The aim of this study was to evaluate attitudes and preferences for the clinical management of hypertensive patients with cardiac organ disease, including left ventricular hypertrophy (LVH) and coronary artery disease (CAD), in Italy. A predefined 15-item questionnaire was anonymously administered to a large community sample of general practitioners (GPs) and specialised physicians between November 2012 and June 2013. Estimated prevalence of hypertension-related clinical conditions was stratified into four groups (10–20%, 20–40%, 40–50%, >50%); preferences were reported as percentage among valid answers to the survey questionnaire. A total of 1319 physicians (672 males, age 55.0±7.1 years, age of medical activity 27.1±7.6 years), among whom 1264 GPs and 55 specialised physicians, was included. LVH was reported to be the most frequent marker of organ damage by the majority of physicians (73.5%). LV diastolic dysfunction was reported to be relatively frequent (>40%) by more than half of the specialised physicians (58.2%) and less frequent (10–20%) by GPs (49.8%); LV systolic dysfunction, atrial fibrillation and CAD were considered to be less frequent (10–20%) by the majority of physicians (61.3, 71.6 and 53.3%, respectively). Echocardiography was the preferred diagnostic tool used to estimate LVH (76.6%). Tight blood pressure control (130/80 mm Hg) was considered to be the most appropriate by the majority of physicians, both in hypertensive patients with LVH and in those with CAD. With the well-known limitations of a cross-sectional survey, this study provides information on attitudes and preferences for the clinical management of outpatients with hypertension and high CV risk profile in general practice in Italy.
Control of high blood pressure (BP) levels represents a key element for any preventing strategy aimed at reducing the burden of hypertension-related cardiovascular diseases. Indeed, high BP levels have been independently related to a significantly high risk of developing major cardiovascular complications, including coronary artery disease (CAD), myocardial infarction, stroke, congestive heart failure and renal disease.1 On the contrary, effective and sustained BP reductions have demonstrated to reduce this risk and improve event-free survival in treated hypertensive patients.2 Despite these benefits, several lines of evidence have demonstrated that treated hypertensive patients remain at substantially higher risk of cardiovascular and renal complications than normotensive patients,3 even when achieving effective BP control, thus suggesting that other aspects should be considered when managing hypertensive patients with comorbidities and high cardiovascular risk. In this view, beyond lowering BP levels, early detection and prompt treatment of asymptomatic organ damage, including left ventricular hypertrophy (LVH), microalbuminuria or proteinuria, carotid or peripheral vascular disease, may provide useful information on potential changes of global cardiovascular risk strata over time in individual hypertensive patients.4
Various initiatives have been proposed and tested at national and local levels to improve BP control rates in several Western countries, including Italy. More recently, an extensive use of epidemiological surveys and observational studies has emerged as a valuable option to evaluate physicians’ work flow,5, 6, 7 particularly when managing hypertensive outpatients at different degrees of cardiovascular risk.8, 9, 10, 11, 12, 13 Such experiences have confirmed an extremely high rate of perceived BP control, an incongruous use of out-of-office BP measurements, a large use of suboptimal dosages or combinations of different antihypertensive drug classes and the need for more updated and interactive interventions on medical communities of physicians who have experience in hypertension and high cardiovascular risk.8, 9, 10, 11, 12, 13
In the present manuscript, we aimed to evaluate the clinical attitudes and preferences for the clinical management of hypertensive patients with cardiac organ damage, namely LVH and CAD, as reported by a large community sample of physicians, predominantly general practitioners (GPs), who were included in an educational programme aimed at improving the management of outpatients with hypertension in Italy.
Materials and methods
Aims of the survey
The primary aim of the Italian Hypertension and Heart Survey was to evaluate the clinical attitudes and preferences of a large community sample of both specialised physicians and GPs included in an educational programme performed in Italy between 2012 and 2013. The programme was aimed at improving knowledge and optimising diagnostic and therapeutic interventions for achieving better BP control at national and local levels.
Secondary aims of the survey were to analyse pharmacological preferences (monotherapy versus combination therapy, and type of combination therapies) in hypertensive patients with either LVH or CAD.
Other aims of the survey were to analyse clinical preferences and attitudes, differences and discrepancies, as well as difficulties and troubles among those physicians included in the survey and stratified according to: (1) clinical expertise (either specialised physicians or GPs); (2) geographical locations (north-east, north-west, center and south of Italy); (3) age of referring physicians; and (4) age of medical activity of referring physicians.
Methodology of the survey
This is an observational, non-interventional, cross-sectional study, designed to evaluate physicians’ attitudes and preferences for the daily clinical management of hypertension, hypertension-related clinical conditions (cardiac disease) and high cardiovascular risk through the administration of a specifically designed survey questionnaire.
The study conformed to the Declaration of Helsinki and its subsequent modifications. Confidentiality on demographic and personal data of each physician included in the present survey was carefully preserved and strictly protected during each phase of the study. No access was made to individual data of physicians’ own patients, nor to their medical databases. Written informed consent to participate in the educational programme was obtained by all involved physicians.
The survey questionnaire was specifically designed for the purposes of the present survey (GT), then reviewed and approved by the advisory board of the educational programme (MV and CB). As such, it has not been previously validated or tested, as this was out of the intention of the descriptive nature of the present survey.
The survey questionnaire included a total of 15 questions, ranging from multiple-choice responses to inquiries designed to encourage unprompted comments on specific issues (prevalence of hypertension-related clinical conditions), and prepared to cover the main areas of the clinical management of outpatients with hypertension and hypertension-related cardiac diseases in a setting of clinical practice in Italy.
The most relevant areas addressed by the main body of the survey questionnaire were: (1) to evaluate the estimated prevalence of major cardiovascular risk factors associated with hypertension (hypercholesterolemia, obesity, family history of cardiovascular disease, smoking habit and unhealthy life style) and the prevalence of markers of hypertension-related organ damage (LVH, carotid or peripheral atherosclerosis, microalbuminuria or proteinuria, reduced glomerular filtration rate or creatinine clearance, impaired ankle-brachial index or pulse wave velocity) (question numbers 01–02); (2) to evaluate the estimated prevalence of hypertension-related cardiac diseases, including LVH, LV diastolic dysfunction, LV systolic dysfunction, atrial fibrillation and CAD (that is, previous myocardial infarction or coronary revascularisation) (question numbers 03–07); (3) to assess the preferred options to identify the presence of signs of cardiac organ damage in hypertensive outpatients with either LVH (question number 8) or CAD (question number 9); (4) to evaluate the optimal BP targets and the primary aims to be achieved by the physicians in a setting of outpatient clinics, when managing hypertensive patients with either LVH (question number 10–11) or CAD (question numbers 13–14, respectively); (5) to assess preferences among different antihypertensive drug classes for lowering BP levels in hypertensive patients with either LVH (question number 12) or CAD (question number 15).
The full survey questionnaire is reported in Supplementary Appendix 1 (online available).
Physicians’ recruitment was carried out during the first 6 months of 2012. Participants involved in this educational programme were randomly selected from a community sample of physicians, including both GPs and specialised physicians, operating in different clinical settings (outpatients clinics and/or in-hospital divisions), geographical locations (north-east, north-west, center and south of Italy) and ages of clinical activity, to have a representative sample of physicians who have experience in patients with hypertension and high cardiovascular risk in Italy.
Physicians were invited to participate in an educational programme, aimed at improving knowledge on hypertension-related cardiovascular diseases and implementing diagnostic and pharmacological strategies for achieving better BP control in Italy. These invitations were phrased in general terms and physicians were asked to participate in one from a list of educational meetings, distributed across the whole Italian territory from November 2012 to June 2013. During this period, the survey questionnaire was administered before starting each training section, to provide unbiased and open-minded answers to predefined questions, which may reflect daily clinical activities of involved physicians. In other words, participating physicians were blind to the real purposes of the survey. Acceptance of this initial invitation placed physicians under no obligations, and interviewees were entitled to drop out of the survey at any stage. Invitations were issued in a sizable number to ensure a sufficient representation of the study population sample and to achieve this target within a period of ~ 8 months.
The educational programme was structured into two sections: one start-up meeting, held in November 2012, for specialised physicians; and 47 local meetings, distributed throughout the whole Italian territory, during which specialised physicians involved in the start-up meeting trained GPs. Before starting each educational meeting, the involved physicians were asked to fill the survey questionnaire anonymously; for this purpose, they were asked to refer to the recommendations from the last available set of European guidelines (and risk chart) on hypertension and cardiovascular risk management. In particular, no specific information on surveyed physicians was collected, with the exception of age, gender, age of medical activity, geographical area and medical expertise. The entire survey questionnaire was completed by participants on-site and then delivered to the data collection centre. Physicians who completed the survey did not receive any compensation for their participation.
The survey was closed when the required number of survey questionnaires had been completed and the last educational meeting finished. Incomplete questionnaires were excluded from the present analysis.
The planned sample size of the survey interviews included more than 1600 physicians to achieve an adequate representation of all Italian regions, as well as to limit excessive heterogeneity in age, gender, professional expertise, geographic location, practice size and access to electronic tools. The predefined minimum percentage of responses required to declare the representative sample size was fixed at 80% of the total sample. Overall, the survey generated more than 20 000 individual questionnaire responses and reflected approximately an outpatient practice of about 80 000 patients per week.
All data derived from the survey questionnaires were reported into a computerised spreadsheet (Microsoft Excel, Microsoft Office, Redmond, WA, USA). Then, comprehensive analyses were performed to generate proportions of individual answers to each question of the survey questionnaire. A separate spreadsheet, containing graphs, was produced for the 15 questions of the survey questionnaire. Data were presented as a percentage of the total answers to each question.
Population sample and questionnaire
Overall, 1687 physicians were included in the educational programme, among whom 1319 (81.7%) provided valid data for the survey questionnaire (672 male, mean age 55.0±7.1 years, average age of medical activity 27.1±7.6 years). In this latter group, 55 (4.2%) were specialised physicians and participated in the national start-up meeting, and 1264 (95.8%) were GPs and participated in local meetings, held in different macro-areas of Italy. In particular, 190 (14.4%) physicians were active in north-east, 264 (20.0%) in north-west, 180 (13.6%) in the center and 630 (47.8%) in south of italy; 55 (4.2%) physicians did not report their geographic location.
Involved physicians provided 20 468 answers to the survey questionnaire. Among these answers, 521 (2.5%) were considered inappropriate or incorrect and 186 (0.9%) were missing or not reported. Thus, a total of 19 761 valid answers were considered for the present analysis, which represents 96.5% of the overall results generated by the survey questionnaire.
Analysis of the survey questionnaire
Part I—Prevalence of hypertension-related cardiovascular risk factors and signs of organ damage. Table 1 reported the perceived prevalence of major cardiovascular risk factors and markers of organ damage in hypertensive outpatients followed up by physicians involved in this survey. Among various cardiovascular risk factors, unhealthy lifestyles were reported to be the most frequent condition associated with arterial hypertension by the majority of specialised physicians (67.3%), followed up by family history of cardiovascular (10.9%) and hypercholesterolemia (7.3%). About half of the GPs (48.4%) reported that unhealthy lifestyles were the most common cardiovascular risk factors in their practice, followed by hypercholesterolemia and family history of cardiovascular disease. Overall, physicians considered both obesity and smoking habit to be relatively less frequent in their practice (question number 01).
LVH was considered the most frequent marker of organ damage by the majority of both specialised physicians (61.8%) and GPs (74.1%), followed by carotid or vascular disease (18.2% and 10.9%, respectively), and microalbuminuria (10.9% and 5.9%, respectively). Renal or vascular impairments were only marginally reported by physicians involved in this survey (question number 02). The cumulative estimated prevalence of renal impairment (as defined by the presence of at least one of the following parameters: microalbuminuria, proteinuria, reduced epidermal growth factor receptor or creatinine clearance), was 125 (9.5%) in the overall population, 9 (16.4%) in the specialised physician group and 116 (9.2%) in the GP group.
Table 2 describes the perceived prevalence of different markers of cardiac disease, including organ damage (that is, LVH), diastolic and systolic dysfunction, atrial fibrillation and ischaemic heart disease (that is, previous Myocardial Infarction (MI) or coronary revascularisation). LVH was reported to be relatively frequent (20–40%) by more than half of the specialised physicians (58.2%) and GPs (49.8%); interestingly, about 16% of specialised physicians reported that LVH was very frequent (>50%), whereas a similar proportion of GPs (about 17%) reported that LVH is less frequent (10–20%) in their practice (question number 03).
LV diastolic dysfunction was reported to be relatively frequent (41–50%) or very frequent (>50%) by more than half of the specialised physicians (23.6% and 32.7%, respectively), whereas about half of the GPs (49.8%) considered this condition to be less frequent in their hypertensive outpatients (10–20%) (question number 04).
Both specialised physicians and GPs considered other hypertension-related clinical conditions as being relatively less frequent (10–20%) in their clinical practice. In particular, the majority of physicians reported very low estimated prevalence (10–20%) for LV systolic dysfunction (question number 05) (70.9% of specialised physicians and 60.9% of GPs), as well for atrial fibrillation (71.6% for both) (question number 06). The vast majority of specialised physicians and GPs reported an estimated prevalence of CAD as ranging between 10 and 40% (question number 07).
Part II—Preferred options to identify hypertension-related cardiac disease. Data for this section are reported in Table 3. More than three-quarters of involved physicians considered echocardiogram as the best way to assess the presence of cardiac organ damage, namely LVH, in their hypertensive outpatients, whereas the remaining proportions of physicians were more oriented towards using a conventional 12-lead electrocardiogram. Other diagnostic examinations for LVH were only marginally considered by GPs (question number 08).
Exercise stress test was cited as the preferred option for assessing the presence of CAD in hypertensive outpatients by about one-quarter of specialised physicians (38.2%) and GPs (35.7%); however, other diagnostic tools, including electrocardiogram, echocardiogram, stress-echocardiogram and myocardial scintigraphy, were substantially homogeneously considered by both specialised physicians and GPs without any clear preference (question number 09).
Part III—Preferred therapeutic targets and BP goals. Data for this section are reported in Table 4. Achievement of the recommended BP targets represents the key priority in the clinical management of hypertensive outpatients with LVH according to both specialised physicians (45.5%) and GPs (36.7%), followed by improvement of adherence and persistence to prescribed medications (21.8%) and protection from organ damage (10.9% of specialised physicians and 20.7% of GPs). Similar proportions of clinical preferences were reported by involved physicians for the clinical management of hypertensive outpatients with CAD. However, beyond the achievement of the recommended BP targets (41.8% of specialised physicians and 30.9% of GPs), protection from organ damage is recognised as a fundamental therapeutic target by about 30% of both groups of physicians (29.1% and 31.9%, respectively), followed by improvement of adherence and persistence on pharmacological therapy. Of note, reduction of side effects and adverse reactions was only marginally considered by both groups of physicians in hypertensive outpatients with either LVH or CAD.
About half of the physicians considered 130/80 mm Hg as the optimal BP target to be achieved through pharmacological therapy in hypertensive outpatients with LVH (Figure 1a); at the same time, while one-third of specialised physicians considered an intermediate target of BP (135/85 mm Hg) as a valid BP target in this high-risk category of hypertensive patients, the same proportion of GPs considered tended to achieve a more ambitious BP target of <120/80 mm Hg. Similar preferences have also been reported by involved physicians for the clinical management of hypertensive outpatients with CAD (Figure 1b). In particular, more than 40% of physicians considered 130/80 mm Hg as the preferred BP target; even in this case, about 30% of specialised physicians considered an intermediate BP target of 135/85 mm Hg, whereas more than 46% of GPs aimed to achieve a more ambitious BP target (120/70 mm Hg). In hypertensive outpatients with either LVH or CAD, the recommended BP target of 140/90 mm Hg was considered only by a minority of specialised physicians (9.1 and 14.5%) and GPs (4.5% and 3.3%, respectively).
Part V—Pharmacological therapies. Given these preferences for therapeutic and BP targets throughout pharmacological therapy, preferred options for pharmacological agents are reported in Figure 2. ACE inhibitors and angiotensin receptor blockers were considered useful, effective and well tolerated options to start the antihypertensive treatment in hypertensive outpatients with LVH by all involved physicians, both in monotherapy (about 30%) and in combination therapy (about 70%), whereas only a minority of them took into consideration other antihypertensive drug classes, including diuretics and beta-blockers (0.7%) (Figure 2a). Indeed, no clear preference for a specific combination therapy was found, with the only exception being the use of combination therapy based on angiotensin receptor blockers and calcium-channel blockers. The latter was the preferred option to start antihypertensive treatment within hypertensive outpatients with LVH by 40.0% of specialised physicians and 14.6% of GPs.
When treating hypertensive outpatients with CAD, combination therapies based on either ACE inhibitors or angiotensin receptor blockers and beta-blockers clearly appeared as the preferred pharmacological options, particularly among specialised physicians (51.8 and 29.6%), but also among GPs (30.1% and 19.8%, respectively); combinations of either angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers and calcium-channel blockers were also considered as valid options by GPs (10.0% and 13.6%, respectively), followed by monotherapy based on either ACE inhibitors or angiotensin receptor blockers (Figure 2b). Even in this case, only a minority of involved physicians took into consideration the combination therapy based on diuretics and beta-blockers. In particular, combination therapies based on renin-angiotensin system (RAS) blockers (including either ACE inhibitors or ARBs) plus beta-blockers was found to be the preferred therapeutic option when treating hypertensive outpatients with CAD in a general practice setting.
In recent years, several observational studies have been performed and large clinical databases have been collected in Italy.14, 15 This gave the opportunity to analyse clinical attitudes and preferences, as well as limitations and drawbacks in the clinical management of hypertensive outpatients at different cardiovascular risk profiles by both specialised physicians and GPs distributed throughout the whole national territory. Despite the well-known limitations of this study protocol, which collect physicians’ replies to predefined questions rather than analysing objective clinical data, these databases provide an actual and updated glimpse of the real practice of hypertension management in our country. The main findings of the present survey address several important aspects for the clinical management of hypertensive outpatients with cardiac disease, including LVH and CAD. Some among the large number of data made available for the analysis deserve specific comments.
First of all, the Italian physicians considered the presence of cardiac organ damage, namely LVH, as the most common marker of organ damage in their hypertensive outpatients followed up in a setting of clinical practice. Also, the estimated prevalence of LVH was substantially higher than those reported for other hypertension-related cardiac diseases, including LV diastolic or systolic dysfunction, CAD or atrial fibrillation, thus highlighting the clinical relevance given by both specialised physicians and GPs to hypertensive heart disease. Although several studies have demonstrated the frequent concomitant presence of other markers of organ damage, mostly renal impairment and microalbuminuria16, 17 or vascular damage18, 19, 20 in treated and untreated hypertensive populations, LVH continues to be viewed as the major factor able to modify prognosis and therapeutic management by the Italian physicians. It should also be noted, however, that despite the most recent European guidelines21 recognising the importance of other markers of cardiac organ damage, mostly including diastolic impairment of left ventricular function, LVH continues to be considered the most important marker of cardiac organ damage by involved physicians. This might be explained by the recommendations provided by previous sets of hypertension guidelines,22, 23, 24 which have substantially considered LV mass as the main determinant of cardiovascular prognosis in hypertensive patients, as well as by the great amount of data demonstrating that in-treatment changes of electrocardiographic and echocardiographic indices of LVH are predictive for future cardiovascular events, thus providing a useful tool for treatment guidance.25, 26
The preferred BP targets of involved physicians in treated hypertensive patients with either LVH or CAD are of particular relevance, because Italian GPs tended to have more ambitious targets than those recommended by recent guidelines.21 An updated analysis of the results of several randomised controlled clinical trials have questioned the achievement of tight BP control in high-risk populations of hypertensive patients, mostly including those with CAD, in view of the potentially increased risk for side effects or adverse reactions for extremely low BP levels.27, 28, 29 Although data collection for the present survey was ruled out before the availability of these guidelines,21 in a setting of real practice physicians’ preferences are oriented to achieve more ambitious BP goals. Similar findings were also observed in a recent survey performed in Italy, which included 557 middle-aged physicians (47% specialised physicians and 53% GPs).15 The physicians included in this survey devoted their time and effort towards achieving the recommended BP targets (<140/90 mm Hg and <130/80 mm Hg in high risk subgroups), yet they reported a very high rate of BP control (about 70%), even in high-risk subgroups of hypertensive outpatients.15
Finally, among various pharmacological options the Italian physicians are clearly oriented for drugs inhibiting the renin-angiotensin system, both in monotherapy and in combination therapy. These drugs, including ACE inhibitors and angiotensin receptor blockers, are considered by physicians as the preferred drug options for treating hypertensive outpatients with both LVH and CAD. In particular, combination therapy with calcium-channel blockers is preferred for treating hypertensive outpatients with LVH, whereas combination therapy with beta-blockers is considered when treating patients with hypertension and CAD, according to the most recent evidence.21
The present study is based on a cross-sectional, descriptive survey. As such, it describes perceptions, attitudes and behaviours reported by physicians, but it cannot provide insights into actual clinical management of patients with hypertension and cardiac organ damage. In view of the relatively small sample size of the target population of specialised physicians, the possibility of sampling bias has to be considered. Dependence on physician self-reporting, rather than more objective measures such as prescription records, may also create potential biases. In fact, the proportions of different clinical conditions reported in this study represent the perceived estimations according to the opinion of involved physicians in their daily clinical practice. Yet, they were very close to those reported in several observational studies and clinical surveys performed in Italy. In addition, the personal views and preferences expressed by participating physicians may not be fully representative of the opinions of the wider physician community who have experience in treating patients with hypertension and high-cardiovascular risk in our country. Data collected during the observational period may be at least, in part, influenced by the relatively short-term teaching programme; thus, the possibility that a more prolonged follow-up might impact the proportions and distributions of physicians’ answers to this survey questionnaire must be considered. Although the geographical area of the participating physicians should be addressed in a further analysis of the data, our analysis cannot provide information about whether the physicians' practices were located in rural or urban areas. As access to medical health-care resources as well as clinical attitudes to health-care problems might be different in rural compared with urban areas, these aspects should be acknowledged, when considering the results of the present analysis. Data collection was ruled out before the availability of the latest sets of European guidelines for the clinical management of hypertension,21 and this may have, at least in part, conditioned some answers on BP targets to be achieved in different categories of hypertensive outpatients. As BP readings were related only to clinic BP measurements, we cannot provide information on other types of BP levels (that is, home and 24-h ambulatory BP monitoring). Finally, the survey was driven by the answers reported by Italian GPs, who predominantly participated in this study, rather than by those reported by cardiologists or other professional figures (nephrologists, diabetologists and specialised physicians in internal medicine), who may be involved in the clinical management of hypertensive outpatients with cardiac disease, and this should be taken into account when interpreting the results of the present analysis. Further analyses, which stratify physicians according to their geographical area or age of clinical activity, may provide relevant messages about the weaknesses of current services for patients with hypertension and either LVH or CAD, even when being managed by GPs.
In conclusion, with the well-known limitations of an observational, cross-sectional survey, in which a predefined questionnaire was administered to physicians rather than collecting data from medical databases, this study provides useful and updated information on the attitudes and preferences of, as well as on difficulties and troubles faced by physicians when managing outpatients with hypertension and cardiac disease in Italy. The main findings of the study confirmed a substantially high rate of LVH and other cardiac diseases in hypertensive outpatients followed up by GPs in Italy. Involved physicians, particularly GPs, considered more ambitious BP targets to be achieved in hypertensive outpatients with either LVH or CAD; of note, about one-third of specialised physicians also considered an intermediate BP target, whereas the same proportion of GPs aimed to achieve a more ambitious BP target. To achieve these thresholds of BP control, pharmacological therapies based on either ACE inhibitors or angiotensin receptor blockers, both in monotherapy and in combination therapy, represented the preferred options by both groups of involved physicians. Further analyses from this database may provide additional and updated information on the clinical practice of Italian physicians, according to their age and gender, clinical expertise, geographical locations and age of medical activity.
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We thank Mrs Giusy Mazza from Springer Healthcare Italy for her help and assistance in data collection, and Mrs Maria Antonietta Savina for project coordinator activities.
MV and CB have served in International Advisory Boards of Daiichi Sankyo, Menarini, Malesci and Guidotti, and have lectured in symposia supported by several drug companies producing ACE Inhibitors and ARBs; GT, AFC, AF and MS have lectured in symposia supported by Menarini, Malesci and Guidotti; PF declares no conflict of interest.
Supplementary Information accompanies this paper on the Journal of Human Hypertension website
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Tocci, G., Cicero, A., Salvetti, M. et al. Attitudes and preferences for the clinical management of hypertension and hypertension-related cardiac disease in general practice: results of the Italian Hypertension and Heart Survey. J Hum Hypertens 29, 409–416 (2015) doi:10.1038/jhh.2014.115
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