Individualized assessment and optimization of post myocardial infarction care by introducing a hybrid clinic - A DGH experience
Authors: El-Din M , Dev D D , Farooqui A F , Helal A M , Elmorshidy M E , Hamid A H , Shaw C S 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Introduction
Optimal secondary prevention remains key in improving cardiovascular outcomes post myocardial infarction. Barriers to achieving timely and individualized medical optimization include unavailability of close follow up’s, compliance to secondary prevention, and more recently, the impact of COVID pandemic on outpatient face to face clinic appointments. With the recent emphasis from the European Society of Cardiology on secondary prevention in addition to optimizing lipid therapy, a dedicated service for post MI patients to address individualized risks can provide a timely opportunity to improve holistic cardiovascular care.

Purpose
To assess established secondary prevention practices, we initially audited 52 patients who presented with ACS between Jan 2020 and July 2020. These patients were assessed for post MI care optimization at 6 weeks post discharge. Utilizing ESC guidelines as audit targets, in our 6-week post discharge audit, we identified that there was scope of ACE-inhibitor up titration in 55.8% of the patients, beta-blocker optimization in 9.6%, Lipid lowering agents in 15.4%, mineralocorticoid receptor antagonist addition in patients with impaired LV systolic function in 5.8% of the patients. 5% of patients with new diagnosis of diabetes required referral to specialist teams for diabetic medication initiation or optimization. These results provided an opportunity to introduce a structured post MI clinic that will allow individualized risk assessment on an outpatient basis.

Method
We proposed a one stop hybrid clinic where all patients discharged following a myocardial infarction received a consultation 6 – 8 weeks following a discharge. These patients were sent blood forms 2-3 weeks prior to their appointment for full blood count levels, renal functions, liver profile, HBa1c levels and lipid profile. Focus of this consultation was to assess and educate the patient on risk factors (smoking, diabetes, cardiac rehab program), assess and address compliance to secondary prevention medications and finally titrate medications to maximum tolerated doses whilst achieving ESC defined targets for secondary prevention (post MI target systolic BP&lt;140mmHg in non diabetics and &lt;130mmHg in diabetics, LDLc &lt;1.4, smoking cessation, HBa1c &lt;49). Where appropriately identified, referral to lipid specialist and diabetes specialist teams were made to provide holistic multi-disciplinary management.

Results
To understand the Impact made by the clinic we obtained patient list through local electronic records to filter those discharged with a primary diagnosis of myocardial infarction in 2022. An audit tool was created and data collection was performed including baseline characteristics as per table 1 and interventions made Table 2.

Conclusion(s)
By establishing the post MI clinic we were able to demonstrate efficient individualized assessment and optimization of secondary prevention risk factors and pharmacotherapy.