Protocol · WHO HEARTS
Cardiovascular risk and statins (HEARTS)
A person with several modest risk factors can be at higher risk of heart attack and stroke than someone with one high reading. Use the WHO risk charts to find the people who will benefit most, counsel everyone, and focus medicines on those at high risk.
- Based on WHO HEARTS
- For doctors, clinical officers and nurses
- Reviewed October 2026
1Who / when
- Adults aged 40 to 74 (the age range of the 2019 WHO charts), especially: smokers, people with obesity, hypertension or diabetes, a first-degree relative with early heart disease or stroke, or a first-degree relative with diabetes or kidney disease.
- People with known heart disease, stroke, peripheral arterial disease or kidney disease: do not use the chart. They are already at high risk (treat as 20% or more).
2Red flags: refer now
- Chest pain now, or signs of a heart attack.
- Signs of stroke or a recent transient ischaemic attack: new weakness, numbness, speech difficulty or facial droop.
- BP 180/110 or higher with headache, breathlessness, blurred vision or confusion.
- A cold, pale, painful limb.
These are emergencies, not risk-chart questions: refer the same day.
3Assess
Information for the chart
- Age, sex, current smoker or not, systolic BP.
- Laboratory chart: diabetes yes or no, and total cholesterol in mmol/L (mg/dL multiplied by 0.02586).
- Non-laboratory chart: body mass index instead (weight in kg divided by height in metres squared). Use it where cholesterol and glucose cannot be measured.
Using the chart
- Choose the chart for your region (21 regions).
- Pick the section (with or without diabetes, laboratory chart), then sex, smoking status and age band.
- Find the cell where systolic BP meets cholesterol (or BMI). Record the percentage.
DiabetesThe non-laboratory chart does not include diabetes, so it underestimates risk in people with diabetes. Use the laboratory chart for them.
4Classify
| 10-year risk | Band | Management (adapted from WHO PEN Protocol 1) |
|---|---|---|
| 30% or more | Very high | As for 20% to under 30% |
| 20% to under 30% | High | Counsel. Consider BP medicines if BP stays 130/80 or more. Give a statin. Follow up every 3 months; refer if risk has not fallen after 6 months |
| 10% to under 20% | Moderate | Counsel. Consider BP medicines if BP stays 140/90 or more. Follow up every 3 to 6 months |
| 5% to under 10% | Low to moderate | Counsel. Follow up every 3 months until targets are met, then every 6 to 9 months |
| Under 5% | Low | Counsel. Reassess in 12 months |
Treat regardless of the chart: established heart disease, stroke or peripheral arterial disease; kidney disease; diabetes with CVD (all as 20% or more); albuminuria, retinopathy or left ventricular hypertrophy; persistent BP 160/100 or higher; total cholesterol 8 mmol/L (320 mg/dL) or higher.
5Treat
Statins
- Give a statin when risk is 20% or more, and after a heart attack or stroke (start it with BP treatment).
- Statins are recommended for everyone with type 2 diabetes aged 40 and over, as long as this does not take money from glucose and BP medicines.
- Do not use statins in pregnancy, or in women who could become pregnant and are not using contraception.
| Medicine | Start | Higher dose | Watch for |
|---|---|---|---|
| Simvastatin | 20 mg in the evening | 40 mg in the evening | Muscle pain. With amlodipine or diltiazem, do not exceed 20 mg a day |
| Atorvastatin (alternative) | 40 mg | 80 mg | Muscle pain |
Other treatment
- Blood pressure: see the hypertension protocol. Diabetes: see the type 2 diabetes protocol.
- Low-dose aspirin (75 to 100 mg) only after a heart attack or ischaemic stroke, not for prevention.
6Follow-up
- Follow-up interval by band (see Classify). Reassess risk every 12 months in people not on medicines, or sooner if symptoms appear.
- Each visit: new symptoms, tobacco and alcohol, activity, diet, adherence, BP; re-estimate risk; refer if needed.
7Counsel
- Everyone: healthy diet (less salt, less fat), regular physical activity, stop all tobacco (smoked and smokeless), avoid harmful alcohol.
- Explain the risk as a number: "about 2 in 10 people like you will have a heart attack or stroke in the next 10 years".
- Risk goes down when BP and cholesterol are both treated; it roughly halves.
- Statins are long-term; keep taking them. Report unexplained muscle pain.
Your chance of a heart attack or stroke in the next 10 years is high. Stopping smoking, eating less salt, and taking these tablets every day will lower it.
8When to refer
- Same day: any red flag above.
- Risk 20% or more with no fall in risk after 6 months of follow-up.
- Total cholesterol 8 mmol/L or more.
- Statin side effects you cannot manage.
9Sources
- World Health Organization. HEARTS technical package for cardiovascular disease management in primary health care: risk-based CVD management. 2020 (ISBN 9789240001367). Risk bands, chart use, management table and follow-up (adapted from WHO PEN Protocol 1).
- WHO CVD Risk Chart Working Group. World Health Organization cardiovascular disease risk charts: revised models to estimate risk in 21 global regions (Lancet Global Health 7: e1332-45). 2019.
- World Health Organization. HEARTS technical package for cardiovascular disease management in primary health care: evidence-based treatment protocols. 2018 (WHO/NMH/NVI/18.2). Statin and aspirin example doses; statins not in pregnancy.
- World Health Organization. Diagnosis and management of type 2 diabetes (HEARTS-D). 2020 (WHO/UCN/NCD/20.1).
- World Health Organization. WHO package of essential noncommunicable (PEN) disease interventions for primary health care. 2020.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.