May Measure Month 2022 in Italy: A Focus on Fixed-dose Combination, Therapeutic Adherence, and Medical Inertia in a Nationwide Survey.

INTRODUCTION: Hypertension is the main risk factor for cardiovascular diseases (CVD). Notably, only about half of hypertensive patients manage to achieve the recommended blood pressure (BP) control. Main reasons for the persistence of uncontrolled BP during treatment are lack of compliance on the patients' side, and therapeutic inertia on physicians' side. METHODS: During the global BP screening campaign "May Measure Month" (MMM) (May 1st to July 31st, 2022), a nationwide, cross-sectional, opportunistic study endorsed by the Italian Society of Hypertension was conducted on volunteer adults ≥ 18 years to raise awareness of the health issues surrounding high BP. A questionnaire on demographic/clinical features and questions on the use of fixed-dose single-pills for the treatment of hypertension was administered. BP was measured with standard procedures. RESULTS: A total of 1612 participants (mean age 60.0±15.41 years; 44.7% women) were enrolled. Their mean BP was 128.5±18.1/77.1±10.4 mmHg. About half of participants were sedentary, or overweight/obese, or hypertensive. 55.5% individuals with complete BP assessment had uncontrolled hypertension. Most were not on a fixed-dose combination of antihypertensive drugs and did not regularly measure BP at home. Self-reported adherence to BP medications was similar between individuals with controlled and uncontrolled BP (95% vs 95.5%). CONCLUSIONS: This survey identified a remarkable degree of therapeutic inertia and poor patients' involvement in the therapeutic process and its monitoring in the examined population, underlining the importance of prevention campaigns to identify areas of unsatisfactory management of hypertension, to increase risk factors' awareness in the population with the final purpose of reducing cardiovascular risk.

Hypertensive emergencies and urgencies: a preliminary report of the ongoing Italian multicentric study ERIDANO.

Hypertensive urgencies (HU) and hypertensive emergencies (HE) are challenges for the Emergency Department (ED). A prospective multicentre study is ongoing to characterize patients with acute hypertensive disorders, prevalence of subclinical hypertension-mediated organ damage (HMOD), short- and long-term prognosis; this is a preliminary report. Patients admitted to the ED with symptomatic blood pressure (BP) ≥180/110 mmHg were enrolled. They were managed by ED personnel according to their clinical presentations. Subsequently they underwent clinical evaluation and subclinical HMOD assessment at a Hypertension Centre within 72 h from enrolment. 122 patients were included in this report. Mean age was 60.7±13.9 years, 52.5% were females. 18 (14.8%) patients were diagnosed with HE, 108 (88.5%) with HU. There were no differences in gender, BMI, and cardiovascular comorbidities between groups. At ED discharge, 66.7% and 93.6% (p = 0.003) of HE and HU patients, respectively, had BP < 180/110 mmHg. After 72 h, 34.4% of patients resulted normotensive; 35.2%, 22.1%, and 8.2% had hypertension grade 1, 2, and 3, respectively. Patients with uncontrolled BP at office evaluation had higher vascular HMOD (49.1 vs. 25.9%, p = 0.045). Cardiac (60 vs. 34%, p = 0.049), renal (27.8 vs. 9.6%, p = 0.010) and cerebral (100 vs. 21%, p < 0.001) HMOD was more frequent in HE compared to HU group. HE showed greater cardiac, renal, and cerebral subclinical HMOD, compared to HU. 72-hours BP control is not associated with different HMOD, except for vascular HMOD; therefore, proper comprehensive examination after discharge from the ED could provide added value in cardiovascular risk stratification of such patients. One third of patients with acute blood pressure rise evaluated to the ED resulted normotensive at office evaluation (<72 hours after discharge). Patients with hypertensive emergency showed greater cardiac, renal, and cerebral subclinical HMOD, compared to the patients with hypertensive urgency. BP: blood pressure; HMOD: hypertension-mediated organ damage; y.o.: years old; mo.: months.

Predictors of poor outcome in tocilizumab treated patients with Sars-CoV-2 related severe respiratory failure: A multicentre real world study.

INTRODUCTION: Despite Tocilizumab is now recognized as a concrete therapeutic option in patients with severe SARS-CoV-2 related respiratory failure, literature lacks about factors influencing the response to it in this context. Therefore, the aim of our study was to provide evidence about predictors of poor outcome in Tocilizumab treated patients in the real-world practice. MATERIALS AND METHODS: We retrospectively analyzed clinical, laboratory and chest computer tomography (CCT) data of patients firstly admitted in non Intensive Care Units (ICU) and suffering from severe respiratory failure, who were treated with the IL-6 antagonist Tocilizumab. We compared patients who died and/or required admission to ICU with oro-tracheal intubation (OTI) with those who did not. RESULTS: Two hundreds and eighty-seven patients (29.9% females) with mean age ± SD 64.1 ± 12.6 years were the study population. In-hospital mortality was 18.8%, while the composite endpoint in-hospital mortality and/or ICU admission with OTI occurred in 23.7%. At univariate analysis, patients who died and/or were admitted to ICU with OTI were significantly older and co-morbid, had significantly higher values of creatinine, C-reactive protein (CRP) and procalcitonin and lower lymphocytes count, PaO2/FiO2 ratio (P/F) and room air pulsossimetry oxygen saturation (RAO2S) at hospital admission. Computed tomography ground glass opacities (CT-GGO) involving the pulmonary surface ≥ 50% were found in 55.4% of patients who died and/or were admitted to ICU with OTI and in 21.5% of patients who did not (p=0.0001). At multivariate analysis, age ≥ 65 years (OR 17.3, 95% CI: 3.7-81.0), procalcitonin ≥ 0.14 (OR 9.9, 95%CI: 1.7-56.1), RAO2S ≤ 90% (OR 4.6, 95%CI: 1.2-17.0) and CCT-GGO involvement ≥ 50% (OR 5.1, 95%CI: 1.2-21.0) were independent risk factors associated with death and/or ICU admission with OTI. CONCLUSION: Tocilizumab has shown to improve outcome in patients with severe respiratory failure associated to SARS-CoV-2 related pneumonia. In our multicentre study focusing on Tocilizumab treated severe COVID-19 patients, age ≥ 65 years, procalcitonin ≥ 0.14 ng/mL, RAO2S ≤ 90% and CCT-GGO involvement ≥ 50% were independent factors associated with poor outcome.

Diffuse prothrombotic syndrome after ChAdOx1 nCoV-19 vaccine administration: a case report.

BACKGROUND: Vaccine-induced immune thrombotic thrombocytopenia is emerging as one of the most relevant side effects of adenoviral-based vaccines against coronavirus disease 2019. Given the novelty of this disease, the medical community is seeking new evidence and clinical experiences on the management of these patients. CASE PRESENTATION: In this article, we describe the case of a 73-year-old Caucasian woman who presented with diffuse prothrombotic syndrome, both in the arterial and venous districts, following the first dose administration of ChAdOx1 CoV-19 vaccine. The main thrombotic sites included the brain, with both a cortical ischemic lesion and thromboses of the left transverse and sigmoid sinuses and the lower limbs, with deep venous thrombosis accompanied by subsegmental pulmonary thromboembolism. The deep venous thrombosis progressively evolved into acute limb ischemia, requiring surgical intervention with thromboendoarterectomy. Anticoagulation was maintained throughout the whole hospitalization period and continued in the outpatient setting using vitamin K antagonists for a recommended period of 6 months. CONCLUSIONS: This case describes the management of vaccine-induced immune thrombotic thrombocytopenia in a complicated clinical scenario, including multisite arterial and venous thromboses. Given the complexity of the patient presentation, this case may implement the comprehension of the mechanisms and clinical features of this disease; it also provides a picture of the challenges related to the management, often requiring a multidisciplinary approach.

Left atrial dimension is related to blood pressure variability in newly diagnosed untreated hypertensive patients.

Variability in daily blood pressure (BPV) recorded 24-h ambulatory blood pressure monitoring (ABPM) is known to be related to left ventricular hypertrophy and an increased incidence of cardiovascular events in hypertensive patients. The aim of this study was to evaluate whether left atrium dimension, which increases early in hypertensive subjects, was related to BPV in a group of 167 drug-naive patients (100M/67F, age: 46±11yr). The patients were chosen among those consecutively sent by their general practitioners to confirm the existence of arterial hypertension and afterwards diagnosed as hypertensive (mean 24-h ABPM ⩾130/80 mm Hg). In each patient, the left atrial posteroanterior diameter index for height (LADi) and the left ventricular mass standardized for body surface area (LVMi) were measured using standardized echocardiographic methods. BPV was calculated as the weighted mean of daytime and nighttime systolic and diastolic blood pressure s.d.'s (ws.d.), according to the formula ws.d.=[(daytime s.d. × 10)+nighttime s.d. × 6)]/16. An increase in left atrial dimension (LADi>24 mm m(-1)) was present in 36 patients (21.6% of the total population). In a univariate regression, LVMi was significantly related to systolic BPV (r=0.24; P=0.02) only in men, whereas LADi was significantly related to both systolic and diastolic BPV in both genders. After adjusting for sex, age, BMI, heart rate, diastolic function and estimated glomerular filtration rate, both systolic and diastolic BPV remained significantly related to LADi (P=0.02 for both) but not to LVMi. In conclusion, this study suggests that BVP, as measured as BPws.d., is significantly and independently associated with increased LADi in newly diagnosed, treatment-naive hypertensive patients.

Gender difference in the relation blood pressure-left ventricular mass and geometry in newly diagnosed arterial hypertension.

Much evidence suggests sexual dimorphism in the relationship linking blood pressure (BP) to both left ventricular mass (LVM) and geometry in hypertension. To better evaluate gender-associated characteristics in the relation BP-LVM among newly diagnosed hypertension (24-h average ambulatory BP monitoring, ABPM, > 125/80 mmHg), we measured indexed LVM and relative wall thickness (RWT) by standardized echographic methods in 209 Caucasian drug-naïve subjects, of whom 162 (100M/62F) were recognized to be hypertensive. Mean office systolic (SBP)/diastolic (DBP), 24-h average and night-time BP values were similar between sexes and significantly related to indexed LVM in both genders. Daytime SBP was significantly related to indexed LVM only in females (r =0.41; p =0.0008 in women; r =0.11; p = NS in males), while LVM was more sensitive to day-to-night SBP change in females. RWT was, on the contrary, significantly related to ABPM values only in males. All these findings were confirmed after adjusting for possible confounders. Percentage of LVM variance explained by 24-h average, daytime or night-time SBP values were higher in females than in males (17% vs 3%; 11% vs 1%; and 17% vs 8%). In conclusion, in early hypertension, LVM was significantly associated with daytime BP and more sensitive to reduced percentage of night BP fall in females. LVM variance explained by ABPM SBP was much higher in females than in males. RWT, expressing concentric LVM remodelling was, conversely, more related to BP increase in males.

Diagnostic accuracy of extended-length electrocardiogram in differentiating between athlete's heart and hypertrophic cardiomyopathy.

BACKGROUND: Standard 12-lead electrocardiogram (ECG) has several limitations in solving the differential diagnosis between physiologic left ventricular hypertrophy (PLVH) and hypertrophic cardiomyopathy (HCM), given the high rate of false-positive results in athletes. The aim of this study was to assess the usefulness of several arrhythmic risk indexes in differentiating PLVH from HCM. METHODS: A multiparametric ECG analysis (extended-length ECG) was performed on 30 male athletes with PLVH and 30 male patients with HCM, with homogeneous age distribution. RESULTS: The combination of 4 extended-length ECG variables, namely, corrected QT interval (Bazett), QT dispersion, mean resting heart rate, and low-amplitude signal duration at 25 Hz (low-amplitude signal duration at the end of filtered QRS) displayed remarkable diagnostic accuracy (area under receiver operating characteristic curve, 94%). The same accuracy was obtained replacing QT dispersion with T-wave complexity index. CONCLUSIONS: Extended-length ECG can be considered an effective, low-cost, and low time-consuming clinical tool for distinguishing between PLVH and HCM.

Day-to-day variability of electrocardiographic diagnosis of left ventricular hypertrophy in hypertensive patients. Influence of electrode placement.

OBJECTIVE: Although electrocardiography (ECG) is recommended in all subjects with hypertension, no information is available on the influence exerted by random changes in the placement of electrodes on the day-to-day variability of ECG criteria for diagnosis of left ventricular hypertrophy (LVH). METHODS: In a multicentre, randomized study, two standard 12-lead ECG were recorded, 24 h apart, from 276 consecutive hypertensive patients (mean age 65 +/- 12 years, 49.6% men). Overall, 142 patients were randomized to ECG with the position of electrodes marked on the skin using a dermographic pen and 134 to traditional ECG without marking the position of electrodes. Day-to-day variability of ECG criteria for LVH was compared between the two groups. RESULTS: Coefficients of variation (SD of the difference between paired voltage measurements divided by the mean value) varied consistently among subjects randomized to ECG without dermographic pen, ranging from 30% (R wave in lead I) to 81% (R wave in lead V5). Dermographic pen led to a lesser variability of ECG voltages with consequent reduction in the coefficients of variation, which ranged from 26% (R-wave amplitude in lead I) to 43% (R-wave amplitude in lead V5). The proportion of subjects who changed classification status for LVH ('reclassification rate') from the first to the second ECG session (LVH present in session 1 and absent in session 2, or vice versa) decreased for effect of dermographic pen from 11 to 4% (P = 0.040) with the Cornell voltage, from 19 to 11% (P = 0.029) with the Sokolow-Lyon voltage, and from 18 to 7% with the Romhilt-Estes criterion (P = 0.018), but not with other criteria. In particular, the typical strain and the Cornell strain were associated with the lowest reclassification rates regardless of dermographic pen. CONCLUSIONS: Random changes in the position of ECG electrodes strongly impair the day-to-day reproducibility of Cornell voltage, Sokolow-Lyon and Romhilt-Estes criteria for LVH. The typical strain and Cornell strain criteria showed a lesser spontaneous day-to-day variability.