Regional and temporal differences in the associations between cardiovascular disease and its classic risk factors: an analysis of 49 cohorts from 11 European countries.

AIMS: The regional and temporal differences in the associations between cardiovascular disease (CVD) and its classic risk factors are unknown. The current study examined these associations in different European regions over a 30-year period. METHODS AND RESULTS: The study sample comprised 553 818 individuals from 49 cohorts in 11 European countries (baseline: 1982-2012) who were followed up for a maximum of 10 years. Risk factors [sex, smoking, diabetes, non-HDL cholesterol, systolic blood pressure (BP), and body mass index (BMI)] and CVD events (coronary heart disease or stroke) were harmonized across cohorts. Risk factor-outcome associations were analysed using multivariable-adjusted Cox regression models, and differences in associations were assessed using meta-regression. The differences in the risk factor-CVD associations between central Europe, northern Europe, southern Europe, and the UK were generally small. Men had a slightly higher hazard ratio (HR) in southern Europe (P = 0.043 for overall difference), and those with diabetes had a slightly lower HR in central Europe (P = 0.022 for overall difference) compared with the other regions. Of the six CVD risk factors, minor HR decreases per decade were observed for non-HDL cholesterol [7% per mmol/L; 95% confidence interval (CI), 3-10%] and systolic BP (4% per 20 mmHg; 95% CI, 1-8%), while a minor HR increase per decade was observed for BMI (7% per 10 kg/m2; 95% CI, 1-13%). CONCLUSION: The results demonstrate that all classic CVD risk factors are still relevant in Europe, irrespective of regional area. Preventive strategies should focus on risk factors with the greatest population attributable risk.

All classic cardiovascular disease (CVD) risk factors are still relevant in Europe, irrespective of regional area. The differences in the associations of CVD risk factors with overt CVD between regions of Europe are generally small. Minor temporal hazard decreases were observed for non-HDL cholesterol and systolic blood pressure, while a minor hazard increase was observed for body mass index.

Thrombotic Events after COVID-19 Vaccination in the Over-50s: Results from a Population-Based Study in Italy.

Several European countries suspended or changed recommendations for the use of Vaxzevria (AstraZeneca) for suspected adverse effects due to atypical blood-clotting. This research aims to identify a reference point towards the number of thrombotic events expected in the Italian population over 50 years of age who received Vaxzevria from 22 January to 12 April 2021. The venous thromboembolism (VT) and immune thrombocytopenia (ITP) event rates were estimated from a population-based cohort. The overall VT rate was 1.15 (95% CI 0.93-1.42) per 1000 person-years, and the ITP rate was 2.7 (95% CI 0.7-11) per 100,000 person-years. These figures translate into 83 and two expected events of VT and ITP, respectively, in the 15 days following the first administration of Vaxzevria. The number of thrombotic events reported from the Italian Medicines Agency does not appear to have increased beyond that expected in individuals over 50 years of age.

[Progress in cardiovascular prevention: from risk charts to polygenic risk score and precision prevention]. / Progressi in prevenzione cardiovascolare: dalle carte del rischio allo score poligenico e alla prevenzione di precisione.

In the last few decades, great epidemiological studies identified the main risk factors and their causative role in cardiovascular diseases (CVD). In this field, the pivotal study was the Framingham Heart Study for the evaluation of classical risk factors and for the production of initial instruments of risk calculation. The Seven Countries Study of Cardiovascular Diseases was the first to compare the influence of different cultural environments on the risks of developing atherosclerosis. In 1980, the Italian Journal of Cardiology published an extensive evaluation of risk factors in nine Italian communities. Since the early '90s, the first risk charts for global and individual risk evaluation were available (Framingham, SCORE, PROCAM, CUORE). Mortality reduction in the period of 1980-2000 can be attributed to risk factor reduction in primary prevention (55%) and to pharmacological treatment in the acute phase of the disease or in secondary prevention (40%). Two important longitudinal studies have been conducted in Italy in the periods of 1998-2002 and 2008-2012 thanks to the cooperation of the National Association of Hospital Cardiologists (ANMCO) and the National Health Institute (ISS), which became the reference point for the influence of lifestyle and risk factors on CVD. During the last 15 years, genetic studies allowed the construction of polygenic risk scores (PRS), that are strongly predictive of developing CVD in the future, thanks to big genomic datasets of individuals followed for more than 10 years (e.g. UK Biobank). PRS can be used as an adjunctive tool to the common risk charts for a better classification of individual risk profile. In addition to PRS, inflammation biomarkers and imaging tools like ultrasound and coronary calcium score and their integration with machine learning can help in the best definition of cardiovascular risk. Precision prevention by the study of "metabotypes" and community prevention provide possible future development of cardiovascular prevention.

Combined Influence of Waist and Hip Circumference on Risk of Death in a Large Cohort of European and Australian Adults.

Background Waist circumference and hip circumference are both strongly associated with risk of death; however, their joint association has rarely been investigated. Methods and Results The MONICA Risk, Genetics, Archiving, and Monograph (MORGAM) Project was conducted in 30 cohorts from 11 countries; 90 487 men and women, aged 30 to 74 years, predominantly white, with no history of cardiovascular disease, were recruited in 1986 to 2010 and followed up for up to 24 years. Hazard ratios were estimated using sex-specific Cox models, stratified by cohort, with age as the time scale. Models included baseline categorical obesity measures, age, total and high-density lipoprotein cholesterol, systolic blood pressure, antihypertensive drugs, smoking, and diabetes mellitus. A total of 9105 all-cause deaths were recorded during a median follow-up of 10 years. Hazard ratios for all-cause death presented J- or U-shaped associations with most obesity measures. With waist and hip circumference included in the same model, for all hip sizes, having a smaller waist was strongly associated with lower risk of death, except for men with the smallest hips. In addition, among those with smaller waists, hip size was strongly negatively associated with risk of death, with ≈20% more people identified as being at increased risk compared with waist circumference alone. Conclusions A more complex relationship between hip circumference, waist circumference, and risk of death is revealed when both measures are considered simultaneously. This is particularly true for individuals with smaller waists, where having larger hips was protective. Considering both waist and hip circumference in the clinical setting could help to best identify those at increased risk of death.

[The Health Examination Survey at regional level: the Emilia-Romagna Region (Northern Italy) example]. / Health examination survey a livello regionale: l'esempio dell'Emilia-Romagna.

OBJECTIVES: to assess time trend of lifestyles, cardiovascular risk factors, and prevalence of high-risk conditions in random samples of the general adult population residing in Emilia-Romagna, examined in two cross-sectional surveys conducted within the Epidemiological Cardiovascular Observatory (OEC 1998-2002) and the Epidemiological Cardiovascular Observatory/Health Examination Survey (OEC/HES 2008-2012). DESIGN: cross-sectional surveys conducted on random samples of general adult population stratified by gender and age group in some municipalities of Emilia-Romagna. SETTINGS AND PARTICIPANTS: in Emilia-Romagna, 341 males and 354 females were examined in 1998-2002 and 307 males and 300 females were examined in 2008-2012. MAIN OUTCOME MEASURES: cardiovascular risk factors, high risk conditions, and proportion of population following healthy lifestyles recommendations. RESULTS: in the second survey, prevalence of hypercholesterolemia and mean values of total and LDL cholesterol were higher. Less than 30% of the sample consumes adequate quantities of vegetables and fish; cheeses, sausages, and sweets are overconsumed, as a higher cholesterol intake. CONCLUSIONS: increased in total and LDL cholesterol are partly due to the reach diet, as suggested by nutrient consumption. Appropriate preventive actions for the improvement of the lifestyles and lipid profile in the general population are recommended.

Nutrients Intake in Individuals with Hypertension, Dyslipidemia, and Diabetes: An Italian Survey.

The aim of this study is to evaluate whether nutrients intake in an Italian adult population receiving pharmacological treatment for hypertension, dyslipidemia, and diabetes are within the recommended values proposed by dietary guidelines. Cross-sectional data from the Cardiovascular Epidemiology Observatory/Health Examination Survey in 8462 individuals 35-79 years were used. Food consumption was assessed with a self-administered semi-quantitative food frequency questionnaire. Dietary sodium and potassium intakes were measured in 24-hour urine collection. Recommendations from WHO were used for salt and potassium intakes, those from the Diabetes and Nutrition Study Group for diabetes, and those from the European Society of Cardiology for hypertension and dyslipidemia. Salt intake in urine collection of participants receiving treatment for hypertension was 11.1 ± 4.0 g/day for men and 8.6 ± 3.3 g/day for women, higher than recommended. In participants treated for dyslipidemia, mean saturated fat intake was 11.4% and 11.6% total Kcal in men and women respectively, higher than recommended, while cholesterol intake was higher only in men (365.9 ± 149.6 mg/day). In both men and women receiving treatment for diabetes, mean intake of saturated fats (12.3% and 12.2% of total Kcal), simple carbohydrates (17.5% and 19.8% of total Kcal) and cholesterol (411.0 ± 150.4 and 322.7 ± 111.1 mg/day) were above the recommendations, while fiber intake was below (19.5 ± 6.3 and 17.5 ± 6.2 mg/day). Overall, 70% to 80% of participants treated for these conditions received advice from family doctors on dietary management; however, nutrition is far from being optimal.

Prevalence and Correlates of Statin Underuse for Secondary Prevention of Cardiovascular Disease in Older Adults 65-79 Years of Age: The Italian Health Examination Survey 2008-2012.

Limited data are available on the prevalence and correlates of statin use for secondary cardiovascular (CV) prevention in the older adult population. We used data of older adults (65-79 years) with established atherosclerotic CV disease from the cross-sectional Italian Health Examination Survey 2008-2012 to address this issue. Lifestyles, CV risk factors, chronic diseases, and therapies were assessed using standardized procedures. A comprehensive geriatric assessment was performed to evaluate cognitive function, disability in basic activities of daily living/instrumental activities of daily living, mobility, and polypharmacy. Multiple regression analyses were performed to identify independent correlates of statin use. A total of 392 participants (mean age 72.1 ± 4.4 years, 61.5% men) were considered for this analysis. Coronary heart disease was identified in 67.1% of participants, cerebrovascular disease in 23.5%, and peripheral artery disease (PAD) in 18.1%. One hundred ninety (48.5%) were statin users. By multiple regression analysis, functional disability (odds ratio [OR] = 0.81; 95% confidence interval [CI] = 0.71-0.92; p = 0.002), cognitive impairment (OR = 0.87; 95% CI = 0.78-0.98; p = 0.018), and polypharmacy (OR = 0.86; 95% CI = 0.75-0.98; p = 0.035) predicted statin nonuse, whereas having hypertension (OR = 1.19; 95% CI = 1.05-1.34; p = 0.005), diabetes mellitus (OR = 1.14; 95% CI = 1.03-1.27; p = 0.013), or a previous myocardial revascularization (OR = 1.31; 95% CI = 1.16-1.48; p < 0.001) predicted statin use. Significant interaction terms were observed between cerebrovascular disease, PAD, cognitive impairment, and disability in predicting statin nonuse. Statin underuse in older adults aged 65-79 years with CV disease, and thus suboptimal secondary CV prevention, is highly prevalent despite current guidelines and recommendations. Common geriatric conditions are associated with statin nonuse. Such results support the need for improving the awareness of statin treatment for secondary CV prevention.

Association Between Antidepressant Medication Use and Prevalence and Control of Cardiovascular Risk Factors in Community-Dwelling Older Adults: The Italian Health Examination Survey 2008-2012.

Background: To assess the association of antidepressant (AD) medication use with prevalence and control of cardiovascular (CV) risk factors. Methods: Data of older adults from the population-based Italian Osservatorio Epidemiologico Cardiovascolare/Health Examination Survey (OEC/HES) Study 2008-2012 were used. CV risk factors were measured using standardized procedures. Information on clinical features, lifestyles, and medications was collected using standardized questionnaires. Logistic regression models were elaborated to assess associations between AD use and prevalence and control of CV risk factors. Results: Around 2549 participants (age 71.4 ± 4.2 years, 51.3% men) were studied; 268 (10.5%) were AD users. Of these, 72.4% used selective serotonin reuptake inhibitors (SSRI). AD users had less favorable CV risk factor profile and were less likely to achieve control of blood pressure and total cholesterol. After multiple adjustment for potentially confounding variables, AD use was associated with greater likelihood of having diabetes (OR = 1.05, 95% CI = 1.02-1.10, P = 0.008), hypertension (OR = 1.10, 95% CI = 1.05-1.20, P = 0.003), and hypercholesterolemia (OR = 1.08, 95% CI = 1.04-1.14, P < 0.001). Among participants treated for hypertension and hypercholesterolemia, AD use was associated with poorer control of BP (OR = 1.07, 95% CI = 1.03-1.12, P = 0.001) and cholesterol (OR = 1.06, 95% CI = 1.01-1.12, P = 0.021). Results persisted virtually unchanged when analyses were restricted to participants on SSRI. Conclusions: AD use was associated with greater prevalence and poorer control of traditional risk factors for CV disease in a population-based sample of older adults. Such results highlight the need for surveillance of CV risk factors and promotion of healthy lifestyles in older adults with psychopathology and, in particular, in those under AD treatment.

Mild to moderate chronic kidney disease and functional disability in community-dwelling older adults. The Cardiovascular risk profile in Renal patients of the Italian Health Examination Survey (CARHES) study.

OBJECTIVES: Chronic kidney disease (CKD) negatively impacts aging success. This study evaluates the association between CKD and functional disability, defined as limitations in performing mobility tasks, basic (ADLs) and instrumental activities of daily living (IADLs), in a population-based sample of older adults. In particular, we examined whether such a relationship extended to mild-moderate CKD stages (G1-G3ab). METHODS: Data from the Cardiovascular risk profile in Renal patients of the Italian Health Examination Survey (CARHES) study were used.Prevalence of CKD was estimated by means of urinary albumin to creatinine ratio (ACR) and eGFR (CKD-EPI equation-enzymatic assay of serum creatinine). A validated questionnaire was used to assess functional limitations. Potentially confounding variables, e.g. socio-demographic features, lifestyles, cardiovascular (CV) risk factors and prevalent CV diseases, were considered. RESULTS: 1309 participants, age 71.4 ± 4.3 years, 53.8% men, were studied. 15.2% of participants were identified as having CKD. Of these, 11.5% were aware of the condition. Prevalence of CKD increased with age, and was similar between men and women. Mild-moderate CKD was found to be significantly associated with disability in mobility (OR = 1.05, 95%CI =1.01-1.09, p = .014) and ADLs/IADLs (OR = 1.06, 95%CI = 1.02-1.12, p = .011) after multiple simultaneous adjustment including socio-demographic variables, CV risk profile, ACR, cognitive impairment and self-rated health. CONCLUSIONS: Mild-moderate CKD independently associated with functional disability in a population-based sample of older adults. Evidence-based recommendations for disability prevention in CKD are needed.

Time trends in first hospitalization for heart failure in a community-based population.

BACKGROUND: This study aims to assess time trends in first hospitalization for heart failure (HF) in a community-based population over the period from 1977 to 2014. METHODS: Population-based cohort study using resources from the "Martignacco project" started in 1977 and promoted by the WHO. Three thousand and sixty-six subjects were involved in the project with follow-up through December 2014. Estimates were made for age-specific incidence rates for the first hospitalization for HF by birth cohort, calendar period, and gender. To disentangle the effects of age, calendar period, and birth cohort on the overall temporal trend in HF, we performed an age-period-cohort (APC) analysis. RESULTS: An incident hospitalization for HF was reported for 427 subjects. In the APC model, a cohort effect with a turning point in 1930 was observed. After 1930, a sharp decrease in the rate ratios (RRs) occurred in among both genders. The estimated RR in the 1940 birth cohort decreased to 0.43, (95% CI 0.19-0.92), in men and to 0.45, (95% CI 0.16-1.26), in women. A residual effect of calendar period on RR was observed with a plateau in 1995 for women and in 2000 for men, followed by a decline. CONCLUSIONS: The current findings showed that HF hospitalization incidence has declined over the period considered in subjects over 65 years living in a geographically defined community in Northeast Italy. Moreover, the age of birth, calendar period of diagnosis, and birth cohort play an important role in the incidence of the first hospitalization for HF.

Time Trends of High Blood Pressure Prevalence, Awareness and Control in the Italian General Population : Surveys of the National Institute of Health.

INTRODUCTION: High blood pressure (BP) is a major risk factor for cardiovascular disease. The urgency of the problem was underlined by the World Health Organization (WHO) Global Action Plan for the prevention and control of noncommunicable diseases, which recommends a 25% relative reduction in the prevalence of raised BP by 2020. A surveillance system represents a useful tool to monitor BP in the general population. Since 1980s, the National Institute of Health has conducted several surveys of the adult general population, measuring cardiovascular risk factors by standardized procedures and methods. AIM: To describe mean BP levels and high BP prevalence from 1978 to 2012 by sex and quinquennia of age. METHODS: Data were derived from the following three studies: (i) Risk Factors and Life Expectancy (RIFLE), conducted between 1978 and 2002 in 13 Italian regions (>70,000 persons); (ii) Osservatorio Epidemiologico Cardiovascolare (OEC), conducted between 1998-2002 in the general population from all Italian regions (>9000 persons); and (iii) Osservatorio Epidemiologico Cardiovascolare/Health Examination Survey (OEC/HES), conducted between 2008-2012 in the general population from all Italian regions (>9000 persons). RESULTS: A significant decrease in mean systolic and diastolic BP levels and prevalence of high BP from 1978 to 2012 was observed both in men and women. BP and high BP increased by age classes in all considered periods. BP awareness and control also improved. CONCLUSION: Our data suggest that BP control could be achieved by 2020, as recommended by WHO.

Combined use of short-term and long-term cardiovascular risk scores in primary prevention: an assessment of clinical utility.

AIMS: To evaluate the clinical utility of cardiovascular disease (CVD) risk stratification based on a combined use of short-term and long-term risk scores in the primary prevention setting. METHODS: CVD-free participants 40-65 years old initially to seven population-based cohorts enrolled in northern and central Italy were stratified as 'low' (ESC-SCORE ≤ 1%), 'intermediate' (SCORE 1-4%) and 'moderate/high' short-term CVD risk (SCORE ≥ 4% or diabetes). The long-term CVD risk was estimated using the CAMUNI-MATISS model, validated for the Italian population. Participants were followed up for a median time of 16 years to ascertain the first major CVD event, fatal or nonfatal. To compare the 'combined' (SCORE + CAMUNI-MATISS) with the 'current' (SCORE alone) stratification, we estimated the difference in Net Benefit between the two strategies. RESULTS: Study sample included 3935 men (468 CVD events) and 4393 women (210 events). Under the 'current' stratification, 76% of men and 21% of women were at 'intermediate' risk and eligible to treatment. Only 40% of them had elevated predicted long-term risk and could have received indication to treatment under the 'combined' strategy. The latter would have saved 3 and 3.5 unnecessary treatments per every CVD case in men and women, respectively, and the Net Benefit significantly increased [men: 4.1, 95% confidence interval (CI): 2.7-5.6; women: 4.4, 95% CI: 1.7-6.9].Similarly, among the 74% of women not receiving indication for prevention because at 'low' short-term risk, the 'combined' stratification significantly increased the Net Benefit (1.4, 95% CI: 0.6-2.1) and reduced from 40 to 10% the proportion of events occurring among women not eligible to any preventive action. CONCLUSION: In the Italian population, a combination of validated short-term and long-term CVD risk scores has the potential to select for prevention women whose risk is currently not fully addressed and to reduce unnecessary costly treatment.

Cardiovascular health of the elderly.

Within the Osservatorio Epidemiologico Cardiovascolare/Health Examination Survey 426 men and 376 women, ages 75-79 years, randomly selected from the general population were examined. Participation rate was 50%; within men 78% were hypertensives, 36% had high serum cholesterol, 28% were diabetics, 25% were obese; within women 81% were hypertensives, 55% had high cholesterol, 19% were diabetics, 37% were obese. Preventive actions at individual and community level are urgent, also at this age range.

Simplifying the audit of risk factor recording and control: A report from an international study in 11 countries.

BACKGROUND: To simplify the assessment of the recording and control of coronary heart disease risk factors in different countries and regions. DESIGN: The SUrvey of Risk Factors (SURF) is an international clinical audit. METHODS: Data on consecutive patients with established coronary heart disease from countries in Europe, Asia and the Middle East were collected on a one-page collection sheet or electronically during routine clinic visits. Information on demographics, diagnostic category, risk factors, physical and laboratory measurements, and medications were included and key variables summarized in a Cardiovascular Health Index Score. RESULTS: Coronary heart disease patients (N = 10,186; 29% women) were enrolled from 79 centres in 11 countries. Recording of risk factors varied considerably: smoking was recorded in over 98% of subjects, while about 20% lacked data on laboratory measurements relevant to cardiovascular disease risk. Sixteen per cent of participants reported smoking, 29% were obese, and 46% had abdominal obesity. Sixty per cent of participants had blood pressure <140/90 mmHg (140/80 mmHg for diabetics), 48% had HbA1c<7%, 30% had low-density lipoprotein <1.8 mmol/l and 17% had a good cardiovascular health index score. There were substantial regional variations. Less than 3% of patients attended cardiac rehabilitation in Asia or the Middle East, compared with 45% in Europe. In Asia, 15% of patients had low-density lipoprotein cholesterol <1.8 mmol/l compared with 33% in Europe and 36% in the Middle East. Variations in medications were noted, with lower use of statins in Asia. CONCLUSIONS: SURF proved to be practical in daily practice. Results indicated poor control of risk factors with substantial variation between countries, calling for development and implementation of clinical standards of secondary prevention of coronary heart disease.

[Eating behaviours of italian adults: results of the Osservatorio epidemiologico cardiovascolare/Health Examination Survey]. / Comportamenti alimentari degli italiani: risultati dell'Osservatorio epidemiologico cardiovascolare/Health Examination Survey.

OBJECTIVES: to describe eating behaviours of the Italian adult population collected by the Osservatorio Epidemiologico Cardiovascolare/Health Examination Survey during 2008- 2012. DESIGN: cross-sectional survey conducted in all Italian regions; random samples of the general population, stratified by age and sex, in 23 municipalities, 220 persons every 1.5 million people. SETTING AND PARTICIPANTS: 9,111 persons examined, aged 25-79 years; participation rate of 53%; data of 8,462 persons were used in this analysis. MAIN OUTCOME MEASURES: lifestyles, risk factors, and high risk conditions were measured. Eating behaviours were assessed by the EPIC questionnaire, which includes principal foods, portions, and eating patterns; principal health eating behaviours and nutrients were described by macroareas; sodium and potassium intake were measured also by 24h urine collection; data were compared to the Mediterranean model described in the Sixties nutritional survey carried out in Nicotera, a municipality of Calabria Region, Southern Italy. RESULTS: the eating behaviours are healthy only in a part of the population: 30% have adequate intake of vegetables and fish; only 10% use cakes/sweets/desserts once a week as recommended. Energy intake from saturated fat and sugars are high. Compared to the Sixties Mediterranean model, consumption of cereals, potatoes, and legumes are reduced by half, while meats, cheeses, milk, and in particular sweets are more than doubled. CONCLUSIONS: taking into account the distribution of risk factors and high risk conditions as overweight/obesity, which affects almost 75% of the adult population, physical inactivity (30-40%), hypertension (50%), hypercholesterolemia (35%), and diabetes (7-11%), community actions for improving diet in the population are urgent. Education of the population is also needed to reduce portions and salt intake, and to use less olive oil and wine given their high caloric values, as recommended by the modern Mediterranean diet.

Geographic and socioeconomic variation of sodium and potassium intake in Italy: results from the MINISAL-GIRCSI programme.

OBJECTIVES: To assess geographic and socioeconomic gradients in sodium and potassium intake in Italy. SETTING: Cross-sectional survey in Italy. PARTICIPANTS: 3857 men and women, aged 39-79 years, randomly sampled in 20 regions (as part of a National cardiovascular survey of 8714 men and women). PRIMARY OUTCOME MEASURES: Participants' dietary sodium and potassium intakes were measured by 24 h urinary sodium and potassium excretions. 2 indicators measured socioeconomic status: education and occupation. Bayesian geoadditive models were used to assess spatial and socioeconomic patterns of sodium and potassium intakes accounting for sociodemographic, anthropometric and behavioural confounders. RESULTS: There was a significant north-south pattern of sodium excretion in Italy. Participants living in southern Italy (eg, Calabria, Basilicata and Puglia >180 mmol/24 h) had a significantly higher sodium excretion than elsewhere (eg, Val d'Aosta and Trentino-Alto Adige <140 mmol/24 h; p<0.001). There was a linear association between occupation and sodium excretion (p<0.001). When compared with occupation I (top managerial), occupations III and IV had a 6.5% higher sodium excretion (coefficients: 0.054 (90% credible levels 0.014, 0.093) and 0.064 (0.024, 0.104), respectively). A similar relationship was found between educational attainment and sodium excretion (p<0.0001). When compared with those with a university degree, participants with primary and junior school education had a 5.9% higher urinary sodium (coefficients: 0.074 (0.031, 0.116) and 0.038 (0.001, 0.075), respectively). The socioeconomic gradient explained the spatial variation. Potassium excretion was higher in central regions and in some southern regions. Those in occupation V (low-skill workers) showed a 3% lower potassium excretion compared with those in occupation I. However, the socioeconomic gradient only partially explained the spatial variation. CONCLUSIONS: Salt intake in Italy is significantly higher in less advantaged social groups. This gradient is independent of confounders and explains the geographical variation.