Hypertension is a common disorder of major clinical, public health, and economic importance. It is a strong independent predictor of premature death and disability from cardiovascular complications and death from all causes. Hypertension in Saudi Arabia represents 25.5% of our population.

One of the main mesures adopted by the ministre of health is the Model oF Care. It was introdused as partof The vision of our country(2030) in 2017.The model represents a method for restructuring health care through interactions between health systems and communities. It focuses on the patient's journey through health system and help to provide an organized, coordinated, and patient centered healthcare services. The outcomes of this model will be reflected on cost reduction, decrease in morbidity and mortality from chronic diseases as well as increase the satisfaction of patients and their caregiver.

We in the chronic care team are working together to improve chronic diseases care in the region that integrate the available resources with the best practices worldwide. We will also engage the healthcare workers at different healthcare levels to activate the role of multidisciplinary team in the management of chronic diseases.

Cardiovascular Risk Stratification ASSESSMENT:

1. Very high risk category : includes patients with: 3 ≥ risk factors and  SBP ≥ 180 or DBP ≥ 110, or patients with Acute Atherosclerotic Cardiovascular disease  (ASCVD)*. (Visit primary health center (PHC) & Acute care in specialized centers every 6 months)
2. High risk category : includes patients with  ≥ 3 risk factors and SBP  reading of (140-179) or DBP reading of (90-109), or 2 ≤ risk factors and SBP ≥ 180 or DBP ≥ 110. (Visit PHC & secondary care every 6 months, including HTN clinic).
3. Moderate risk category includes patients with 2 ≤ risk factors and  SBP reading of (140-179), or DBP reading of (90-109). (Visit PHC)
4. Low risk category includes patients with 1 ≥ risk factors and SBP  reading of (130-139) or DBP reading of (85-89). (Visit PHC)

PHC Referral Guidelines:

1. Patients grade I or II with no risk factors should not be referred to 2nd or 3rd care.
2. Patient grade I, II or III Hypertensive with the following should be referred to 2nd or 3rd care: TOD (CKD stage 3 or more).
3. Diagnosed diabetes type II and taking ≥ 3 anti HTN medications. ASCVD e.g. MI, PVD, TIA, or Stroke.
4.  Patients diagnosed with acute ASCVD must be referred to acute care centers. Identifying patients who are at risk of cardiovascular disease is based on Cardiovascular Risk Factors Assessment (check attachment in the appendix 6.3).
5.  Risk factors for Cardiovascular Diseases (CVD). Asymptomatic (Subclinical) Target Organ Damage (TOD). Associated clinical conditions (Established Clinical Cardiovascular Diseases).

Target Population for screening: based on Saudi Hypertension Management Society Guidelines (SHMS) Adults aged ≥ 18 Years