Cardiovascular Risk Stratification of Hypertensive Patients in the Community Setting

Introduction

The new paradigms seek the interpenetration of technical knowledge of diagnosis and treatment with a biopsychosocial view of the disease, for this reason, perfecting the educational teaching process implies the continuous improvement of the training of health professionals, preferably in primary health care meaning at the level of the family doctor’s office and the polyclinics. Patient care in primary health care requires the professionalization of the specialist-teacher, which translates into improving performance in this scenario, in which patient and family education is very important, beyond therapy pharmacological. The doctor who works in primary health care; represents a complex and multifaceted professional who must have as a fundamental objective in his training a great social commitment, expressed in humanism and the transformation of the health of the individual and the population [1- 3]. Cuban medicine currently advocates preventive health from the community, so the Specialist in Comprehensive General Medicine must be a faithful follower of the principle of permanent and continuous training [4]. This physician at each historical moment has had to face scientific and social challenges, currently the group of cardiovascular diseases expresses a high rate of morbidity and mortality and specifically arterial hypertension.

This disease is considered the main risk factor for death worldwide, it is recognized as the cause of myocardial infarction, stroke, kidney failure, blindness, peripheral vascular disease and heart failure. This risk is increased if the disease coexists with others, especially diabetes [5]. As it is logical to think, cardiovascular risk refers to danger to life, and includes a wide range of consequences, which go beyond the biological, involving economic, environmental, political, and cultural aspects, and which are generally expressed in the society. Once the cardiovascular risk factors and the modifications that must be made to prevent cardiovascular disease with each factor in isolation are known, a global risk assessment can be carried out on patients. It is important to know that for a correct grading of risk, stratification systems arise and allow the calculation of the absolute risk of having a cardiovascular event in the following 10 years [6]. In relation to the foregoing, the National Program for the Care of Noncommunicable Diseases and the Cuban Guide to Hypertension have a social commitment to individually stratify cardiovascular risk in hypertensive patients, which reflects the need for permanent preparation. and continuous of the specialist in Comprehensive General Medicine. Therefore, we feel motivated to carry out this mini review with the aim of characterizing the cardiovascular risk stratification process of hypertensive patients in the community context.

Developing

The current world panorama is characterized by the increase in the number of people suffering from chronic non-communicable diseases, the re-emergence of communicable diseases, lack of protection, marginalization and social risk in areas belonging to the industrialized world. Arterial hypertension and cardiovascular risk. The definition of high blood pressure has become a global health problem, it is estimated that 1 billion people suffer from it. It is a direct cause of disability and death; and represents the most important modifiable risk factor for coronary heart disease (the leading cause of death in the Western Hemisphere), cerebrovascular disease, congestive heart failure, end-stage renal disease, and peripheral vascular disease. Cuba in the existing context maintains a large part of its population obese, smoker and with a tendency to metabolic syndrome; this means that 63.3% of deaths from heart disease occur due to ischemic heart disease, of which 45.2% are due to acute myocardial infarction. In 2017, Santiago de Cuba presented a prevalence of 195.6 hypertensives per 1,000 inhabitants, and after one year a prevalence of 208.3 per 1,000 inhabitants is reported. The need to reduce morbidity and mortality due to cardiovascular and cerebrovascular diseases is the main reason to approach the problem of controlling arterial hypertension from a more comprehensive point of view and not only focused on blood pressure figures as the main variable for decide the need and type of treatment. This approach is especially based on the proven success of preventive aspects in reducing mortality from coronary heart disease in Western European countries, Canada, and the United States. When they coexist, arterial hypertension and other cardiovascular risk factors can potentiate each other, resulting in a total cardiovascular risk greater than the sum of its individual components. In Cuba there are no large cohort studies whose final objective is the evaluation of the influence of a certain risk factor on cardiovascular mortality. Given this limitation, it is proposed to use a modification of the Framinhgan, World Health Organization and Systematic Coronary Risk Evaluation models, in which total cardiovascular risk is stratified into different categories based on blood pressure, cardiovascular risk factors, damage asymptomatic organ or target organ injury and the presence or absence of diabetes mellitus, and total cardiovascular risk is classified as low, moderate, and high.

Cardiovascular risk stratification should be performed in all hypertensive patients in the initial evaluation, to decide the type and intensity of the therapeutic strategy to be used [7]. It constitutes a useful tool for the family doctor in terms of establishing priorities in primary care. Reasonably, the adequate stratification of cardiovascular risk must become a daily practical task in the family doctor’s offices [8]. Consequently, the professionalization of Specialists in Comprehensive General Medicine must be carried out to respond to current health demands that reveal the need for a properly professionalized comprehensive general practitioner, with excellent performance. Añorga J [9], reflects on professionalization, and considers that it is a process that reaches its fullness in Advanced Education [10]. In this context, Valcárcel N., states that the Cuban school requires “... something more than people trained for the specific function of the world of work, it needs human resources... with motivations and capacities for creative and independent activity, both in carrying out work and in research”. Sánchez M [11], defined that through professionalization in Hygiene and Epidemiology; as the process developed by a subject through the social, economic, cultural and ecological relationships that are established in the application of the epidemiological method for the fulfillment of their work, in correspondence with the demands of the context; which is achieved from permanent and continuous preparation, aimed at updating and strengthening professional skills; which leads to developing professionalization with a creative and innovative character, transforming reality in a positive sense, with personal, professional, socioeconomic, ecological and human satisfaction of the demands of the profession in accordance with the development of society, of course [12-17].

The doctor must be endowed not only with knowledge and skills, but also with ethical values and human sensitivity to treat the patient. Today it becomes a necessity that the sciences of Medical Education structure their training model in the integration of the pedagogical model of higher education with the health model, structured on the strategy of Primary Health Care, with the purpose of face the challenges of contemporary society and fulfill the historical social, economic and health commitment to contribute to solving health problems in the context, with a marked humanistic, equity, justice and solidarity approach. The conceptualization of Cuban Comprehensive General Medicine is a legitimate fruit of the historical development of medicine in Cuba, which had its most remote antecedents two centuries ago, but which has reached its maximum expression in the National Health System in the revolutionary stage. In the specialty training program, the comprehensive general practitioner was defined as “a specialist with a broad profile capable of guaranteeing care for the assigned population without distinction of age or gender, with an integrating approach to biological, social, psychological and environmental, with actions of promotion, prevention, diagnosis, treatment and rehabilitation”. It is well known that the best doctor is not only the one who knows the most, he is the one who is provided with a solid scientific knowledge harmoniously balanced with the practice of the art, the only path that can lead him to know, through empathy and sensitivity, the patient’s history, his thoughts, his feelings and sufferings, in order to discover what he really needs [18-25].

Conclusion

The process of cardiovascular risk stratification of hypertensive patients in the community context requires the professionalization of the Comprehensive General Medicine specialist and the basic health team; since the majority of patients suffering from high blood pressure are diagnosed and followed up at the community level. Therefore, the family doctor is the main actor for the stratification of cardiovascular risk, who, professionalized in an appropriate way, can successfully perform his four basic functions (comprehensive, educational, investigative and managerial care) defined in primary health care.

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