Blood pressure (BP) control remains unsatisfactory worldwide. Better knowledge of BP management in clinical practice is needed to develop more effective improving strategies. Using a large Italian primary care database, we selected the subjects diagnosed with hypertension, and extracted the diagnosis of myocardial infarction, angina pectoris/coronary disease, stroke/transitory ischemic attack (TIA), heart failure, atrial fibrillation, peripheral arterial disease, diabetes mellitus, the serum total cholesterol, HDL cholesterol, triglycerides, creatinine, BP, electrocardiogram, weight, height and the prescription of cardiovascular (CV)

Background:In Italian primary care, chronic heart failure (CHF) patients are mainly managed by general practitioners (GPs). However, there are few studies analysing CHF management challenges in primary care and identifying opportunities for improvement. Objectives: To describe CHF care as implemented by GPs in the Veneto Region and to identify opportunities for improvement. Methods: In 2008, using an audit process, 114 Venetian GPs analysed their electronic health records, identifi ed CHF patients and collected clinical and care related information: prevalence, co-morbidity, caring conditions, diagnostic and therapeutic management, and hospitalization. After two training sessions, data on pharmacotherapy were analysed again in 2009. Results: The prevalence of CHF was 1.2% (95% CI: 1.1 -1.3%). Diagnostic echocardiography was used in 57% of cases. At baseline, the proportions of patients that used specifi c medication were: diuretics 88%; angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) 77%, beta-blockers 46% and anti-aldosterone agents 32%. After two training sessions, the use of ACE inhibitors/ARB and beta-blockers increased to 80% and 56%, respectively. Renal failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus and dementia were the most prevalent concomitant diseases, posing specifi c management problems. Half of the patients were generally visited at home; they were dependent on some kind of care given. Conclusion:In Veneto a large number of CHF patients are mainly managed by GPs. Further improvements are necessary to meet standards of care with regard to diagnosis, medication, follow-up and home care. The care situation aff ected hospitalization and the quality of follow-up visits.

BackgroundRandomized clinical trials (RCTs) about Ezetimibe's efficacy on patient-oriented outcomes have given discordant results. The aim of this study was to determine the net effect of Ezetimibe and of the widely marketed combination, Ezetimibe+simvastatin, on mortality and morbidity outcomes.Methods and FindingsWe searched for RCT on Ezetimibe using MEDLINE, CCTR, EMBASE, ClinicalTrials.gov databases up to December 2013, Merck and Novartis online registers, and personal communications. Two authors independently selected trials fulfilling these criteria: RCTs comparing Ezetimibe±statin or another lipid-lowering drug against placebo, or against the same lipid-lowering drug at the same dosage, with a follow-up at least 24 weeks and one or more of these outcomes: all-cause mortality, cardiovascular (CV) mortality, stroke, myocardial infarction (MI), cancer, serious adverse events (SAEs); we assessed the risk of bias using the Cochrane checklist. We extracted the data for major clinical events as a dichotomous measure, with the patient the unit of analysis. Pooled analysis was done with random and fixed effect based models. Trials comparing Ezetimibe plus a lipid-lowering drug against the same lipidlowering drug representing the net effect of Ezetimibe, showed a nonsignificant tendency toward damage for cancer, MI, stroke and SAEs. Ezetimibe+simvastatin vs. simvastatin alone showed a stronger tendency towards a higher risk for all-cause death (2.52; 0.65-9.74), CV death (3.04; 0.48-19.21), non-CV death (3.03; 0.12-73.50), MI (1.91; 0.42-8.70), stroke (2.38; 0.46-12.35), cancer (RR 11.11; 0.62-198.29), and SAEs (1.45; 0.95-2.23). Limitations include small numbers of events and inadequate power of the pooling. Trials comparing Ezetimibe+simvastatin vs placebo showed non-significant effects: MI (0.81; 0.66-1.00 p = 0.051), all-cause death (1.02; 0.95-1.09), CV death (0.91; 0.80-1.04), non-CV death (108; 0.99-1.18), stroke (0.86; 0.72-1.04), cancer (1.18; 0.80-1.74), SAEs (1.01; 0.96-1.06).ConclusionsEzetimibe±simvastatin had inconsistent effects on important outcomes. No firm conclusions are possible, but findings indicative of damage suggest much more selective use of Ezetimibe±simvastatin.

Context: Both frailty and multimorbidity are strong predictors of clinical endpoints for older people. In Italy, the interventions targeting chronicity are mainly based on the treatment of diseases: sufficient epidemiological literature is available about these strategies. Less is known about the territorial distribution of the frailty status.Aims: To estimate the prevalence of frailty in older people (65+) and to evaluate the relationship between frailty and multimorbidity.Methods and material: A group of general practitioners working in Veneto (Italy) was enrolled on a voluntary basis. Older individuals were both community dwelling and institutionalized patients, that is, the older people normally followed by Italian general practitioners. A centrally randomized sample was extracted from the pool of physician-assisted elderly. Each doctor evaluated the frailty status through the CSHA Clinical Frailty Scale and the multimorbidity status through the Charlson score (Frailty = CSHA Clinical Frailty Scale’s score >4; serious multimorbidity = Charlson score ≥4). Prevalence and its confidence interval (CI) 95% were evaluated through the Agresti’s method for proportions. The relation between frailty and multimorbidity was studied through a logistic regression model adjusted for age and sex.Results: Fifty-three physicians were enrolled, whose population of elderly individuals (N = 82919) was highly representative of the population of Veneto. The prevalence of frailty in the randomized sample of 2407 older people was 23.18% (CI 95%: 21.53%–24.91%). Sex was shown to be a strong predictor of frailty (female status OR = 1.58 p < .0001) and multimorbidity was shown to be an independent predictor only for individuals <85 years of age.Conclusions: In Veneto, more than 20% of elderly people are frail. Physicians should pay close attention to frailty and multimorbidity because both are important prognostic factors toward clinical endpoints relevant to territorial care. The CSHA Clinical Frailty Scale (easy and quick) should become part of their professional routine.

Federica Braga and coworkers [1] stated recently that hyperuricemia shows to be an independent predictor of coronary heart disease (CHD) risk (RR CHD = 1.206 [1.066-1.364]; RR CHD death = 1.209 [1.003-1.457]), mainly for the results found in women. That message seems to be of great importance: if it is true, the treatment of hyperuricemia should be included in the landscape of the therapeutic strategies to reduce the coronary risk. To ascertain the methodologic validity and robustness of that work, we considered it as a critical appraisal of some methodological aspects.In our approach, (a) we evaluated the overall quality of that systematic review through the AMSTAR checklist [2]; (b) we recovered the nine studies selected by Braga and colleagues [1] in order to repeat the meta-analysis and quantified the heterogeneity through I 2 statistic [3]; (c) we launched new subgroup and sensitivity and metaregression analyses in order to better explore the heterogeneity, considering the following as potential effect modifiers: gender, number of CHD covariates used in the adjustment models (i.e. age, BMI, total cholesterol or LDL-cholesterol or presence of dyslipidemia, blood pressure values or presence of hypertension, smoke, glucose values or presence of diabetes) and lack of nutritional information; (d) we estimated the prevalence of metabolic syndrome in single-trial samples using an Italian epidemiological research as reference sample [4]; (e) we investigated the quality of included trials and their risk of bias through the ACROBAT Cochrane checklist [5]; and (f) we used a generalized least-squares regression model to inspect some dose-response effect [6] both at trial level and with a doseresponse meta-analysis; the goodness of fit was explored with a χ 2 -test [7]. We restricted all our described analyses to the end point 'CHD incidence'; their methodological details are available in the online Supplementary material. What were our results?1. The quality of the meta-analysis assessed with the AMSTAR checklist [2] appears to be medium/low: only 4/11 items were fully satisfied, 3/11 not satisfied and 4/11 uncertain. 2. The metaregression (Figure 1) demonstrates that the number of confounders could be an important cause of heterogeneity, with the risk ratio of CHD associated to hyperuricemia decreasing by 13% for each covariate added to the model (p = 0.056). The subgroup analysis using the number of covariates as effect modifier coherently indicates that the role of hyperuricemia tends to disappear in the best adjusted models (test of interaction, p = 0.056). Notably, the trials that were not adjusted for nutritional status [8][9][10]