Study population involved in this data review is the same of Save Your Heart, a cross-sectional, multicentre, observational study, which involved 21 community pharmacies belonging to the Italian Society of Clinical Pharmacy (SIFAC) spread over 15 Italian regions, with the primary aim of determining the prevalence of uncontrolled hypertension as well as that of untreated/uncontrolled hypercholesterolemia and diabetes among treated hypertensive women and men aged 50 years and above without established CVD [9]. Patients who were willing to take self-analysis of BP, lipid profile, and blood glucose as well as to fill out a questionnaire on adherence to current therapies were enrolled. In this regard, the following information was collected: the presence of cardiovascular risk factors (age, smoking habits, reported previous cardiovascular events, reported CKD); demographic data; any known diagnosis of hypercholesterolaemia and/or diabetes; BP (systolic and diastolic); pharmacological treatments taken; lipid profile (total cholesterol, high-density lipoprotein [HDL] and low-density lipoprotein [LDL]) and glycaemia; adherence to current treatments. The secondary analysis of the Save Your Heart study data was possible thanks to the approval for secondary use of these latter obtained by the Ethics Committee ATS Sardinia-Sassari (approval code 294/2021/CE of 16/03/2021) [9]. Signed informed consent was obtained from each participant. The survey and related research fulfil the principles stated in the Declaration of Helsinki [9].

To estimate cardiovascular risk the revised prediction model Systematic COronary Risk Evaluation 2 (SCORE2) was applied in non-CVD individuals aged 50–69 years among those enrolled in the Save Your Heart study [8]. Briefly, SCORE2 is an updated prediction algorithm that provides age-, sex-, and region-specific estimates for 10-year CVD risk for four distinct European risk regions (low, moderate, high, and very high risk). By combining demographic and clinical features (age, sex, European region, smoking habits, systolic BP values, and non HDL-cholesterol), the algorithm stratifies the risk of future fatal and non-fatal cardiovascular events that is calibrated to current CVD rates, with improved risk prediction for individuals at younger ages and for non-fatal cardiovascular events. In the age range 50–69 years, risk is defined as low-to-moderate for scores < 5%, high for scores between 5 and 10%, and very high for scores equal or higher than 10% [5]. For CVD individuals enrolled in the Save Your Heart study population the classification criteria of European guidelines for the management of dyslipidaemia were considered and, for this reason, included in the highest cardiovascular risk group [10].

Participating individuals self-measured BP and answered a questionnaire on adherence to ongoing therapies. BP was measured in sitting position using a validated automatic digital BP monitor (Omron M6^®) [11].

BP was used as a continuous (mmHg) and categorical (controlled/uncontrolled hypertension) variable. Based on the 2021 European Society of Cardiology guidelines, uncontrolled hypertension was defined as mean BP ≥ 130/80 mmHg in treated participants with self-reported normal renal function aged < 70 years, and ≥ 140/80 mmHg if ≥ 70 years or with self-reported CKD [5]. This definition of hypertension is more stringent than the one used for the assessment of patients in the Save Your Heart study, which referred to the 2018 European guidelines on the management of high BP. In the latter, uncontrolled hypertension was defined as mean BP ≥ 140/80 mmHg in treated patients aged > 65 years [7]. Hypertension control rates were defined as having BP values below the previously specified targets.

Covariates of interest in this analysis included main demographics (age as both a dichotomous [< or ≥ 70 years] and a continuous [if < 70 years] variable; sex) and clinical features (body mass index [BMI]; smoking habits; self-reported history of CVD, CKD, high blood cholesterol, and diabetes), which were used for descriptive statistics and cardiovascular risk assessment.

Differences in participants’ characteristics were evaluated with unpaired t tests for continuous variables (mean ± standard deviation, SD) and χ² tests for categorical variables (N, %). Hypertension control rates were assessed overall and across strata of SCORE2. The likelihood estimate for the difference in hypertension control rates (95% confidence intervals) according to 2018 ESC/ESH guidelines [7] or 2021 ESC recommendation on cardiovascular prevention [5] was assessed using Yates correction for continuity [4]. Statistical analyses were performed using R (v 4.0.2) [12]. Statistical significance was set at p < 0.05.

The review of data collected during the Save Your Heart study, in the light of the changes introduced by the 2021 European guidelines on prevention in clinical practice [5], clearly shows how the percentage of patients at high or very high risk increases considerably compared with the previous assessment [9]. Indeed, although the risk in the population aged > 70 years is underestimated, a more overall alarming picture arises than in the Save Your Heart study. Indeed, with the application of the new parameters for fatal and non-fatal cardiovascular risk assessment, the proportion of individuals at high or very high risk rises over 80% of the cases (86.7–41.9% at high risk and 44.7% at very high risk) (Fig. 1), while, with the previous indications, cases with a high or very high risk of a fatal cardiovascular event were almost the half of the population (48.7%). In this assessment, however, it should be considered that, unlike the SCORE, which assesses the risk of fatal cardiovascular events, the SCORE2 also assesses the risk of non-fatal cardiovascular events (Table 2).

As already mentioned, the 512 participants enrolled in the Save Your Heart study were reassessed about the achievement of BP target. According to 2021 ESC guidelines on cardiovascular prevention, 30.3% (95% CI 26.4–34.5%) of participants achieved the target BP values. Women were more likely than men to be at goal based on the updated targets (Fig. 2). In comparison, the hypertension control rate according to 2018 ESC/ESH hypertension guidelines was higher (32.0%, 95% CI 20.8–36.3%), though the observed difference was not significant (1.76%, 95% CI − 4.1 to 7.6%, p = 0.589). No sex-based differences were observed in achieving 2018 BP targets (Fig. 2).