Motivation In Work the Environment

ISSN: 1981-8963 Santos LB dos, Lima WL de, Souza JMO de et al. https://doi.org/10.5205/1981-8963-v12i5a234979p1303-1309-2018 Cardiovascular Risk In Hypertensive Primary… ORIGINAL ARTICLE CARDIOVASCULAR RISK IN HYPERTENSIVE PRIMARY HEALTH CARE USERS RISCO CARDIOVASCULAR EM USUÁRIOS HIPERTENSOS DA ATENÇÃO PRIMÁRIA À SAÚDE RIESGO CARDIOVASCULAR EN USUARIOS HIPERTENSOS DE LA ATENCIÓN PRIMARIA DE SALUD Ludmilla Borges dos Santos1, Wellington Luiz de Lima2, Josiane Maria Oliveira de Souza3, Marcia Cristina da Silva Magro4, Tayse Tâmara da Paixão Duarte5 ABSTRACT Objective: to identify the factors associated with risk for cardiovascular diseases in hypertensive primary health care (PHC) users. Method: quantitative and cross-sectional study conducted with 115 hypertensive users enrolled in a Brazilian primary health center (UBS). Data were recorded in a semi-structured questionnaire. A descriptive and inferential analysis was performed (Student’s t-test and multivariate logistic regression). P values < 0.05 were regarded as significant. Results: there was predominance of women (67.8%), the elderly (> 60 years) (66.1%), continuous users of diuretic drugs (65.2%). By stratifying PHC users according to the risk for cardiovascular diseases, we observed that the majority showed high risk (59.1%), medium risk (26.1%), and low risk (14.8%). Hypertensive patients with diabetes mellitus (DM) (p = 0.000), acute myocardial infarction (AMI) (p = 0.000), congestive heart failure (CHF) (p = 0.000), and those using diuretic drugs (p = 0,001) are associated with an increased risk for cardiovascular events. Motivation In Work the Environment

Conclusion: hypertensive patients with DM, AMI, CHF, and those using diuretic drugs evolved with a greater risk for a cardiovascular event. In this context, there is a need for providing an integrated and preventive care based on prevention not only to minimize the occurrence of complications, but mainly to extend the life of hypertensive PHC users on a qualitative basis. Descriptors: Hypertension; Cardiovascular Diseases; Primary Health Care; Risk Factors; Office Nursing; Delivery of Health Care. RESUMO Objetivo: identificar os fatores associados ao risco de doenças cardiovasculares em usuários da atenção primária à saúde (APS) hipertensos. Método: estudo quantitativo e transversal realizado com 115 usuários hipertensos cadastrados em uma unidade básica de saúde (UBS). Os dados foram registrados em questionário semiestruturado. Realizou-se análise descritiva e inferencial (teste t de Student e regressão logística multivariada). Valores p < 0,05 foram considerados significativos. Resultados: houve predomínio do sexo feminino (67,8%), idosos (> 60 anos) (66,1%), em uso contínuo de diuréticos (65,2%). Ao estratificar os usuários da APS de acordo com o risco para doenças cardiovasculares, observou-se que a maioria apresentou risco elevado (59,1%), risco médio (26,1%) e baixo risco (14,8%). Estão associados ao maior risco de eventos cardiovasculares os hipertensos com diabetes mellitus (DM) (p = 0,000), infarto agudo do miocárdio (IAM) (p = 0,000), insuficiência cardíaca congestiva (ICC) (p = 0,000) e aqueles em uso de diuréticos (p = 0,001). Conclusão: usuários da APS hipertensos com DM, IAM, ICC e em uso de diuréticos evoluíram com maior risco de evento cardiovascular. Nesse contexto, faz-se necessário proporcionar uma assistência integrada e pautada na prevenção não apenas para minimizar a ocorrência de complicações, mas principalmente para prolongar qualitativamente a vida dos usuários da APS hipertensos. Descritores: Hipertensão; Doenças Cardiovasculares; Atenção Primária à Saúde; Fatores de Risco; Consulta de Enfermagem; Assistência à Saúde. RESUMEN Objetivo: identificar los factores asociados con el riesgo de enfermedades cardiovasculares en usuarios de la atención primaria de salud (APS) hipertensos. Método: estudio cuantitativo y transversal realizado con 115 usuarios hipertensos inscritos en un centro de salud primaria (UBS) brasileño. Los datos se registraron en un cuestionario semi-estructurado. Se realizó un análisis descriptivo e inferencial (prueba t de Student y regresión logística multivariable). Los valores p < 0,05 se consideraron significativos. Resultados: hubo predominio de mujeres (67,8%), ancianos (> 60 años) (66,1%), usuarios continuos de diuréticos (65,2%). Al estratificar a usuarios de la APS de acuerdo con el riesgo de enfermedades cardiovasculares, observamos que la mayoría mostraba alto riesgo (59,1%), medio riesgo (26,1%) y bajo riesgo (14,8%). Los pacientes hipertensos con diabetes mellitus (DM) (p = 0,000), infarto agudo de miocardio (IAM) (p = 0,000), insuficiencia cardíaca congestiva (ICC) (p = 0,000) y aquellos que usan diuréticos (p = 0,001) están asociados con un mayor riesgo de eventos cardiovasculares. Conclusión: pacientes hipertensos con DM, IAM, ICC y aquellos que usan diuréticos evolucionaron con un mayor riesgo de evento cardiovascular. En este contexto, existe la necesidad de proporcionar una atención integrada y preventiva basada en la prevención no solo para minimizar la aparición de complicaciones, sino principalmente para extender la vida de los usuarios de la APS hipertensos sobre una base cualitativa. Motivation In Work the Environment

Descriptores: Hipertensión; Enfermedades Cardiovasculares; Atención Primaria de Salud; Factores de Riesgo; Enfermería de Consulta; Prestación de Atención de Salud. 1Nurse, School of Ceilândia, University of Brasília (FCE/UnB). Brasília (DF), Brazil. Email: ludy_lbs@hotmail.com ORCID iD: https://orcid.org/0000-0002-97832174; 2Specialist in Nursing, Centro Universitário Planalto do Distrito Federal (UNIPLAN). Brasília (DF), Brazil. Email: wellingtonporteriras@hotmail.com ORCID iD: https://orcid.org/0000-0002-7023-7244; 3Ph.D., FCE/UnB. Brasília (DF), Brazil. Email: josianemaria@unb.br ORCID iD: https://orcid.org/0000-0002-84002948; 4Ph.D., FCE/UnB. Brasília (DF), Brazil. Email: marciamagro@unb.br ORCID iD: https://orcid.org/0000-0002-4566-3217; 5MS, FCE/UnB. Brasília (DF), Brazil. Email: taysepaixao@unb.br ORCID iD: https://orcid.org/0000-0003-1608-618X English/Portuguese J Nurs UFPE online., Recife, 12(5):1303-9, May., 2018 1303 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i5a234979p1303-1309-2018 Santos LB dos, Lima WL de, Souza JMO de et al. Cardiovascular Risk In Hypertensive Primary… INTRODUCTION Non-communicable chronic diseases (NCDs) show up as the biggest global health problem and they are mainly associated with bad habits, such as smoking, unbalanced eating, sedentary lifestyle, and overweight. In Brazil, 59.5 million people (31.3%) reported having at least 1 chronic disease; out of the total population, 5.9% reported having 3 or more chronic diseases and these percentages increased with age.1 Among the NCDs there are cardiovascular diseases (CVDs), responsible for the leading causes of death in the world. Motivation In Work the Environment

It is highlighted that 1 in 4 deaths is a consequence of CVDs, in addition both systemic arterial hypertension (SAH) and diabetes mellitus (DM) constitute their main risk factors.2-4 In Brazil, the incidence of SAH varies according to age, i.e. it affects 32% of adults, more than 50% of the individuals from 60 to 69 years, and 75% of those older than 70 years of age. According to the Brazilian Primary Health Care Information System (SIAB), in the Brazilian Federal District there are 56,267 hypertensive patients enrolled, out of whom 37,942 are Family Health Strategy (FHS) users.4 SAH is defined as a clinical condition diagnosed in individuals with systolic blood pressure (SBP) greater than or equal to 140 mmHg and diastolic blood pressure (DBP) greater than or equal to 90 mmHg. In order to avoid error in the diagnosis of SAH, it should be verified within the interval of 1 week in 3 different days, since the identification of a high value in only 1 day, even at different times, is not enough for the diagnosis of this disease.5 The Brazilian Society of Cardiology (SBC) recommends the follow-up of primary health care (PHC) users with SAH according to the cardiovascular risk (CVR), which means that in those at high risk the follow-up should be quarterly, semi-annual in those at intermediate risk, and annual in those at low risk, in order to achieve reduction in injuries and, consequently, maintain user safety.5 This study is justified by the need for an expanded follow-up of hypertensive PHC users according to cardiovascular risk, in order to identify factors related to risk stratification for cardiovascular diseases, thus better targeting the real needs of PHC users and aiming to equalize and qualify health care. OBJECTIVE ● To identify the factors associated with risk for cardiovascular diseases in hypertensive PHC users. METHOD Quantitative and cross-sectional study, conducted between March and November 2016, with PHC users with SAH enrolled in a Brazilian primary health center (UBS) in the Brazilian Federal District. PHC users were classified according to the risk for developing cardiovascular diseases established by the Brazilian Guidelines for Hypertension (Table 1).5 Table 1. Risk stratification of hypertensive PHC user according to additional risk factors, presence of target-organ injury, and cardiovascular or renal disease. Motivation In Work the Environment

Ceilândia, 2016. No risk factor 1-2 risk factors ≥ 3 risk factors Presence of TOI, CVD, CKD, or DM SBP 130-139 mmHg or DBP 85-89 mmHg SAH stage 1 SBP 140-159 mmHg or DBP 90-99 mmHg SAH stage 2 SBP 160-179 mmHg or DBP 100-109 mmHg SAH stage 3 SBP ≥ 180 mmHg or DBP ≥ 110 mmHg No additional risk Low risk Moderate risk High risk Low risk Moderate risk High risk Moderate risk High risk High risk High risk High risk High risk High risk High risk High risk CVD = cardiovascular disease; CKD = chronic kidney disease; DM = diabetes mellito; TOI = target-organ injury. Source: Malachias et al. (2016).5 The convenience study sample, consisting of 115 PHC users, considering the following inclusion criteria: medical diagnosis of SAH and users enrolled in the UBS during the data collection period. We excluded children and PHC users who had an isolated diagnosis of DM. Data collection was based on the application of a questionnaire containing English/Portuguese J Nurs UFPE online., Recife, 12(5):1303-9, May., 2018 anthropometric measurements, sociodemographic variables, and clinical data needed to stratify the risk for cardiovascular diseases, applied during the office nursing appointment previously scheduled, with an average length of 30 minutes. The anthropometric measurements included weight, height, and waist circumference (WC) and the body mass index 1304 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i5a234979p1303-1309-2018 Santos LB dos, Lima WL de, Souza JMO de et al. Cardiovascular Risk In Hypertensive Primary… (BMI) (kg/m²) was also calculated.6 To measure weight, we asked people to take their shoes off, as well as accessories that could interfere with the final value of weight. Therefore, a transparent tempered glass digital scale (Magna 150 kg Ng – G-Life) was used. Those with BMI from 30 to 34.9 kg/m2 were classified as obese grade I, grade II ranged from 35 to 39.9 kg/m2, and grade III was ≥ 40 kg/m2. WC was determined using a measuring tape in centimeters, positioned at the midpoint between the last rib and the iliac crest at the end of expiration. Women with values ≥ 88 cm and men with values ≥ 102 cm were considered at high risk for cardiovascular events.6 SBP was measured with an aneroid pressure device having a nylon brace with Velcro fastener (Premium brand), where the individual sits after a 5-minute rest period. Blood pressure with systolic values < 90 or > 140 mmHg and diastolic values < 60 or > 100 mmHg were considered altered.5 Fasting or postprandial glycemia was checked using the device and its respective Accu-Chek strips, model Active, and G-Tech brand lancets. According to the Brazilian Society of Diabetes (SBD), fasting users with postprandial glycemia ≥ 126 mg/dL or ≥ 200 mg/dL are regarded as diabetic and they do not require collection of glycated 7 hemoglobin. For data analysis, descriptive statistics was employed, represented by absolute and relative frequency, and multivariate logistic regression and Student’s t-test were used to verify the associations between categorical variables. P values < 0.05 were accepted as statistically significant. Study approved by the Research Ethics Committee of the Health Sciences Teaching and Research Foundation (FEPECS) of the State Department of Health of the Brazilian Federal District (SES/DF), under the Brazilian Certificate of Submission for Ethical Assessment (CAAE) no. 51577815.4.0000.5553. All PHC users included in the research have signed the free and informed consent form. RESULTS This study included 115 PHC users diagnosed with SAH, with predominance of women (67.8%), the elderly (> 60 years) (66.1%), and continuous users of diuretic drugs (65.2%). On the other hand, there was lower incidence of diabetic patients (32.2%), smokers (9.6%), and sedentary individuals (34.8%), in addition to PHC users with established cardiac impairment, such as previous acute myocardial infarction (AMI) (9.6%) and congestive heart failure (CHF) (8.7%). By stratifying PHC users according to cardiovascular risk, we observed that the majority had a high risk for cardiovascular diseases (59.1%), according to Table 2. Table 2. Risk stratification of hypertensive patients based on the Brazilian Arterial Hypertension Guideline. Ceilândia, 2016. Cardiovascular risk Low Medium High Source: Prepared by the authors. Among those individuals at a high cardiovascular risk there was predominance of smokers (72.7%), overweight (65.5%), N 17 30 68 % 14.8 26.1 59.1 dyslipidemia (66.7%), and altered postprandial glycemia (62.5%) (Table 3). Table 3. Risk distribution for cardiovascular diseases according to several clinical factors. Ceilândia, 2016. Variables Sex Age Male Female Up to 59 60+ Diuretic drugs Family history of heart disease Diabetes mellitus Smoking Alcoholism Sedentary lifestyle Overweight AMI English/Portuguese J Nurs UFPE online., Recife, 12(5):1303-9, May., 2018 Risk for Low N % 4 10.8 13 16.7 8 20.5 9 11.8 8 10.7 8 9.4 0 0.0 1 9.1 3 20.0 7 17.5 7 12.1 0 0.0 cardiovascular Medium N % 11 29.7 19 24.4 9 23.1 21 27.6 26 34.7 21 24.7 0 0.0 2 18.2 5 33.3 11 27.5 13 22.4 0 0.0 diseases High N % 22 59.5 46 59.0 22 56.4 46 60.5 41 54.7 56 65.9 37 100.0 8 72.7 7 46.7 22 55.0 38 65.5 11 100.0 1305 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i5a234979p1303-1309-2018 Santos LB dos, Lima WL de, Souza JMO de et al. Cardiovascular Risk In Hypertensive Primary… CHF Dyslipidemia Altered postprandial glycemia 0 5 12 0.0 16.7 24.0 0 5 15 0.0 16.7 30.0 10 20 23 100.0 66.7 46.0 AMI = acute myocardial infarction; CHF = congestive heart failure. Source: Prepared by the authors. By investigating the medicines in continuous use among hypertensive PHC users with high risk for cardiovascular diseases, the use of angiotensin receptor antagonists has been at a higher frequency (63,8%) (Table 4). Table 4. Medicines used by hypertensive patients. Ceilândia, 2016. Variables Low Diuretic drugs Betablockers Inhibitors of angiotensin converting enzyme Calcium channel blockers Angiotensin receptor antagonist N 8 7 2 % 10.7 21.2 7.1 3 8 11.5 13.8 Cardiovascular risk Medium N % 26 34.7 7 21.2 12 42.9 8 13 30.8 22.4 High N 41 19 14 % 54.7 57.6 50.0 15 37 57.7 63.8 Source: Prepared by the authors. Considering that different variables are related and determine a higher cardiovascular risk. a multivariate analysis was performed and DM (p = 0.000), AMI (p = 0.000), CHF (0.000) and the use of diuretic drugs (p = 0.001) were identified as risk factors (Table 5). Table 5. Factors associated with increased risk for cardiovascular diseases. Motivation In Work the Environment

Ceilândia, 2016. Variable Diabetes mellitus AMI CHF Use of diuretic drugs OR 3,66 2,50 1,64 13,50 P value 0,000 0,000 0,000 0,001 Odds ratio = obtained by multivariate logistic regression; p value = calculated by multivariate logistic regression; AMI = acute myocardial infarction; CHF = congestive heart failure. Source: Prepared by the authors. DISCUSSION Cardiovascular events often originate from SAH, which in turn, when untreated, favors the development of several other complications, aggravating the health status of an individual. In this regard, these complications are represented by genetic or behavioral factors or by lifestyle, age, DM, AMI, CHF, stroke, and kidney diseases.8-10 Scientific evidence, just as in our study, showed an association between women and the elderly with SAH and cardiovascular events.11-2 The predominance of women with hypertensive origin of cardiovascular risk may be associated, on the one hand, with the fact that a woman has a longer survival and, on the other hand, with a strong association between blood pressure and menopause. It is known that the lower production of female hormones, such as estrogen, decreases protection, thus causing an increase in blood pressure levels, and this predisposes to NCDs.13-5 The high incidence of PHC users at high risk for cardiovascular diseases due to overweight is usually related to increase in both cardiac output and peripheral resistance, something English/Portuguese J Nurs UFPE online., Recife, 12(5):1303-9, May., 2018 which determines vasoconstriction and myocardial overload. Thus, maintaining adequate weight is indispensable for reducing and preventing complications. Sedentary lifestyle is directly related to weight gain. A finding of this study was the fact that 55% of the PHC users at high cardiovascular risk did not had the habit of practicing physical activities. Modifiable risks such as these may be prevented resorting to changes in habits and lifestyle, such as adequate eating and regular physical activities.1,11,14 It is believed, according to the Brazilian Guidelines for Hypertension, that the primary objective of treating SAH is the reduction of cardiovascular morbidity and mortality rates. Thus, the medicines used serve not only to reduce blood pressure, but also to minimize or prevent fatal and non-fatal cardiovascular events. In this study, the diuretic drugs (p = 0.001) stood out among the medicines adopted to control SBP, because their effect is related with the ability to decrease extracellular volume and, consequently, peripheral vascular resistance. Above all, their efficacy has been proven in studies where the results showed a decrease in 1306 ISSN: 1981-8963 Santos LB dos, Lima WL de, Souza JMO de et al. morbidity and mortality due to cardiac events.5,16-9 There was a high incidence of users with SAH combined to DM. The SBC highlights that this association poses a high risk for the development of cardiovascular diseases, a factor that contributes to justify the high rate of PHC users with this stratification in this study. Motivation In Work the Environment

DM consists of endocrine and metabolic changes that trigger insulin resistance. It is noteworthy that AMI, stroke, and kidney diseases are common complications due to DM, making it a major risk factor that can lead to various complications.5,20-1 We also have dyslipidemia in relation to the comorbidities associated with an increased risk for cardiovascular events. Uncontrolled lipid production causes serious problems, such as blood vessel obstruction. Although in this study the results do not show significant statistical difference, the high percentage of dyslipidemia among those at a high risk for CVD stands out. By means of scientific evidence, an association between lipid abnormalities and the occurrence of AMI has been observed.22-3 The association between the risk factors listed has a cumulative effect and this contributes to a higher risk for cardiovascular events, therefore, … Motivation In Work the Environment