Scaling up cardiovascular disease management in primary care through HEARTS in the Americas.

While the world continues to grapple with the COVID-19 pandemic, the Region of the Americas, among the hardest-hit, has worked hard to respond to the pandemic while also maintaining essential public health programs. Noncommunicable diseases (NCDs) are among these programs, as they are the leading causes of death, disability and ill-health in this Region. Of the NCDs, cardiovascular diseases (CVDs) are responsible for 2 million (34.5%) of the 5.8 million NCD deaths (1), and have been a top priority for governments in the Americas since 2000. This is when the Pan American Health Organization (PAHO) Directing Council adopted a resolution urging governments to ‘strengthen and prioritize community and health service interventions, especially in primary care, that will lead to the prevention and control of cardiovascular disease and hypertension in particular’. Twenty-two years later, CVDs continue to prevail as the leading cause of death. Hypertension, the main risk factor for ischemic heart disease and cerebrovascular disease is highly prevalent, affecting more than a third (35.4%) of adults, and there has been little change since 2000 (prevalence of 34.5%)(2). Furthermore, there is a significant gap in hypertension treatment in the Americas, where only 40.9% of women and 32.3% of men with hypertension are adequately controlled (2).

There are renewed global and regional commitments to improve the response to NCDs, with the recent World Health Assembly adoption of the NCD roadmap towards the achievement of the Sustainable Development Goal target 3.4, to reduce premature NCD mortality by one-third by 2030. For CVDs, PAHO adapted the WHO Global HEARTS initiative to the Region in 2017, and has provided technical guidance to Member States on standardized hypertension treatment as described in the article by Ordunez et al. (3). Regional public goods have been created through training and education materials, resources to improve accuracy of blood pressure measurement, and a clinical pathway for hypertension control. The implementation is led by the Ministries of Health, with the participation of local stakeholders to strengthen existing health delivery services at the first level of care through standardized evidence-based treatment protocols. Various articles of this special issue of the Pan American Journal of Public Health report on the country experiences implementing Hearts in the public health programs of Chile, Colombia, Cuba, Mexico, Peru, St. Lucia, and Trinidad and Tobago.

But improving CVD prevention and control will take more than standardizing hypertension treatment guidelines, promoting behavior change, training providers and ensuring essential medicines and diagnostics are available. As highlighted in the article by Luciani et al. (4), transformation will be required in health system governance, and service organization and financing, so that NCDs are fully integrated throughout the health system and become a core pillar of routine primary care services. Indeed, as we look towards the post-pandemic period the focus should be on increasing capacity of the first level of care to address multiple chronic conditions, and integration with other complementary programs, such as women’s health, to strengthen diagnosis and management of NCDs.

Primary prevention of cardiovascular risk is critical, and includes prevention and control of tobacco use, healthy diets including reduced consumption of salt and trans fatty acids, and promotion of physical activity. The Americas has made important progress on tobacco control, with 30 Member States ratifying the WHO Framework Convention on Tobacco Control and 6 Member States implementing the Protocol to Eliminate Illicit Trade in Tobacco Products (5). But more work is needed on salt reduction and trans-fatty acids (TFA). PAHO’s regional sodium reduction targets and ongoing efforts to support countries to adopt and implement these targets are described by Allemandi et al (6). For TFA, while a 2008 PAHO Trans Fat Free Americas initiative pledged cooperation between the public sector and industry to eliminate and replace industrially producted TFA (IP-TFA) in the food supply, stronger regulatory measures are needed. Rincón-Gallardo et al. (7) note the progress in adoption of PAHO/WHO best practice policies for the elimination of IP-TFA by countries, including Brazil and Peru where the use of IP-TFA is now limited to no more than 2% of total fat in food products, which effectively eliminates their use.

No single organization can deliver the technical know-how, funding, and changes in management processes needed to transform health services and public policies to improve CVD prevention and control. In this regard, PAHO is proud to partner with national governments throughout the Americas, work with local professional associations and non-governmental organizations and to collaborate with leading health institutions that include WHO, the US Centers for Disease Control and Prevention, American Heart Association, Resolve to Save Lives, World Hypertension League, Inter-American Society of Cardiology, Latin American Society for Nephrology and Hypertension, among others, to improve the response to CVDs.

As PAHO celebrates its 120 year history of improving health in the Americas, and through this special supplement on the Hearts in the Americas Initiative published in the Pan American Journal of Public Health, it is my hope that successes in this Region can inspire, motivate and provide new knowledge to accelerate progress towards reducing cardiovascular diseases.