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

Andres Rosende; Cesar Romero; Donald J. DiPette; Jeffrey Brettler; Patrick Van der Stuyft; Gautam Satheesh; Pablo Perel; Niamh Chapman; Andrew E. Moran; Aletta E. Schutte; James E. Sharman; Vilma Irazola; Mark D. Huffman; Norm R. C. Campbell; Abdul Salam; Fernando Lanas; Antonio Coca; Sebastian Garcia-Zamora; Alejandro Ferreiro; Patricio Lopez-Jaramillo; Jorge Rico-Fontalvo; Emily Ridley; Dean Picone; David Flood; Daniel José Piñeiro; Carolina Neira Ojeda; Gonzalo Rodriguez; Irmgardt A. Wellmann; Marcelo Orias; Marcela Rivera; Matías Villatoro Reyes; Oyere Onuma; Shaun Ramroop; Taskeen Khan; Yamile Valdes Gonzalez; Weimar Kunz Sebba Barroso; Frida L. Plavnik; Eric Zuniga; Ana María Grassani; Carlos Tajer; Ezequiel Zaidel; Marcos J. Marin; Shana Cyr-Philbert; Ignacio Amorin; Miguel Angel Diaz Aguilera; Luiz Bortolotto; Alvaro Avezum; Antonio Luiz P. Ribeiro; Sheldon Tobe; Teresa Aumala; Sonia Angell; Pablo Lavados; Sheila Ouriques Martins; Ana Munera Echeverri; Marc G. Jaffe; Dorairaj Prabhakaran; Gianfranco Parati; Xin Hua Zhang; Anthony Rodgers; Salim Yusuf; Paul K. Whelton; Pedro Ordunez

doi:10.5334/gh.1428

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

Volume 20 (2025): Issue 1

By: Andres Rosende , Cesar Romero , Donald J. DiPette , Jeffrey Brettler , Patrick Van der Stuyft , Gautam Satheesh , Pablo Perel , Niamh Chapman , Andrew E. Moran , Aletta E. Schutte , James E. Sharman , Vilma Irazola , Mark D. Huffman , Norm R. C. Campbell , Abdul Salam , Fernando Lanas , Antonio Coca , Sebastian Garcia-Zamora , Alejandro Ferreiro , Patricio Lopez-Jaramillo , Jorge Rico-Fontalvo , Emily Ridley , Dean Picone , David Flood , Daniel José Piñeiro , Carolina Neira Ojeda , Gonzalo Rodriguez , Irmgardt A. Wellmann , Marcelo Orias , Marcela Rivera , Matías Villatoro Reyes , Oyere Onuma , Shaun Ramroop , Taskeen Khan , Yamile Valdes Gonzalez , Weimar Kunz Sebba Barroso , Frida L. Plavnik , Eric Zuniga , Ana María Grassani , Carlos Tajer , Ezequiel Zaidel , Marcos J. Marin , Shana Cyr-Philbert , Ignacio Amorin , Miguel Angel Diaz Aguilera , Luiz Bortolotto , Alvaro Avezum , Antonio Luiz P. Ribeiro , Sheldon Tobe , Teresa Aumala , Sonia Angell , Pablo Lavados , Sheila Ouriques Martins , Ana Munera Echeverri , Marc G. Jaffe , Dorairaj Prabhakaran , Gianfranco Parati , Xin Hua Zhang , Anthony Rodgers , Salim Yusuf , Paul K. Whelton and Pedro Ordunez

Open Access

|May 2025

Figures & Tables

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

Table 1

Number of improvement interventions agreed by action and area.

ACTION RECOMMENDED	DIAGNOSIS	RISK ASSESSMENT	NON-PHARMACOLOGIC TREATMENT	PHARMACOLOGIC TREATMENT	CONTINUITY OF CARE	DELIVERY SYSTEM	SYSTEM FOR MONITORING	IMMUNIZATION	TOTAL
Include	3	8	7	6	7	3	2	0	36
Modify	3	4	0	6	2	0	0	3	18
Reinforce	2	0	0	1	0	0	0	0	3
Remove	0	0	0	0	0	0	0	0	0
With high median score	4/8	9/12	6/7	13/13	6/9	3/3	2/2	2/3	45/57

Table 2

Candidate Interventions for the HEARTS Clinical Pathway Upgrade.

INTERVENTION AREAS	ACTION TO BE TAKEN	IMPROVEMENT PROPOSALS AGREED
Diagnosis	Reinforce	1. Exclusive use of clinically validated BPMD.
	Reinforce	2. Improving the clinical environment for accurate BP measurement.
	Include	3. Expanding community outreach for hypertension screening.
	Include	4. Set BP diagnostic thresholds for hypertension at ≥140/90 mmHg in the general population and SBP ≥130 mmHg for patients at high cardiovascular risk.
Risk assessment	Modify	5. Set CKD definition: eGFR < 60 ml/min and/or uACR index ≥ 30 mg/g.
		6. Set BP goals in elderly patients to SBP <130 mmHg.
		7. Define a CVD risk approach for young adults (18–40 years).
	Include	8. CKD screening for high-risk individuals using uACR and eGFR.
		9. Assessment of HTN-mediated organ damage with ECG in high CVD risk patients.
		10. Screening for dyslipidemia and diabetes in patients with HTN and obesity.
		11. Opportunistic screening for atrial fibrillation in high CVD risk patients of any age and those aged ≥ 65 years.
		12. Closely monitor individuals with a history of hypertension during pregnancy.
		13. Add a warning: Avoid treatment with short-acting and parenteral agents in individuals with severe asymptomatic uncontrolled hypertension.
Non-Pharmacologic Treatment	Include	14. Promote low-sodium /potassium-enriched salt.
		15. Prescribe isometric exercise.
		16. Warning against smoking Cannabis.
		17. Warning against Electronic Cigarette use/Vaping.
		18. Avoid sedentary lifestyle.
		19. Prescribe exercise.
Pharmacologic Treatment	Reinforce	20. SPC antihypertensive medicines.
	Modify	21. Add the third drug, at half maximum dose, in the second step of the treatment protocol instead of increasing the first two drugs to maximum doses.
		22. Maximum statin doses in secondary prevention (Atorvastatin 80 mg or Rosuvastatin 40 mg).
		23. High statin doses in primary prevention (Atorvastatin 40 mg or Rosuvastatin 20 mg).
		24. Use of Polypills (antihypertensives plus statins with or without aspirin) for primary and secondary prevention of CVD.
		25. Intensify antihypertensive medication at intervals of 2 weeks instead of 4 weeks.
		26. Warning on assessing childbearing potential before treatment initiation.
	Include	27. Triple SPC for those patients who do not reach BP control using double SPC.
		28. Spironolactone in patients with 3 drugs at maximum doses and lack of HTN control.
		29. Treatment for tobacco cessation (bupropion, varenicline, nicotine substitutes).
		30. Prescribe SGLT2i in patients with CKD.
		31. Prescribe SGLT2i in patients with heart failure.
		32. Prescribe SGLT2i in patients with diabetes and established CVD.
Continuity of Care	Modify	33. Intensive BP (SBP < 130 mmHg) goals restricted to patients <80 years.
	Include	34. Home BP treatment monitoring.
		35. Telemedicine/mHealth apps to monitor recommendation adherence and to reduce loss to follow-up.
		36. Lipid targets in high CVD risk patients.
		37. An established target time to achieve BP control.
		38. Warning to avoid statin discontinuation once the control target has been reached.
Delivery System	Include	39. Medication intensification by non-physician healthcare workers following a protocol.
		40. HTN screening and CVD risk stratification by non-physician healthcare workers.
		41. Healthy lifestyle counseling and support for medication adherence by non-physician healthcare workers.
Immunization	Modify	42. Influenza vaccination to all patients with HTN regardless of CVD risk level.
Immunization	Modify	43. Pneumococcus vaccination should exclude patients in primary prevention <65 years.
System for Monitoring	Include	44. Importance of registering clinical variables.
System for Monitoring	Include	45. Relevance of having a strategy of performance evaluation with feedback.

[i] BP: blood pressure; BPMD: blood pressure measuring devices; HTN: hypertension; CVD: cardiovascular disease; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate; AlbU: urine albumin; CrU: urine creatine; uACR: urine albumin-creatinine ratio; ECG: electrocardiogram; AF: atrial fibrillation; SPC: single pill combination; SGLT2i: sodium-glucose co-tranporter-2 inhibitors.

Articles in this issue

DOI: https://doi.org/10.5334/gh.1428 | Journal eISSN: 2211-8179

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Language: English

Submitted on: Jan 29, 2025

Accepted on: May 2, 2025

Published on: May 27, 2025

Published by: Ubiquity Press

In partnership with: Paradigm Publishing Services

Publication frequency: 1 issue per year

Keywords:

hypertension,

Primary Health Care,

Cardiovascular Diseases,

diabetes mellitus,

Renal Insufficiency,

Chronic,

Stroke

© 2025 Andres Rosende, Cesar Romero, Donald J. DiPette, Jeffrey Brettler, Patrick Van der Stuyft, Gautam Satheesh, Pablo Perel, Niamh Chapman, Andrew E. Moran, Aletta E. Schutte, James E. Sharman, Vilma Irazola, Mark D. Huffman, Norm R. C. Campbell, Abdul Salam, Fernando Lanas, Antonio Coca, Sebastian Garcia-Zamora, Alejandro Ferreiro, Patricio Lopez-Jaramillo, Jorge Rico-Fontalvo, Emily Ridley, Dean Picone, David Flood, Daniel José Piñeiro, Carolina Neira Ojeda, Gonzalo Rodriguez, Irmgardt A. Wellmann, Marcelo Orias, Marcela Rivera, Matías Villatoro Reyes, Oyere Onuma, Shaun Ramroop, Taskeen Khan, Yamile Valdes Gonzalez, Weimar Kunz Sebba Barroso, Frida L. Plavnik, Eric Zuniga, Ana María Grassani, Carlos Tajer, Ezequiel Zaidel, Marcos J. Marin, Shana Cyr-Philbert, Ignacio Amorin, Miguel Angel Diaz Aguilera, Luiz Bortolotto, Alvaro Avezum, Antonio Luiz P. Ribeiro, Sheldon Tobe, Teresa Aumala, Sonia Angell, Pablo Lavados, Sheila Ouriques Martins, Ana Munera Echeverri, Marc G. Jaffe, Dorairaj Prabhakaran, Gianfranco Parati, Xin Hua Zhang, Anthony Rodgers, Salim Yusuf, Paul K. Whelton, Pedro Ordunez, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.

Volume 20 (2025): Issue 1

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

Figures & Tables

Figure 1

Figure 2

Table 1

Table 2

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