Regarding the communication and liaison between hospitals in the referral network, for referral of patients to the various levels of the network, a clear distinction was observed between urban hospitals and inland hospitals. Urban hospitals have a relatively small referral area for level 2 services (for cardiac surgery services, this area is larger, given the small number of level 3 centers) where knowledge of the network among referring hospital professionals was good and human resources were available for patient communication and transport. At inland hospitals, to which patients from larger areas were referred, there were barriers to effective patient movement. There was a reported lack of liaison between hospitals in the network, motivated in part by the lack of knowledge of the network structure itself by the professionals responsible for referral to higher level hospitals. This scenario, combined with the shortage of physicians (who are by law required to be present in-patient transport), resulted in reported delays in access to revascularization by percutaneous coronary intervention in a hemodynamic laboratory for AMI patients.

With regard to the communication of patients’ clinical information between health professionals, only in level 3 hospitals in the referral network was there a greater interconnection among systems and consequent greater ease in information flows, as the same clinical information platform (SClinico) is used by cardiologists and general practitioners. At the remaining sites, the method used to refer patients to health centers was by letter written and printed by the cardiologist, containing the relevant discharge information, which should then be delivered by the patient to the physician or to the administrative services of the health center.

In the area of cardiac rehabilitation, a noticeable cleavage was perceived between level 2 hospitals in the inland and rural part of the country in contrast to hospitals in denser urban areas. The latter, predominantly level 3, generally had established and structured cardiac rehabilitation programs, which included the integration of in-house and community facilities, according to the ESC recommendations for structuring into program phases8,9 as reported by practitioners. The smaller geographical dispersion of patients followed in these hospitals also helped the pursuit of these programs, which facilitated logistics in the interaction between hospital, gym, and home. On the other hand, in the set of inland hospitals and covering a wider coverage area, a structured cardiac rehabilitation plan was not available; there was mention of pilot projects to be implemented, and occasional and ad hoc attempts to provide specialized counseling (by physiotherapists, for example) to the patient, still during hospitalization. In one of the hospitals in a lower-density urban area, the existence of a structured program with in-hospital and out-of-hospital phases was mentioned; however, it was discontinued due to the impact of the COVID-19 pandemic and when it was operational it had experienced low adherence due to the difficulty of travel for patients to the facilities where it was conducted.

Regarding the availability of specialists from different areas complementary to Cardiology and General Practice (especially Psychologists, Nutritionists, Physical Medicine and Rehabilitation Physicians and Smoking Cessation specialists), the national panorama was more heterogeneous. Still, hospitals with highly structured cardiac rehabilitation programs infrequently offered these valences on an individualized basis. On the other hand, services traditionally provided by GPs (smoking cessation and nutritional counseling) were more often relegated to the professionals who would necessarily be in contact with the patient (cardiologists and GPs) in the center and south regions, both in-hospital and in primary health care. The availability of psychology consultations, when available, was mainly at the level of primary care centers, with differences in the location of the consultation and time slots available.

Finally, regarding the frequency of post-discharge hospital follow-up and the professionals involved, in most hospitals, a follow-up was reported with the first visit at three months post-discharge, repeating, on average, every six months for a period between one and two years in non-atypical patients. However, these values were indicated as being highly volatile. Indeed, different values were collected with different professionals in the same hospital. In all hospitals, the possibility of referral to specialized consultations was found in case of comorbidities present after discharge from the hospital consultation (mainly heart failure and cardiac devices consultation). Only one hospital reported telephone contact with the patient between hospital discharge and the first consultation, with the purpose of assessing the relevance of anticipating the consultation in less clinically stable patients. Detailed results are presented in Appendix 5, with the feedback collected from the cardiologists and GPs in the interviews performed during the study.

After analysis of the interviews with health professionals and based on the research conducted, experts conceived, by consensus, an ideal model of the post-AMI patient's pathway, as presented in the flowchart in Figure 1. This pathway takes in account needs consensually stated by experts, including:

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  The existence of a Cardiac Rehabilitation (CR) program in all hospitals with a Cardiology department with an in-hospital (Phase 1) and an out-hospital (Phase 2) phases, including exercise risk evaluation and intervention, education program, nutrition evaluation and intervention, risk factors evaluation and management (including smoking cessation, obesity and diabetes consults), medication optimization and adherence promotion and psychology evaluation and intervention components. After Phase 2, the patients should be referred to a community CR program (Phase 3) and to a General Practitioner (GP) with a referral letter. Patients should maintain regular appointments with a cardiologist according to the clinical situation.

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  Follow-up by a GP after CR (Phase 2) discharge, along with the cardiac rehabilitation program and in direct communication with the cardiologist of the cardiac rehabilitation program. This component will place emphasis on lifestyle advice and continued cardiovascular risk factor management. It also includes continuation of the CR Program in the community (Phase 3).

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  Possibility of referral to dedicated consultations in Nutrition, Smoking Cessation and Psychology through the CR program (Phase 3) and through the GP.

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  Possibility of referral by the GP to specialized cardiology consultations (heart failure, arrhythmology, etc.), or others (e.g. nephrology) manifesting comorbidities.

Figure 1.

Flowchart of the ideal post-AMI patient pathway.

(0.41MB).

In this pathway, the patient is admitted after traveling autonomously to the emergency department (if in existence at the hospital in question), via the Coronary Fast Track, or referral from a lower-level hospital in the Cardiology Referral Network. All these ports of entry are possible and were identified in the mapping with the hospitals.

After acute treatment, mostly focused on primary angioplasty, the patient is kept for 24–48 h in the coronary intensive care unit and then taken to the cardiology ward, where the patient remains for three to six days, if stable. During hospitalization, the parameters and doses of pharmacological therapy are optimized, and the necessary complementary diagnostic and therapeutic tests are ordered and analyzed.

Phase 1 of the CR program is also initiated, with intervention for the patient's education for lifestyle modification and risk factors management by the medical and nurse team. Early mobilization is promoted by physiotherapist and nurse. Intervention by specialists in Psychology, Nutrition, Smoking Cessation, and Physical Therapy, according to the patient's needs, can be done during hospitalization or early after discharge and hospitalization areas for this support must be available. An informed hospital discharge should be provided by a trained nurse or a cardiologist. The first Cardiology outpatient appointment and the onset of CR program (Phase 2) are also scheduled.

After clinical discharge from hospital, the patient's recovery can be grouped into four primary areas: Cardiac Rehabilitation Program, Cardiology Consultation, General Medicine Consultation and Everyday Life. In the period between discharge and the first visit, approximately in the first month, there should be a follow-up telephone contact by the Cardiology department where the patient was followed, to assess the patient's recovery and, if deemed necessary, change the priority of the first outpatient cardiology visit. This telephone contact should be performed by a cardiology nurse, to record outcomes of the first month of day-to-day life for the patient. This should be done independently from the CR Sessions and aims to question the patient on the actual experienced outcomes. In this call, a reminder should be given regarding the upcoming first post-discharge appointment.

In the CR program, according to national10 and European recommendations11 the patient enters Phase 2, which includes a clinical and functional evaluation for exercise capacity and possible limitations to exercise. The program includes CV risk factor management, the promotion of adherence to optimized treatment and modified lifestyle, a structured exercise program of two to three weekly sessions supervised by an exercise expert for an ideal period of three months (that can be extended to six months) and nutritional and psychological evaluation and intervention with a structured education program, identification of unstable cardiac situations and referral to exams and assistant cardiologist or hospital, as necessary. After this period, the patient is referred to a community institution, with a referral letter, where they can exercise and remain under surveillance (Phase 3). After Phase 2, decision to maintain dedicated consultations in Nutrition, Smoking Cessation and Psychology will depend on the patient's needs and health professional advice.

The Cardiology consultation takes place three months after hospital discharge, after Phase 2 of the CR program and is maintained with the regularity considered adequate by the attending physician for a period of one to two years in asymptomatic patients. Over follow-up, therapeutic adjustment and patient education are conducted, and it must be possible to refer patients to any of the areas highlighted above (Psychology, Nutrition, Smoking Cessation, and Physical Therapy). For a symptomatic patient, the follow-up at coronary patient consultations should be maintained. If new comorbidities are diagnosed, such as heart failure, or the need for implantation of a device (e.g., implantable cardioverter-defibrillator), the patient should be referred to a specialized consultation.

Follow-up by a GP starts when the patient goes to their usual attending physician, who has access (via computer system and/or letter) to information about the AMI event and CR program results. It is also a moment to adjust the pharmacological therapy, if necessary, and it is a vital moment for continuing patient education on lifestyles and cardiovascular risk reduction, which will be present in the patient's daily life. There should also be referrals to psychology, nutrition, smoking cessation, or other medical appointments that might be needed. Follow-up by GPs is done on an open-ended basis, and after discharge from the external cardiology consultation; GPs should be able to refer the patient back to the same or to a specialized cardiac appointment for comorbidities (e.g., heart failure) if necessary.

It is expected that the various strands of action listed above will be reflected in the patient's daily life, combining the ability to persuade the patient to adopt habits (non-smoking, healthy nutrition, increased physical activity and therapeutic adherence) and therefore reducing cardiovascular risk factors, predictors of new event, higher morbidity and higher mortality.