Candidate Interventions for Integrating Hypertension and Cardiovascular-Kidney-Metabolic Care in Primary Health Settings: HEARTS 2.0 Phase 1

Andres Rosende¹, Cesar Romero², Donald J DiPette³, Jeffrey Brettler⁴, Patrick Van der Stuyft⁵, Gautam Satheesh⁶, Pablo Perel⁷, Niamh Chapman⁸, Andrew E Moran^{9

10}, Aletta E Schutte^{6

11}, James E Sharman¹², Vilma Irazola¹³, Mark D Huffman^{14

15}, Norm R C Campbell¹⁶, Abdul Salam⁶, Fernando Lanas¹⁷, Antonio Coca¹⁸, Sebastian Garcia-Zamora¹⁹, Alejandro Ferreiro²⁰, Patricio Lopez-Jaramillo²¹, Jorge Rico-Fontalvo²², Emily Ridley²³, Dean Picone^{24

25}, David Flood²⁶, Daniel José Piñeiro²⁷, Carolina Neira Ojeda²⁸, Gonzalo Rodriguez²⁹, Irmgardt A Wellmann³⁰, Marcelo Orias³¹, Marcela Rivera³², Matías Villatoro Reyes³³, Oyere Onuma³⁴, Shaun Ramroop³⁵, Taskeen Khan¹⁰, Yamile Valdes Gonzalez³⁶, Weimar Kunz Sebba Barroso³⁷, Frida L Plavnik³⁸, Eric Zuniga³⁹, Ana María Grassani⁴⁰, Carlos Tajer⁴¹, Ezequiel Zaidel⁴², Marcos J Marin⁴³, Shana Cyr-Philbert⁴⁴, Ignacio Amorin⁴⁵, Miguel Angel Diaz Aguilera⁴⁶, Luiz Bortolotto⁴⁷, Alvaro Avezum⁴⁸, Antonio Luiz P Ribeiro⁴⁹, Sheldon Tobe⁵⁰, Teresa Aumala⁵¹, Sonia Angell⁵², Pablo Lavados⁵³, Sheila Ouriques Martins⁵⁴, Ana Munera Echeverri⁴², Marc G Jaffe⁴, Dorairaj Prabhakaran⁵⁵, Gianfranco Parati^{56

57}, Xin Hua Zhang⁵⁸, Anthony Rodgers⁶, Salim Yusuf⁵⁹, Paul K Whelton⁶⁰, Pedro Ordunez¹

Affiliations

¹ Department of Noncommunicable Diseases and Mental Health, Pan American Health Organization, Washington, District of Columbia, USA.
² Emory University, Atlanta, USA.
³ University of South Carolina, USA.
⁴ Kaiser Permanente, California, USA.
⁵ Department of Public Health and Primary care, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium.
⁶ The George Institute for Global Health, Australia.
⁷ London School of Hygiene & Tropical Medicine, United Kingdom.
⁸ University of Sydney, Australia.
⁹ Columbia University Medical Center, USA.
¹⁰ Resolve to Save Lives, USA.
¹¹ School of Population Health, University of New South Wales, Australia.
¹² Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
¹³ Department of Research in Chronic Diseases, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina.
¹⁴ Washington University in St. Louis, USA.
¹⁵ The George Institute for Global Health, UNSW, Australia.
¹⁶ Department of Medicine, University of Calgary, Canada.
¹⁷ Universidad de La Frontera, Temuco, Chile.
¹⁸ Universitat Abat Oliba CEU, Barcelona, Spain.
¹⁹ Cardiology Department, Sanatorio Delta, Rosario, Argentina.
²⁰ Centro de Nefrología, Facultad de Medicina, Universidad de la República, Uruguay.
²¹ Masira Research Institute, Medical School, Universidad de Santander (UDES), Bucaramanga, Colombia.
²² Departamento de Nefrología, Universidad Simón Bolivar, Barranquilla, Colombia.
²³ Prisma Health, Columbia, South Carolina, USA.
²⁴ School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Australia.
²⁵ Menzies Institute for Medical Research, University of Tasmania, Australia.
²⁶ Department of Medicine, University of Michigan, USA.
²⁷ World Heart Federation -University of Buenos Aires, Argentina.
²⁸ Department of Noncommunicable Diseases, Ministry of Health of Chile, Santiago, Chile.
²⁹ Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina.
³⁰ Research Center for Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala.
³¹ Yale University School of Medicine, USA.
³² Division of Primary Healthcare, Ministry of Health of Chile, Santiago, Chile.
³³ Oficina de Enfermedades No Transmisibles del Ministerio de Salud de El Salvador, El Salvador.
³⁴ Harvard University School of Medicine, USA.
³⁵ Chief Medical Officer of Bermuda, Bermuda.
³⁶ Institute of Endocrinology, National Committee of Hypertension, Ministry of Public Health of Cuba, Cuba.
³⁷ Hypertension Unit, Medicine School, Federal University of Goiás, Brazil.
³⁸ Heart Institute of the Hospital das Clínicas of FMUSP -São Paulo, Brazil.
³⁹ Universidad de Antofagasta, Servicio de Salud Antofagasta, Chile.
⁴⁰ Ministry of Health of Tierra del Fuego, Ushuaia, Argentina.
⁴¹ Cardiology Department, Hospital El Cruce, Florencio Varela, Buenos Aires, Argentina.
⁴² Inter-American Society of Cardiology, USA.
⁴³ Argentine Society of Hypertension, Argentina.
⁴⁴ Ministry of Health, St. Lucia.
⁴⁵ Universidad de la República, Montevideo, Uruguay.
⁴⁶ National Center for Preventive Programs and Disease Control (CENAPRECE) of the Mexican Ministry of Health, Mexico.
⁴⁷ InCor, Sao Paulo, Brazil.
⁴⁸ Instituto de Cardiologia Dante Pazzanese, Sao Paulo, Brazil.
⁴⁹ Department of Internal Medicine, Faculdade de Medicina, and Telehealth Center and Cardiology Service, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.
⁵⁰ University of Toronto and Northern Ontario School of Medicine, Toronto, Canada.
⁵¹ Instituto Ecuatoriano de Seguridad Social, Quito, Ecuador.
⁵² Johns Hopkins Bloomberg School of Public Health, USA.
⁵³ Iberoamerican Stroke Society, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile.
⁵⁴ World Stroke Organization, Switzerland.
⁵⁵ Centre for Chronic Disease Control, New Delhi, India.
⁵⁶ IRCCS, Italian Auxology Institute, San Luca Hospital, Milan, Italy.
⁵⁷ Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.
⁵⁸ Beijing Hypertension League Institute, China.
⁵⁹ McMaster University, Ontario, Canada.
⁶⁰ World Hypertension League, Tulane University, New Orleans, Louisiana, USA.

PMID: 40454106
PMCID: PMC12124280
DOI: 10.5334/gh.1428

Candidate Interventions for Integrating Hypertension and Cardiovascular-Kidney-Metabolic Care in Primary Health Settings: HEARTS 2.0 Phase 1

Andres Rosende et al. Glob Heart. 2025.

. 2025 May 27;20(1):45.

doi: 10.5334/gh.1428. eCollection 2025.

Authors

Affiliations

¹ Department of Noncommunicable Diseases and Mental Health, Pan American Health Organization, Washington, District of Columbia, USA.
² Emory University, Atlanta, USA.
³ University of South Carolina, USA.
⁴ Kaiser Permanente, California, USA.
⁵ Department of Public Health and Primary care, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium.
⁶ The George Institute for Global Health, Australia.
⁷ London School of Hygiene & Tropical Medicine, United Kingdom.
⁸ University of Sydney, Australia.
⁹ Columbia University Medical Center, USA.
¹⁰ Resolve to Save Lives, USA.
¹¹ School of Population Health, University of New South Wales, Australia.
¹² Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
¹³ Department of Research in Chronic Diseases, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina.
¹⁴ Washington University in St. Louis, USA.
¹⁵ The George Institute for Global Health, UNSW, Australia.
¹⁶ Department of Medicine, University of Calgary, Canada.
¹⁷ Universidad de La Frontera, Temuco, Chile.
¹⁸ Universitat Abat Oliba CEU, Barcelona, Spain.
¹⁹ Cardiology Department, Sanatorio Delta, Rosario, Argentina.
²⁰ Centro de Nefrología, Facultad de Medicina, Universidad de la República, Uruguay.
²¹ Masira Research Institute, Medical School, Universidad de Santander (UDES), Bucaramanga, Colombia.
²² Departamento de Nefrología, Universidad Simón Bolivar, Barranquilla, Colombia.
²³ Prisma Health, Columbia, South Carolina, USA.
²⁴ School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Australia.
²⁵ Menzies Institute for Medical Research, University of Tasmania, Australia.
²⁶ Department of Medicine, University of Michigan, USA.
²⁷ World Heart Federation -University of Buenos Aires, Argentina.
²⁸ Department of Noncommunicable Diseases, Ministry of Health of Chile, Santiago, Chile.
²⁹ Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina.
³⁰ Research Center for Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala.
³¹ Yale University School of Medicine, USA.
³² Division of Primary Healthcare, Ministry of Health of Chile, Santiago, Chile.
³³ Oficina de Enfermedades No Transmisibles del Ministerio de Salud de El Salvador, El Salvador.
³⁴ Harvard University School of Medicine, USA.
³⁵ Chief Medical Officer of Bermuda, Bermuda.
³⁶ Institute of Endocrinology, National Committee of Hypertension, Ministry of Public Health of Cuba, Cuba.
³⁷ Hypertension Unit, Medicine School, Federal University of Goiás, Brazil.
³⁸ Heart Institute of the Hospital das Clínicas of FMUSP -São Paulo, Brazil.
³⁹ Universidad de Antofagasta, Servicio de Salud Antofagasta, Chile.
⁴⁰ Ministry of Health of Tierra del Fuego, Ushuaia, Argentina.
⁴¹ Cardiology Department, Hospital El Cruce, Florencio Varela, Buenos Aires, Argentina.
⁴² Inter-American Society of Cardiology, USA.
⁴³ Argentine Society of Hypertension, Argentina.
⁴⁴ Ministry of Health, St. Lucia.
⁴⁵ Universidad de la República, Montevideo, Uruguay.
⁴⁶ National Center for Preventive Programs and Disease Control (CENAPRECE) of the Mexican Ministry of Health, Mexico.
⁴⁷ InCor, Sao Paulo, Brazil.
⁴⁸ Instituto de Cardiologia Dante Pazzanese, Sao Paulo, Brazil.
⁴⁹ Department of Internal Medicine, Faculdade de Medicina, and Telehealth Center and Cardiology Service, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.
⁵⁰ University of Toronto and Northern Ontario School of Medicine, Toronto, Canada.
⁵¹ Instituto Ecuatoriano de Seguridad Social, Quito, Ecuador.
⁵² Johns Hopkins Bloomberg School of Public Health, USA.
⁵³ Iberoamerican Stroke Society, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile.
⁵⁴ World Stroke Organization, Switzerland.
⁵⁵ Centre for Chronic Disease Control, New Delhi, India.
⁵⁶ IRCCS, Italian Auxology Institute, San Luca Hospital, Milan, Italy.
⁵⁷ Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.
⁵⁸ Beijing Hypertension League Institute, China.
⁵⁹ McMaster University, Ontario, Canada.
⁶⁰ World Hypertension League, Tulane University, New Orleans, Louisiana, USA.

PMID: 40454106
PMCID: PMC12124280
DOI: 10.5334/gh.1428

Abstract

Background: HEARTS in the Americas is the regional adaptation of the WHO Global HEARTS Initiative, aimed at helping countries enhance hypertension and cardiovascular disease (CVD) risk management in primary care settings. Its core implementation tool, the HEARTS Clinical Pathway, has been adopted by 28 countries. To improve the care of hypertension, diabetes, and chronic kidney disease (CKD), HEARTS 2.0 was developed as a three-phase process to integrate evidence-based interventions into a unified care pathway, ensuring consistency across fragmented guidelines. This paper focuses on Phase 1, highlighting targeted interventions to improve and update the HEARTS Clinical Pathway.

Methods: First, the coordinating group defined the project's scope, objectives, principles, methodological framework, and tools. Second, international experts from different disciplines proposed interventions to enhance the HEARTS Clinical Pathway. Third, the coordinating group harmonized these proposals into unique interventions. Fourth, experts appraised the appropriateness of the proposed interventions on a 1-to-9 scale using the adapted RAND/UCLA Appropriateness Method. Finally, interventions with a median score above 6 were deemed appropriate and selected as candidates to enhance the HEARTS Clinical Pathway.

Results: Building on the existing HEARTS Clinical Pathway, 45 unique interventions were selected, including community-based screening, early detection and management of risk factors, lower blood pressure thresholds for diagnosing hypertension in high-CVD-risk patients, reinforcement of single-pill combination therapy, inclusion of sodium-glucose cotransporter-2 inhibitors for patients with diabetes, CKD, or heart failure, expanded roles for non-physician health workers in team-based care, and strengthened clinical documentation, monitoring, and evaluation.

Conclusion: HEARTS 2.0 Phase 1 identifies key interventions to integrate and improve hypertension and cardiovascular-kidney-metabolic care within primary care, enabling their seamless incorporation into a unified and effective clinical pathway. This process will inform an update to the HEARTS Clinical Pathway, optimizing resources, reducing care fragmentation, improving care delivery, and advancing health equity, thereby supporting global efforts to combat the leading causes of death and disability.

Keywords: Cardiovascular Diseases; Chronic; Primary Health Care; Renal Insufficiency; Stroke; diabetes mellitus; hypertension.

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Conflict of interest statement

AR and PO are staff members of the Pan American Health Organization. The authors alone are responsible for the views expressed in this publication, and they do not necessarily represent the decisions or policies of the Pan American Health Organization. GS, ARod, AES, MDH, and AS work for The George Institute for Global Health, which has a patent and has received investments to commercialize fixed-dose combination therapies for cardiovascular disease prevention through its social enterprise company, George Medicines. AES also declares receiving consulting fees from Servier, Abbott, Medtronic, and Sky Labs, and honoraria for lectures from Servier, Abbott, Medtronic, AstraZeneca, Aktiia, Sanofi, Novartis, and Omron. MDH has received travel support from the World Heart Federation and consulting fees from PwC Switzerland. MDH has pending patents for heart failure polypills. AF declares receiving honoraria for lectures from Boehringer-Ingelheim, Ely Lilly, Bayer, Jafron Biomedical, and Nipro Medical. GP declares receiving honoraria for lectures from Omron, Merck, Viatris and Somnomedics. MO declares receiving honoraria for lectures from GlaxoSmithKline and AstraZeneca. PL declares receiving consulting fees from Pfizer and Boehringer-Ingelheim, and honoraria for lectures from Boehringer-Ingelheim, Ferrer, Servier, Pfizer, and Novartis. DP declares receiving honoraria for lectures from Servier and holds the copyright for a decision support software to manage hypertension and diabetes. GR declares holding stocks in Catalisia SA. EZ declares receiving honoraria for lectures from Novo Nordisk, Pfizer, PTC Therapeutics, AstraZeneca, Medicamenta, and Janssen. AC declares receiving honoraria for lectures from Adium, Berlin-Chemie, Ferrer, Menarini, and Sanofi. JRF declares receiving honoraria for lectures from Novo Nordisk, AstraZeneca, Eli Lilly, Boehringer-Ingelheim, and Bayer. ST declares receiving honoraria for lectures from Boehringer- Ingelheim, Novo Nordisk, CHEP Plus, and KMH. The remaining authors declare no conflicts of interest related to the content of this manuscript.

Figures

**Figure 1**
The HEARTS Clinical Pathway.

**Figure 2**
Flowchart summarizing the process for evaluating the appropriateness of candidate interventions to be included in the HEARTS Clinical Pathway.

See this image and copyright information in PMC

References

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Candidate Interventions for Integrating Hypertension and Cardiovascular-Kidney-Metabolic Care in Primary Health Settings: HEARTS 2.0 Phase 1

Affiliations

Candidate Interventions for Integrating Hypertension and Cardiovascular-Kidney-Metabolic Care in Primary Health Settings: HEARTS 2.0 Phase 1

Authors

Affiliations

Abstract

Conflict of interest statement

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References

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Medical