HEARTS in the Americas: Targeting Health System Change to Improve Population Hypertension Control

Improving Implementation of NCD Care in Low- and Middle-Income Countries: The Case of Fixed Dose Combinations for Hypertension in Kenya

Health systems in low- and middle-income countries face the challenge of addressing the growing burden of non-communicable diseases (NCDs) with scarce resources to do so. There are cost-effective interventions that can improve management of the most common NCDs, but many remain poorly implemented. One example is fixed dose combinations (FDCs) of medications for hypertension. Included in WHO's Essential Medicines List, FDCs combine two or more blood pressure lowering agents into one pill and can reduce burden on patients and the health system. However, implementation of FDCs globally is poor. We aimed to identify health systems factors affecting implementation of evidence-based interventions for NCDs, and opportunities to address these, using the case study of FDCs in Kenya. We conducted semi-structured interviews with 39 policy-makers and healthcare workers involved in hypertension treatment policy and identified through snowball sampling. Interview data were analyzed thematically, using the Access Framework to categorize themes. Our interviews identified factors operating at the global, national, county, and provider levels. These include lack of global implementation guidance, context specific cost-effectiveness data, or prioritization by procurement agencies and clinical guidelines; perceived high cost; poor data for demand forecasting; insufficient budget for procurement of NCD medications; absence of prescriber training and awareness of clinical guidelines; and habitual prescribing behavior and understaffing limiting capacity for change. We propose specific strategies to address these. The findings of this work can inform efforts to improve implementation of other evidence-based interventions for NCDs in low-income settings.

Priorities for Research on Hypertension Care Delivery: A WHO Report Executive Summary

In 2024, the World Health Organization released a report on Priorities for Research on Hypertension Care Delivery; this article provides its executive summary. The World Health Organization and its technical experts formed a leadership team, developed a scope and objectives, created a thematic framework, developed a survey for each theme, and identified research priorities. The 5 themes included (1) Health care workforce for hypertension care delivery, (2) Service delivery system/models, (3) Patient retention/adherence, (4) Financing the care delivery system, and (5) Research gaps identified in the World Health Organization 2021 Hypertension Guideline. The leadership team received feedback from diverse experts through webinars and online surveys. The final report was peer-reviewed by external experts. According to postwebinar surveys, we identified 5 to 7 research priorities within each theme, totaling 29 research priorities. The 10 highest priorities were (1) Cost-effectiveness of combination therapy in low/middle-income countries, (2) A system allowing hypertension care closer to home, (3) Health system reform allowing trained community health workers to refill/initiate/titrate antihypertensive medications, (4) Health system reform allowing nurses to diagnose and treat hypertension, (5) Gaps in the medication supply chain, (6) New approaches integrating the management of hypertension and other diseases, (7) Digital approaches for improving medication adherence, (8) Optimal approaches to train health care workers, (9) Approaches to finance hypertension control programs, and (10) Implementation research on task-sharing approaches. These research priorities provide guidance to researchers, with immediate implications for substantially improve hypertension care and prevent its sequelae. We urge governments, funding agencies, and organizations to consider supporting these research topics.

Expanding team-based care for hypertension and cardiovascular risk management with HEARTS in the Americas

Cardiovascular diseases remain the leading cause of premature morbidity and mortality globally, with hypertension as their main modifiable risk factor. In Latin America and the Caribbean, hypertension affects more than 30% of adults, yet control rates remain alarmingly low. The HEARTS in the Americas Initiative, led by the Pan American Health Organization, promotes a model of team-based care to enhance risk management for hypertension and cardiovascular diseases within primary health care. Team-based care leverages the skills of diverse health professionals, including nurses, pharmacists and community health workers, to optimize resource allocation, task-sharing and care delivery. Evidence underscores the effectiveness of team-based care in improving blood pressure control, reducing hospitalizations and enhancing quality of life through strategies such as periodic follow up and medication titration. Despite its benefits, implementing team-based care faces cultural and systemic barriers. This special report outlines a policy framework to scale team-based care across the Region of the Americas, ensuring equitable access to high-quality, cost-effective prevention and care for cardiovascular diseases.

HEARTS Pharmacy: A framework for integrating pharmacists in hypertension and cardiovascular disease risk management in primary care

HEARTS Pharmacy, a project within the HEARTS in the Americas Initiative, provides a framework to integrate pharmacists into primary health care. Pharmacists are highly respected in health care but face challenges, such as limited scope of practice, regulatory barriers, and insufficient recognition, compounded by social norms that hinder their full potential. This paper presents compelling evidence that pharmacist-led interventions improve blood pressure control, lower cardiovascular risk, and reduce health care costs. It underscores the role of national pharmacy systems in ensuring access to high-quality medications. HEARTS Pharmacy emphasizes the role pharmacists play in team-based care, highlighting their expertise in medication management, patient education, and adherence. This paper advocates policy changes that empower pharmacists with greater responsibility, enabling them to play an active role in patient care. It also recommends actions to fully integrate pharmacists into care teams, positioning them as key players in hypertension control and cardio-vascular disease risk management within primary health care.

Telehealth intervention involving the HEARTS Technical Package and the additional use of an activity monitor to increase physical activity level post-stroke: Protocol for a feasibility randomized controlled trial

BACKGROUND

Low physical activity level is a common risk factor for recurrent stroke. Feasibility studies show behavior change interventions can increase physical activity participation, but face barriers (e.g., home visits or internet access). Low-cost telehealth approaches, like telephone calls, may overcome these challenges. Another low-cost strategy involves motivational tools supporting "Behavioral Regulation," such as physical activity monitors. However, evidence is insufficient to support their use in increasing physical activity levels post-stroke. A systematic review suggests integrating these devices into multifaceted behavior change interventions (e.g., the 5As brief intervention outlined in the HEARTS Technical Package) may enhance their effectiveness. Combined with physical activity monitors and telephone follow-up, this approach has proven feasible for individuals post-stroke. These findings underscore the need to explore combining the 5As brief intervention with physical activity monitors to assess potential added benefits. This feasibility randomized controlled trial (RCT) study will investigate whether the telehealth intervention (by telephone call) combining the 5As brief intervention, as outlined in the HEARTS Technical Package, and physical activity monitoring, compared to a control group receiving only the 5As brief intervention, is feasible and supports a fully powered RCT.

METHODS

A feasibility RCT study, with blinded assessment, will assign 24 individuals post-stroke (diagnosed ≥ 6 months), aged ≥ 18 years, inactive, able to walk 10 meters independently, and medically approved for physical activity, to experimental (n = 12) or control group (n = 12). Both groups will undergo the 5As brief intervention (Ask, Advise, Assess, and Assist delivered face-to-face, and Arrange via telephone call follow-up), for 12 weeks, with the experimental group also using a physical activity monitor. Outcomes include feasibility of recruitment, intervention, measurement, and blinding the outcome assessor, cost and clinical outcomes.

DISCUSSION

The intervention aligns with stroke secondary prevention recommendations and utilizes low-cost telehealth approaches. This study will contribute to defining future RCT phases.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06068036.

Hypertension diagnosis and management in Bamako, Mali

Problem

The capacity and site readiness for delivering hypertension management services in Mali were unknown, hindering the effective implementation of the World Health Organization (WHO) HEARTS technical package for cardiovascular disease management.

Approach

We selected one tertiary and two secondary hospitals to be assessed. From December 2021 to January 2022, hospital cardiologists collected data on indicators of capacity and site readiness using an adapted version of the WHO service availability and readiness assessment questionnaire. The study team verified the collected data through site inspection and review of administrative documents.

Local setting

Mali, a low-income country with a population of 22 395 489, had an estimated hypertension prevalence among adults of 35% in 2019. Most people with hypertension receive care from primary care clinicians, but there are no national hypertension treatment guidelines.

Relevant changes

The tertiary hospital had a larger workforce (392 personnel) compared to the two other sites (124 and  182 personnel, respectively) and treated approximately three times more patients with high blood pressure (324 patients versus 106 and 132 patients, respectively). Diuretics and centrally acting agents were the only antihypertensive medications available at all three sites. While all three sites had the capacity to diagnose and confirm hypertension, only one site was fully equipped to provide comprehensive hypertension treatment.

Lessons learnt

Political engagement is important for expanding service availability and readiness assessments across health-care facilities, and supporting the implementation and funding of the HEARTS package. Improving access to antihypertensive medications will be essential to ensuring better treatment options for patients.

Risk and impact of stroke across 38 countries and territories of the Americas from 1990 to 2021: a population-based trends analysis from the Global Burden of Disease Study 2021

Background

Despite substantial declines in burden over time, stroke remains a public health threat in the Americas. This study aimed to assess the current magnitude, trends, and disparities in the estimates of stroke burden by sex and age in the Americas from 1990 to 2021.

Methods

Estimates from the Global Burden of Disease, Injuries and Risk Factors Study 2021 were used to analyze incidence, prevalence, mortality, years of life lost due to premature death, years lived with disabilities, and disability-adjusted life years (DALYs) caused by stroke and its major subtypes stratified by age, and sex in the Americas from 1990 to 2021. We used Joinpoint regression analysis to estimate the average annual percent change (AAPC) of stroke mortality and disease burden outcomes and assessed trends.

Findings

In 2021, there were 1.1 million (95% uncertainty interval: 1.0-1.2) new cases, 12.9 million (12.3-13.7) prevalent cases, 0.5 million (0.5-0.6) deaths, and 11.4 million (10.6-12.1) DALYs due to stroke in the Americas. The absolute number of stroke burden outcomes increased from 1990 to 2021, but their corresponding age-standardized rates significantly declined. A deceleration in reduction rates of burden outcomes for all strokes and most stroke subtypes occurred over the last decade, with pronounced difference between sexes mainly in incidence among younger groups. From 2015 to 2021, trends in incidence rates from all stroke and stroke subtypes reversed to increase in most age groups, and strikingly, trends in mortality and DALY rates from ischemic stroke among younger populations reversed to upward with AAPC over 1.4%. A substantial number of countries contributed to these increasing trends.

Interpretation

Regionally, the annual number of stroke cases and deaths significantly increased from 1990 to 2021, despite reductions in age-standardized rates. The declining pace in age-standardized stroke rates has decelerated in recent years, while trends in incidence, and ischemic stroke mortality and DALY among middle-aged adults and adults, reversed towards upward in the period 2015-2021. Further studies are needed to understand the determinants of this recent pattern and identify the most cost-effective interventions to stem this alarming trend.

Funding

There was no funding source for this study.

Cardiovascular disease in the Americas: the epidemiology of cardiovascular disease and its risk factors

This first article of the Series about Cardiovascular Disease in the Americas summarizes the epidemiology of CVD and its risk factors, and population-level strategies in place aimed at CVD prevention. While age-standardized CVD incidence and CV mortality rates have been decreasing across in the Americas since 1990, the annual number of CVD cases and related deaths have increased due to population growth and ageing. The burden of CVD is also slowly transitioning from high-income countries in North America to middle-income countries in Latin America and the Caribbean. Trends in CV risk factor levels have been mixed, with declines in smoking and mean cholesterol counterbalanced by higher prevalence of obesity and diabetes. Population-wide strategies aimed at controlling cardiometabolic risk factors and tobacco use have been implemented with varying degrees of success. There is a need to better implement existing CVD prevention strategies in the region.

Evaluating the World Health Organization's Hearts Model for Hypertension and Diabetes Management: A Pilot Implementation Study in Guatemala

Background

The World Health Organization HEARTS Technical Package is a widely implemented global initiative to improve the primary care management of cardiovascular disease risk factors. The study's objective is to report outcomes from a pilot implementation trial of integrated hypertension and diabetes management based on the HEARTS model in Guatemala.

Methods

We conducted a single-arm pilot implementation trial over six months from October 2023 to May 2024 in 11 Guatemalan Ministry of Health primary care facilities in two districts. The pilot evaluated a package of five HEARTS-aligned implementation strategies to improve the pharmacological treatment of hypertension and diabetes. The primary outcomes were feasibility and acceptability, measured through 20 structured interviews with Ministry of Health employees and by examining enrolment and retention data. Secondary outcomes included a suite of implementation and clinical outcomes, including treatment rates. When baseline data were available, we analyzed secondary outcomes as the net change from baseline or using an interrupted time series approach.

Results

The study enrolled 964 patients, of whom 58.8% had hypertension only, 30.4% had diabetes only, and 10.8% had both conditions. Surveys on feasibility and acceptability among Ministry of Health staff had a median score of 5.0 (IQR: 5.0 to 5.0) and 5.0 (IQR range: 4.8 to 5.0), respectively, exceeding the prespecified benchmark of ≥3.5. Both districts achieved the prespecified benchmark of enrolling ≥25 hypertension patients and ≥25 diabetes patients. Only 36% of patients attended a follow-up visit within three months, lower than the prespecified benchmark of ≥75%. Monthly treatment rates during the pilot increased by 22.3 (95% CI: 16.2 to 28.4; P < 0.001) and 3.5 (95% CI: -1.6 to 8.7; P = 0.17) patients per month for hypertension and diabetes, respectively.

Conclusions

Implementation of an integrated hypertension and diabetes model based on HEARTS was generally feasible and acceptable in the Ministry of Health in Guatemala. Findings can refine national scale-up in Guatemala and inform HEARTS implementation projects in other settings.

Hypertension control and risk of age-associated dementia in people with HIV infection

OBJECTIVE

Hypertension is a major risk factor for dementia, but sustained blood pressure control is difficult to achieve. We evaluated whether inadequately controlled hypertension may contribute to excess dementia risk among people with HIV.

DESIGN

A retrospective cohort study.

METHODS

We studied demographically matched people with and without HIV between July 1, 2013, and December 31, 2021, who were at least 50 years old and had a hypertension diagnosis but no dementia diagnosis. Hypertension control was calculated using a disease management index (DMI), which captured degree and duration above the hypertension treatment goals of SBP less than 140 mmHg and DBP less than 90 mmHg. DMI values ranged from 0 to 100% (perfect control); hypertension was considered 'inadequately controlled' if DMI was less than 80% (i.e., in control for <80% of the time). Annual, time-updated DMI was calculated for SBP and DBP. Associations of SPB and DPB control with incident dementia were evaluated using extended Cox regression models.

RESULTS

The study included 3099 hypertensive people with HIV (mean age: 58.3 years, 90.2% men) and 66 016 people without HIV. Each year of inadequate SBP control was associated with greater dementia risk in both people with HIV (adjusted hazard ratio [aHR] = 1.26, 0.92-1.64) and people without HIV (aHR = 1.27 (1.21-1.33); P- interaction = 0.85). Similarly, inadequate DBP control was associated with greater dementia risk in both people with HIV (aHR = 1.43, 0.90-1.95) and people without HIV (aHR = 1.71, 1.50-1.93; P -interaction = 0.57).

CONCLUSION

Findings suggest the association of inadequate hypertension control with greater dementia risk is similar by HIV status. Stronger associations of DBP control with dementia merit further investigation.

Epidemiology of cardiometabolic health in Latin America and strategies to address disparities

In Latin America and the Caribbean (LAC), sociodemographic context, socioeconomic disparities and the high level of urbanization provide a unique entry point to reflect on the burden of cardiometabolic disease in the region. Cardiovascular diseases are the main cause of death in LAC, precipitated by population growth and ageing together with a rapid increase in the prevalence of cardiometabolic risk factors, predominantly obesity and diabetes mellitus, over the past four decades. Strategies to address this growing cardiometabolic burden include both population-wide and individual-based initiatives tailored to the specific challenges faced by different LAC countries, which are heterogeneous. The implementation of public policies to reduce smoking and health system approaches to control hypertension are examples of scalable strategies. The challenges faced by LAC are also opportunities to foster innovative approaches to combat the high burden of cardiometabolic diseases such as implementing digital health interventions and team-based initiatives. This Review provides a summary of trends in the epidemiology of cardiometabolic diseases and their risk factors in LAC as well as context-specific disease determinants and potential solutions to improve cardiometabolic health in the region.

Optimal Antihypertensive Systolic Blood Pressure: A Systematic Review and Meta-Analysis

BACKGROUND

Systolic blood pressure (SBP) lowering reduces major cardiovascular disease (CVD) and all-cause mortality. However, the optimal target for SBP lowering remains controversial.

METHODS

We included trials with random allocation to an SBP <130 mm Hg treatment target and CVD as the primary outcome. Data were extracted from each study independently and in duplicate using a standardized protocol. Random-effects meta-analysis was used to obtain pooled hazard ratios (HRs) and 95% CIs for CVD and all-cause mortality comparing SBP <130 and ≥130 mm Hg treatment targets. A secondary analysis compared the same outcomes for randomization to an SBP target of <120 or <140 mm Hg.

RESULTS

Seven trials, including 72 138 participants, met the eligibility criteria. Compared with an SBP target of ≥130 mm Hg, an SBP target of <130 mm Hg significantly reduced major CVD (HR, 0.78 [95% CI, 0.70-0.87]) and all-cause mortality (HR, 0.89 [95% CI, 0.79-0.99]). Compared with an SBP target of <140 mm Hg, an intensive SBP target of <120 mm Hg significantly reduced major CVD (HR, 0.82 [95% CI, 0.74-0.91]), but all-cause mortality was marginally insignificant (HR, 0.85 [95% CI, 0.71-1.01]). Adverse events were significantly more likely in the intensive SBP target groups, but the absolute risks were low.

CONCLUSIONS

This study suggests targeting an SBP <130 mm Hg significantly reduces the risks of major CVD and all-cause mortality. The findings also support an SBP target of <120 mm Hg, based on a smaller number of trials.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42023490693.

Health system barriers to hypertension care in Peru: Rapid assessment to inform organizational-level change

Traditional patient- and provider-level hypertension interventions have proven insufficient to halt hypertension as the leading cause of morbidity and mortality globally. Systems-level interventions are required to address factors challenging hypertension control across a social ecological framework, an under-studied topic particularly salient in low- and middle-income countries (LMICs) such as Peru. To inform such interventions, we sought to identify key health systems barriers to hypertension care in Puno, Peru. A participatory stakeholder workshop (October 2021) and 21 in-depth interviews (October 2021-March 2022) were conducted with 55 healthcare professionals (i.e., doctors, nurses, midwives, dentists, nutritionists), followed by a deductive qualitative analysis of transcripts and notes. Participating healthcare providers indicated that low prioritization and lack of national policies for hypertension care have resulted in limited funding and lack of societal-level prevention efforts. Additionally, limited cultural consideration, both in national guidelines as well as by some providers in Puno, results in inadequate care that may not align with local traditions. Providers highlighted that patient care is also hampered by inadequate distribution and occasional shortages of medications and equipment, as well as a lack of personnel and limited opportunities for training in hypertension. Multiple incompatible health information systems, complicated referral systems, and geographic barriers additionally hinder continuity of care and care seeking. Insights gained from health providers on the healthcare system in Puno provide essential contextual information to inform development of organizational-level strategies necessary to improve provider and patient behaviors to achieve better hypertension care outcomes.

Population-based approaches for reducing stroke risk: an update on their success and the challenges ahead

INTRODUCTION

Stroke is a significant public health challenge as it is the second most common cause of death and the third leading cause of disability globally. Additionally, stroke incidence and the number of stroke deaths have been rising. Efforts to prevent stroke have been made, including high-risk approaches where patients are screened for cardiovascular risk factors, and population-based approaches which attempt to reduce stroke rates by improving overall population health.

AREAS COVERED

We summarize studies of population-based approaches to stroke prevention involving greater than 1,000 participants identified on a PubMed database search. Based on these programs, challenges of population-based stroke prevention programs are discussed and potential keys to success are highlighted.

EXPERT OPINION

Population-based stroke prevention programs face challenges including cost and interest of the public and certain stakeholders. Additionally, secular trends for improvement in risk factors and catastrophic adverse environmental circumstances add to the complexity of analyzing program success. Factors leading to successful programs include validated digital solutions for self-monitoring of risks, backing by global policy and legislation, flexibility to the needs of the population, intersectoral programs, community engagement, information dissemination back to the populations, and high-risk screening to develop a complementary combination approach to stroke prevention.