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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234

Rev. esc. enferm. USP vol.46 no.2 São Paulo Apr. 2012 



Cardiovascular risk among health professionals working in pre-hospital care services*


Riesgo cardiovascular en profesionales de salud de servicios de atención prehospitalaria



Luciane CavagioniI; Angela Maria Geraldo PierinII

IRN. Ph.D. In Nursing, Graduate Program in Adult Health Nursing, University of São Paulo. São Paulo, SP, Brazil.
IIFull Professor, Medical-Surgical Nursing Department, University of São Paulo School of Nursing. São Paulo, SP,

Correspondence addressed




The objective of this study was to assess the cardiovascular risk factors among health professionals, particularly hypertension, and stratify them according to the Framingham Risk Score (FRS). The participants were 154 professionals working in pre-hospital care in São Paulo, Brazil, and on the Br-116 highway. Values were considered significant for p<0.05. The prevalence of hypertension was 33%, 20.1% were smokers, 47% consumed alcoholic beverages, 64% were sedentary, 66% were obese/overweight and 70% had an altered abdominal circumference. In terms of laboratory values: glucose>110mg/dL- 11%, total cholesterol >200mg/dL- 36%, LDL-c >130mg/dL- 33%, HDL-c<60mg/dL- 89%, triglycerides>150mg/dL- 30% and C reactive protein>0.5mg/dL- 16%. The FRS was average in 10.3% and high in 1.3%. In logistic regression analysis, it was verified that hypertension was associated with: HDL-c (odds ratio: 0.257,) and FRS (odds ratio: 23.159). There was strong correlation between hypertension and FRS. Data are noteworthy, as this is a relatively young sample of health professionals.

Descriptors: Hypertension; Risk factors; Health personnel


Evaluar los factores de riesgo cardiovascular con énfasis en hipertensión y estratificarlos de acuerdo a Score de Riesgo de Framingham (ERF). Estudio con 154 profesionales con actuación en atención prehospitalaria en ciudad de São Paulo y ruta Br-116. Se consideró significativo el valor p<0,05. La prevalencia de hipertensión fue 33%, 20,1% eran fumadores, 47% ingería bebidas alcohólicas, 64% sedentarios, 66% con obesidad/sobrepeso, 70% con cintura abdominal alterada, glucemia > 110mg/dl-11%, colesterol total >200mg/dl-30%, LDL-c >130mg/dl-33%, HDL-c <60mg/dl-89%, triglicéridos >150mg/dl-30% y proteína C reactiva >0,5mg/dl-16%. El ERF fue medio en 10,3% y alto en 1,3%. En análisis de regresión logística se verificó que la hipertensión se asociaba a las variables: HDL-c (odds ratio: 0,257), y ERF (odds ratio: 23,159). Hubo fuerte asociación entre ERF e hipertensión. Los datos llaman la atención por tratarse principalmente de profesionales del área de la salud relativamente jóvenes.

Descriptores: Hipertensión; Factores de riesgo; Personal de salud




According to the World Health Organization, cardiovascular illnesses are responsible for approximately 30% of deaths around the world. In developed countries, 80% of deaths can be attributed to cardiovascular illnesses(1). The etiology of these diseases involves multiple factors, deriving from inadequate habits and lifestyles, such as smoking, alcohol intake, physical and mental stress, obesity and sedentariness. These lifestyles contribute to the development of atherosclerosis and arterial hypertension, which are factors responsible for the development of cardiovascular diseases. Ministry of Health data reveal that cardiovascular illnesses were the main mortality causes in 2007, corresponding to 30% of deaths(2). Due to its high prevalence, chronicity, low control and high socio-financial cost, arterial hypertension stands out among cardiovascular risk factors. It is estimated that about one billion people are hypertensive around the world. This condition is responsible for approximately 7.1 million deaths per year(3).

In recent decades, other emerging risk factors were overweight/obesity and sedentariness. Health authorities and experts consider overweight and sedentariness a pandemic, with a positive correlation between overweight, sedentariness and high arterial hypertension prevalence rates. In line with this view, the Framingham study revealed that 70% of new arterial hypertension cases were directly related with overweight(4).

In the current cardiovascular prevention context, a person should not only be characterized as hypertensive, hyperlipidemic, obese or diabetic. His/her total cardiovascular risk factor should also be determined. One of the studies that most contributed to this new total cardiovascular risk view was the Framingham study. After its termination, a score was elaborated that estimates cardiovascular risk, adding up clinical characteristics, allowing health professionals to make the best therapeutic decision and, together with the patient, to elaborate preventive interventions according to the total cardiovascular risk factor found and primary prevention of cardiovascular illnesses(5).

Pre-hospital care professionals can be subject to cardiovascular risk factors due to their lifestyle and specific characteristics of their occupation. No known records about cardiovascular risk among these professionals exist in the Brazilian context. Therefore, this study aimed to: assess cardiovascular risk factors, particularly arterial hypertension, and rank them according to the Framingham Risk Score (FRS).



A cross-sectional study was developed, involving 154 health professional who worked at the following pre-hospital care services: Medical Urgency Care Service–192 (SAMU-192) and Emergency Care Group-193 (GRAU-193), both in São Paulo City, Brazil, and attending the four regions of the city (North, South, East and West) and SAMU - Vale do Ribeira-SP, located on the BR-116 highway. The sample size was calculated for a dichotomous variable in a descriptive study, in which the proportion of expected cases corresponded to 20%, with a 0.10 confidence interval (0.5 above and 0.5 below) and a 99% confidence interval, resulting in a minimum sample of 130 participants. The inclusion criteria were: being a health professional, working directly in care delivery to victims and having at least three months of professional experience in pre-hospital care. Professionals were randomly invited to participate in the study, through telephone contact, e-mail or personally at their workstations. All of them signed the Informed Consent Term. Approval for the project was obtained from the Institutional Review Board at the University of São Paulo School of Nursing, under No 742/2008.

Blood pressure was measured at the participants' workplace, using a validated automatic device (OMROM HEM 705CP), in line with the orientations of the VI Brazilian Hypertension Guidelines(6), which recommend: three measurements; after 5 minutes of rest; sitting position; back rested and legs uncrossed; use of adequate cuff size and length for arm size; empty bladder; no smoking and/or alcohol, coffee and food intake for at least 30 minutes. For statistical analysis, the mean result of the last two verifications was considered. Participants were classified as hypertensive if systolic pressure was > 140 mmHg and/or diastolic pressure > 90 mmHg or if they indicated the use of hypertensive medication.

Participants received a self-applied questionnaire that addressed the following socioeconomic variables: age (in years); professional category (physician, nurse and nursing auxiliary); smoking (any number of cigarettes/day and people who quite less than one year earlier); alcohol consumption (anyone who indicated alcohol use, independently of type and quantity); physical exercise (at least 30 minutes of activity, in a continuous or accumulated form, three or more times per week, was considered normal); time since graduation; weekly work load and current medication use.

Weight (in kilograms) and height (in meters) were determined using mechanical anthropometric scales, permitting the calculation of the Body Mass Index (weight/height2), classified as follows according to World Health Organization (WHO) criteria: healthy (<25 kg/m2), overweight (25 to 29.9 kg/m2) and obese (> 30 kg/m2)(7). The waist circumference was determined at the midpoint between the iliac crest and the lower rib, using a non-elastic metric tape adjusted to the body, classified according to WHO criteria (for men: <94 cm, normal; >94 cm, increased risk; and >102 cm, strongly increased risk. For women, circumferences were classified as: <80 cm, normal; >80 cm, increased risk; and > 88 cm, strongly increased risk).

For laboratory test collection, the vacutainer system was used. Blood was collected from the antecubital veins, after 12 hours of fasting, and immediately forwarded to the laboratory. After receiving the laboratory results, participants were classified according to their lipid profile, glucose and C-reactive protein (in quartiles).

Based on the Framingham risk score, each individual's global cardiovascular risk was calculated. In its analysis, the Framingham risk score includes the following risk factors: age, total cholesterol, HDL-c, blood pressure, diabetes and smoking, with specific scores for each item(8). Adding up the scores provided each individual's global score, distinguished as follows: low risk < 10%; intermediate risk, higher than 10% but lower than 20%; and high risk > 20%.

For statistical analysis, Statistical Package for Social Sciences (SPSS) software version 7.5 was used. Descriptive hierarchical variables are presented as absolute (n) and relative (%) frequencies and continuous data as means and standard deviations. Chi-square and Fisher's exact test were used when pertinent. Statistical significance was set at p<0.05. Variables showing significance in univariate analysis were submitted to logistic regression.



The assessment considered 154 professionals. Little more than half of the sample referred to nurses (59%), followed by physicians (26%) and nursing auxiliaries (15%). The female gender (60% vs. 40%) and young adults (40.9 ± 7.8 years) were predominant. High levels of family members with hypertension were found (82.5%) and only 20.1% mentioned personal antecedents. Regarding life habits, one fifth informed smoking, but alcohol consumption levels were much higher (47.5%). The same was true for the lack of regular physical exercise (65%). As for professional characteristics, little less than half (43.5%) worked more than 60 hours per week, and a similar percentage (45%) indicated sleeping during the day while at work in pre-hospital care. The majority had graduated two decades earlier (74%), had worked at the service for up to 10 years (70%) and more than half mentioned working while feeling tired frequently or sometimes (58.8%). The interviewees also informed that, at the time of the research, they were undergoing a health treatment (48%), with anti-depressive treatment as the most frequent type (77%). Information about accidents during pre-hospital care work was also verified (43.5%), with piercing-cutting injuries as the most frequent type (33%) (Table 1).

Clinical and anthropometric data are summarized in Table 2. As for blood pressure, 33.1% of professionals displayed altered pressure levels, compatible with arterial hypertension; more than half also revealed altered Body Mass Index and waist circumference results (65.6% and 70.2%, respectively). Eleven percent showed glucose levels above the normality range. Cholesterol exceeded desired levels in 35.7%, LDL-c in 29.2% and triglycerides in 29.8%. Only 11.0% displayed ideal HDL-c levels and 40.3% C-reactive protein in the highest quartiles. Concerning the Framingham Risk Score, 11.6% were classified in the intermediate or high risk range for a coronary event within 10 years.

Data in Table 3 display the study variables associated with blood pressure levels, classified as hypertension or not, with statistical significance (p<0.05). Thus, the presence of levels compatible with arterial hypertension were associated with the male gender, age over 40 years, frequently working tired and intermediate and high risk levels on Framingham Risk Score.

Data in Table 4 display the distribution of anthropometric and laboratory variables for blood pressure levels among professionals in the categories that are considered altered for the following variables: body mass index, waist circumference, total cholesterol level and glucose, who showed higher blood pressure levels. For professionals with low and, hence, inadequate HDL-c, higher systolic pressure levels were found.

In the logistic regression model, it was verified that the presence of arterial hypertension was favorably associated with HDL-c and Framingham Risk Score variables. Hence, HDL-c appeared as a protective factor. The chance of hypertension decreased by approximately 25% when HDL-c was in the range superior to 40 mg/dL. On the other hand, for the Framingham Risk Score, the chance of hypertension increased by 23 times when changing from the intermediate to the high risk range (Table 5).



This study identified a relatively young population, fully active in professional terms, with a high prevalence of cardiovascular risk factors. The prevalence level of 33.1% for arterial hypertension among the health professionals under analysis coincides with Brazilian research. In Brazil, it is considered that 30% of adults are hypertensive, which can double in the elderly age rang(6). Studies in other specific occupational groups demonstrated variable arterial hypertension prevalence levels. Among workers in the soft drink industry(9), 27% of hypertensive people were observed, against 24.7% among workers at an iron and steel company(10). Hypertension prevalence among employees at a hospital complex in São Paulo City, Brazil, corresponded to 26%(11) and, in the same city, a referred prevalence study showed a 32% prevalence level.(12)

The type of activity these professionals perform may have influenced the prevalence of hypertension in this study, including more intense exposure to physical and mental stress and circadian rhythm change during the workday (generally 24 hours). A close relation has been found between stress and increased pressure levels(13).

Another aspect that could influence the observed hypertension prevalence was the body mass index above healthy levels in 65.6% of professionals. This finding exceeds data from a study(14) that observed 35.7% of overweight and 17.7% of obesity among health professionals in Teresina, Piauí State. A research of truck drivers on the São Paulo part of the Regis Bittencourt highway also showed high levels, as 46% suffered from overweight, 36% obesity and 58% increased waist circumference(15). This study also showed that overweight was more present among men and obesity among women.

Literature data demonstrate the importance of overweight for arterial hypertension. The Framingham study reported that 70% of new arterial hypertension cases were related to excess body mass(16). Given the association between hypertension, aging and obesity, one may suppose that the prevalence of hypertension among the professionals in this study can progressively increase if they do not change their lifestyle and control their body weight, as aging is a non-modifiable variable. A study of hypertensive patients attended in a Hypertension League in São Paulo City, Brazil, showed that higher blood pressure (diastolic>110 mmHg) was associated with aging and increased body weight(17). Together with high overweight and obesity levels, waist circumferences above normal levels were found in 70% of professionals. These data are a source of concern. In this context, abdominal subcutaneous tissues constitutes a fat tissue compartment that strongly influences a person's sensitivity to insulin, predisposing to Diabetes mellitus, besides secreting inflammatory mediators and, thus, increasing the risk for Diabetes mellitus and glucose intolerance. The high level of sedentariness adds up to this context, as 65% of participants practiced no physical exercise. It is widely accepted that regular physical exercise produces a range of beneficial reactions in the cardiovascular system. In the study population, the high prevalence of sedentariness prevails, as these professionals are constantly exposed to physical demands in their routine pre-hospital activities.

Findings were also concerning with regard to the lipid profile. A positive relation has been evidenced between overweight and dyslipidemia, with mild to moderate rises in triglyceride levels and lower HDL-c serum levels. LDL-c serum levels, however, can be increased or not(6). Dyslipidemia is involved in the genesis of atherosclerosis, characterized by an inflammatory response of the vascular wall to injuries, including increased LDL-c and C-reactive protein. In this study, the fact that 15% of professionals displayed high C-reactive protein levels can characterize a state of inflammation and/or infection. The relation between HDL-c and blood pressure demonstrates its importance, as it continued in the logistic regression model.

Another relevant aspect was the presence of smoking and alcohol intake, with higher data than research findings. As observed, 47.5% of professionals indicated alcohol consumption, which exceeds the findings of a study(18) in a general population in rural Minas Gerais (37.6%).

Considerable reference was made to other health problems, as about a quarter of professionals mentioned treating depression. Hence, the prevalence of depression in this group was higher than in the general population, with an estimated prevalence of between 3% and 11%(18), and also higher than that found among nursing residents in a research(19) that used Beck's Depression Inventory and found a prevalence level of 19.1%. In a Brazilian study that used a sample of 258 freight transportation drivers on a Brazilian highway, 37% of hypertension prevalence was found and 33% suffered from possible common mental disorders. The participants mentioned feeling nervous, tense or concerned (56%), sleeping badly (47%), headaches (37%), difficulties to make decisions (38%) and difficulties to think clearly (20%)(20). Depression is a highly disabling and chronic illness. Besides the emotional, cognitive and physical symptoms, it exerts important influence on quality of life. Depression symptoms include depressed mood, loss of interest, fatigability, decreased concentration and attention, disturbing sleep and decreased or increased appetite. In this group of professionals, particularly decreased concentration and attention are extremely dangerous, as these professionals are exposed in extreme biological and environmental risk situations, which can increase the chances of occupational accidents. Almost half of the professionals (43.5%) mentioned occupational accidents, approximately one-third (33%) of which involving piercing-cutting material.

The analysis of cardiovascular risk distribution in the study sample, according to the current cardiovascular prevention concept, when applying the Framingham Risk Score, revealed that the large majority (88.4%) belonged to the low-risk range, similar to the data of researchers(21) who used a sample of bus drivers (85%). The higher prevalence of people with low-risk scores is probably due to the fact that they are in the fourth decade of life, as age is an important factor in the determination of the Framingham Risk Score. It should be highlighted that the fundamental principle of prevention is that a large number of individuals exposed to low risk will probably produce more cases than a small number of people exposed to high risk. The Framingham Risk Score showed to be an important tool as a predictor of coronary disease, as it continued in the logistic regression model.



These study findings showed high prevalence levels for arterial hypertension and a strong association with the Framingham Risk Score. The data are noteworthy, mainly because they refer to health professionals in a relatively young age range. The presence of inadequate lifestyles and habits, in combination with the work characteristics of the study sample, were important determinants for the presence of blood pressure levels compatible with arterial hypertension. It is highlighted that cross-sectional studies do not permit the attribution of causal relations to the identified associations, as they analyze outcome and exposure simultaneously, which can represent one of the limitations in the present study. It was verified, however, that the professionals in this research are exposed to cardiovascular risks, especially those resulting from increased body mass index. The challenge is even greater, as this is a sample of health professionals, a group that possesses information. Conciliation should be stimulated between professional experience, gained over long years of pre-hospital work, and good health conditions through physical exercise, as a way to prevent and revert high levels of overweight, obesity and sedentariness. On the other hand, institutions are responsible for watching over their employees' good health conditions. The excessively long work journeys identified probably derive from insufficient wages to guarantee a satisfactory minimum income.



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Correspondence addressed to:
Angela Maria Geraldo Pierin
Escola de Enfermagem da USP
Av. Dr. Enéas de Carvalho Aguiar, 419 – Cerqueira Cesar
CEP 05403-000 – São Paulo, SP, Brasil



* Extracted from the dissetation "Influência do plantão de 24 horas sobre a pressão arterial e o perfil de risco cardiovascular em profissionais da área da saúde que atuam em serviços de atendimento pré-hospitalar", Graduate Program in Adult Health Nursing, University of São Paulo School of Nursing. São Paulo, 2010.

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