Manuel Delfín Pérez Caballero, MD1;
Liliam Cordiés Jackson, MD2;
Alfredo Vázquez Vigoa, MD3
Due to its significance, consequences and high incidence, hypertension is a health problem in most countries of the
world, including Cuba. The Cuban National Health System has given special attention to this problem. In the last few decades, after successful achievements in the control and eradication of a large number of
infectious diseases in Cuba, through vaccination drives and prevention work, as well as in the reduction of infant and maternal mortality rates, through special maternal and child care programs, emphasis has been made on
the control and management of non-communicable chronic diseases. Cuba's more than 28,000 family doctor-and-nurse teams have played a crucial role in this development.
Studies carried out in different municipalities across the country since the beginning of the 1980s, reveal that 30% of the population in urban areas suffer from hypertension, while there's a lower incidence of this
disease (15%) in rural areas. Our definition of arterial hypertension includes people over 15 years of age with a blood pressure of greater than 140/90 mmHg. In Cuba, a country with 11 million
inhabitants (70% of whom live in urban areas) there are approximately 2 million hypertensives. Our study shows that arterial hypertension is more frequent in people of African descent (blacks) (38.2%) than in whites
(25.6%), although these figures are not exact since race differentiation in Cuba is not always clear. (1) Studies on the incidence of hypertension in Cuba have also been
conducted. However, this type of study proves a difficult task due to the fact that in many cases hypertension is asymptomatic for many years. Dueñas and cols. (2) have reported an annual incidence of 2.5 in
the 10 de Octubre Municipality, in Havana. In Cienfuegos Province, located in Cuba's central region, an interesting program for the control and management of non-communicable chronic diseases, the Proyecto Global Cienfuegos
, has been in place since 1995. As a result of this program, the prevalence of arterial hypertension in the province's population studied has decreased from 43.9% to 38.5%. According to the
Word Health Organization (WHO), a two percent reduction in average arterial pressure of a given population results in a 6% reduction in the annual mortality rate from cerebrovascular accidents, and a 4%
in that of patients with heart disease. Accordingly, the achievements in Cienfuegos could mean a reduction by 9% in the mortality rate from cerebrovascular accidents and by 6% from heart disease in general. (3-4)
In 1997, 10% of the Cuban adult population (862,302 patients) had been diagnosed and evaluated by family doctors using continuous assessment and risk evaluation
(CARE), which is used to evaluate risk factors and patient condition on an ongoing basis. (5) By the end of that year, the Cuban National Program for the Control and Management of
Hypertension (HTA) was modified, and a national training campaign launched, aimed at better control and management of hypertension at the primary care level. The Cuban press
and mass media, as well as neighborhood social organizations actively participated in this campaign. Nine months later, a first evaluation of the campaign was carried out. Results showed that
the number of patients diagnosed had reached 1,085,595 (12.5% of the adult population), which represents a 25% increase in the number of patients diagnosed and under treatment in
the HTA program. (6,7) A second evaluation of the campaign showed that the number of patients under treatment in the HTA program had markedly increased in some provinces. In
Matanzas province, 22.3% of the adult population (from both urban and rural areas) were diagnosed and incorporated into the HTA program, 47% of whose blood pressure is now
under control (systolic pressure below 140 mm Hg and diastolic pressure below 90 mm Hg). (8) Studies by Professor Ignacio Macías Castro, MD, a pioneer in epidemiological research on
hypertension in Cuba, show that 65% of patients with arterial hypertension are mild hypertensives (according to the classification suggested by the 5th Report of the Joint
National Committee for the Detection, Assessment and Treatment of Hypertension), 25% are moderate hypertensives, and 10% severe hypertensives. (1)
Cuba was one of the countries chosen by the World Health Organization (WHO) to participate in the INTERHEALTH intervention study on health problems. In the 1990-95
period, significant results were obtained with direct participation by primary care professionals and supervision by the multidisciplinary hypertension study team from the Hermanos Ameijeiras Hospital.
Surveys carried out after five years show a significant reduction in the prevalence of hypertension, from 30.5% to 26.5%. And average blood pressure values for the population
under study also decreased from 126.5/83.8 mm Hg to 123/81 mm Hg. Furthermore, between 1990 and 1993, mortality from cerebrovascular accidents decreased from 9 to 7,
and from heart disease in general, from 26.5 to 21.2 per 100,000 inhabitants, in the INTERHEALTH population under study. (9) A three-year study on hospital mortality (11) carried out in a Havana hospital with an over
97% autopsy rate. Based on autopsy results of patients from the Internal Medicine Wards and Intensive Care Units, and applying criteria of multiple causes of death, the study
revealed that hypertension was directly linked to 37.06% of all deaths during that period. Another epidemiological feature of arterial hypertension in Cuba is that 11% of hypertensives
have purely systolic hypertension and 12.5% suffer from the so-called predominantly systolic hypertension, calculated by the formula Systolic Pressure>2 (Diastolic Pressure-15). (1)
Worldwide, 92-95% of patients with hypertension are diagnosed with primary (or essential) hypertension. Sinclair (1) has reported 92.1% in Scotland and Wilhelmen and Bergland (13)
94.2% in Sweden. In Cuba, Dr. Macías and colleagues studied 1,000 patients hospitalized with hypertension at the Salvador Allende Hospital in Havana, and found that 91.3% of them
suffered from essential hypertension, with only 8.7% showing secondary hypertension, of which 8.3% was related to renal disorders (renovascular and parenchymal). (14)
In recent years, with 98% the Cuban population receiving attention from the family doctor-and-nurse teams at the community level, there has been significant improvement in the
control and management of non-communicable chronic diseases, the HTA Program a fundamental pillar in this regard. In 1991, Alfredo Dueñas, MD, carried out a study in the 10 de Octubre
municipality of Havana on the control and management of hypertension at the community level, obtaining the following data:
The Cuban National Survey on Cardiovascular Risk Factors (15), carried out in 1996 with the support of family doctor-and-nurse teams in selected populations and the Ministry of
Public Health, showed that 60.8% of the hypertensives surveyed were aware of their condition, 75% of these were under treatment (12.3% with non-pharmacological
intervention, change in lifestyles, and 42.2% with a combination of pharmacological and non-pharmacological treatment). This survey revealed that 45.2% of hypertensives under
treatment had brought their blood pressure under control (below 140/90). Results from the new Cuban National Program for the Control and Management of
Hypertension are encouraging, and in the coming years, it is expected that increased knowledge and HTA control will help to further reduce morbidity and mortality rates from
heart and vascular disease in Cuba.
References
1. Macías I. Epidemiología de la hipertensión arterial. Acta Médica del Hospital Hermanos Ameijeiras, 1977,7(1)15-24.
2. Dueñas H.A. Reports of the Epidemiology Department. Cuban Institute of Cardiology and Cardiovascular Surgery. Havana. Cuban Ministry of Public Health, 1991.
3. Cuban National Program for the Prevention, Diagnosis, Evaluation and Control of Hypertension. Cuban Ministry of Public Health, 1998.
4. Vázquez L.E., Espinosa A. Marcadores de riesgo en enfermedades crónicas no transmisibles. Second Edition. Proyecto Global de Cienfuegos, 1994-1995. Dissertation for the degree of specialist. Cienfuegos, 1997.
5. Cuban Yearbook of Statistics. Cuban Ministry of Public Health. 1997.
6. Cuban Yearbook of Statistics. Cuban Ministry of Public Health. 1998.
7. Cuba. Assessment of the National Training Campaign for the Control and management of Hypertension. Havana, 1998.
8. Evaluation of the Cuban National Program for the Control and Management of Hypertension . Workshop. Matanzas Province, 1999.
9. INTERHEALTH: Last Report. 1997. Montreal, Canada.
10. Payá O, Macias I. Criterios de la mortalidad por hipertensión arterial. Rev Cub Med. 1998;27-8:47-63.
11. Aguilar V, Cordiés L. La hipertensión arterial como causa de muerte. Dissertation for the degree of specialist. 1995.
12. Sinclair H M. Secondary Hypertension in a Blood Pressure Clinic. Arch Interm Med; 1987;147:1289-93.
13. Wilhelmsen L, Bergland C. Prevalence of Primary and Secondary Hypertension. Am Heart J. 1997;94:543-48.
14. Macias I. Resultados del estudio de mil pacientes con diagnósticos de hipertensión arterial ingresados en la sala Lidia Doce del Hospital Salvador Allende. Rev Cub Med. 1980;19:247-57.
15. Bonet M. Results of the First Cuban National Survey on Risk Factors. Second Cuban National Workshop on Arterial Hypertension. December 1997. Havana. Cuba.
This article originally appeared in Spanish in the Revista Archivos Dominicanos de Hipertensión, Año II, No. 1 y 2, 1998(19-20), revised and updated for publication by MEDICC Review by the author.
