Original article 837
Hypertension prevalence, awareness, control and association
with metabolic abnormalities in the San Marino population:
the SMOOTH study
Giuseppe Manciaa,b, Gianfranco Paratia,b, Claudio Borghic, Giuseppe
Ghironzid, Egidio Andrianie, Liano Marinellif, Mariaconsuelo Valentinia,
Francesco Tessarig and Ettore Ambrosionic on behalf of the SMOOTH
investigators
Background The aim of the SMOOTH (San Marino
Observational Outlooking Trial on Hypertension) study
was to explore hypertension awareness, treatment and
control and the associated metabolic abnormalities and
risk factors in the population of San Marino, a small state
in the Mediterranean area, for which limited evidence is
available.
Methods Nine general practitioners enrolled 4590
consecutive subjects (44% of the San Marino population
age 40–75 years), seen in their office by collecting history,
physical and laboratory data and office blood pressure (BP)
measurements.
Results Of these subjects, 2446 were normotensive and
2144 hypertensive; 62.3% of hypertensive patients were
aware of their condition, 58.6% were treated (monotherapy
31.5%, combination therapy 27.1%), and 21.7% were
controlled. Hypertension awareness and treatment were
more frequent above age 50 and in females; BP control was
similarly low in both genders. As compared to
normotensives, hypertensive subjects were less frequently
smokers (20.1 versus 27.8%), had greater body mass index
(28.1 W 4.5 versus 25.8 W 3.7 g/m2), and a higher
prevalence of diabetes mellitus (15.8 versus 6.3%), lower
high-density lipoprotein (HDL) cholesterol and higher
prevalence of increased blood total cholesterol (66.1
versus 51.3%), triglycerides and serum uric acid. Values of
Introduction
Several studies performed in European and extra-Euro-
pean countries have shown that awareness of hypertension
in the population is limited. They have also shown that
the percentage of hypertensive patients under medical
treatment is less than that of aware patients, and that
treated patients with adequate blood pressure (BP) con-
trol (i.e. with systolic blood pressure < 140 mmHg and
diastolic blood pressure < 90 mmHg) are no more than
a small fraction of the overall hypertensive population
[1–13].
0263-6352 ß 2006 Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
subjects with ‘high-normal’ blood pressure were closer
to those of hypertensive subjects. The prevalence of
metabolic syndrome was higher in hypertensive than in
normotensive subjects, and in treated than in untreated
hypertensives.
Conclusions Even in a small Mediterranean country with
high health-care standards, hypertension awareness,
treatment and control are inadequate and hypertension
clusters with metabolic abnormalities and risk factors as in
non-Mediterranean areas. J Hypertens 24:837–843 Q 2006
Lippincott Williams & Wilkins.
Journal of Hypertension 2006, 24:837–843
Keywords: antihypertensive treatment, epidemiology, hypertension,
Mediterranean diet, metabolic factors, risk factors
a
Clinica Medica and Department Medicina Clinica, Prevenzione e Biotecnologie
Sanitarie, Università di Milano-Bicocca, bCardiologia II, Ospedale S.Luca, Istituto
Auxologico Italiano, Milan, Italy, cClinica Medica, Università di Bologna, dSocietà
di Cardiologia, San Marino, eIstituto di Sicurezza Sociale, Repubblica di S.Marino,
f
Unità di Cardiologia, Ospedale Statale, Repubblica di S. Marino and gCentro
Elaborazione Dati – Idea 99, Padova, Italy
Correspondence and requests for reprints to Professor Giuseppe Mancia, Clinica
Medica, Ospedale S. Gerardo, via Pergolesi, 3320052 Monza, Italy
Tel: +39 00 92333357; e-mail: giuseppe.mancia@unimib.it
Sponsorship: This work was supported by Recordati S.p.A.
Received 23 November 2005 Revised 23 February 2006
Accepted 23 February 2006
The present study reports the data obtained in the
SMOOTH (San Marino Observational Outlooking Trial
on Hypertension) study, which was a survey of the
population living in San Marino, a small independent
state within the Italian territory. The purpose of the study
was to determine the status of hypertension awareness,
treatment and control in an enclave characterized by
uniform social characteristics and a high level of health
care. It was also to determine whether hypertension is
associated with metabolic abnormalities, an association
frequently described in populations of northern Europe,
 838 Journal of Hypertension 2006, Vol 24 No 5
North America and Australia [14–16], while information
for southern Europe and Mediterranean countries is
limited and in most cases obtained a number of years
ago [17,18].
Methods
The SMOOTH study is a population-based study, per-
formed in the Republic of San Marino, a European
country with about 27 000 citizens, having demographic
and social characteristics similar to those of the general
Italian population. The study design consisted of a two-
step observation period: a ‘cross-sectional’ phase of 8
months’ duration, focused on screening for hypertensive
subjects and on collecting data on their associated car-
diovascular risk factors; and a subsequent ‘longitudinal’
phase focusing on a 2-year follow-up of the hypertensive
subjects screened in phase 1.
Nine general practitioners belonging to the primary care
service of the Republic of San Marino were asked to enrol
all subjects aged between 40 and 75 years seen in their
office over a period of 8 months. Each general practitioner
was required to obtain from each subject an informed
consent to the study and then: clinical history, focusing
on presence of diabetes mellitus, antidiabetic treatment
and cigarette smoking; physical examination; and labora-
tory data on blood glucose, total, low (LDL) and high-
density lipoprotein (HDL) cholesterol, triglycerides and
uric acid. Blood pressure (BP) was measured by the Riva–
Rocci/Korotkoff sphygmomanometric technique, with
the patient in the sitting position for 10 min before the
measurement. The average of two consecutive measure-
ments, spaced by an interval of 5–10 min, was considered
as the representative BP value of the subject. All
physicians were trained to carefully perform BP measure-
ments according to European Society of Hypertension–
European Society of Cardiology (ESH/ESC) 2003
recommendations [19].
Patients were stratified according to their systolic (SBP)
or diastolic blood pressure (DBP) values in five BP
categories:
(1) optimal (SBP < 120 mmHg, DBP < 80 mmHg);
(2) normal (SBP < 130 mmHg; DBP 80–84 mmHg);
(3) high normal (SBP 130–139 mmHg; DBP 85–89
mmHg);
(4) hypertension (SBP
140 mmHg, DBP
90 mmHg),
with further subdivision into grades 1, 2 and 3
according to the 1999 World Health Organization–
International Society of Hypertension (WHO/ISH)
and the 2003 ESH/ESC Guidelines [1,19]; and
(5) isolated systolic hypertension (SBP
140 mmHg;
DBP < 90 mmHg) [1,2].
Patients were also considered hypertensives if they were
under antihypertensive drug treatment, regardless of the
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
BP values obtained. In the case of a discrepancy between
SBP and DBP values, patients were assigned to the
higher BP category. Metabolic abnormalities were con-
sidered to be a blood cholesterol > 200 mg/dl (5.17
mmol/l), triglycerides > 180 mg/dl (> 2.03 mmol/l),
HDL cholesterol < 43 mg/dl (< 1.11 mmol/l) (females)
and < 34 mg/dl (< 0.88 mmol/l) (males); or uric acid
8
mg/dl (
474 mmol/l). Diabetes was identified by a blood
glucose
140 mg/dl (
7.7 mmol/l), or by use of antidia-
betic drugs. Body mass index (BMI; weight in kg divided
by the squared height value, m2) was regarded to be
increased if
27 kg/m2. We also assessed the prevalence
of the metabolic syndrome, according to the ATP III
definition [20,21], that is, based on the presence of at least
three out of the following five criteria: abdominal obesity,
elevated serum triglycerides (
150 mg/dl), low HDL
cholesterol (< 40 mg/dl in men and < 50 mg/dl in
women), elevated BP (office BP
130/85 mmHg) and
elevated serum fasting glucose (
110 mg/dl) [22].
Data were collected through an ad-hoc designed chart,
entered into a V-Basic databank program for a Windows-
based personal computer and analysed by means of SAS
Version 6.2 statistical software [23]. Comparisons
between groups were performed by x 2 test for dis-
crete/qualitative variables, and by analysis of variance
(ANOVA) whenever suitable. A probability value of
P < 0.05 was considered statistically significant. The
Pearson correlation coefficient was used to test associ-
ation between quantitative variables. Data are shown as
means  standard deviations (SD) for the various groups.
Patients were included after obtaining informed consent
to analysis of their clinical data. The local ethics com-
mittee approved this study which complied with the
Declaration of Helsinki.
Results
The present study reports the data collected in the
cross-sectional phase of the survey. 4590 subjects were
enrolled – a large (44%) and age- and gender-represen-
tative sample of the San Marino population aged between
40 and 75 years (Fig. 1).
As shown in Table 1, 2144 (46.7%) subjects were hyper-
tensive, whereas the remaining 2446 (53.3%) were nor-
motensives, 4.8, 21.7 and 26.8% in the high-normal,
normal and optimal BP categories, respectively. Hyper-
tensives had an overall gender distribution similar to, but
an average age greater than normotensive individuals.
As shown in Fig. 2, 62.3% of the hypertensive patients
were aware of their condition and 58.6% were under
antihypertensive drug treatment, with a slight preva-
lence of monotherapy (31.5%) over combination therapy
(27.1%). Angiotensin-converting enzyme (ACE) inhibi-
tors were the most frequently prescribed drugs (29.4%),
 San Marino hypertension study Mancia et al. 839

Fig. 1

18 18
16 16
14 14
12 12

FEMALES
MALES
10 10
% %
8 8
6 6
4 4
2 2
0 0
40-49 50-59 60-69 70-74 40-49 50-59 60-69 70-74
Age (years) Age (years)

San Marino Population SMOOTH

18
16
14
12
10
%
8
6
4
2
0
40-44 45-49 50-54 55-59 60-64 65-69 70-74
Age (years)

San Marino Population SMOOTH

Comparison of age and gender distribution in the sample of the San Marino Observational Outlooking Trial on Hypertension (SMOOTH) study and in
the San Marino population of the same age range (40–75 years).

followed by diuretics (24.7%) and calcium-channel
blockers (19.8%). Combined control of SBP and DBP
was found in 21.7% of the overall hypertensive group
(corresponding to 37.0% of the treated patients), the
control of SBP alone being much less frequent than
the control of DBP alone (4.1 versus 17.1% of the whole
hypertensive group, corresponding to 6.9 versus 29.2% of
the treated patients). Hypertension awareness and drug
treatment were more frequent in females than in males,
while BP control was similarly low in both genders
(Fig. 3a). Hypertension awareness, drug treatment and
BP control were progressively more frequent from the
youngest to the oldest age stratum (Fig. 3b). Isolated
systolic hypertension accounted for 34.5% (n ¼ 740) of
the hypertensive group; in this subgroup 52.2% were
aware of their hypertension while 50% were treated.
Table 2 shows the metabolic abnormalities identified in
the study separately for normotensive and hypertensive
subjects. Compared to the normotensive group, hyper-
tensives showed a lower prevalence of smoking, but a
greater prevalence of increased body mass index, dia-
betes mellitus (for which the difference was marked), and
increased blood cholesterol, triglycerides and uric acid.

Table 1 Age, gender and prevalence, (%) of various blood pressure (BP) categories. Mean (W SD) of systolic (SBP) and diastolic (DBP) values
are also shown
Class n (%) Age (years) Gender (M/F, n) Gender (M/F, %) SBP (mmHg) DBP (mmHg)

Hypertensives 2144 (46.7) 60.5  9.4 1002/1142 46.7/53.3 143.4  15.2 86.3  8.4
Normotensives 2446 (53.3) 52.8  9.2 1126/1320 46.0/54.0 121.2  10.5 77.4  6.4
High normal BP 222 (4.8) 53.2  8.5 125/97 56.0/44.0 133.4  2.9 86.1  1.3
Normal BP 995 (21.7) 53.9  9.2 502/493 50.4/49.6 126.8  5.4 81.1  2.0
Optimal BP 1229 (26.8) 51.8  9.3 499/730 40.6/59.4 114.5  10.0 72.9  5.8

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 840 Journal of Hypertension 2006, Vol 24 No 5

Fig. 2 Table 2 Prevalence (%) of smoking and metabolic abnormalities in

normotensive and hypertensive subjects
62.3% 58.6%
70 Normotensives Hypertensives
N=1336 N=1257
(n ¼ 2446) (n ¼ 2144) x2 test
60
Smoking 27.8 20.1 x22 ¼ 40.8
50 (P < 0.0001)
Increased BMI 29.7 55.1 x21 ¼ 302.6
40 (P < 0.0001)
% Increased plasma 51.3 66.1 x21 ¼ 103.9
21.7% 17.1% total cholesterol (P < 0.0001)
30
N=465 N=367 Increased plasma 10.0 16.8 x21 ¼ 46.4
20 triglycerides (P < 0.0001)
4.1% Low plasma HDL 6.1 7.0 x21 ¼ 0.90
N=87 -cholesterol (P ¼ 0.342)
10
Increased serum 3.3 8.3 x21 ¼ 52.6
0 uric acid (P < 0.0001)
Diabetes mellitus 6.3 15.8 x21 ¼ 15.97
Only SBP
Aware

Treated

SBP/DBP
Control
combined

controlled

Only DPB
controlled
(P < 0.0001)

BMI, body mass index; HDL, high-density lipoprotein.

Hypertension awareness, treatment and control of systolic blood

pressure (SBP) only, diastolic blood pressure (DBP) only, and
combined SBP and DBP in the hypertensive patients of the San Marino more prevalent in treated than in untreated hypertensive
Observational Outlooking Trial on Hypertension (SMOOTH) study.
patients (30 versus 16%, P < 0.0001).

Smoking rate was slightly lower, but other risk factors
(dyslipidaemia and increased serum uric acid) were more
frequent in treated than in untreated hypertensives
(Table 3). Subjects with a ‘high-normal’ BP displayed
a prevalence of diabetes mellitus and increased blood
cholesterol, triglycerides and uric acid that were greater
than those of subjects with a normal or optimal BP.
Values were similar or lower than those of untreated
hypertensive patients (Table 4). The overall prevalence
of metabolic syndrome was 13.4%, being much higher in
hypertensive than in normotensive subjects (24 versus
4%, P < 0.0001). The metabolic syndrome was much
Discussion
Our study shows that in the San Marino Republic,
hypertension, as diagnosed by office SBP
140 and/or
DBP
90 mmHg, had a high prevalence (46.7%). It also
shows that about two-thirds of the hypertensive patients
were aware of their condition, that about 60% were taking
antihypertensive drug treatment, and that only slightly
more than 20% of the overall hypertensive population
(i.e. only about one-third of the treated fraction) had
values below 140/90 mmHg. Thus, hypertension preva-
lence is by no means less in this small Mediterranean
country than in large European and extra-European
countries [3–13,24–26].

Fig. 3

(a) (b)
Males 40 – 50
Females 51 – 65
70 80
67.1%
66 – 75
74.3%
60
N=766 63.6% 70 N=574 71.5%
N=726 N=553
56.9%
N=570 53.0% 60 60.2%
50 N=531 N=594 56.1%
50 N=554
40
% % 40 43.7%
N=168 39.1%
30 N=150
30
22.7% 25.6%
20 20.6%
N=206 N=259 20 21.1% N=198
15.4% N=208
10 10 N=59

0 0
Aware Treated Controlled Aware Treated Controlled

Hypertension awareness, treatment and systolic (SBP) and diastolic (DBP) blood pressure control in the hypertensive patients of the San Marino
Observational Outlooking Trial on Hypertension (SMOOTH) study according to (a) gender and (b) age. Controlled rates refers to control of SBP and
DBP combined.

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 San Marino hypertension study Mancia et al. 841

Table 3 Prevalence (%) smoking and metabolic abnormalities in mentioned because of their similarity or difference with
untreated and treated hypertensive subjects previous studies addressing a similar issue. First, as in
Untreated Treated previous studies [1,2,27,28], the percentage of patients
hypertensives hypertensives with unsatisfactory SBP control was greater than that with
(n ¼ 887) (n ¼ 1257) x2 test
unsatisfactory DBP control. This may have been
Smoking 22.2 18.6 x22 ¼ 6.1 favoured by the inclusion, in the overall group, of subjects
(P ¼ 0.0485)
with isolated systolic hypertension, in whom only SBP is
Increased BMI 48.9 59.4 x21 ¼ 23.2
(P < 0.0001) elevated. However, similar findings were obtained both
Increased plasma 60.3 70.3 x21 ¼ 22.9 in subgroups in which isolated systolic hypertension is
total cholesterol (P < 0.0001) highly prevalent (the elderly) and in subgroups in which
Increased plasma 14.3 18.5 x21 ¼ 6.6
triglycerides (P ¼ 0.0101)
it is not (middle-aged and younger subjects). This allows
Low plasma HDL 5.2 7.8 x21 ¼ 3.17 us to conclude that, in agreement with previous studies,
-cholesterol (P ¼ 0.075) target SBP is less frequently obtained than target DBP.
Increased serum 5.3 10.3 x21 ¼ 17.46
uric acid
This may be due to greater attention paid by physicians
(P < 0.0001)
Diabetes mellitus 12.1 18.5 x21 ¼ 15.97 to DBP rather than SBP control. However, it also prob-
(P < 0.0001) ably reflects the greater difficulty posed by effective SBP
reduction, because in clinical trials average SBP values
BMI, body mass index; HDL, high-density lipoprotein.
have also frequently failed to be reduced to < 140 mmHg
[28]. Second, as in previous studies [29,30], monotherapy
Furthermore, despite some important favourable circum- was more common than combination therapy. This can
stances (small geographical size, limited traffic and trans- be one of the reasons for the low rate of BP control,
portation problems, uniform social characteristics, high because clinical trials have shown combinations of two or
income and health-care level) hypertension control is more drugs to be necessary to effectively reduce BP
affected by the same drawbacks described in studies values in the majority of hypertensive patients, presum-
on different and much more heterogeneous populations ably because a multiregulated variable such as BP can be
[1–13,24–26], namely unawareness of the increased BP more easily modified by acting on several controlling
condition in a substantial number of patients and inef- factors [8,28–30]. Thirdly, as in previous studies
fective BP control in most treated individuals. These [1,2,31], women were more frequently aware of their
conclusions are of particular interest because the large high BP condition than men. However, at variance from
sample studied was representative of the San Marino other studies: the rate of patients with controlled BP was
population within the age-range explored; and our results similar for men and women; this goal was more frequently
offer more up to date information on BP control and achieved in older than in younger patients; and the
cardiovascular risk factors in a Mediterranean country percentage of individuals aware of their hypertension
than that provided by most surveys so far available. was only slightly greater than the percentage under drug
treatment (62 versus 58%). Thus, in the San Marino
Several other results of the SMOOTH study on hyper- Republic, the health-care system should further improve
tension awareness, treatment and control deserve to be the procedures that favour the discovery of a high BP

Table 4 Prevalence of metabolic abnormalities in various normotensive and untreated hypertensive categories, separately for non-smokers
and smokers, Values are given as numbers (%)
Untreated hypertensives
Optimal BP (n ¼ 1229) Normal BP (n ¼ 995) High-normal BP (n ¼ 222) (n ¼ 887) x2 test

Between BP
Non-smokers Smokers Non-smokers Smokers Non-smokers Smokers Non-smokers Smokers group comparison

(N ¼ 559) (N ¼ 670) (N ¼ 499) (N ¼ 495) (N ¼ 98) (N ¼ 124) (N ¼ 416) (N - 471)

Increased BMI 135 (24.2) 166 (24.8) 152 (30.5) 177 (35.8) 39 (39.8) 58 (46.8) 189 (45.4) 245 (52.0) x23 ¼ 144
P < 0.0001
Increased cholesterol 263 (47.0) 332 (49.6) 262 (52.5) 269 (54.3) 59 (60.2) 69 (55.6) 245 (58.9) 290 (61.6) x23 ¼ 30:9
P < 0.0001
Increased triglycerides 33 (5.9) 65 (9.7) 47 (9.4) 72 (14.5) 9 (9.2) 18 (14.5) 39 (9.4) 88 (18.7) x23 ¼ 22:4
P < 0.0001
Low plasma HDL 12 (3.9) 29 (7.8) 11 (5.9) 15 (6.6) 1 (2.7) 3 (7.5) 6 (2.9) 18 (7.2) x23 ¼ 0:57
cholesterol P ¼ 0.90
Increased uric acid 9 (1.6) 20 (3.0) 15 (3.0) 23 (4.6) 3 (3.1) 11 (8.9) 11 (2.6) 36 (7.6) x23 ¼ 16:1
P ¼ 0.001
Diabetes mellitus 29 (5.2) 34 (5.1) 27 (5.4) 34 (6.9) 9 (9.2) 20 (16.1) 43 (10.3) 64 (13.6) x23 ¼ 47:0
P < 0.0001

BP, blood pressure; BMI, body mass index; HDL, high-density lipoprotein. P < 0.01; P < 0.05 for the comparison between smokers and non-smokers.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 842 Journal of Hypertension 2006, Vol 24 No 5
condition, although once hypertension is identified, drug
treatment is almost always implemented, with no greater
conservative attitude in the elderly. Full success remains
an elusive goal in most of the patients, however, which
has serious adverse consequences because treated hyper-
tensive patients in whom BP is not controlled remain at
higher risk [32]. Furthermore, in treated hypertensive
patients in whom BP was controlled, average values were
141.3  16.1/84.8  8.6 mmHg. This means that most
patients remained in the high-normal range [1,2,19]
which, given that BP is a risk factor on a continuum
basis [33], carries a risk higher than that accompanying
more ‘normal’ BP.
Our study also aimed to collect data on the association
between hypertension and metabolic abnormalities,
because such information from Mediterranean popu-
lations dates back many years and is much more limited
than that from northern European and extra-European
populations [1,2,17–19]. This is important for clinical
practice because in hypertension calculation of total
cardiovascular risk profile [19,34] guides the timing
and the initiation of drug treatment as well as the BP
values to be reached and the need for multiple risk-factor
correction. The data provided by the SMOOTH study,
however, do not show quantitative differences from those
obtained in the above-mentioned populations. That is,
compared to normotensives, the hypertensive individuals
of the San Marino sample showed a greater prevalence of
dyslipidaemias and increased uric acid levels, together
with a much greater frequency of obesity, diabetes and
metabolic syndrome. Thus, an association between
hypertension and metabolic abnormalities can be seen
in populations that differ for many lifestyle character-
istics, suggesting their origin from an independent and
specific pathophysiological link. Interestingly, metabolic
abnormalities, as well as a metabolic syndrome, were
more common in treated than in untreated hypertensive
patients. This could be accounted for by the dysmeta-
bolic effect of antihypertensive drugs such as diuretics
and beta-blockers; however, these were not largely used.
It is thus more likely for these effects to depend on the
fact that treated hypertensives were those in whom the
high BP condition was more severe, because there is
evidence of a quantitative relationship between BP levels
and metabolic disturbances [34,35].
Two other points should be mentioned. First, in line with
the data obtained in North American populations [36,37]
in subjects with BP values in the so-called ‘high-normal’
range, metabolic abnormalities were either similar or less
frequent than in untreated hypertensives, but more fre-
quent than in subjects with normal or optimal BP. Thus,
regardless of geographical, dietary and other lifestyle
factors, the high-normal BP condition appears to be
characterized by an overall increase in the prevalence
of metabolic abnormalities, accounting for the increased
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
absolute cardiovascular risk it has been shown to display
in epidemiological studies [36]. This strengthens the
belief that these individuals are not entirely normal
and that they may be considered candidates for active
treatment, although the benefit obtained by BP reduction
strategies from high-normal BP levels has so far been
documented only in those with a very high-risk profile
[19,38,39].
Second, the high prevalence of hypertension seen in the
SMOOTH population may originate from a selection-
bias, that is, from the fact that screening was done via
attendance of the San Marino residents to medical visits.
It may also originate from an alerting reaction that
elicited a pressor response at the time of the doctor’s
visit [40]. This may have been particularly the case
because the study was based on a single visit only.
However, values were derived from the average of two
measurements, following a 10-min rest, a procedure that
minimizes the alerting-dependent BP rise [40]. Further-
more, several studies have shown that BP values obtained
over a single visit are predictive of future cardiovascular
disease and death [41]. In addition, the prevalence of
hypertension in the SMOOTH sample was similar to that
found, for the same age range, in other studies, including
those in northern Italy [18,42]. Finally, hypertensive
patients differed from normotensives on several other
variables, which suggests that their increased BP values
were not just an occasional finding but reflected a stable
hypertensive condition.
Acknowledgements
We thank the Health Ministry of San Marino Republic
for its cooperation. We also thank Recordati S.p.A for the
unrestricted financial support given to the study.
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