, more active, with normal BMI, regular vegetable consumers, not salt users, with personal history of CKD/CVD and low–moderate CV risk. No difference in dyslipidemia (p = 0.881) or family history of CVD/CKD (p = 0.274) was observed between controlled and uncontrolled hypertensives. Although Italy is considered a low-CV-risk country, about 41% of the examined population had moderate–very high CV risk, substantially due to modifiable risk factors. The prevalent risk conditions at younger ages included unhealthy lifestyle habits, whereas older generations showed much awareness about the latter, simultaneously displaying higher rates of metabolic syndrome components. Although this discrepancy might reflect the adhesion to prevention strategies among older participants,5 the lack of it among younger individuals betrays a careless approach to CV health, or a distorted self-perception of risky behaviours. Successful prevention strategies should be able to overcome this potential limit and convey the importance of a timely action before the development of established risk factors, although achieving lifestyle targets6 besides intensified medical therapy is also recommended in secondary prevention.7 In spite of its limitations (selection bias, self-reported qualitative information, no data on medication classes and treatment compliance, lack of generalizability), this survey highlights the importance of CV prevention campaigns for a timely diffusion of CV risk awareness from youth, as well as an opportunity to identify new/uncontrolled hypertension. Supplemental material for Prevalence of hypertension and associated cardiovascular risk factors among pharmacies customers: an Italian nationwide epidemiological survey Supplemental Material for Prevalence of hypertension and associated cardiovascular risk factors among pharmacies customers: an Italian nationwide epidemiological survey by Rita Del Pinto, Silvia Pagliacci, Martina De Feo, Davide Grassi, Claudio Ferri and on behalf of the Italian Society of Hypertension and Federfarma in European Journal of Preventive Cardiology The authors would like to acknowledge the work of all the pharmacists who collected the data during the campaign, and the contribution of Teva®, Omron®, and Corman®. The authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. RDP and MDF are Young Investigators of the Italian Society of Hypertension. CF is President of the Italian Society of Hypertension. SP is President of Sunifar, Federfarma. This study was previously presented at the XXXV National Conference on Hypertension, Italian Society of Hypertension, Rome, Italy, 27 September 2018. Federfarma and the Italian Society of Hypertension, here represented by SP and CF, conceived the study. RDP analysed the data. RDP, MDF, DG and CF wrote the first draft. RDP and CF interpreted the results and edited the manuscript. CF provided critical guidance throughout the manuscript drafting. All the authors have read and approved the final version of the manuscript. The Italian Society of Hypertension Board: Prof. Claudio Ferri, Prof. Gianfranco Parati, Prof. Guido Grassi, Prof. Massimo Salvetti and Dr Maurizio Destro. Board members: Prof. Arrigo FG Cicero, Prof. Ferruccio Galletti, Prof. Lorenzo Ghiadoni, Prof. Pietro Minuz, Prof. Paolo Mulatero, Prof. Giuseppe Mulè, Prof. Carmine Savoia, Prof. Alberto Morganti and Prof. Massimo Volpe. Scientific Committee: Prof. Claudio Borghi, Prof. Francesco Cipollone, Prof. Giovambattista Desideri and Prof. Agostino Virdis. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This work was supported by an ‘Alberto Zanchetti’ memorial scholarship 2018, sponsored by Federfarma and granted to MDF on the occasion of the XXXV National Conference on Hypertension, Italian Society of Hypertension, Rome, Italy, 27 September 2018.