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The Pan American Health Organization (PAHO) is promoting HEARTS 2.0, a clinical pathway that consolidates dozens of scattered guidelines into a single framework comprising 38 prioritized interventions to improve early detection, timely treatment, and follow-up of high blood pressure and common comorbidities such as diabetes and chronic kidney disease. The tool was unveiled in a webinar ahead of World Hypertension Day and was published in the American Journal of Hypertension and The Lancet Primary Care.

HEARTS 2.0 expands PAHO’s HEARTS initiative to the cardio-renal-metabolic field. The initiative has already become the national standard for protocol-based detection and treatment of hypertension in 29 countries across the region. “HEARTS 2.0 is much more than a clinical tool. It is an instrument for transforming care models that make integrated care for non-communicable chronic diseases possible at the primary healthcare level. I am convinced it is here to be implemented,” said Esteban Londoño Agudelo, PhD, one of the co-authors and an international PAHO consultant on noncommunicable diseases, during the HEARTS 2.0 webinar attended by 3,000 professionals.

Although care is still managed in silos, there is no longer any doubt that hypertension, diabetes, and chronic kidney disease often coexist: They form a cluster of conditions that interact and increase the risk of complications, said the initiative’s leader, Pedro Ordúñez, MD, PhD, a physician and public health expert and senior adviser for cardiovascular (CV) disease management at PAHO.

Ordúñez described development of the HEARTS 2.0 clinical pathway as a rigorous evaluation of the highest scientific and academic evidence so that clinicians can return to their clinics, report to their countries, and tell health authorities, "Here is the evidence to address the cardio‑renal‑metabolic syndrome in primary care."

Marc Jaffe, MD, an endocrinologist at The Permanente Medical Group in San Francisco, California, said, “A 100‑page guideline may be interesting to read, but to treat people I wonder whether that is useful in practice.” He added, “The key is to identify people who are at high risk and prioritize them, giving them a little more attention. I’m very excited to see a simple treatment plan summarized on a single page.”

Thirty‑Eight Prioritized Interventions

The tool was developed in several phases. First, an international panel of experts reviewed the HEARTS recommendations for hypertension and identified 45 areas for improvement to expand the initiative’s scope to cardiorenal metabolic syndrome. In the second phase, 26 ministries of health across the region evaluated the feasibility of implementing these measures in primary care and identified the main barriers. In the third stage, a comprehensive evidence review using the GRADE methodology was conducted to select the 38 prioritized interventions included in the clinical pathway.

Andrés Rosende, MD, is a cardiologist and an international consultant for the HEARTS Initiative in the Americas at PAHO and an emerging leader in the World Heart Federation. He said the clinical pathway uses high blood pressure as a “gateway” and is organized into four stages:

• Diagnosis. “We need a standardized, very clear protocol that tells us how to diagnose hypertension and to use clinically validated automated devices so we can have confidence in the blood pressure reading that’s recorded,” Rosende said. The guideline sets standards for correct blood pressure measurement — including taking two readings and averaging them — and defines hypertension as a blood pressure of 140 mm Hg/90 mm Hg or higher in people not considered high risk, and 130 mm Hg/80 mm Hg or higher in those deemed high risk.
• Risk Stratification. “There is an interrelationship among risk factors. If I have a patient with hypertension, they are more likely to also have diabetes, especially if they are overweight. Moreover, if they have hypertension, overweight, and diabetes, they are much more likely to have chronic kidney disease. If I don’t think this way, I will never be able to detect these conditions and I won’t be able to prevent their progression to end‑stage disease,” Rosende said. The clinical pathway proposes identifying patients as “high risk” if they have at least one of the following conditions or scores: established CV disease; chronic kidney disease (glomerular filtration rate below 60 mL/min/1.73 m² or persistent albuminuria greater than 30 mg/g for more than 3 months); type 2 diabetes (A1c ≥ 6.5% or fasting glucose ≥ 126 mg/dL on two separate visits, or a random plasma glucose ≥ 200 mg/dL); or a CV risk score ≥ 10% according to the HEARTS risk calculator.
• Treatment. Once hypertension is confirmed, the guideline recommends a standardized treatment approach that starts with a two‑drug combination (for example, valsartan/amlodipine 160/5 mg) and then either uptitrates the dose or adds a diuretic, based on repeat blood pressure checks every two weeks. Rosende said, “Monotherapy should no longer be the rule except in very particular cases. Combined therapy must finally become the standard of care. If those two drugs are combined in a single pill, even better. And when we reach step three (adding hydrochlorothiazide 25 mg), we are beginning to see options that already combine three drugs. But each country will be able to adapt this clinical pathway to its possibilities.” Lifestyle modification remains essential, and high‑risk patients should also be considered for complementary treatments such as statins, aspirin, and SGLT2 inhibitors.
• Follow‑Up. “We should be able to give primary health care the tools to screen for frequent complications — that is, to monitor kidney function, glucose metabolism, or look for target organ damage with electrocardiograms, which are complementary interventions for CV prevention,” Rosende said. For example, if atrial fibrillation is detected, it is a “golden opportunity” to start anticoagulation therapy, which reduces the risk of stroke by up to 80%. The plan also recommends use of telemedicine to monitor adherence to prescribed regimens, dispensing medication for 3 months at a time, advising vaccination against influenza, COVID‑19, and pneumococcus, and involving nonphysician professionals and community health workers in blood pressure monitoring and treatment intensification.

In an interview with Medscape's Spanish edition, the authors were asked whether implementation of the clinical pathway could increase consultation time for primary care physicians and become a barrier to adoption.

“Not necessarily,” the authors said, “because the pathway redistributes workloads by optimizing processes and incorporating nonphysician staff in key roles. Also, clinical inertia and fragmented consultations end up being more time‑consuming in the long run than a standardized, comprehensive visit. Regarding kidney function tests and certain innovative drugs whose access varies across the region, the HEARTS 2.0 proponents believe the initiative can act as a catalyst to facilitate inclusion.” In the case of SGLT2 inhibitors, “Demonstrating their benefit in preventing hospitalizations for heart failure and delaying the need for dialysis is the technical evidence countries need to include them on essential medicines list and negotiate bulk purchases.”

“Could Have a Huge Impact”

The initiative has been well received by regional experts. “The implementation of HEARTS 2.0 could have a huge public‑health impact because it could reduce morbidity and mortality associated with hypertension and related cardiometabolic and renal diseases,” said Ricardo Gabriel López Santi, MD, president‑elect of the Inter-American Society of Cardiology, which will dedicate a panel on the topic at its next annual congress in Panama.

For Alejandro Ferreiro-Fuentes, MD, a nephrologist and former president of the Latin American Society of Nephrology and Hypertension, it is a “formidable” tool that turns theory into action. He stressed that its scope is primary care — where patients are — and that specialists can serve as referral sources when a patient’s clinical response differs from what is expected.

The tool is being presented amid warnings from experts about the difficulty of overcoming clinical inertia and turning evidence into action with population‑level impact. “Despite having more evidence, better treatments, and updated guidelines, population results are far from what’s expected. The gap is not in knowledge, but in implementation,” said Pablo Gulayín, MD, coordinator, and Vilma Irazola, MD, director, both of the Department of Research on Chronic Diseases at the Institute for Clinical Effectiveness and Health Policy in Buenos Aires, Argentina.

With its focus on primary care and its pragmatic synthesis of actionable interventions, the HEARTS 2.0 clinical pathway integrates multiple protocols and positions itself as a “super instrument” to respond to highly prevalent diseases, Rosende concluded.

Ordúñez, Rosende, and Londoño reported being members of the PAHO staff or serve as PAHO consultants. Jaffe, Ferreiro, and Irazola reported participating in Phase 1 of the HEARTS 2.0 project. 

This story was translated from Medscape's Spanish edition.