Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM)

The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended.

Influence of atrial fibrillation subtypes on anticoagulant therapy in a high-risk older population: the FAI project

BACKGROUND AND AIM

Benefits of oral anticoagulants (OAC) in atrial fibrillation (AF) patients with moderate-to-high risk of stroke are independent of AF pattern. We evaluated whether AF clinical subtype influenced OAC use in a representative sample of the Italian older population.

METHODS

A cross-sectional examination of all subjects aged 65 + years from three general practices in northern, central, and southern Italy started in 2016. A double-screening procedure was followed by clinical and ECG confirmation. Patients were categorized as having paroxysmal, persistent, or permanent AF. OAC use was evaluated in confirmed AF patients.

RESULTS

The sample included 6016 subjects. Excluding 235 non-eligible, participation was 78.3%, which left 4528 participants (mean age 74.5 ± 6.8 years, 47.2% men). Overall, 319 AF cases were identified: 43.0% had paroxysmal, 21.3% persistent, and 35.7% permanent AF. Frequency of OAC therapy was 91.2% in permanent, 85.3% in persistent, and only 43.0% in paroxysmal AF (P < 0.001). In multivariate analysis, controlled for baseline variables and risk scales, persistent and permanent AF were associated with a significant increase in the likelihood of receiving OAC compared with paroxysmal AF (P < 0.001). This was confirmed for permanent AF also in multivariate analyses considering separately vitamin K antagonists or direct-acting oral anticoagulants (OR, 4.37, 95% CI, 2.43-7.85; and 1.92, 95% CI, 1.07-3.42, respectively) and for persistent AF and direct-acting oral anticoagulants (OR, 4.33, 95% CI, 2.30-8.15).

CONCLUSIONS

In a population-based survey, AF pattern was an independent predictor of OAC treatment. Paroxysmal AF is still perceived as carrying a lower risk of vascular events.

Routine assessment of cognitive function in older patients with hypertension seen by primary care physicians: why and how-a decision-making support from the working group on 'hypertension and the brain' of the European Society of Hypertension and from the European Geriatric Medicine Society

: The guidelines on hypertension recently published by the European Societies of Hypertension and Cardiology, have acknowledged cognitive function (and its decline) as a hypertension-mediated organ damage. In fact, brain damage can be the only hypertension-mediated organ damage in more than 30% of hypertensive patients, evolving undetected for several years if not appropriately screened; as long as undetected it cannot provide either corrective measures, nor adequate risk stratification of the hypertensive patient.The medical community dealing with older hypertensive patients should have a simple and pragmatic approach to early identify and precisely treat these patients. Both hypertension and cognitive decline are undeniably growing pandemics in developed or epidemiologically transitioning societies. Furthermore, there is a clear-cut connection between exposure to the increased blood pressure and development of cognitive decline.Therefore, a group of experts in the field from the European Society of Hypertension and from the European Geriatric Medicine Society gathered together to answer practical clinical questions that often face the physician when dealing with their hypertensive patients in a routine clinical practice. They elaborated a decision-making approach to help standardize such clinical evaluation.

Prevalence of atrial fibrillation in the Italian elderly population and projections from 2020 to 2060 for Italy and the European Union: the FAI Project

Aims

To estimate prevalence of atrial fibrillation (AF) in a representative sample of the Italian elderly population, projecting figures for Italy and the European Union.

Methods and results

A cross-sectional examination of all subjects aged 65+ years from three general practices in Northern, Central, and Southern Italy started in 2016. Participants were administered a systematic and an opportunistic screening, followed by clinical and electrocardiogram confirmation. The study sample included 6016 subjects. Excluding 235 non-eligible, among the remaining 5781 participation was 78.3%, which left 4528 participants (mean age 74.5 ± 6.8 years, 47.2% men). Prevalence of AF was 7.3% [95% confidence intervals (CI) 6.6–8.1], higher in men and with advancing age (6.6% from systematic plus 0.7% from opportunistic screening). Using prevalence figures, Italian elderly having AF in 2016 were estimated at ∼1 081 000 (95% CI 786 000–1 482 000). Considering stable prevalence, this number will increase by 75% to ∼1 892 000 in 2060 (95% CI 1 378 000–2 579 000). European Union elderly having AF in 2016 were estimated at ∼7 617 000 (95% CI 5 530 000–10 460 000), increasing by 89% to ∼14 401 000 in 2060 (95% CI 10 489 000–19 647 000). In 2016, subjects aged 80+ years represented 53.5% of cases in Italy and 51.2% in the European Union; in 2060, 69.6% and 65.2%, respectively.

Conclusions

Our findings indicate a high burden of AF in coming decades, especially among the oldest-old, who carry the higher AF-related risk of stroke and medical complications.

An update of the Italian Stroke Organization–Stroke Prevention Awareness Diffusion Group guidelines on carotid endarterectomy and stenting: A personalized medicine approach

Although proof-based medicine has generated much valid evidence for the drawing up of guidelines and recommendations for best clinical practice in symptomatic and asymptomatic carotid stenosis, whether and when it is better to employ endarterectomy or stenting as the intervention of choice still remain matters of debate. Moreover, guidelines have been targeted up to now to the ‘representative’ patient, as resulting from the statistical analyses of the studies conducted on the safety and efficacy of both interventions as well as on medical therapy alone. The Italian Stroke Organization (ISO) and Stroke Prevention and Awareness Diffusion (SPREAD) group has thus decided to update its statements for an 8th edition. To this end, a multidisciplinary team of authors representing Italian scientific societies in the neurology, neuroradiology, vascular and endovascular surgery, interventional cardiology, and general medicine fields re-examined the literature available on stroke. Analyses and considerations on patient subgroups have allowed to model the risks/benefits of endarterectomy and stenting in the individual. Accordingly, the guideline's original methodology has been revised to follow the new SIGN (Scottish Intercollegiate Guideline Network) Grade-like approach, integrating it with new considerations on Precision, or Personalized Medicine. Therefore, this guideline offers recommendations on precision medicine for the single patient, and can be followed in addition to the more standard guidelines.

An Update on Italian Stroke Organization Guidelines on Carotid Endarterectomy and Stenting

One hundred and fifty-three authors, 45 Italian scientific societies, and two Italian patients' associations participated in drafting the Italian Stroke Organization document, which has become the national guideline for the prevention and treatment of stroke in Italy. For the surgical therapy section of the Italian Stroke Organization document, the main trials on carotid endoarterectomy and stenting were critically reviewed in order to formulate recommendations for these procedures. Recommendations are presented here for the referral of patients to either carotid endarterectomy or stenting on the basis of whether carotid stenosis is symptomatic or asymptomatic.

Body mass and osteoarthritic pain: results from a study in general practice

OBJECTIVES

To define the relationship between BMI and pain due to osteoarthritis (OA) of the hand, hip, and knee in patients seen in general practice; to evaluate if overweight is related to co-morbidity and education, and influences the prescription patterns of GPs.

METHODS

2,764 Italian GPs recruited 10 consecutive patients with symptomatic OA, diagnosed according to the ACR criteria. Pain intensity on a visual analogue scale, BMI, years of formal education, comorbidities, pharmacological and non-pharmacological interventions, and referral to specialists were recorded.

RESULTS

The most painful joints were the knee in 12,827 patients (53.6%), the hip in 5,645 (23.6%), and the hand in 5,467 (22.8%). A BMI indicative of overweight or obesity was found in 74.8% of men and in 68.3% of women. Mean BMI was higher in knee OA (27.9±3.9), in generalised OA (27.5±4.2), and hip OA (27±3.7) than in hand OA (25.5±3.4). The prevalence of obesity for hip and knee OA was higher than that reported for the general Italian population. Obesity was an important risk factor for pain in all OA localisations. Co-morbidities and lower education were associated with obesity and more intense pain (p<0.0001). Obesity and overweight were less frequent in institutionalised patients.

CONCLUSIONS

Our study confirms that more than two thirds of Italian patients with symptomatic OA seen by GPs are overweight or obese. Obesity is clearly associated with OA pain, a finding which is probably underestimated by GPs who are not used to modulate treatment and specialist referral according to patients' BMI.

Atherothrombotic burden and medium-term prognosis in patients with acute ischemic stroke: findings of the SIRIO study

BACKGROUND

Short- and medium-term mortality after acute stroke is related to the severity of the index event and the patient's age. However, recent studies have reassessed the prognostic value of the systemic atherothrombotic burden in these patients, not only in the long term. This post hoc analysis of the findings of the SIRIO trial (Stroke in Italy and Related Impact on Outcome) examined the prognostic impact of systemic atherothrombosis.

METHODS

SIRIO was a multicenter observational study enrolling patients during the acute phase of stroke of both ischemic and hemorrhagic origin. The present analysis, however, only covered patients with ischemic stroke. At baseline, the main personal and clinical details were recorded and patients were classified as having either polyvascular disease or single arterial disease on the basis of whether they had symptomatic atherothrombotic disease in other sites besides the cerebrovascular location. For all patients we calculated the Essen Stroke Risk Score (ESRS), dividing them into groups with scores of less than 3 or 3 and more. We recorded total mortality and nonfatal vascular events 12 months after enrolment. Multivariate logistic regression analysis was used to select predictors of medium-term mortality and nonfatal cardiovascular events. There were 2,561 patients with ischemic stroke, 823 of them classified as having polyvascular disease; 940 (out of 2,485) had an ESRS of less than 3 and 1,545 had a score of 3 or more.

RESULTS

The combined endpoint 'death (all causes) and nonfatal cardiovascular events within 12 months of hospital discharge' was significantly dependent on the following factors: ESRS, Rankin scale and National Institutes of Health Stroke Scale scores, and polyvascular disease. Polyvascular disease status significantly affected mortality and nonfatal cardio- and cerebrovascular events after discharge (OR = 1.44, 95% CI = 1.10-1.88). Age was also confirmed as a significant predictor of the combined endpoint.

CONCLUSIONS

Besides age and the clinical severity of the index event, symptomatic involvement of several vascular districts was also an important predictor of mortality and nonfatal cardiovascular events in the medium term in patients with ischemic stroke.

SPREAD-STACI Study: A Protocol for a Randomized Multicenter Clinical Trial Comparing Urgent with Delayed Endarterectomy in Symptomatic Carotid Artery Stenosis

Rationale

In patients with >50% carotid artery stenosis (as measured by North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria) suffering a transient ischemic attack or a minor ipsilateral stroke, carotid endarterectomy exerts maximum benefits, when performed within the first 15 days from the initial ischemic symptom. It is also known that the probability of a major stroke spikes within the first few days after a transient ischemic attack/minor stroke and then flattens out in the following days and weeks. It could be hypothesized that urgent carotid endarterectomy has greater benefit than delayed procedure.

Aims

Demonstrate that urgent carotid endarterectomy is more effective than delayed interventions.

Design

Centers employing neurolgist/stroke physicians and vascular surgeons will enroll TIA or minor stroke patients with >50 % carotid artery stenosis (Nascet criteria), randomized in two groups: urgent carotid endarterectomy (within 48 hours) and delayed carotid endarterectomy (operated between 48 hours and 15 days after onset of symptoms) Risk factors will be evaluated at enrollment. TIA will be classified by ABCD2 scoring system, and minor stroke by National Institutes of Health Stroke Scale (NIHSS) scores. The study will last 90 days per patient, starting from their initial symptom, and the follow-up will be performed by an indipendent neurologist. A total of 456 patients (228 / group) is needed to observe an absolute difference of 10% between groups.

Outcomes

Primary end-point is reduction in all types of stroke, AMI or death in urgent endarterectomy groupo compared to delayed ones. Secondary end-points are: Reduction of ipsilateral ischemic stroke in group 1 with respect to Group 2 Identification of predictive risk factors and Confirmation of no different rate for hemorragic/ischemiccomplications between groups.

Effect of prior medical treatments on ischemic stroke severity and outcome

Antiplatelets, antihypertensives, and statins might reduce the severity of the event or improve outcome in patients who, despite prior medical treatment, have a stroke. We evaluated, in patients who had an ischemic stroke, the effect, on stroke severity and outcome, of prior treatment with antiplatelets, antihypertensives, and statins, used either alone or in a three-drug combination. Stroke in Italy and Related Impact on Outcome (SIRIO) was a prospective, nationwide, multicenter, hospital-based, observational study that included patients aged.18 years with acute ischemic stroke. We studied 2,529 acute ischemic stroke patients from the SIRIO population: 887 were antiplatelet users, 1,497 antihypertensive users, 231 statin users, and 138 three-drug combination users prior to the index event. The adjusted logistic regression analysis showed an association between prior treatment with statins and good functional outcome at discharge, while prior treatment with antiplatelets, antihypertensives or the three-drug combination did not influence severity or outcome. The absolute probability of a good functional outcome was 46.3% (95% CI: 40.3%-53.2%) in statin users and 36.7% (95% CI: 34.7%-38.7%) in non-users of statins; the absolute risk difference was 9.6% (95% CI: 2.9%-16.4%; p=0.004). Prior treatment with antiplatelets, antihypertensives, or the three-drug combination did not influence stroke severity or outcome, while prior treatment with statins did not influence stroke severity but was associated with a better functional outcome.

Blocking the RAAS at different levels: an update on the use of the direct renin inhibitors alone and in combination

The renin–angiotensin–aldosterone system (RAAS), an important regulator of blood pressure and mediator of hypertension-related complications, is a prime target for cardiovascular drug therapy. Angiotensin-converting enzyme inhibitors (ACEIs) were the first drugs to be used to block the RAAS. Angiotensin II receptor blockers (ARBs) have also been shown to be equally effective for treatment. Although these drugs are highly effective and are widely used in the management of hypertension, current treatment regimens with ACEIs and ARBs are unable to completely suppress the RAAS. Combinations of ACEIs and ARBs have been shown to be superior than to either agent alone for some, but certainly not all, composite cardiovascular and kidney outcomes, but dual RAAS blockade with the combination of an ACEI and an ARB is sometimes associated with an increase in the risk for adverse events, primarily hyperkalemia and worsening renal function. The recent introduction of the direct renin inhibitor, aliskiren, has made available new combination strategies to obtain a more complete blockade of the RAAS with fewer adverse events. Renin system blockade with aliskiren and another RAAS agent has been, and still is, the subject of many large-scale clinical trials and furthermore, is already available in some countries as a fixed combination.

Ezetimibe/simvastatin vs simvastatin in coronary heart disease patients with or without diabetes

BACKGROUND

Treatment guidelines recommend LDL-C as the primary target of therapy in patients with hypercholesterolemia. Moreover, combination therapies with lipid-lowering drugs that have different mechanisms of action are recommended when it is not possible to attain LDL-C targets with statin monotherapy. Understanding which treatment or patient-related factors are associated with attaining a target may be clinically relevant.

METHODS

Data were pooled from two multicenter, randomized, double-blind studies. After stabilization on simvastatin 20 mg, patients with coronary heart disease (CHD) alone and/or type 2 diabetes mellitus (T2DM) were randomized to ezetimibe 10 mg/simvastatin 20 mg (EZ/Simva) or simvastatin 40 mg. The change from baseline in low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), TC/HDL-C ratio, triglycerides, and the proportion of patients achieving LDL-C < 2.6 mmol/L (100 mg/dL) after 6 weeks of treatment were assessed, and factors significantly correlated with the probability of achieving LDL-C < 2.6 mmol/L in a population of high cardiovascular risk Italian patients were identified. A stepwise logistic regression model was conducted with LDL-C < 2.6 mmol/L at endpoint as the dependent variable and study, treatment, gender, age (> or = 65 years or < 65 years), as independent variables and baseline LDL-C (both as continuous and discrete variable).

RESULTS

EZ/Simva treatment (N = 93) resulted in significantly greater reductions in LDL-C, TC, and TC/HDL-C ratio and higher attainment of LDL-C < 2.6 mmol/L vs doubling the simvastatin dose to 40 mg (N = 106). Study [including diabetic patients (OR = 2.9, p = 0.003)], EZ/Simva treatment (OR = 6.1, p < 0.001), and lower baseline LDL-C (OR = 0.9, p = 0.001) were significant positive predictors of LDL-C target achievement. When baseline LDL-C was expressed as a discrete variable, the odds of achieving LDL-C < 2.6 mmol/L was 4.8 in favor of EZ/Simva compared with Simva 40 mg (p < 0.001), regardless of baseline LDL-C level.

CONCLUSION

EZ/Simva is an effective therapeutic option for patients who have not achieved recommended LDL-C treatment targets with simvastatin 20 mg monotherapy.

TRIAL REGISTRATION

Clinical trial registration numbers: NCT00423488 and NCT00423579.

New strategies and drugs in the treatment of hypertension: monotherapy or combination?

Hypertension is one of the major risk factors associated with cardiovascular diseases. A range of blood pressure-lowering agents is available including diuretics, alpha- and beta-blockers, aldosterone antagonists, calcium-channel blockers (CCB), angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB) and direct renin inhibitors (DRI). Most patients require two or more medications to control their blood pressures within normal ranges. When high blood pressure cannot be controlled by low-dose monotherapy, physicians employ either high-dose monotherapy or combination therapy. High-dose ARB monotherapy is more effective for reducing proteinuria against low-dose ARB monotherapy or CCBs. Combination therapy is recommended for hypertension patients to facilitate prompt maintenance of blood pressure. Single-pill combination therapy simplifies treatment and optimizes long-term compliance. Thiazide diuretics such as hydrochlorothiazide (HCTZ), alone or in combination are still widely used as first-line hypertension treatment. Recent studies have shown that double (CCB+ARBs) or triple (CCB+ARBs+HCTZ) combination therapies have a greater lowering efficacy and are better tolerated. Moreover, the use of DRIs has been patented and proven effective in selected categories of hypertensive patients with or without concomitant target organ damage (TOD).

Role of valsartan, amlodipine and hydrochlorothiazide fixed combination in blood pressure control: an update

The treatment of moderate or severe hypertension in most cases requires the contemporaneous use of multiple antihypertensive agents. The most available two-drug combinations have an agent that addresses renin secretion and another one that is statistically more effective in renin-independent hypertension. The practice of combining agents that counteract different mechanisms is the most likely explanation for the fact that most available two-drug combinations have an agent that addresses renin secretion (beta-blocker, angiotensin converting enzyme inhibitor, angiotensin II receptor blocker or direct renin inhibitor) and another one that is more effective in renin-independent hypertension (diuretic, dihydropyridine or non-dihydropyridine calcium channel blocker). Based on these considerations, addition of hydrochlorothiazide to the combination of an antagonist of the renin-angiotensin system with a calcium channel blocker would constitute a logical approach. Inclusion of a diuretic in the triple combination is based on the evidence that these agents are effective and cheap, enhance the effect of other antihypertensive agents, and add a specific effect to individuals with salt-sensitivity of blood pressure. The benefit of triple combination therapy with amlodipine, valsartan and hydrochlorothiazide over its dual component therapies has been demonstrated, and the use of a single pill will simplify therapy resulting in better blood pressure control.

Physicians' attitudes toward post-MI aspirin prophylaxis: findings from an online questionnaire in Asia-Pacific

Mortality from cardiovascular diseases, such as myocardial infarction (MI), is predicted to increase dramatically in Asia-Pacific countries. However, there are few studies that estimate utilization of prophylactics, such as low-dose aspirin, in these countries. To determine this, an online survey was sent to physicians in 18 countries worldwide, and this article reports the findings from the Asia-Pacific region (N = 4372 respondents). The overall mean number of MI patients per respondent was 246 in the Asia-Pacific countries, and 55% of physicians (overall) rated their patient as having total compliance with aspirin. The use of aspirin monotherapy or combination therapy, aspirin dosage, and physician contact were all found to have a significant impact on compliance (all P < 0.00001). Educational material on the role of aspirin was ranked as the most effective measure to improve compliance. In conclusion, this survey indicates that educational initiatives on secondary prevention are urgently needed in Asia-Pacific countries.

Physicians' attitudes toward post-MI aspirin prophylaxis: findings from an online questionnaire in Europe and Latin America

Few surveys have assessed physicians' attitudes toward preventive treatment in post-myocardial infarction (MI) patients, although these patients have a high risk of recurrence. A newly developed online survey, which aimed to determine physicians' attitudes toward aspirin prophylaxis post-MI, was sent to physicians in 18 countries. This report describes findings from 7 European (n = 2842 respondents) and 2 Latin American (n = 149 respondents) countries. Although low-dose aspirin therapy was recommended by most physicians (> 90%), compliance was suboptimal; 29% of patients in Europe and 35% in Latin America were partially or totally noncompliant, and 18% of physicians in Europe and 20% in Latin America had lost contact with their patients. Low-dose aspirin monotherapy or combination therapy, dosage, and physician contact all had a significant effect on compliance (P < 0.00001). Shared decision making by the physician and patient was rated as the most effective measure to improve compliance, which clearly indicates the need for a change in management.

SPREAD Italian Guidelines for stroke. Indications for carotid endarterectomy and stenting

This multidisciplinary guideline provides an overview of the current evidence on the benefits obtained by endoarterectomy and stenting for the surgical treatment of patients with symptomatic and asymptomatic carotid stenosis. A hundred forty-six authors, 37 Italian scientific societies and two Italian patients' associations participated in drafting the Stroke Prevention and Educational Awareness Diffusion (SPREAD) document, which has become the national guideline for the prevention and treatment of stroke in Italy. For the surgical therapy section of this document, the main trials on carotid endoarterectomy and stenting were critically reviewed following The Scottish Intercollegiate Guideline Network Oxford Centre for Evidence-Based Medicine methodology in order to formulate recommendations and syntheses for these procedures. The final document was peer reviewed and approved by all the participants. Recommendations and syntheses are presented for the referral of patients to either carotid endoarterectomy or stenting on the basis of whether carotid stenosis is symptomatic or asymptomatic, on the presence of various risk factors such as degree of arterial narrowing, and on concomitant pathology (cardiopathy and acute stroke).

The prevalence of diarrhea and its association with drug use in elderly outpatients: a multicenter study

OBJECTIVES

To evaluate the prevalence of diarrhea and its association with drug use in elderly outpatients.

METHODS

The study was carried out by 133 general practitioners (GPs) who referred to 24 geriatric units in Italy. The demographic data, disability, gastrointestinal symptoms, and current medications were evaluated using a structured interview, including the evaluation of the activities of daily living (ADL), the instrumental activities of daily living (IADL), and the gastrointestinal symptoms rating scale (GSRS).

RESULTS

The study included 5,387 elderly subjects who regularly completed the structured interview. In total, 488 patients (9.1% of the whole population, 210 men and 278 women, mean age 75.6 +/- 6.2 yr, range 65-100 yr) reported diarrhea, that is, items 11 and 12 of the GSRS, during the 7-day period before the interview. The prevalence of diarrhea significantly increased with older age (P = 0.025), the severity of ADL (P < 0.0001) and IADL disability (P < 0.0001), and the number of drugs taken (P = 0.0002). A multivariate analysis demonstrated that the presence of diarrhea was significantly associated with the use of antibiotics (odds ratio [OR] 4.58, 95% confidence interval [CI] 1.95-10.73), proton pump inhibitors (OR 2.97, 95% CI 2.03-4.35), allopurinol (OR 2.19, 95% CI 1.26-3.81), psycholeptics (OR 1.82, 95% CI 1.26-2.61), selective serotonin reuptake inhibitors (OR 1.71, 95% CI 1.01-2.89), and angiotensin II receptor blockers (OR 1.46, 95% CI 1.08-1.99), also accounting for sex, age, and the use of antidiarrheal agents and drugs for functional gastrointestinal disorders.

CONCLUSION

Diarrhea is a common problem in elderly outpatients. Its prevalence increases with old age, the severity of disability, and the number of drugs. Monitoring the presence of diarrhea and its complications in elderly patients who need treatments with drugs significantly associated with diarrhea may be clinically useful.

A case of familial hypercholesterolemia

We report a case of a 50-year-old woman with familial hypercholesterolemia (FH). Patients with FH have an increased incidence of atherosclerotic cardiovascular disease (CVD). Lifestyle measures, including fat-modified diets, and pharmacotherapy, particularly with statins, can substantially decrease the risk of CVD. FH fulfils all the WHO criteria for disease screening: to avoid cardiovascular events, screening is one of the most important features, but regrettably this is not practiced regularly at present. Healthcare systems must implement well-organized screening strategies, supported by an efficient disease management program. These initiatives will require optimization of primary care, because general practitioners are in first line in the overall prevention of CVD.

Carotid Artery Stenting

BACKGROUND AND PURPOSE

The prevention of stroke and the correct treatment of carotid artery stenosis represent today a major debate in cardiovascular medicine. Beside carotid endarterectomy, carotid angioplasty and stenting is becoming more widely performed for the treatment of severe carotid obstructive disease, and is now accepted as a less invasive technique that may provide an alternative for selected patients, particularly those with significant comorbidities. An Italian multidisciplinary task force, in which converged the most representative scientific societies involved in carotid treatment, was created to provide neurologists, radiologist, cardiologists, vascular surgeons, and all those involved in prevention and treatment of carotid disease with a simple, clear and updated evidence-based consensus document.

SUMMARY OF REVIEW

This First Consensus Document of the ICCS (Italian Consensus Carotid Stenting)/SPREAD group addressed the main issues related to methodology, definition of symptomatic and asymptomatic carotid stenosis, indication and procedures for carotid artery stenting, including the use of devices for preventing procedural embolic complications. Special attention was paid to credentials and competency for physicians qualifications to perform vascular angioplasty and stent placement, including training, acceptable complication rates and certification.

CONCLUSIONS

As any guideline or consensus statement, also this document is valid as long as the evidence on which it is based remains up-to-date. In such a fast-evolving field of medicine as the management of carotid stenosis, it is mandatory to stimulate a continuous and fruitful discussion among all the professionals involved in this very evolutionary field.

Italian SPREAD Guidelines: from past to future

The development of the Italian Guidelines on Stroke involved a multidisciplinary working group, named the "SPREAD Collaboration" (Stroke PREvention and Awareness Diffusion), composed at present of different professional organisations and two patients' associations. The group was organised into operative subcommittees. Each subcommittee dealt with a different area covered by the guidelines and was composed of 5-10 experts in the specific field. A "scientific task force" and an editorial board were responsible for coordinating and reviewing the texts progressively processed and produced.

The Stroke in Italy and Related Impact on Outcome (SIRIO) study: design and baseline data

The SIRIO study collected detailed information on the stroke care of patients treated in neurological departments in Italy. This report refers to the baseline profile of patients. Each centre recorded the incident cases of ischaemic and haemorrhagic stroke, excluding SAH, for 1-4 months. Baseline data include demographics, risk factors, comorbidities, pre-event medications, social conditions, NIHSS and Rankin scale on entry, Barthel Index pre-event, diagnostic tests and treatments applied on entry. Overall, 3018 patients (56.7% men; mean age 72.1+/-12.2 years) with ischaemic (85.3%) or haemorrhagic stroke were hospitalised in 103 centres; 51% arrived by ambulance. Median time to hospital was 140 min (RIQ: 60-615). TOAST classification of the 2573 ischaemic strokes was: 29.4% large-artery atherosclerosis, 24.6% cardioembolic, 26.2% small vessels occlusion, 6.5% other determined causes and 13.3% undetermined. CT and/or MR were performed in all patients. Total Greenfield's comorbidity score was 5.4+/-3.5. Mean Barthel Index pre-event was 93+/-17; Rankin score on entry was 4-5 in 48% of the patients and 0-1 in 25%. Mean NIHSS on entry was 7.1+/-5.4; 52% of the patients had a NHISS <6 and 1% >22. SIRIO began giving the expected insights on the in-hospital management of stroke in Italy. Further information will be provided by the longitudinal phase of the study, which is in progress. Pre-event patient management and mode of reporting call for additional educational actions.

Drug use by the elderly in general practice: effects on upper gastrointestinal symptoms

OBJECTIVE

To evaluate the prevalence of drug use by elderly outpatients in Italy and to identify the association between drug use and gastrointestinal symptoms.

STUDY DESIGN AND SETTING

The study was carried out by 133 general practitioners (GPs) who referred to 24 geriatric units in Italy. All consenting elderly patients seen at the GPs' offices were evaluated for gender, age, disability, current medications, and upper gastrointestinal symptoms.

RESULTS

The study included 5,515 elderly subjects. The prevalence of drug use was 91.6%, and the mean number of drugs taken was 2.86 per person. Both the prevalence and the mean number of drugs significantly increased with advancing age. Regarding gastrointestinal symptoms, 32.7% of patients reported at least one upper gastrointestinal symptom: 25% with indigestion syndrome, 16.2% with abdominal pain, and 14.2% with reflux symptoms. A significantly higher prevalence of symptoms was observed in females, patients who were taking a higher number of drugs, and those who had higher disability. Adjusted multivariate analysis demonstrated that the use of nonsteroidal antiinflammatory drugs, steroids, psycholeptics, diuretics, selective beta2 adrenoreceptor agonists or adrenergics, and antiplatelet drugs was significantly associated with upper gastrointestinal symptoms.

CONCLUSION

The prevalence of drug use is very high in this elderly outpatient population. The number of drugs and the use of some specific drug classes are significantly associated with the presence of upper gastrointestinal symptoms.

Do physicians treat symptomatic osteoarthritis patients properly? Results of the AMICA experience

OBJECTIVE

The main objective of the AMICA project was to photograph the Italian scenario of osteoarthritis (OA) and its treatment in general and specialty practice. The study was designed to evaluate their prescription modalities to determine whether they matched the recently proposed treatment guidelines for OA (ACR 2000; EULAR 2000; APS 2002).

METHODS

The study involved 2764 general practitioners (GPs) and 316 specialists who enrolled a total of 25,589 patients with OA of the hand, knee, and hip.

RESULTS

Pharmacological treatment alone was prescribed to 55% of the patients seen by GPs, 25% of those seen by rheumatologists, 8% of those seen by orthopedic surgeons, and 17% of those seen by physical medicine specialists (GPs versus specialists, P < 0.001). Specialists often prescribed a combined pharmacological and nonpharmacological approach (rheumatologists 51%, orthopedic surgeons 66%, physical medicine specialists 76%). Concomitant comorbidities and their treatment do not seem to influence OA prescription modalities except for peptic ulcer and anticoagulant therapy. The presence of peptic ulcer was associated with a reduction in NSAID prescriptions (OR 0.61, CI 0.53 to 0.69) and more frequent use of Coxibs (OR 1.15, CI 1.03 to 1.28) and simple analgesics (OR 1.42; CI 1.26 to 1.61), as well as physical therapy. NSAIDs and Coxibs also were less frequently prescribed if patients were receiving anticoagulant therapy (NSAIDs OR 0.86, CI 0.70 to 1.06; Coxibs: OR 0.77; CI 0.64 to 0.93). Gastroprotective therapy was more frequently used in patients treated with NSAIDs, Coxibs, and analgesics. There was no significant difference in therapies prescribed for patients with hypertension or cardiac disease (myocardial infarction and/or angina pectoris).

CONCLUSIONS

The published guidelines appear to be properly used by most of the physicians in terms of the pharmacological approach; however, the increased use of Coxibs has not reduced the amount of prescribed gastroprotection. No specific precautions were observed in the treatment of patients with hypertension or cardiac problems. Nonpharmacological treatments are mainly used in conjunction with medications and did not take into account the findings of evidence-based medicine. Continuing education of GPs and specialists caring for OA patients is essential.

Analysis of pharmacologic and nonpharmacologic prescription patterns of general practitioners and specialists in the AMICA study

OBJECTIVE

To evaluate the prescription modalities of general practitioners (GPs) and specialists in symptomatic osteoarthritis (OA) patients enrolled in the AMICA study.

PATIENTS AND METHODS

This study started in 2001 as a cohort investigation of OA patients seen by 2764 GPs and 316 specialists. Enrolled were 28,981 patients with symptomatic OA of the hand, hip, or knee.

RESULTS

GPs and physical medicine specialists treated OA less frequently with pharmacological therapy than rheumatologists (OR 0.35; CI 0.26 to 0.47) or orthopedic surgeons (OR 0.65; CI 0.54 to 0.77). Pharmacological therapies (alone or in association with nonpharmacological modalities) were selected by 97% of the GPs, 96% of the rheumatologists, 94% of the orthopedic surgeons, and 85% of the physical medicine specialists. In comparison with GPs, all of the specialists more frequently used disease-modifying OA drugs (DMOADs) (rheumatologists: OR 6.86, CI 6.03 to 7.80; orthopedic surgeons: OR 2.20, CI 1.94 to 2.49; physical medicine specialists: OR 2.11, CI 1.69 to 2.63). Nonpharmacological therapies were selected by 44% of the GPs, 54% of the rheumatologists, 71% of the orthopedic surgeons, and 90% of the physical medicine specialists. They were used alone uncommonly (by 3% of the GPs, 3% of the rheumatologists, 6% of the orthopedic surgeons, and 15% of the physical medicine specialists). GPs use nonpharmacological treatment less than specialists: OR 0.53; CI 0.47 to 0.60 versus rheumatologists; OR 0.20; CI 0.18 to 0.21 versus orthopedic surgeons; and OR 0.07; CI 0.05 to 0.09 versus physical medicine specialists. Ultrasound (US) (11%) and transcutaneous electrical nerve stimulation (TENS) (7%) were the nonpharmacological therapies most frequently prescribed by GPs. Among the specialists, physical medicine specialists most frequently prescribed US (35%) and TENS (21%); US was also preferred by rheumatologists, whereas the orthopedic surgeon's choice was magnetotherapy (21%). Exercises and other passive or active rehabilitation strategies were prescribed for only 13% of the patients seen by GPs, but all 3 categories of specialists prescribed exercises and manual techniques far more frequently: rheumatologists, OR 1.63: 1.40 to 1.63; orthopedic surgeons, OR 1.67: 1.48 to 1.88; physical medicine specialists, OR 3.19: 2.66 to 3.82.

CONCLUSIONS

Italian rheumatologists and orthopedic surgeons are the specialists who most frequently use pharmacological treatment for OA. Nonpharmacological treatment is used commonly among both GPs and specialists but rarely as single therapy. Exercise and passive or active rehabilitation strategies are not frequently prescribed, although they are recommended by all the published guidelines.

Osteoarthritis: an overview of the disease and its treatment strategies

Osteoarthritis (OA) is currently defined by the American College of Rheumatology as a "heterogeneous group of conditions that leads to joint symptoms and signs which are associated with defective integrity of articular cartilage, in addition to related changes in the underlying bone at the joint margins." Its prevalence after the age of 65 years is about 60% in men and 70% in women. The etiology of OA is multifactorial, with inflammatory, metabolic, and mechanical causes. A number of environmental risk factors, such as obesity, occupation, and trauma, may initiate various pathological pathways. OA indicates the degeneration of articular cartilage together with changes in subchondral bone and mild intraarticular inflammation. The principal treatment objectives are to control pain adequately, improve function, and reduce disability. Acetaminophen is frequently used for symptomatic OA with mild to moderate pain. Nonsteroidal antiinflammatory drugs (NSAIDs) are more effective in the case of moderate-severe pain, but they have an increased risk of serious upper gastrointestinal adverse events. The newer cyclooxygenase COX-2 specific inhibitors (Coxibs) are as efficacious as traditional NSAIDs and have a better gastrointestinal safety profile. Other compounds (eg, chondroitin sulfate, diacerein, glucosamine sulfate) have a symptomatic effect that is slower and less than that of NSAIDs. The structure-modifying effects of drugs are currently being evaluated, and both glucosamine sulfate and diacerein have been shown in some trials to have a beneficial structural effect. Nonpharmacological interventions are frequently and widely used in the management of OA patients, but there is little evidence that they are effective: the best studied and most successful nonpharmacological interventions are patient education, self-management, and exercise. There is some evidence for the pain-relieving efficacy of thermotherapy and transcutaneous electrical nerve stimulation (TENS) but not of electrotherapy, acupuncture, homeopathy, or manual therapy. The value of interventions aimed at improving function and maximizing independence (occupational therapy, walking aids, workplace adaptation) is also unclear. The disease course and patient's requirements often change over time, thus requiring a periodic review and readjustment of therapy rather than the rigid continuation of a single treatment.

Clinical Presentation of Osteoarthritis in General Practice: Determinants of Pain in Italian Patients in the AMICA Study

OBJECTIVE

To assess the clinical characteristics and determinants of pain observed by general practitioners (GPs) in Italian patients with osteoarthritis (OA) of the hand, hip, and knee.

METHODS

The 2764 GPs participating in the study were asked to enroll 10 consecutive patients with OA diagnosed according to the American College of Rheumatology (ACR) clinical criteria. To standardize the diagnosis, the GPs received ad hoc training from musculoskeletal system specialists. A questionnaire evaluating demographic data, the clinical characteristics of OA, and previous diagnostic and therapeutic interventions was administered by the GPs.

RESULTS

25,589 evaluable patients were enrolled during a mean period of 2.8 weeks by the GPs: 17,567 women (69%) and 7878 men (31%). The most painful OA joints were the knee in 12,827 patients (54%), the hip in 5645 patients (24%), and the hand in 5467 patients (23%)--percentages calculated on the 23,939 patients for whom this information was available. The weekly incidence of referrals to GPs for OA was higher for women and for knee OA. The median age of the patients was 70 years (range 50 to 104 years) and disease duration was 8.3 +/- 7.10 years. The most frequent comorbidities were hypertension (53%), obesity (22%), osteoporosis (21%), type II diabetes mellitus (15%), and chronic obstructive pulmonary disease (13%). The median pain visual analog scale (VAS) score was higher for women than for men, for hip OA, and for generalized OA (GOA) than for knee and hand OA (P < 0.0001). Intense pain, defined as VAS readings of >60 mm, was increased in women only in the knee (OR = 1.24; 95% CI 1.15 to 1.34) and in GOA (OR = 1.17; 95% CI 1.03 to 1.33). It was also significantly increased in patients older than 70 years (OR = 1.46; 95% CI 1.39 to 1.54), those with a low educational level (OR = 1.44; 95% CI 1.36 to 1.5), a BMI of > or =30 (OR = 1.52; 95% CI 1.42 to 1.61), a disease duration of more than 7 years (OR = 1.60; 95% CI 1.52 to 1.68), comorbidities (OR = 1.61; 95% CI 1.5 to 1.73), and GOA (OR = 2.05; 95% CI 1.91 to 2.19). Manual occupations were associated with highly intense pain only in men.

CONCLUSIONS

The results of this study underscore the major impact of OA on care in general practice, the high frequency of OA-associated comorbidities, and the role of different risk factors in OA pain.

Comorbid Conditions in the AMICA Study Patients: Effects on the Quality of Life and Drug Prescriptions by General Practitioners and Specialists

OBJECTIVE

Osteoarthritis (OA) has been identified as the disease with the highest rate of comorbidities, which may increase the likelihood of disability. The AMICA study evaluated how the presence of a coexistent disease and/or its chronic pharmacological treatment influenced the prescription of pharmacological and nonpharmacological therapy in patients with OA.

PATIENTS AND METHODS

The 2764 general practitioners (GPs) and 316 specialists (98 rheumatologists, 166 orthopedic surgeons, 52 physical medicine specialists) participating in the study were asked to enroll 10 consecutive patients with OA diagnosed according to the American College of Rheumatology clinical criteria. Information was collected regarding demographics, the clinical characteristics of OA, and previous diagnostic and therapeutic interventions. Pain intensity was assessed using a 100-mm visual analog scale (VAS); the patients were also asked to report on their quality of life and joint function, as well as the presence of any concomitant disease and/or therapy. The influence of comorbidities on the quality of life, pain, and drug prescription was evaluated.

RESULTS

A total of 29,132 evaluable patients was observed (25,589 recruited by GPs and 3543 by specialists). The most frequent comorbidities were hypertension (52%), osteoporosis (21%), type II diabetes mellitus (15%), and chronic obstructive pulmonary disease (12%); myocardial infarction and/or angina pectoris were present in 6% and peptic ulcer was present in 5%. Comorbidities were more frequent in older patients and, except in the case of hypertension, were closely related to more intense pain and a decreased quality of life; they were also generally associated with worsened joint function. The presence of peptic ulcer was associated with a reduction in the prescription of nonsteroidal antiinflammatory drugs (NSAIDs) (odds ratio (OR) 0.61; confidence intervals (CI) 0.53 to 0.69) and the more frequent use of Coxibs (OR 1.15; CI 1.03 to 1.28) and simple analgesics (OR 1.42; CI 1.26 to 1.61), as well as with greater use of physical therapy. Hypertension was associated with a reduction in the prescription of physical therapy. NSAIDs and Coxibs were less frequently prescribed if the patients were on anticoagulant therapy (NSAIDs: OR 0.86; CI 0.70 to 1.06; Coxibs: OR 0.77; CI 0.64 to 0.93). Gastroprotective therapy was more frequently used in patients treated with NSAIDs, Coxibs, and analgesics, with GPs giving greater preference to proton pump inhibitors than specialists.

CONCLUSIONS

Comorbidities decrease the quality of life and worsen the joint function in OA patients. Comorbidities and their treatment generally do not influence the physician's choice of OA treatment, with the exception of peptic ulcer and anticoagulant therapy, both of which were associated with a reduction in the prescription of antiinflammatory drugs. There was a preferential use of Coxibs in patients with peptic ulcer, and an underuse of gastroprotective measures in OA patients treated with NSAIDs.

The Characteristics of Symptomatic Osteoarthritis in General and Specialist Practice in Italy: Design and Methods of the AMICA Study

OBJECTIVE

The diagnostic and clinical approach to osteoarthritis (OA) of the hand, knee, and hip in general practice and specialist practice in Italy as determined by the AMICA project.

METHODS

Eligible subjects were identified among patients aged > or =50 years consecutively observed by their general practitioner (GP) or a specialist during the study period for diagnosis or treatment of symptomatic OA of the hand, knee, or hip. OA was diagnosed according to the American College of Rheumatology clinical criteria. The general characteristics and symptoms of all eligible subjects were evaluated. Data were also collected on diagnostic work-up and treatment. All subjects were also asked to quantify the intensity of their OA-related pain according to a 100-mm visual analog scale (VAS) where 0 = no pain and 100 = the worst pain.

RESULTS

A total of 2764 GP and 331 specialists (98 rheumatologists, 166 orthopedic surgeons, and 67 other specialists) participated in the study. The area of residence was largely similar for both GPs and specialists and covered all of Italy. A total of 25,589 valuable subjects with OA were identified by the GPs, while 3543 were identified by the specialists. Among the latter, 1777 were identified by orthopedic surgeons, 1067 by rheumatologists, and 699 by other specialists (specialists in physical medicine and internal medicine, geriatricians, etc). The median age of patients identified by GPs was 70 years; the corresponding value was 66 years for the patients identified by the orthopedic surgeons, 69 years by the rheumatologists, and 68 years by other specialists. Overall, 69% of patients were women: this proportion was similar among patients identified by the GPs, the orthopedic surgeons, and other specialists, but patients identified by the rheumatologists were women in 80% of cases. Patients observed by the specialists had a higher level of education than those observed by GPs (P < 0.05). This finding was partially explained by the younger age of the patients observed by the specialists.

CONCLUSIONS

This large data set reveals the attitudes of Italian GPs and specialists toward the diagnosis and treatment of OA of the hand, knee, and hip.

Upper gastrointestinal symptoms and therapies in elderly out-patients, users of non-selective NSAIDs or coxibs

BACKGROUND

The association between coxib or non-steroidal anti-inflammatory drug use with gastrointestinal symptoms and drug prescriptions in ambulatory elderly patients is not well defined.

AIM

To evaluate the association between non-steroidal anti-inflammatory drug NSAID and coxib use with gastrointestinal symptoms and therapies in elderly subjects managed by their general practitioner.

MATERIALS

The study was carried out by 133 general practitioners in Italy. By using a structured interview, sex, age, physical function, current medications, new drug prescriptions and upper gastrointestinal symptoms were registered from all elderly subjects who were referred to their general practitioners during a 2-week period. The numbers of hospitalizations, gastrointestinal bleeding events and gastrointestinal diagnostic procedures occurring during the last 6-month period were recorded.

RESULTS

Included in this study were 5515 elderly subjects. The overall prevalence of drug use was 92%. Musculo-skeletal drugs were taken by 15% of patients; NSAIDs were taken by 6%, and coxibs by 3% of patients. A significantly higher prevalence of upper gastrointestinal symptoms was observed in elderly NSAID users compared with coxib users and non-users of musculo-skeletal drugs (44% vs. 33% vs. 32% respectively, P = 0.001). The prescriptions of drugs for acid-related disorders were significantly higher in patients who were concomitantly taking NSAID rather than coxibs (13% vs. 6%, P < 0.01). The prescriptions of drugs for acid-related disorders were significantly associated with the presence of upper gastrointestinal symptoms (OR = 1.7, 95% CI = 1.6-1.9), previous gastrointestinal disorders (OR = 1.1, 95% CI = 1.0-1.3) and NSAID use (OR = 1.5, 95% CI = 1.0-2.2), but no coxib use.

CONCLUSION

In this elderly population, upper gastrointestinal symptoms and prescriptions for gastroenterological drugs were higher in non-steroidal anti-inflammatory drug users than coxib users and non-users of musculo-skeletal drugs.

Detected atrial fibrillation in north Italy: rates, calculated stroke risk and proportion of patients receiving thrombo-prophylaxis

BACKGROUND

Atrial fibrillation (AF) is a major risk factor in the development of ischaemic stroke. The rate of embolic events can be reduced significantly by appropriate therapy. Epidemiological data and information about the attitude of physicians towards prophylaxis of thromboembolism are crucial to determine future strategies to decrease strokes in patients with AF. Unfortunately, these data are unknown in Italy.

OBJECTIVES

The aims of this study were to study the prevalence of diagnosed AF in northern Italy, to estimate the percentage of high, moderate and low risk patients and to investigate the pattern of embolic prophylaxis among GPs.

METHODS

Fifty-one GPs reviewed all the clinical records of subjects aged >/=40 years and identified those patients with chronic or paroxysmal AF.

RESULTS

Among 41 050 patients, 719 [1.75%; 95% confidence interval (CI) 1.59-1.91] had AF (70% chronic, 30% paroxysmal). Only 4% were at low risk for ischaemic stroke, whereas 32% were at moderate and 64% at high risk. Contraindications to antiplatelet or anticoagulant therapy were present in 11% of AF patients. Antithrombotic prophylaxis was underused among the 51 GPs.

CONCLUSIONS

Detection of AF could be 30-40% lower than real prevalence and, therefore, adequate evaluation and treatment aimed at avoiding ischaemic stroke could be denied to a great number of Italian patients. AF detection and prophylaxis of thromboembolic risk can be improved among GPs in northern Italy.

Ventricular arrhythmias in normotensive subjects and in mild hypertensive patients

Twenty-five normotensive subjects (14 men, 11 women) aged from 25 to 60 years (mean 36) and 30 untreated patients with mild hypertension (stages 1 and 2, JNC V) without target organ damage (16 men, 14 women), aged 26-59 years (mean 35.8) underwent continuous 24-hour ECG Holter monitoring with a Fukuda Denshi SM-40 ambulatory recorder and SCM-400 ECG analyzer. During 24-hour ambulatory ECG recording, mean heart rate was slightly but not significantly higher in hypertensive patients (73.3 +/- 10 beats per minute [bpm]) in comparison with normotensive subjects (71.2 +/- 12 bpm). The prevalence of premature atrial contractions was similar in the two groups. Total ventricular arrhythmias were more prevalent in the group of mild hypertensive patients (P < 0.05), who also had a higher prevalence in complex forms of ectopy (r = 0.81 for bigeminy; r = 0.83 for trigeminy; r = 0.83 for couplets). Holter recordings did not show abnormalities of ST-T wave or episodes of silent ischemia.

Ambulatory-determined 24-hour blood pressure in mild hypertensives and in normotensives

Noninvasive ambulatory twenty-four-hour blood pressure (BP) monitoring was carried out in 30 normotensive subjects (16 women, 14 men), aged twenty-five to sixty years (mean thirty-eight) and in 29 mild essential hypertensive patients without target organ damage (14 women, 15 men), aged twenty-three to sixty-one years (mean thirty-nine). Hypertensive patients were not treated, and they discontinued any antihypertensive treatment at least four weeks before the study. During the daytime period (6 AM-10 PM) BP was monitored every fifteen minutes, and during the night (10 PM-6 AM), every thirty minutes. Obviously, mean twenty-four-hour systolic blood pressure (SBP) and diastolic blood pressure (DBP) were higher in hypertensive patients (P < 0.001). There was a persistent correlation in the group of mild hypertensives between successive BP hourly mean readings (r ranged from 0.61 to 0.93 for SBP and from 0.45 to 0.82 for DBP). In normotensive subjects these correlations failed in particular periods: 8 AM-9 AM, r = 0.30 for SBP and 0.45 for DBP; 1 PM-3 PM, r = 0.17-0.49 for SBP and 0.28-0.37 for DBP; 9 PM to midnight, r = 0.21-0.57 for SBP and 0.23-0.38 for DBP.

[Ambulatory monitoring of blood pressure profiles in in hypertensive patients 26-65 years of age]

We evaluated blood pressure profile in a population of 380 untreated hypertensives (210 males, 170 females, stage 1 and 2 JNC 1993) observed consecutively. A 24-hour ambulatory blood pressure monitoring was performed using and A&D TM 2420 model 6 device programmed to measure systolic and diastolic blood pressure every 15 min from 7 am to 10 pm (daytime) and every 30 min from 10 pm to 7 am (night-time). Statistical analysis was carried out by dividing the patients into four groups on the basis of age: Group I, from 26 to 35 years (26 males, 14 females); Group II, from 36 to 45 years (48 males, 39 females); Group III, from 46 to 55 years (85 males, 72 females); Group IV, from 56 to 65 years (51 males, 45 females). Systolic blood pressure was higher in older male hypertensives (56 to 65 years) who also had a persistent systolic blood pressure elevation during night-time (non-dippers); diastolic blood pressure was significantly higher in male hypertensives aged 36 to 55 years.

[Elevated cardiovascular mortality in subjects over 75 with low values of arterial pressure]

PURPOSE

The purpose of this study was to extend the observations from recent studies that have shown an increased mortality in elderly people with low blood pressure.

METHODS

In 1982 we enrolled 88 subjects, 30 males, 58 females, aged 75-90 years, divided into 3 groups, according to their blood pressure and matched for sex, serum cholesterol, smoking and body mass index: Group I: 20 people with blood pressure equal or less than 120/75 mmHg; Group II: 46 subjects with blood pressure level ranging from 130/80 to 145/90 mmHg; Group III: 22 patients with hypertension (blood pressure equal or more than 160/95 mmHg). These three groups were followed for 6 years (1983-1988) to evaluate the mortality from cardiovascular diseases. During this period, no antihypertensive drugs were given, nor did any other treatment significantly modify the value of blood pressure. No patient changed starting group.

RESULTS

Mortality from cardiovascular diseases was as follows: Group I: 14 deaths (mean age 82 +/- 5, 8 for heart failure, 2 for myocardial infarction, 4 for stroke); Group II: 8 (p < 0.001 versus Group I, mean age 81 +/- 3, 6 for heart failure, 1 for myocardial infarction, 1 for stroke); Group III: 4 (p < 0.001 versus Group I, mean age 80 +/- 2, 1 for heart failure, 1 for myocardial infarction, 1 for stroke and 1 for sudden death).

CONCLUSIONS

This study adds further observations indicating an increase of mortality for cardiovascular diseases in subjects over 75 years with low levels of blood pressure, which could be more dangerous than moderately high levels in older people.

Snoring and risk of cardiovascular disease

In order to evaluate the possible role played by snoring as a risk factor for cardiovascular disease, we studied 400 patients aged 30-80 years, divided into 4 groups matched for age, sex and body mass index. The first group consisted of 100 patients who snored, having risk factors (hypertension, diabetes, obesity, smoking, high serum cholesterol level) for cardiovascular disease. The second group consisted of 100 non-snoring patients with risk factors. The third and fourth groups were formed by 100 snoring and 100 non-snoring patients without risk factors. We investigated the morbidity and the mortality from cardiovascular disease over a period of five years (1982-1987). An increase in morbidity and mortality was found for snorers with risk factors (36 and 17 respectively) compared to non-snorers with risk factors (10 and 4, P less than 0.001), and also to both snorers and non-snorers without risk factors (7 and 3, P less than 0.001; 3 and 1, P less than 0.001 respectively). No difference was noted between snorers and non-snorers without risk factors. A higher morbidity and mortality for cardiovascular disease was found in snorers with risk factors as compared with non-snorers having risk factors. Furthermore, the morbidity and mortality in patients without risk factors was found to be lower compared with that found in snorers with risk factors. In conclusion, snoring worsened the prognosis of patients with risk factors for cardiovascular disease, but did not represent an independent or predictive risk factor in itself.

Extended release felodipine in essential hypertension. Variations in blood pressure during whole-day continuous ambulatory recording

Intraarterial blood pressure (BP) monitoring during free ambulation (Oxford technique) was carried out in 12 essential mild-to-moderate hypertensive patients undergoing 4 weeks treatment with felodipine, 10 mg given once daily in an extended release formulation. Compared to placebo, felodipine significantly reduced systolic and diastolic blood pressure throughout 24 h. The greatest reduction was observed at 10 AM, 3 h after drug administration (-32 +/- 6/-24 +/- 5 mm Hg for systolic and diastolic BP, respectively, P less than .001). Hourly BP values remained significantly lower up to and including the 24th hour during felodipine extended release treatment (-18 +/- 5/-11 +/- 3 mm Hg, P less than .001). Felodipine extended release also reduced 24 h blood pressure variability, evaluated on the standard deviation of each hourly mean (from 16.3 +/- 0.9/12.6 +/- 0.6 to 13.4 +/- 0.6/10.4 +/- 0.6 mm Hg, P less than .01). Furthermore, absolute BP values dropped significantly at the peaks of dynamic exercise (bicycle ergometer: from 248 +/- 13/123 +/- 11 to 204 +/- 24/102 +/- 13 mm Hg, P less than .001), isometric exercise (hand grip: from 232 +/- 18/133 +/- 16 to 180 +/- 20/101 +/- 16 mm Hg, P less than .001), and cold pressor test (from 229 +/- 20/127 +/- 14 to 178 +/- 22/99 +/- 15 mm Hg, P less than .001). In conclusion, felodipine extended release exerts a good antihypertensive effect which is maintained for 24 h and reduces the level of blood pressure peaks reached under different physical stresses.

[Circadian pressure variability and pressure peaks during treatment of mild to moderate essential hypertension with felodipine]

It is not yet known how blood pressure variability contributes to the vascular changes associated with hypertension, but 2 possibly relevant factors are mean blood pressure levels over time and pressure peaks. It has been observed that patients in whom the variability in 24-hour blood pressure is low have a lower prevalence and severity of target organ damage. We carried out a whole-day continuous intraarterial blood pressure recording (Oxford method) in 12 essential hypertensive patients after a 2-week placebo period and after a 4-week felodipine treatment, administered in an extended release formulation, 10 mg once daily at 7 am. Felodipine significantly lowered systolic and diastolic blood pressure values throughout the 24 hours (p less than 0.005 to 0.001). Also, hourly variabilities of systolic and diastolic blood pressure during whole-day monitoring were significantly reduced (p less than 0.05 to 0.001), evaluated on the basis of the hourly means of standard deviation of systolic and diastolic blood pressure. In addition, felodipine significantly lowered the values of blood pressure reached during both dynamic exercise (bicycle ergometer, p less than 0.001) and isometric exercise (handgrip, p less than 0.001).