Hypertension and cardiovascular risk: a 2-hour HEARTS session

Key messages to land

1. Measure every adult, properly: rest 5 minutes, no talking, right cuff, second reading.
2. Confirm on a second day unless BP is 160/100 or more.
3. Use one protocol, step up every month, and never delay treatment for tests.
4. No ACE inhibitor, ARB or thiazide in women who could become pregnant without contraception: use amlodipine. If she is pregnant, follow the antenatal protocol: WHO (2020) favours methyldopa or a beta-blocker for non-severe hypertension in pregnancy.
5. Total risk decides how hard to treat; established heart disease or stroke is high risk without a chart.
6. Monthly until controlled, then every 3 to 6 months; adherence is built at every visit.

Running the skills station

• Measure the arm first. Participants are often surprised how many adults need a large cuff (over 32 cm).
• Ask the "patient" to talk through one reading and stay silent for the next, and compare.
• If you only have manual devices, add 10 minutes and pair less experienced participants with confident ones.

Common misunderstandings

"Headache means high BP"

Most people with hypertension have no symptoms. Headache is a poor guide.

"Stop the tablets once BP is normal"

Normal BP on treatment means the tablets are working. Stopping lets it rise again.

"We need blood tests before treating"

WHO advises testing only if it does not delay treatment. Amlodipine is suitable to start without tests.

"Aspirin for everyone at risk"

Low-dose aspirin is for people who have had a heart attack or ischaemic stroke, not for prevention.

Adapting the session

Replace the example medicines with those in your national protocol before the session. In a humanitarian setting, add 10 minutes on the page "Continuity of NCD care in emergencies" and shorten the risk section.

Case 1: The market trader

Mrs E, 49, came for a cough. Her BP is 152/96 on a careful reading. She has no symptoms, does not smoke, and has no diabetes. She has an implant for contraception.

1. Does she have hypertension?
   Answer: Not yet confirmed. A reading of 140 to 159 or 90 to 99 needs a repeat on another day, usually within 1 to 4 weeks. If it is 140/90 or more again, the diagnosis is confirmed.
2. Two weeks later her BP is 150/94. What treatment does your protocol give, and when do you see her next?
   Answer: Start the protocol medicines (for example an ACE inhibitor or ARB with amlodipine at starting doses, or the first step of your national protocol). She uses effective contraception, so an ACE inhibitor or ARB is acceptable. Review in one month and step up if still 140/90 or more.

Case 2: The young teacher

Ms F, 31, has confirmed BP of 158/98. She is not using contraception and hopes to have a baby in the next year. There is no laboratory at the clinic.

1. Which medicine is safest, and why?
   Answer: Amlodipine. ACE inhibitors, ARBs and thiazides should not be used in pregnancy or in women who may become pregnant without effective contraception. Amlodipine is also suitable to start without blood tests.
2. What if her BP is still raised on amlodipine 10 mg?
   Answer: Refer, as the WHO HEARTS protocols advise for women who could become pregnant and are not controlled at full dose.

Case 3: Two men, the same reading

Mr G is 46, a non-smoker without diabetes, BMI 24, BP 138/88. Mr H is 64, smokes, has diabetes, BMI 31, BP 138/88. Use the non-laboratory risk chart for your region.

1. Which man is at higher risk, and what changes in his plan?
   Answer: Mr H, who will be in a high-risk colour band on most regional charts. At 20% or more: counselling (stop smoking), consider BP medicines if BP stays 130/80 or more, a statin, and review every 3 months. With diabetes, WHO also suggests treating systolic 130 to 139. Mr G needs lifestyle advice and a recheck.
2. Why does WHO say risk scoring should not delay treatment?
   Answer: Most people with BP of 140/90 or more need treatment anyway. Scoring matters most for borderline readings (systolic 130 to 139) and should be done at or after starting treatment where feasible.

Read the questions aloud or print them. Participants choose one answer each. The answer key with reasons follows.

1. What should you do before measuring BP?
   1. Measure straight away to save time
   2. Let the person rest quietly for 5 minutes, seated with back supported
   3. Ask them to stand
   4. Take the reading over clothing
2. An adult's upper arm measures 34 cm. Which cuff?
   1. Standard cuff
   2. Large cuff
   3. Child cuff
   4. Either
3. Which first reading allows treatment on the same day?
   1. 142/88
   2. 150/95
   3. 162/102
   4. 135/85
4. Which is a WHO first-line class?
   1. Beta-blockers
   2. Long-acting dihydropyridine calcium channel blockers
   3. Loop diuretics
   4. Alpha-blockers
5. What does WHO suggest for initial treatment?
   1. One medicine at a low dose only
   2. Two medicines from different classes, preferably in a single pill
   3. Three medicines at full dose
   4. Lifestyle only for a year
6. Which medicine is safest for a woman who may become pregnant without contraception?
   1. Lisinopril
   2. Telmisartan
   3. Amlodipine
   4. Chlorthalidone
7. What is the usual target for someone with hypertension and no other conditions?
   1. Below 160/100
   2. Below 140/90
   3. Below 120/80
   4. No target
8. How often should someone be seen after starting treatment?
   1. Monthly until controlled
   2. Every 6 months
   3. Yearly
   4. Only if unwell
9. Who should take low-dose aspirin?
   1. Everyone with hypertension
   2. Everyone over 50
   3. People who have had a heart attack or ischaemic stroke
   4. People with headaches
10. Which conditions let a nurse start and adjust BP treatment under WHO guidance?
    1. Experience alone
    2. Training, prescribing authority, a protocol and physician oversight
    3. Patient request
    4. A doctor's verbal permission once

Answer key

1. B. Rest 5 minutes in silence, seated with back supported and legs uncrossed.
2. B. Use a large cuff when the arm is more than 32 cm round; a small cuff reads falsely high.
3. C. 160/100 or more can be treated the same day; lower raised readings need a second day.
4. B. The three first-line classes are thiazide-type diuretics, ACE inhibitors or ARBs, and long-acting dihydropyridine calcium channel blockers.
5. B. WHO suggests combination therapy, preferably a single-pill combination, to improve adherence and persistence.
6. C. Avoid ACE inhibitors, ARBs and thiazides; use a calcium channel blocker and refer if not controlled at full dose.
7. B. Below 140/90; systolic below 130 for people with cardiovascular disease, and suggested for high-risk groups.
8. A. Monthly until at target, then every 3 to 6 months.
9. C. Aspirin is for secondary prevention only.
10. B. All four conditions: training, prescribing authority, a specific protocol and physician oversight (which can be remote).