Avaliação do risco cardiovascular em hipertensos e diabéticos adscritos a uma equipe de saúde da família em Montes Claros/MG: proposta de intervenção

Abstract

Montes Claros is a city with about 400 thousand inhabitants, in development, with a complex health care system, presenting approximately 130 Family Health Teams (ESFs) and hospitals. The ESF Village three / Novo Jaraguá presents a wide area of coverage, limited by problems arising from the low socioeconomic level of its population. Among these, the high index of hypertensive and diabetic patients without adequate control of their comorbidities and cardiovascular risk classification is of importance. The situational analysis of the territory assigned to ESF Village three / Novo Jaraguá made it possible to identify several problems, prioritizing for this work the adequate monitoring of diabetic and hypertensive patients and cardiovascular risk classification. The follow-up of patients with diabetes mellitus (DM) and systemic arterial hypertension (HBP) is extremely necessary in reducing complications from these diseases, as well as their costs for the public health system. In addition, classifying patients according to cardiovascular risk allows real recognition and prioritization of those who need more regular follow-up with shorter time, priority attendance with specialists, in addition to the main effect of disease prevention. The objective of this work is to elaborate an intervention plan for the stratification of the cardiovascular risk of patients with DM and SAH, through the Framingham score, for improvements in their health. Patients with DM and SAH were surveyed in an area assigned to ESF Village three / Novo Jaraguá, with spreadsheets and cardiovascular risk assessment (Framingham score), with further medical and nursing care in accordance with the Strategic Situational Planning (PES).. Also, training was developed for the team, with multiplier knowledge trends and to organize the work process. A literature review was carried out in the Scientific Library on Line (SciELO) and in the Virtual Health Library.