Introduction:This research investigated the capabilities of ChatGPT-4 compared to medical students in answering MCQs using the revised Bloom's Taxonomy as a benchmark.Methods:A cross-sectional study was conducted at The University of the West Indies, Barbados. ChatGPT-4 and medical students were assessed on MCQs from various medical courses using computer-based testing.Results:The study included 304 MCQs. Students demonstrated good knowledge, with 78% correctly answering at least 90% of the questions. However, ChatGPT-4 achieved a higher overall score (73.7%) compared to students (66.7%). Course type significantly affected ChatGPT-4's performance, but revised Bloom's Taxonomy levels did not. A detailed association check between program levels and Bloom's taxonomy levels for correct answers by ChatGPT-4 showed a highly significant correlation (p<0.001), reflecting a concentration of "remember-level" questions in preclinical and "evaluate-level" questions in clinical courses.Discussion:The study highlights ChatGPT-4's proficiency in standardized tests but indicates limitations in clinical reasoning and practical skills. This performance discrepancy suggests that the effectiveness of artificial intelligence (AI) varies based on course content.Conclusion:While ChatGPT-4 shows promise as an educational tool, its role should be supplementary, with strategic integration into medical education to leverage its strengths and address limitations. Further research is needed to explore AI's impact on medical education and student performance across educational levels and courses.

Global Hearts is the flagship initiative of the World Health Organization to reduce the burden of cardiovascular diseases, the leading cause of death and disability worldwide. HEARTS in the Americas Initiative is the regional adaptation that envisions HEARTS as the model for cardiovascular disease risk management, including hypertension and diabetes, in primary health care in the Americas by 2025. This initiative is entering its sixth year of implementation and now includes 22 countries and 1 380 primary health care centers. The objectives of this report are three-fold. First, it describes the emergence and the main elements of HEARTS in the Americas. Secondly, it summarizes the main innovations developed to catalyze and sustain implementation of the initiative. These innovations include: a) introduction of hypertension control drivers; b) development of a comprehensive and practical clinical pathway; c) development of a strategy to improve the accuracy of blood pressure measurement; d) creation of a monitoring and evaluation platform; and e) development of a standardized set of training and education resources. Thirdly, this report discusses future priorities of the initiative. The goal of implementing these innovative and pragmatic solutions is to create a more effective health system and shift the focus of cardiovascular and hypertension programs from the highly specialized care level to primary health care. In addition, HEARTS in the Americas can serve as a model for more comprehensive, effective, and sustainable noncommunicable disease prevention and treatment practices.

La Iniciativa Mundial HEARTS. es la iniciativa emblemática de la Organización Mundial de la Salud para reducir la carga de las enfermedades cardiovasculares, la principal causa de muerte y discapacidad en todo el mundo. La Iniciativa HEARTS en las Américas es la adaptación regional que propone usar HEARTS como modelo para el manejo del riesgo de enfermedades cardiovasculares, incluida la hipertensión, y la diabetes en la atención primaria de salud en la Región de las Américas para el año 2025. Esta iniciativa está iniciando su sexto año de aplicación y ya incluye a 22 países y 1 380 centros de atención primaria de salud. Este informe tiene tres objetivos. En primer lugar, describir cómo surgió la Iniciativa HEARTS en las Américas y cuáles son sus principales elementos. En segundo lugar, resumir las principales innovaciones logradas para catalizar la iniciativa y mantener su aplicación. Entre estas innovaciones se encuentran: a) la introducción de factores impulsores del control de la hipertensión; b) el desarrollo de una vía clínica integral y práctica; c) la elaboración de una estrategia para mejorar la precisión de la medición de la presión arterial; d) la creación de un marco de seguimiento y evaluación; y e) la elaboración de un conjunto estandarizado de recursos de capacitación y formación. En tercer lugar, en este informe se examinan las futuras prioridades de la iniciativa. El objetivo de poner en marcha estas soluciones innovadoras y pragmáticas es crear un sistema de salud más efectivo y trasladar el enfoque de los programas cardiovasculares y de hipertensión del nivel de atención altamente especializada a la atención primaria de salud. Además, HEARTS en las Américas puede servir como modelo para unas prácticas más integrales, efectivas y sostenibles en la prevención y el tratamiento de las enfermedades no transmisibles.

Cardiovascular diseases are the leading cause of mortality and morbidity in the Region of the Americas, and hypertension represents its main risk factor. However, population hypertension control rates in the Region are poor. Global Hearts is the World Health Organization's flagship initiative to reduce the burden of cardiovascular diseases. HEARTS in the Americas Initiative is its regional adaptation that seeks to be the cardiovascular disease risk management model, including hypertension and diabetes, in primary health care throughout the Americas by 2025. HEARTS in the Americas is being implemented in 22 countries and over 2 095 primary care centers. All implementing countries have defined their treatment protocols, and HEARTS in the Americas has supported continuous improvement. Because WHO recently released the 2021 Guideline for the Pharmacological Treatment of Hypertension in Adults and HEARTS in the Americas introduced the key drivers for hypertension control, the initiative generated a methodology to help countries update and strengthen their treatment protocols. This article describes the process of developing the treatment protocol appraisal checklist and defines the resulting clinical pathway. This tool can help countries and primary care centers to improve their protocols by identifying the improvement points and upgrading clinical pathways.

The World Health Organization (WHO) Global Hearts Initiative offers technical packages to reduce the burden of cardiovascular diseases through population-wide and targeted health services interventions. The Pan American Health Organization (PAHO) has led implementation of the HEARTS in the Americas Initiative since 2016. The authors mapped the developmental stages, barriers, and facilitators to implementation among the 371 primary health care centers in the participating 12 countries. The authors used the qualitative method of document review to examine cumulative country reports, technical meeting notes, and reports to regional stakeholders. Common implementation barriers include segmentation of health systems, overcoming health care professionals' scope of practice legal restrictions, and lack of health information systems limiting operational evaluation and quality improvement mechanisms. Main implementation facilitators include political support from ministries of health and leading scientific societies, PAHO's role as a regional catalyst to implementation, stakeholder endorsement demonstrated by incorporating HEARTS into official documents, and having a health system oriented to primary health care. Key lessons include the need for political commitment and cultivating on-the-ground leadership to initiate a shift in hypertension care delivery, accompanied by specific progress in the development of standardized treatment protocols and a set of high-quality medicines. By systematizing an implementation strategy to ease integration of interventions into delivery processes, the program strengthened technical leadership and ensured sustainability. These study findings will aid the regional approach by providing a staged planning model that incorporates lessons learned. A systematic approach to implementation will enhance equity, efficiency, scale-up, and sustainability, and ultimately improve population hypertension control.

The COVID-19 pandemic has changed most aspects of everyday life in both the non-medical and medical settings. In the medical world, the pandemic has altered how healthcare is delivered and has necessitated an aggressive and new coordinated public health approach to limit its spread and reduce its disease burden and socioeconomic impact. This pandemic has resulted in a staggering morbidity and mortality and massive economic and physical hardships. Meanwhile, non-communicable diseases such as hypertension, diabetes mellitus, and cardiovascular disease in general continue to cause significant disease burden globally in the background. Though presently receiving less attention in the public eye than the COVID-19 pandemic, the hypertension crisis cannot be separated from the minds of healthcare providers, policymakers and the general public, as it continues to wreak havoc, particularly in vulnerable populations in resource limited settings. On this background, many of the strategies being employed to combat the COVID-19 pandemic can be used to re-energize and galvanize the fight against hypertension and hopefully bring the public health crisis associated with uncontrolled hypertension to an end.

Objectives: To raise awareness of blood pressure, measured by number of countries involved, number of people screened, and number of people who have untreated or inadequately treated hypertension. Methods: An opportunistic cross-sectional survey of volunteers aged at least 18 years was carried out in May 2017. Blood pressure measurement, the definition of hypertension and statistical analysis followed the standard May measurement month protocol. Eighteen countries in Latin America and the Caribbean participated in the campaign, providing us with a wide sample for characterization. Results: During May measurement month 2017 in Latin America and the Caribbean, 105 246 individuals were screened. Participants who had cardiovascular disease, 2245 (2.3%) had a prior myocardial infarction, and 1711 (1.6%) a previous stroke, additionally 6760 (6.4%) individuals were diabetic, 7014 (6.7%) current smokers and 9262 (8.8%) reported alcohol intake once or more per week. Mean SBP was 122.7 mmHg and DBP was 75.6 mmHg. After imputation, 42 328 participants (40,4%) were found to be hypertensive. Conclusion: The high numbers of participants detected with hypertension and the relatively large proportion of participants on antihypertensive treatment but with uncontrolled hypertension reinforces the importance of this annual event in our continent, to raise awareness of the prevention of cardiovascular events.

Hypertension is the leading risk factor for cardiovascular disease (CVD) worldwide. Despite the availability of effective antihypertensive medications, the control of hypertension at a global level is dismal, and consequently, the CVD burden continues to increase. In response, countries in Latin America and the Caribbean are implementing the HEARTS in the Americas, a community-based program that focuses on increasing hypertension control and CVD secondary prevention through risk factor mitigation. One key pillar is the implementation of a standardized hypertension treatment protocol supported by a small, high-quality formulary. This manuscript describes the methodology used by the HEARTS in the Americas program to implement a population-based standardized hypertension treatment protocol. It is rooted in a seamless transition from existing treatment practices to best practice using pharmacologic protocols built around a core set of ideal antihypertensive medications. In alignment with recent major hypertension guidelines, the HEARTS in the Americas protocols call for the rapid control of blood pressure, through the use of two antihypertensive medications, preferably in the form of a single pill, fixed-dose combination, in the initial treatment of hypertension. To date, the HEARTS in the Americas program has seen the improvement in antihypertensive medication formularies and the establishment of pharmacologic treatment protocols tailored to individual participating countries. This has translated to significant increases in hypertension control rates post-program implementation in these jurisdictions. Thus, the HEARTS in the Americas program could serve as a model, for not only the Americas Region but globally, and ultimately decrease the burden of CVD.

Aims Raised blood pressure (BP) is the biggest contributor to mortality and disease burden worldwide and fewer than half of those with hypertension are aware of it. May Measurement Month (MMM) is a global campaign set up in 2017, to raise awareness of high BP and as a pragmatic solution to a lack of formal screening worldwide. The 2018 campaign was expanded, aiming to include more participants and countries. Methods and results Eighty-nine countries participated in MMM 2018. Volunteers (>= 18 years) were recruited through opportunistic sampling at a variety of screening sites. Each participant had three BP measurements and completed a questionnaire on demographic, lifestyle, and environmental factors. Hypertension was defined as a systolic BP >= 140 mmHg or diastolic BP >= 90 mmHg, or taking antihypertensive medication. In total, 74.9% of screenees provided three BP readings. Multiple imputation using chained equations was used to impute missing readings. 1 504 963 individuals (mean age 45.3 years; 52.4% female) were screened. After multiple imputation, 502 079 (33.4%) individuals had hypertension, of whom 59.5% were aware of their diagnosis and 55.3% were taking antihypertensive medication. Of those on medication, 60.0% were controlled and of all hypertensives, 33.2% were controlled. We detected 224 285 individuals with untreated hypertension and 111 214 individuals with inadequately treated (systolic BP >= 140 mmHg or diastolic BP >= 90 mmHg) hypertension. Conclusion May Measurement Month expanded significantly compared with 2017, including more participants in more countries. The campaign identified over 335 000 adults with untreated or inadequately treated hypertension. In the absence of systematic screening programmes, MMM was effective at raising awareness at least among these individuals at risk.

Pragna Patel, MD, MPH, Pedro Ordunez, MD, PhD, Kenneth Connell, MBBS, PhD, Dan Lackland, DrPH, Donald DiPette, MD, and Standardized Hypertension Treatment and Prevention Network Centers for Disease Control and Prevention, Atlanta, Georgia, the Pan American Health Organization, Washington, DC, the University of the West Indies, Cave Hill Campus, St Michael, Barbados, the Medical University of South Carolina, Charleston, and the University of South Carolina School of Medicine, Columbia.

The American College of Cardiology (ACC), the American Heart Association (AHA), and several other organizations jointly produced the 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults, which was published in late 2017.1 While comprehensive and instructive, some components of this guideline were met by controversy and welcomed debate. The major controversial issues include the redefinition and reclassification of hypertension, new blood pressure (BP) treatment thresholds and targets, and the inclusion of individual cardiovascular risk evaluation in treatment decisions. Additionally, the guideline places increased emphasis on lifestyle modification, out-of-office BP measurements, fixed-dose combination drug therapy, and a team-based approach to the management of hypertension. The evidence behind these bold recommendations, as well as the practicality of their inclusion in real-world practice, have been questioned in the United States and other Western, high-income countries. Many of these nations have well-developed healthcare systems, and, despite this, might find it difficult to adopt some aspects of this new guideline. Consequently, societies such as the American College of Physicians, the American Academy of Family Physicians, and Hypertension Canada, have disagreed with some aspects of the new ACC/AHA hypertension guideline. Arguments have been made against the new classification of hypertension, the lower BP treatment thresholds, and the new BP targets now being recommended. To this end, these organizations have opted not to make significant changes to their existing treatment guidelines.2, 3 However, the discussion surrounding the application of this new hypertension guideline in Latin America and the Caribbean, a setting that lacks country-specific or up-to-date regional guidelines,4 has been sparse. Here, we will explore the practicality of the ACC/AHA 2017 hypertension guideline on the management of hypertension in low- and middle-income countries (LMICs), particularly those in Latin America and the Caribbean. We will also discuss strategies to improve cardiovascular outcomes in these settings. The 2017 ACC/AHA hypertension guideline is an update of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), published in 2003.5 The theme “lower is better” is dominant in the new 2017 ACC/AHA guideline with a complete reclassification of BP. Hypertension is here defined as a BP ≥ 130/80 mm Hg, a threshold that previously would be considered prehypertension. Other significant changes include new BP ranges for defining stage 1 and stage 2 hypertension, as well as the elimination of the category “prehypertension” (Table 1). Along similar lines, the treatment BP target, irrespective of cardiovascular risk factors, has been lowered to < 130/80 mm Hg. This is significantly lower than the previous 140/90 mm Hg target for the general population in prior versions of the guideline. Driving a number of the changes in the 2017 ACC/AHA hypertension guideline were the findings of the SPRINT (Systolic Blood Pressure Intervention Trial). SPRINT demonstrated that in patients with hypertension at high risk for developing cardiovascular complications, reducing systolic BP (SBP) to a goal of < 120 mm Hg, when compared with a standard treatment goal of < 140 mm Hg, resulted in a 25% reduction in primary cardiovascular end points and all-cause mortality. This was led primarily by a reduction in the rate of the development of congestive heart failure in the < 120-mm Hg treatment arm.6 Although noteworthy, the clinical applicability of SPRINT has been questioned. Important considerations, which may also be relevant to LMICs, particularly those in Latin America and the Caribbean, include the following: Despite these observations, SPRINT was well designed and conducted and the results obtained are valid. It is the first study to demonstrate that intensive lowering of SBP to a goal of < 120 mm Hg in high-risk patients with hypertension improves cardiovascular outcomes, including mortality. From the outset, applying the findings of SPRINT to real-world medicine has been deemed challenging and is likely to be impractical. Perhaps realizing some of the concerns of SPRINT, including the limited patient population and the methodology employed, as well as conflicting results from studies such as the HOPE-3 (Heart Outcomes Prevention Evaluation) trial,8 the ACC/AHA guideline set the BP treatment target to < 130/80 mm Hg. This target is higher than the 120/80 mm Hg target set in SPRINT. However, different than the well-defined, high-risk, restricted population of SPRINT, the ACC/AHA guideline extends the same BP treatment target of < 130/80 mm Hg to adults with hypertension of all ages, including persons with diabetes mellitus. This sweeping application to individuals who do not fit the SPRINT inclusion criteria was surprising to many, especially in the face of contradictory results from other trials2, 9; specifically, intense lowering of SBP to < 120 mm Hg in patients with diabetes mellitus, as was studied in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial, which failed to demonstrate significant benefit in reducing the composite of primary cardiovascular outcomes when compared with an SBP < 140 mm Hg in the standard treatment group.10 However, the longer-term, 9-year follow-up of the ACCORD participants, in what the investigators are calling ACCORDION (ACCORD Follow-on) trial, suggests benefit in the < 120-mm Hg treatment group.11 To date, there are limited data to confirm whether a reduction in cardiovascular outcomes can be achieved through the aggressive lowering of SBP achieved in SPRINT in other hypertensive settings, particularly, in patients with lower cardiovascular risk, younger individuals, current real-world clinical care settings, and in populations such as the very elderly where greater harm caused by adverse effects may occur. These questions might be amplified when considering the implications of the guideline and SPRINT outcomes to LMICs in Latin America and the Caribbean. Hypertension is now a global public health problem and its impact on disease burden is amplified in the resource-limited settings that define Latin America and the Caribbean. In this context, hypertension affects one third of the adult population. Of these hypertensive individuals, more than half are undiagnosed, approximately two third are untreated, and more than 80% are not adequately controlled to a BP of < 140/90 mm Hg.12 In Latin America and the Caribbean, this has resulted in an immense disease burden attributable to hypertension, quantified at 6.62% of disability-adjusted life-years.13 The barriers to the control of hypertension in Latin America, the Caribbean, and other resource-limited LMICs are complex and vast, going far beyond the BP value at which hypertension is diagnosed and treated. Some key barriers include the following.14-16 Of these barriers, the low awareness of hypertension status (approximately 63% in Southern Latin America and lower in other LMICs) is possibly most crippling to successfully increasing the control rates of hypertension and thereby decreasing the cardiovascular and renal complications from hypertension.12, 18, 19 In resource-limited settings such as Latin America and the Caribbean, the present healthcare infrastructure, as mentioned above, is a barrier to the widespread screening for hypertension. This has contributed to the high rates of undiagnosed and untreated hypertension, as well as to the poor control rates seen there. Fueling this problem is the presence of significant gaps in the provision of effective primary care services across the region, as has been highlighted in studies conducted in Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama.20 Consequently, access to appropriate healthcare facilities, particularly in remote rural locations, is often meager. This results in inconsistent screening for hypertension and poor follow-up.21, 22 This is the case with aboriginal communities across the Caribbean and Latin America region, which have reported hypertension control rates as low as 14%.23 To address this deficiency, the Pan American Health Organization (PAHO) developed and made available tools for population-based screening for hypertension in resource-limited settings; however, use of these resources has been poor.13 The release of the new hypertension guideline and its associated lower thresholds for diagnosing hypertension brings to the forefront the need for improved strategies to screen for hypertension, particularly in the Caribbean and Latin America. Continued exploration of population screening, including the utilization of creative means for nonphysician screening for hypertension, is urgently needed.24 One practical strategy is to enhance community-based screening for hypertension by building on existing infrastructure, which has been successful in addressing tuberculosis and HIV.14, 25 This approach has been employed in some African countries with positive results.26 Some success has already been achieved, through the efforts of both governmental and nongovernmental agencies, in increasing the awareness of chronic noncommunicable diseases, including hypertension, through an increased focus on population screening. In the Caribbean, there is the “Declaration uniting to stop the endemic of chronic noncommunicable diseases” (frequently termed the “Port of Spain Declaration”), which was signed in 2007 by the 15 member countries of the Caribbean Community.27 This government-level commitment to decreasing the burden of noncommunicable diseases has been deemed a success and acts as an essential background for governments to mobilize the resources needed to conduct screening for hypertension. Regarding nongovernment organization–led screening programs, several successful examples exist across the Caribbean. One such example is the recently concluded screening initiative conducted by the Healthy Caribbean Coalition, in which widespread screening for hypertension in Haiti, Saint Vincent and the Grenadines, Dominica, Jamaica, and Saint Lucia was undertaken.28 In Guyana, a recently concluded pilot study demonstrated that the establishment of pharmacy and pharmacist-based screening of hypertension is feasible.29 This emphasis on hypertension screening and surveillance in Latin America and the Caribbean will be essential to the successful application of the new ACC/AHA hypertension guideline, if adopted in whole or in part. Adopting the new hypertension guideline will logically result in a surge in the number of people diagnosed with hypertension and those requiring care. In the United States, for example, if the new 130/80-mm Hg diagnostic threshold were applied, the prevalence of hypertension among adults would reach as high as 50%, an increase of approximately 15%.1 Similar increases should be expected in Latin America and the Caribbean. This would result in a significant strain on resources, not only in developed countries but especially in LMICs, which are home to three quarters of the world's hypertensive population.30 The financial burden associated with hypertension is massive. Current global estimates of the cost of hypertension (both direct and indirect) are staggering, in excess of US $370 billion per year.31 In 2015, conservative estimates for select countries in Latin America, including Brazil, Chile, Columbia, Ecuador, El Salvador, Panama, Peru, Mexico, and Venezuela, noted an economic impact attributable to hypertension of US $5.3 billion. This equates to 0.12% of Gross Domestic Product32 which is certain to rise with the application of the new hypertension guideline. This is of added concern in LMICs, where a significant proportion of the financial impact of hypertension is absorbed through out-of-pocket spending by individuals.33 In this context, a “call to action,” similar to that triggered by the PAHO and the Centers for Disease Control and Prevention in 2013 to help combat the soaring impact of hypertension in LMICs in Latin America and the Caribbean14 is of even greater relevance in the face of these new guidelines To successfully cope with these increased financial demands, strategic planning by health officials will be paramount, with efforts focused on the prevention of hypertension, as well as reducing the cost of managing individuals diagnosed with hypertension. Such planning will need to include the development and implementation of well-structured, standardized, and simple programs. For example, one such program is the Standardized Hypertension Treatment and Prevention Project, now called the HEARTS in the Americas Initiative, which was recently piloted in Barbados, with noteworthy results.28 This program, which focuses on strengthening the healthcare system through the partnership of governmental and nongovernmental organizations and communities, is one viable way to move forward.34 Under the new ACC/AHA guideline recommendations, hypertension should be treated to a BP target of < 130/80 mm Hg in most adults starting with the use of aggressive lifestyle modification alone or together with pharmacologic intervention. This key step depends on the presence of cardiovascular risk and/or the stage of the hypertension. This new recommendation comes on the backdrop of the observation that achieving BP control, even when using a BP target of < 140/90 mm Hg, has been difficult in both high-income countries and LMICs.35 This is true in most countries in Latin America and the Caribbean, in which population control of hypertension falls as low as 19%.12 Indeed, even in Westernized, high-income countries such as the United States, the rate of control as defined by < 140/90 mm Hg is only 50% to 60% among adults.36 To best achieve these lower BP targets, strategies should be implemented to develop hypertension registries and to formulate simple diagnostic, treatment algorithms and evidence-based guided medication formularies. These formularies should include effective, affordable, and readily available antihypertensive drugs, including fixed-dose combinations, an approach that has been proven to be effective in improving control rates.37 This comprehensive approach will require health authorities in Latin America and the Caribbean to focus on both the effectiveness and the efficiency of the programs, which are already putting pressure on their limited health budgets.34 With this approach, the region can meet its goal of increasing population control of hypertension to 35% by 2019,38 as well as achieve the lower BP targets, if adopted. Given the theme of the ACC/AHA guideline of a more intensive approach to the management of hypertension, undoubtedly more individuals will require additional antihypertensive medications to reach BP targets. This will likely have significant downstream effects. Indeed, an increase of 15% to 20% in the prevalence of hypertension could further aggravate the current situation of poor availability and affordability of BP-lowering medicines, particularly in Latin America and the Caribbean. Two of the new recommendations are particularly relevant in this regard. First, in addition to lifestyle modification, pharmacologic treatment is now recommended for individuals with stage 1 hypertension and a cardiovascular risk > 10% (moderate risk) using the atherosclerotic cardiovascular disease (ASCVD) risk calculator. It is estimated that this will affect approximately 5% of individuals with stage 1 hypertension in the United States.1 For persons with stage 1 hypertension and a cardiovascular risk < 10%, the recommendation is to encourage lifestyle modification and follow up in the next 3 to 6 months. Importantly, no explicit recommendation is offered as to what to do if lifestyle modification fails to reach a goal BP of < 130/80 mm Hg within this time frame. If the goal BP is not achieved in this group, providers may opt to initiate drug therapy. Second, in individuals with stage 2 hypertension, (defined as a BP ≥ 140/90 mm Hg), if the goal BP is > 20/10 mm Hg from the treatment target goal of 130/80 mm Hg, it is now recommended to start treatment with two BP-lowering medications. While the use of fixed-dose combination therapy may help this situation, the added need for medications may pose a major challenge unless special measures are put in place to ensure sustainable medication procurement and increase pharmacy capacity. Fortunately, in Latin America and the Caribbean, PAHO has in place a strategic fund for the acquisition of a core set of affordable BP-lowering drugs available to each member state.39 Such initiatives will be key in offsetting the astronomical cost increase for the procurement of antihypertensive medications that might occur with the adoption of the AHA/ACC hypertension guidelines in Latin America and the Caribbean. At the patient level, this new recommendation translates to increased drug costs, increased pill burden, and polypharmacy, especially if concomitant diseases exist. While the use of complimentary pharmacologic classes of antihypertensive agents may reduce drug-related side effects, if BPs are lowered too rapidly or too low or there is an aggressive use of diuretics, an increased likelihood of undesirable side effects, such as dizziness, syncope, and falls may occur, especially in the elderly. Results from SPRINT demonstrated that intensive lowering of SBP was accompanied by an increase in dosage, as well as number of antihypertensive agents, used. This led to an increased incidence of adverse effects, including syncope, falls, electrolyte abnormalities, and acute kidney injury. However, unlike the intense monitoring of patients that was available during SPRINT, individuals in LMICs in Latin America and the Caribbean are unlikely to have the close follow-up needed to address these complications in a timely manner in order to avert more serious consequences. Interestingly, the ACC/AHA guideline uses the ASCVD risk calculation, mentioned above, to determine the need for pharmacologic treatment in stage 1 hypertension (Table 2). This recommendation has significant implications in LMICs, including those in Latin American and the Caribbean. Even though the cardiovascular disease risk can be estimated without laboratory tests,40 the use of the ASCVD risk calculator might prove challenging in LMICs, where obtaining key laboratory data (such as the lipid measurements needed to use the ASCVD risk calculator) are at times difficult and/or limited. Additionally, there are limited data to confirm whether the pooled cohort equations used by the ACC/AHA ASCVD risk calculator are accurate in predicting ASCVD risk in non-US settings, particularly in LMICs, for which the risk factors for cardiovascular complications are likely different. Indeed, there are no validated risk tables for most LMICs, where more than three quarters of deaths from cardiovascular disease occur.41 The PAHO has attempted to address this issue of regionally relevant cardiovascular risk calculators with the development of the PAHO/WHO cardiovascular risk calculator. This mobile phone application, which has been used increasingly in the region, uses WHO tables to estimate risk and might serve as an alternate, region-specific tool instead of the AHA/ACC ASCVD risk calculator, which uses American populations.42 The new hypertension guideline has increased the emphasis on the technique of measuring BP in the office setting, as well as the use of out-of-office BP measurements to augment in-office readings when making treatment decisions. Unfortunately, some aspects of these methods of measuring BP are not practical in real-world practice, including those similar to the robust in-office measurement performed in SPRINT. Thus, incorporating these recommendations in LMICs will prove challenging, given the limited availability of the dedicated clinic space, staff numbers, and level of training needed to perform BP measurements using the methodology in the guideline. Other limiting factors include the large numbers of patients, short visit times, and the availability of validated BP monitors. Within Latin America and the Caribbean, one approach would be to place emphasis on the affordable acquisition of both office and home BP monitors, and streamlining their use in certain populations, eg individuals for whom the diagnosis of hypertension is not certain and for those whose hypertension is difficult to control. Similarly, emphasis could be placed on achieving BP measurements using proper technique and validated devices in multiple community settings, such as at pharmacies, supermarkets, worksites, and churches. Recently, success was seen in a novel barbershop BP monitoring program conducted in black communities. With this approach, most participants in the intervention arm achieved BP < 130/80 mm Hg. Emulating such a program in Latin America and the Caribbean could reap dividends.43 Even though the new ACC/AHA hypertension guideline raises many questions and concerns, attempting to apply their recommendations, totally or in part, in LMICs, including those in Latin America and the Caribbean, may have a positive impact on decreasing the cardiovascular disease burden. However, for this to be realized, a robust effort will be required (Table 3). Since the introduction of the ACC/AHA hypertension guideline is still relatively recent, when focusing on LMICs, including those in Latin America and the Caribbean, we recommend that the following additional questions be considered and discussed: Much more impactful than the novelty of the guidelines and the inherent challenge to being adopted in LMICs, such as those in Latin America and the Caribbean, is the continued need to examine and address the present deficiencies in the detection and management of hypertension in the developing world. Significant strengthening of the existing healthcare systems and infrastructure is critical, through the widespread screening for hypertension, use of registries, and ensuring the availability of affordable, reliable BP-lowering medications and BP measurement devices. Until such systems are planned, and successfully implemented, and new evidence-based studies are available that address the areas of expert opinion incorporated in the new guidelines, these new recommendations are likely to be impractical in many LMICs. Finally, we recognize that the 2017 ACC/AHA new hypertension guideline poses an important ethical challenge. That challenge includes how the serious and thoughtful recommendations/guidelines of an expert panel can be adopted and followed in the real-world practice, when resources present a significant barrier. In this instance, it is not a matter of turning one's head and ignoring recommendations, but of establishing a more strategic plan to improve resources and to place a greater emphasis on the primary prevention of hypertension and finding innovative, cost-effective ways to improve the awareness, treatment, and control of hypertension. Donald J. DiPette, MD, is a Distinguished Health Sciences Professor of the University of South Carolina and of the University South Carolina, School of Medicine, Columbia, South Carolina, USA. The content, findings, and conclusions in this report are solely the responsibility of the authors and do not necessarily represent the official position of the PAHO or any of the authors' affiliated institutions.

•In the Americas, CVD represents about 38% of noncommunicable disease deaths.•A roadmap for secondary prevention in Latin America and the Caribbean is warranted.•Simple and practical guidelines should be developed and implemented.•PAHO proposes a realistic and efficient prevention coalition plan in Latin America to fight CVD.•The inclusion of the health system through health workers is highly recommended for a successful nationwide preventive program.

Cardiovascular diseases and stroke, especially hypertension, represent a significant global disease burden for both morbidity and mortality, with a disproportionately higher impact in vulnerable low- to middle-income countries. International initiatives such as the Centers for Disease and Prevention and the Pan American Health Organization Standardized Hypertension Treatment Project have been developed to address this burden on the Caribbean and Latin America populations. The disparity in disease burden observed in low- to middle-income countries is explained, in part, by differences in disease risks for different racial and ethnic groups with high blood pressure more prevalent and hypertension-related morbidity significantly higher in men and women of African heritage. In addition to the race and ethnic differences in indicators of socioeconomic status, access to care and health service delivery, the physiologic mechanism of high blood pressure including salt-sensitivity, may also play a significant role in the disparities in hypertension and hypertension-related outcomes. This article focuses on potential racial and ethnic differences in influences on the pathophysiology of hypertension in the Caribbean region of the world. The identification of such differences may be used in the development of population hypertension control strategies and treatment approach that address the excess disease burden in these populations. The consideration of strategies, such as salt reduction and hypertension awareness and treatment, are particularly relevant to the high-risk Caribbean region.

London Dialogue event, The Hospital Club, 24 Endell St, London, WC2H 9HQ, London, UK, 1 December 2015 Hypertension is a global health issue causing almost 10 million deaths annually, with a disproportionate number occurring in low- and middle-income countries. The condition can be managed effectively, but there is a need for innovation in healthcare delivery to alleviate its burden. This paper presents a number of innovative delivery models from a number of different countries, including Kenya, Ghana, Barbados and India. These models were presented at the London Dialogue event, which was cohosted by the Novartis Foundation and the London School of Hygiene & Tropical Medicine Centre for Global Noncommunicable Diseases on 1 December 2015. It is argued that these models are applicable not only to hypertension, but provide valuable lessons to address other noncommunicable diseases.

BackgroundHealthy People 2020 aim to reduce fatal atherosclerotic cardiovascular disease (ASCVD) by 20%, which translates into 310 000 fewer events annually assuming proportional reduction in fatal and nonfatal ASCVD. We estimated preventable ASCVD events by implementing the American College of Cardiology/American Heart Association (ACC/AHA) 2013 Cholesterol Guideline in all statin‐eligible adults. Absolute risk reduction (ARR) and number needed‐to‐treat (NNT) were calculated. Methods and ResultsNational Health and Nutrition Examination Survey data for 2007–2012 were analyzed for adults aged 21 to 79 years and extrapolated to the US population. Literature‐guided assumptions were used including (1) low‐density lipoprotein cholesterol falls 33% with moderate‐intensity statins and 51% with high‐intensity statins; (2) for each 39 mg/dL decline in low‐density lipoprotein cholesterol, 10‐year ASCVD10 risk would fall 21% when ASCVD10 risk was ≥20% and 33% when ASCVD10 risk was <20%; and (3) either all statin‐eligible untreated adults or all with ASCVD10 risk ≥7.5% would receive statins. Of 175.9 million adults aged 21 to 79 years not taking statins, 44.8 million (25.5%) were statin eligible. Treating all statin‐eligible adults would prevent an estimated 243 589 ASCVD events annually (ARR 5.4%, 10‐year NNT 18). Treating all statin‐eligible adults with ASCVD10 risk ≥7.5% reduces the number treated to 32.2 million (28.2% fewer), whereas ASCVD events prevented annually fall only 10.5% to 217 974 (6.8% ARR, NNT 15). ConclusionsImplementing the ACC/AHA 2013 Cholesterol Guideline in all untreated, statin‐eligible adults could achieve ≈78% of the Healthy People 2020 ASCVD prevention goal. Most of the benefit is attained by individuals with 10‐year ASCVD risk ≥7.5%.

Electronic health record data were analyzed to estimate the number of statin‐eligible adults with the 2013 American College of Cardiology/American Heart Association cholesterol guidelines not taking statin therapy and the impact of recommended statin therapy on 10‐year atherosclerotic cardiovascular disease (ASCVD 10 ) events. Adults aged 21 to 80 years in an outpatient network with ≥1 clinic visit(s) from January 2011 to June 2014 with data to calculate ASCVD 10 were eligible. Moderate‐intensity statin therapy was assumed to lower low‐density lipoprotein cholesterol by 30% and high‐intensity therapy was assumed to reduce low‐density lipoprotein cholesterol by 50%. ASCVD events were assumed to decline 22% for each 39 mg/dL decline in low‐density lipoprotein cholesterol. Among 411,768 adults, 260,434 (63.2%) were not taking statins and 103,478 (39.7%) were eligible for a statin, including 79,069 (76.4%) patients with hypertension. Estimated ASCVD 10 events were 18,781 without and 13,328 with statin therapy, a 29.0% relative and 5.3% absolute risk reduction with a number needed to treat of 19. The 2013 cholesterol guidelines are a relatively efficient approach to reducing ASCVD in untreated, statin‐eligible adults who often have concomitant hypertension.

Cardiometabolic risk describes a collection of risk factors, with a likely underlying pathophysiology, resulting in accelerated atherosclerosis and the terminal cardiovascular events of myocardial infarction and stroke. Beta-blockers, which are divided as vasodilators or non-vasodilators, are used in the treatment of hypertension and other cardiovascular diseases. Vasodilators have been shown to be of particular benefit in both blood pressure control and other cardiometabolic components with limited disturbance in metabolic parameters. Nebivolol, a third-generation beta-blocker (BB), acts by increasing nitric oxide (NO) bioavailability. This property may be especially important in NO-deficient population, such as black people, in regulating both blood pressure control and glucose homeostasis.