In this study, we examined the prevalence, clustering, and ongoing management of key cardiovascular risk factors, beside hypertension, among adult patients at the time of their first referral to a hypertension specialized center. Our findings show substantial metabolic complexity in the examined population, but also concomitant significant undertreatment in terms of both pharmacological and non-pharmacological management strategies. Specifically, most hypertensive participants were smokers, had a sedentary lifestyle, were overweight/obese, suffered from high LDL-cholesterol, had never changed their habits to lose weight, and were not on a low-salt diet. Only a minority reported previous specialist counseling, and one in 3 individuals had never received recommendations to correct their unhealthy lifestyle habits. Not only hypertension, but also hypercholesterolemia and diabetes were poorly controlled. More importantly, nearly 90% of individuals with high/very high cardiovascular risk conditions did not achieve the recommended LDL-cholesterol targets.

With an age-standardized average prevalence of 34% in men and 32% in women in the age range of 30-79 years [5], hypertension is the most prevalent modifiable cardiovascular risk factor at a global scale [4], yet approximately 4 out of every 5 people with hypertension are not adequately treated [18] and less than 25% of treated patients achieve the recommended BP targets [3]. In parallel, and similar to our findings, recent data from more than 9000 high- and very high-risk adults from primary and secondary care settings enrolled in the multinational observational SANTORINI study indicate that failure to achieve LDL-cholesterol goals occurs in 80% of individuals [19, 20], which was attributed to cardiovascular risk underestimation and underutilization of combination lipid-lowering therapies.

The estimation of total cardiovascular risk is crucial in each hypertensive patient because it provides valuable information that can guide hypertension management through a personalized and individualized approach. Different patients may have varying degrees of risk based on a combination of factors such as age, gender, BP levels, cholesterol levels, smoking status, and existing comorbidities. The Systemic Coronary Risk Evaluation (SCORE) method, based on a large European database, estimates the risk of death from CVD over 10 years in either high-and low-risk European countries [21]. The more recent 2021 European Guidelines on CVD prevention updated and substituted the SCORE method with the SCORE2, which estimates the risk of fatal and nonfatal cardiovascular events over 10 years in apparently healthy individuals aged 40–69 years with stable/untreated risk factors, and the SCORE2-OP for older people (age 70–89 years) [15]. Strict control of risk factors is even more relevant in some high-risk categories, like individuals with masked hypertension and non-dipping/reverse dipping profiles, who are at increased risk of hypertension-mediated organ damage (HMOD) and cardiovascular events [4] and were not uncommon in the subset of individuals with complete BP profile in our study. Similarly, both orthostatic hypotension and hypertension are correlated with an increased risk of mortality and cardiovascular events [22, 23], and more than one in 10 individuals in our population suffered from either one of these conditions, in line with data from high-risk hypertensive populations [24]. The observation that a significant number of participants, particularly those at high and very high cardiovascular risk, did not meet the target LDL-cholesterol values highlights the need for more effective and targeted strategies for lipid management in these patients.

Regarding lifestyle behaviors, more than 30% of participants declared having never received recommendations to correct their lifestyle for cardiovascular prevention and 20.4% of participants declared having become overweight/obese. Lifestyle interventions play a pivotal role in reducing premature cardiovascular morbidity and mortality. Among all the established, effective lifestyle measures for cardiovascular well-being, weight loss in overweight or obese individuals is associated with improvements in BP, cholesterol levels, and overall cardiovascular health [25]. A regular physical activity, such as brisk walking, jogging, or cycling, has numerous cardiovascular benefits, including helping to lower BP, improve the cholesterol levels, and enhance overall cardiovascular fitness [26, 27]. However, in our population, only 24.7% declared adequate physical exercise. In parallel, consumption of fruits, vegetables, whole grains, lean proteins, and low-fat dairy products, together with reduced sodium and adequate potassium intake, has been shown to lower BP and reduce the risk of heart disease, leading to significant cardiovascular benefits [28,29,30]. Current evidence indicates that restriction of sodium intake leads to improved BP control, especially in hypertensive patients and in those at increased risk due to older age, diabetes, and metabolic syndrome [31,32,33], with the added value of a possible reduction in the number of drugs needed to achieve hypertension control [4]. The magnitude of BP benefits attributable to sodium intake restriction (< 5.8 g salt per day) was approximately 5/2 mmHg systolic/diastolic BP reductions in individuals with hypertension [34]. In agreement with this, current hypertension guidelines recommend not to exceed 2.0 g per day of sodium intake (approximately 5.0 g salt per day) [4, 13]. Still, a substantial portion of the examined hypertensive population—more than 4 in 10 individuals—reported not adhering to dietary measures to reduce sodium intake. Consuming alcohol in moderation and quit smoking are additional lifestyle measures associated with reduced risk of CVD [35, 36]. In our population, while only 0.8% reported high alcohol consumption, cigarette smoking represented the second most common risk factor, and nearly one in 4 smoker individuals had never received any recommendation to quit smoking.

With regard to antihypertensive treatments reported in our study, renin-angiotensin-system blockers, in particular ARBs, seem to represent the most frequently adopted antihypertensive strategy, in line with the most recent guidelines, followed by calcium antagonists. Unfortunately, the use of fixed-combination therapy compared to monotherapies was not investigated in our population.

Altogether, our findings highlight the need for greater integration of guidelines into clinical practice and increased patient-centeredness in the healthcare team, to ensure adequate patient understanding of the clinical benefit of a comprehensive cardiovascular prevention strategy and to identify and remove any potential barriers to virtuous lifestyle implementation. Physicians should measure office BP both in sitting and standing positions, especially in older individuals, in those with high-risk conditions, and during titration and changes of the antihypertensive treatment. This approach provides additional insights into the dynamics of BP regulation and helps healthcare providers take more informed decisions for a satisfactory management of hypertension.

This study has some limitations, including its observational nature, which does not allow any causal inferences, and the limited sample size, which should be considered in the interpretation of results and could limit their generalizability. Results could also not be generalizable to other healthcare systems. However, our study is the first to explore the degree and effectiveness of ongoing management strategies among hypertensive individuals upon their first referral to hypertension specialists, thereby providing valuable insights into hypertension management in general medicine settings that could help to overcome cultural barriers, and to tailor more targeted and effective interventions before referral to specialist care. As such, our findings may have broader implications for hypertension management.

In conclusion, this study underscores the ongoing challenges in achieving optimal BP management, emphasizing the need for greater integration of guidelines into clinical practice and implementation of a proactive patient-centered approach. Educating patients on the importance of therapeutic adherence/persistence and a healthy lifestyle, encouraging a heart-healthy diet, promoting regular physical activity, and performing periodic review and optimization of current medication regimens represent crucial points for an effective therapeutic alliance. In parallel, tailored strategies to address individual barriers to achieving risk factors control and continuous support and education through traditional and technology-based approaches can help improve cardiovascular outcomes. By addressing these issues, our study can contribute valuable data to inform healthcare policies, improve clinical practice, and enhance the overall cardiovascular health of hypertensive patients.