National Guidelines for the Management of Cardiovascular Diseases

Objectives

The guidelines seek to support a healthy population and national development by reducing chronic non-communicable disease incidence, unhealthy lifestyles, morbidity and mortality, while improving quality of life for people living with these conditions.[1]They provide nationally approved, standardised guidance for cardiovascular disease risk assessment, prevention, early detection, management, referral and health-worker capacity-building in Ghana.[1][2]

• Reduce cardiovascular disease morbidity and mortality through prevention, risk assessment and timely clinical management.[1][2]
• Address modifiable risks including hypertension, diabetes, dyslipidaemia, obesity, unhealthy diet, physical inactivity, tobacco use, excessive alcohol consumption and psychosocial stress.[3][4]
• Promote long-term lifestyle modification, including healthy eating, physical activity, weight management, tobacco avoidance, moderated alcohol consumption and stress management.[5][4]
• Strengthen early identification and treatment of major cardiovascular conditions, including cardiac arrest, hypertension, stroke, coronary artery disease, acute coronary syndromes, heart failure, venous thromboembolism, rheumatic heart disease, infective endocarditis and arrhythmias.[6][7][8]
• Use cardiovascular risk prediction to guide prevention and treatment, including the World Health Organization and International Society of Hypertension risk chart for Ghana and the wider Africa zone D.[9]
• Support secondary prevention and complication reduction through risk-factor control, appropriate medicines, rehabilitation, patient education and specialist care where needed.[10][11][12]

Implementation

The guidelines use a tiered, facility-based delivery model that matches assessment, treatment, equipment, medicines and referral responsibilities to service capacity, from facilities without a doctor to facilities with doctors, physician specialists or family physicians, and cardiologist-led specialist centres.[13]Clinical guidance is designed to standardise practical decision-making while enabling escalation where staff expertise, diagnostics, medicines or advanced procedures are unavailable.[14][15]

• Apply five levels of care: all levels; facilities without a doctor; facilities with a doctor; facilities with a physician specialist or family physician; and specialist facilities with cardiologists and sophisticated equipment.[13]
• Equip lower-level facilities with essential diagnostic tools, first-line medicines, basic life-support capacity and defined referral routes; provide higher-level facilities with laboratory testing, imaging, electrocardiography, advanced cardiac investigations, catheterisation, telemedicine and specialist medicines.[16]
• Train healthcare workers, community health officers, midwives, nurses, physician assistants, doctors, pupils, students, commercial drivers and security personnel in basic or advanced life support according to their roles.[16]
• Establish emergency response teams for each unit, day and shift, with the skills, equipment and medicines to respond within five minutes, and train paramedics and equip ambulances for resuscitation and patient care.[17]
• Use the World Health Organization technical package for cardiovascular disease management in primary health care to guide recommended technologies, resources, tools and medicines.[13]
• Implement clinical pathways covering immediate resuscitation and defibrillation for cardiac arrest, standardised blood-pressure measurement and stepped hypertension treatment, rapid stroke imaging and referral, acute coronary syndrome triage, heart-failure management, anticoagulation for venous thromboembolism, and rhythm assessment and treatment.[18][19][20][21][22][23][24]
• Refer patients promptly when necessary expertise, diagnostic tools or medicines are unavailable, investigations are abnormal, complications arise, a second opinion is requested or a higher level of care is required.[15]
• Notify and discuss referrals with receiving facilities in advance, provide structured referral letters, and return feedback detailing final diagnosis, treatment, follow-up instructions and contact details to support continuity of care.[15][25]
• Engage the Ministry of Health, Ghana Health Service, Non-Communicable Disease Control Programme, Korle-Bu Teaching Hospital, University of Ghana School of Medicine and Dentistry, Ghanaian Society of Cardiology and Ghana Heart Initiative Governance Committee in guideline development, coordination and governance.[26][2]
• Involve teaching and regional hospitals, universities, the National Health Insurance Authority, community health facilities, professional bodies, non-governmental and faith-based organisations, traditional leadership and other health-sector partners.[26][27]
• Grade clinical evidence from A to C, ranging from multiple randomised trials or meta-analyses to expert consensus, small studies, retrospective studies and registries.[13]
• Use clinical measures to guide individual care, including cardiovascular risk scores, blood-pressure targets, lipid and glucose targets, repeat investigations, medicine adherence, referral response and emergency response readiness.[4][28][29]
• Maintain documented referral, feedback, diagnosis, treatment, outcome, discharge and review information to support continuity of care and professional accountability.[25]

The guidelines identify clinical performance standards and follow-up measures, but do not specify a comprehensive programme-level monitoring and evaluation framework, routine reporting system, surveillance arrangements, indicator ownership, audit process, implementation timetable, budget or financing mechanism.[14][26][16][25]

Monitoring & Evaluation

The guidelines provide extensive clinical monitoring and decision-support measures across cardiovascular conditions, but do not establish a unified programme monitoring and evaluation framework, national indicator set, reporting schedule, surveillance system, audit process or formal accountability targets for implementation.[14][2][25]

• Use governance and quality functions within the Ghana Health Service, including the Policy Planning Monitoring and Evaluation Division, Non-Communicable Disease Control Programme, Ghana Heart Initiative Governance Committee and a regional quality focal person.[26]
• Document referrals and feedback using Ghana Health Service forms that record patient details, examination and investigation findings, treatment, diagnoses, outcomes, discharge status, recommendations, review dates and responsible officers; return feedback forms in duplicate to the referring facility.[25]
• Apply evidence grading for clinical recommendations, ranging from level A evidence from multiple randomised trials or meta-analyses to level C expert consensus, small studies, retrospective studies or registries.[13]
• Monitor service readiness through the availability of recommended equipment, medicines, trained personnel, ambulance resuscitation capacity and emergency teams able to respond within five minutes.[16][17]
• Assess cardiovascular risk with World Health Organization/International Society of Hypertension charts for Africa zone D, using age, sex, diabetes status, smoking, systolic blood pressure and total cholesterol, or a cholesterol-free chart where testing is unavailable.[9]
• Track prevention and risk-factor management through blood-pressure, glycaemic, lipid, physical-activity, sedentary-time, tobacco, diet, weight and waist-circumference measures.[4][30]
• Review lipid-treatment adherence and response through repeat lipid testing four to twelve weeks after starting or adjusting statins and then every three to twelve months as needed.[28][31]
• Monitor hypertension through standardised repeated blood-pressure measurements, ambulatory monitoring where available and home readings taken over at least three days before clinic review.[19][32]
• Use clinical follow-up and referral triggers, including blood-pressure response after two to four weeks, abnormal investigations, complications and persistent lack of control.[33][34]
• Monitor emergency and acute-care patients through vital signs, consciousness, oxygen saturation, blood glucose, seizure activity and condition-specific investigations, while using rapid referral where facility capability is insufficient.[35][20][36]
• Apply condition-specific scores and diagnostic pathways, including ABCD2 for transient ischaemic attack, ROSIER for suspected stroke, Wells scores for deep-vein thrombosis and pulmonary embolism, CHA₂DS₂-VASc and HAS-BLED for atrial fibrillation, and modified Jones and Duke criteria for rheumatic fever and infective endocarditis.[37][11][38][23][24][39][40]
• Undertake specified clinical follow-up, such as international normalised ratio testing for warfarin, serum potassium checks for selected resistant-hypertension treatment, repeat echocardiography where indicated, and clinical and echocardiographic review during the first year after infective endocarditis treatment.[41][42][43][44]

Costing & Financing

No overall implementation budget, financial allocation, financing source, resource-mobilisation plan, funding-gap assessment or economic assumption is specified for the cardiovascular disease guidelines.[1][2]

• Identify substantial resource requirements through the recommended tiered package of diagnostic equipment, laboratory and imaging capacity, medicines, specialist technologies, emergency teams, ambulances, training and referral communication, but provide no associated prices or financing arrangements.[16][17]
• Recognise that magnetic resonance imaging availability and cost constrain its use in acute stroke care in Ghana.[36]
• Recognise that medical complications after stroke increase care costs, length of hospital stay, readmissions, rehabilitation delays and mortality.[45]
• Consider cost alongside comorbidities and patient preference when selecting antiplatelet treatment.[11]
• Recognise affordability barriers to fibrinolysis and revascularisation, with maximised medical therapy recommended when patients cannot afford these interventions.[46]
• Specify medicines, investigations, devices and specialist services across conditions, including statins, anticoagulants, thrombolysis, cardiac catheterisation, implantable devices and advanced imaging, without costing these inputs or defining their funding source.[30][47][48]