Pan American Health Organization · 2022 edition
Step-by-step manual for implementing the HEARTS model for hypertension and cardiovascular disease risk management in primary health care.
- Issuer
- Pan American Health Organization
- Edition
- 2022 edition
- Audience
- National and subnational health ministry staff, PAHO/WHO country office focal points, HEARTS coordinating teams, primary health care managers and clinicians
- Evidence
- Based on WHO HEARTS Technical Package, Chronic Care Model, and field experiences from 22 implementing countries
- Reviewed
- 18 Oct 2026 · GMJ
What this guideline says
GMJ summary
This implementation guide operationalizes the WHO HEARTS Technical Package for cardiovascular disease risk management in primary health care across the Americas. It provides a practical roadmap for ministries of health, focal points, and health facility teams to implement evidence-based interventions focused on hypertension control as the entry point for comprehensive CVD prevention.
The HEARTS model encompasses six technical pillars: training and education, validated blood pressure measurement devices, standardized treatment protocols, team-based care delivery, data systems for monitoring, and implementation research. The guide describes a staged implementation approach (assess, develop, introduce, early expansion, scaling up, mature expansion) designed to achieve institutionalization of the model across health systems by 2025.
By 2022, 22 countries in the Americas were implementing HEARTS at various stages. The guide presents practical tools including the Maturity Index (scoring system for implementation quality across 8 hypertension control drivers), Performance Index (combining coverage and control outcomes), and detailed checklists for pre-implementation, national coordinating teams, site selection, training workshops, and launch activities.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Blood pressure control target: <140/90 mmHg for all hypertensive patients; <130 mmHg systolic for high CVD risk patients including those with diabetes
- Exclusive use of validated automated blood pressure measurement devices in primary health care by 2025
- Standardized treatment protocols using fixed-dose combination antihypertensive medications as first-line therapy
- Follow-up intervals: 2–4 weeks if blood pressure not controlled; 3 months for high CVD risk patients; 6 months for stable, well-controlled patients
- Three-month medication refill intervals for all stable and controlled patients
- Task-shifting: non-physician health workers trained to measure blood pressure (≥90% goal), conduct follow-up visits (≥70%), and titrate medications under supervision (≥70%)
- Coverage goal: register and treat all people with hypertension based on expected prevalence in the catchment area
- Monthly performance evaluation with feedback to health facilities (bi-monthly acceptable for small facilities; quarterly minimum)
HEARTS Maturity Index: Hypertension Control Drivers and Scoring
Table extracted from the guideline
| Driver | Recommendations | Goal | Score |
|---|---|---|---|
| 1. BP measurement accuracy | Training every 6 months; standardized protocols; validated devices | ≥90% each | 3 points |
| 2. CVD risk assessment | Assess all hypertensive patients; combination therapy for high-risk | ≥80% each | 2 points |
| 3. Standardized treatment protocol | Protocol with specific medications/doses; FDC medications | Implemented | 2 points |
| 4. Treatment intensification | Immediate treatment initiation; medication added/intensified per protocol | ≥70%, ≥80% | 2 points |
| 5. Continuity of care | Follow-up 2-4 weeks if uncontrolled; 6 months stable; 3 months high-risk | ≥80% each | 3 points |
| 6. Team-based care | BP by trained NPHW; follow-up by NPHW; medication titration by NPHW | ≥90%, ≥70%, ≥70% | 3 points |
| 7. Medication refill | 3-month refill intervals for stable patients | 3 months | 3 points |
| 8. Performance evaluation | Monthly evaluation with feedback | Monthly | 3 points |
Source: Pan American Health Organization, HEARTS in the Americas: Guide and Essentials for Implementation. Reproduced in summary form.
From the guideline
Verbatim
“By 2025, HEARTS will be the institutionalized model for cardiovascular disease risk management, including hypertension, diabetes, and dyslipidemia in primary health care in the Americas.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As someone who has worked closely with WHO on health systems strengthening, I recognize that this HEARTS implementation guide offers Georgia a proven framework to address our persistent cardiovascular disease burden through primary care. The most critical recommendation for Georgian clinicians is the adoption of standardized treatment protocols with immediate medication initiation and systematic intensification—our current practice too often delays treatment or under-treats hypertension. The Maturity Index scoring system provides an objective way to measure implementation quality across our polyclinics, which would support accountability under our universal health coverage programme. However, Georgian implementers must realistically assess two caveats: first, our current hypertension prevalence estimates may be outdated and need updating before setting coverage targets; second, the regulatory approval process for validated blood pressure devices will require sustained coordination between the Ministry of Health and the State Regulation Agency for Medical and Pharmaceutical Activities, which historically moves slowly on device standards.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 18 Oct 2026
Applicability
Georgia and the South Caucasus
For Georgia and the South Caucasus, this guide is highly relevant given the region’s high burden of cardiovascular disease and the emphasis on strengthening primary health care under universal health coverage reforms. Georgian implementers would need to adapt the scalable unit definition to the country’s polyclinic system and integrate HEARTS monitoring into existing electronic health records. The regulatory pathway for validated blood pressure devices would require coordination with Georgia’s national medicines agency. The emphasis on fixed-dose combination medications and task-shifting to nurses aligns well with ongoing primary care reforms in Armenia, Azerbaijan, and Georgia, though each country would need to assess current hypertension prevalence estimates, treatment protocols, and workforce capacity to set realistic coverage and control targets for initial implementation sites.
Questions this guideline answers
Quick answers
What is the minimum population size needed to start HEARTS implementation?
For countries with populations over 1 million, the recommended catchment area is at least 100,000 people served by a network of primary care centers. Countries with populations between 500,000–1 million should begin in selected health centers across the country. Countries under 500,000 should consider countrywide implementation early on.
How long does it take to see results from HEARTS implementation?
Changes in coverage and hypertension control at the primary care level should be visible within 6–9 months of full implementation. Reductions in cardiovascular events (acute myocardial infarction, stroke) can potentially be observed within one year. Medium-term impacts on complications like chronic kidney disease or peripheral vascular disease require longer observation.
What are the five levels of the HEARTS Maturity Index?
Level 1 (incipient): <7 points; Level 2: 7–10 points; Level 3: 11–14 points; Level 4: 15–18 points; Level 5 (mature): 19–21 points. The index scores implementation across 8 hypertension control drivers with a maximum of 21 points, helping facilities track quality improvement progress.
Who should be on the national HEARTS coordinating team?
The team should include representatives from: governing health institutions, primary care services, NCD programmes, medicines and health technologies departments, procurement, regulatory agencies, professional societies (cardiology, internal medicine, nephrology, family medicine, nursing, pharmacy), academic institutions, civil society organizations representing patients with chronic conditions, and PAHO/WHO.
Related on GMJ
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- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- 2022 edition
- Status
- Current
- Published
- 2022-01-01
- Languages
- English
- Scope
- Implementation of cardiovascular disease risk management in primary health care, with focus on hypertension control
- Audience
- National and subnational health ministry staff, PAHO/WHO country office focal points, HEARTS coordinating teams, primary health care managers and clinicians
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-75-12529-8 (print versi
- Evidence
- Based on WHO HEARTS Technical Package, Chronic Care Model, and field experiences from 22 implementing countries
- Record history
- Created 18 Oct 2026 · updated 18 Oct 2026 · next check Apr 2027
Pan American Health Organization. HEARTS in the Americas: Guide and Essentials for Implementation. Washington, D.C.: PAHO; 2022. Licence: CC BY-NC-SA 3.0 IGO.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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