Norman R. C. Campbell

Background: HEARTS in the Americas is the regional adaptation of the WHO Global HEARTS Initiative. This paper presents Phase 3 of HEARTS 2.0, an evidence-informed process to prioritize clinical and health-system interventions to support the operationalization of integrated cardiovascular, kidney, and metabolic (CKM) care in primary health care (PHC) and to inform the update of the HEARTS Clinical Pathway. CKM conditions frequently coexist, sharing common risk factors and pathophysiological mechanisms that exacerbate cardiovascular disease burden. Despite their overlap, clinical practice often remains siloed due to condition-specific guidelines, and its integration remains limited. To prioritize evidence-informed clinical and health-system interventions that support the operationalization of integrated CKM care within PHC and inform the update of the HEARTS Clinical Pathway. Methods: Building on previous phases of HEARTS 2.0, a multidisciplinary panel evaluated 45 candidate interventions in different areas. The selection process utilized structured evidence appraisal, Evidence-to-Decision frameworks, and a modified RAND/UCLA appropriateness method involving anonymized rating rounds. Results: A total of 38 interventions were prioritized for implementation. Although hypertension management remains the primary entry point, the resulting framework integrates early detection of diabetes and chronic kidney disease, lifestyle interventions, risk-based combination pharmacotherapy, task-sharing, and longitudinal follow-up. Conclusions: By translating dispersed guideline recommendations into implementable interventions, Phase 3 of HEARTS 2.0 provides an evidence-informed basis for advancing integrated CKM care at scale in PHC and guiding the forthcoming update of the HEARTS Clinical Pathway. The resulting framework offers a flexible, scalable approach for countries confronting similar epidemiological and health system challenges.

RESUMEN HEARTS Farmacia, un proyecto que forma parte de la iniciativa HEARTS en las Américas, proporciona un marco para integrar a profesionales de farmacia en la atención primaria de salud. Los profesionales de farmacia son muy respetados en el ámbito de la atención de salud, pero se enfrentan a diversos desafíos, como el alcance limitado de su labor, los obstáculos en la regulación y un reconocimiento insuficiente, que se ven agravados por normas sociales que les impiden desarrollar todo su potencial. En este artículo se presenta evidencia convincente que indica que las intervenciones dirigidas por profesionales de farmacia mejoran el control de la presión arterial, disminuyen el riesgo cardiovascular y reducen los costos de la atención de salud. Se subraya el papel de los sistemas nacionales de farmacia para garantizar el acceso a medicamentos de gran calidad. HEARTS Farmacia hace hincapié en el papel que desempeñan los profesionales de farmacia en la atención en equipo, y destaca su competencia en el manejo de medicamentos, la educación del paciente y la adherencia al tratamiento. En este artículo se aboga por cambios de política que empoderen a los profesionales de farmacia dándoles mayor responsabilidad y que les permitan desempeñar un papel activo en la atención del paciente. También se recomiendan medidas para la integración plena de los profesionales de farmacia en los equipos de atención, y para que sean un elemento clave en el control de la hipertensión y la gestión del riesgo de enfermedades cardiovasculares en la atención primaria de salud.

Wuopio et al. (22:104, 2025) examined associations between urinary sodium excretion and metabolic markers using an invalid method (a spot urine sample and the Kawasaki estimating equation (‘spot method’)). The spot method has both high random and systematic error, and has been shown to produce spurious health outcome and disease association. Due to false controversy generated by studies using spot method, it has been recommended not to be used in research associating dietary sodium to health outcomes by major international and national scientific organizations and experts. Wuopio et al. are aware of the methods limitations and concerns about its use but in our opinion did not address these issues in their manuscript. The spot urine method represents a good example of how an inappropriate research method can undermine scientific understanding and generate false controversy.

BACKGROUND: Inconsistent terminology and conceptual overlap among clinical practice guidelines, treatment protocols, and care pathways can lead to confusion in program design and implementation. METHODS: Drawing on the implementation experience of HEARTS in the Americas—the largest regional adaptation of the WHO Global HEARTS Initiative—this communication describes the characteristics, functions, and interrelationships of clinical practice guidelines, treatment protocols, and care pathways. It outlines their respective roles in development, approval, and execution to clarify their contributions to both health system organization and clinical practice. RESULTS: Clinical practice guidelines are composed of evidence-based recommendations grounded in rigorous scientific evaluation to support clinical decision-making. Care pathways serve as implementation tools that translate guidelines into standardized, multidisciplinary plans that organize hypertension management, facilitate task-sharing, and engage patients. Embedded within pathways, treatment protocols offer a simplified, step-by-step approach tailored to most patients, specifying a limited set of medications and dosages to ensure timely blood pressure control, reduce therapeutic inertia, and promote consistent care delivery. CONCLUSIONS: Clarifying the distinctions and synergies among guidelines, protocols, and care pathways might enhance alignment between clinical guidance and service delivery, supporting effective implementation and scale-up of hypertension and chronic disease management programs.

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.

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.