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Background The World Health Assembly 2018 approved a resolution on rheumatic heart disease to strengthen programmes in countries where this condition remains a substantial public health problem. We aimed to describe the regional burden, trends, and inequalities of rheumatic heart disease in the Americas. MethodsIn this secondary analysis of the Global Burden of Disease, Injuries, and Risk Factors Study (GBD) 2017, we extracted data for deaths, prevalence of cases, disability-adjusted life-years (DALYs), years lived with disability, and years of life lost (YLL) as measures of rheumatic heart disease burden using the GBD Results Tool. We analysed 1990-2017 trends in rheumatic heart disease mortality and prevalence, quantified cross-country inequalities in rheumatic heart disease mortality, and classified countries according to rheumatic heart disease mortality in 2017 and 1990-2017.Findings GBD 2017 estimated that 3 604 800 cases of rheumatic heart disease occurred overall in the Americas in 2017, with 22 437 deaths. We showed that in 2017 rheumatic heart disease mortality in the Americas was 51% (95% UI 44-59) lower (1•8 deaths per 100 000 population [95% uncertainty interval 1•7-1•9] vs 3•7 deaths per 100 000 population [3•4-3•9]) and prevalence was 30% (29-33) lower (346•4 cases per 100 000 [334•1-359•2] vs 500•6 cases per 100 000 [482•9-519•7]) than the corresponding global estimates. DALYs were half of those globally (55•7 per 100 000 [49•8-63•5] vs 118•7 per 100 000 [108•5 to 130•7]), with a 70% contribution from YLL (39•1 out of 55•7 per 100 000). A significant reduction in rheumatic heart disease mortality occurred, from a regional average of 88•4 YLL per 100 000 (95% uncertainty interval 88•2-88•6) in 1990 to 38•2 (38•1-38•4) in 2017, and a significant reduction in income-related inequality, from an excess of 191•7 YLL per 100 000 (68•6-314•8) between the poorest and richest countries in 1990 to 66•8 YLL per 100 000 (6•4-127•2) in 2017. Of the 37 countries studied, eight (22%) had both the highest level of premature rheumatic heart disease mortality in 2017 and the smallest reduction in this mortality between 1990 and 2017.Interpretation The Americas have greatly reduced premature mortality due to rheumatic heart disease since 1990. These health gains were paired with a substantial reduction in the magnitude of income-related inequalities across countries, which is consistent with overall socioeconomic and health improvements observed in the Region. Countries with less favourable rheumatic heart disease situations should be targeted for strengthening of their national programmes.

This study provides the most comprehensive mortality analysis of this epidemic published to date and confirms an excess of CKD-N18 mortality and its relation with the epidemic of CINAC. The overall trends and the mortality pattern among women, children and adolescents suggest that the heat stress-dehydration hypothesis cannot fully explain this epidemic and that other environmental factors, more likely agricultural practices and agrochemicals, may be causally involved.

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 Pan American Health Organization (PAHO)-World Hypertension League (WHL) Hypertension Monitoring and Evaluation Framework is summarized. Standardized indicators are provided for monitoring and evaluating national or subnational hypertension control programs. Five core indicators from the World Health Organization hearts initiative and a single PAHO-WHL core indicator are recommended to be used in all hypertension control programs. In addition, hypertension control programs are encouraged to select from 14 optional qualitative and 33 quantitative indicators to facilitate progress towards enhanced hypertension control. The intention is for hypertension programs to select quantitative indicators based on the current surveillance mechanisms that are available and what is feasible and to use the framework process indicators as a guide to program management. Programs may wish to increase or refine the number of indicators they use over time. With adaption the indicators can also be implemented at a community or clinic level. The standardized indicators are being pilot tested in Cuba, Colombia, Chile, and Barbados.