Internal Medicine PGY3 McMaster University Hamilton, Ontario, Canada
Background: In Canada, the hub-and-spoke model is utilised in the management of patients with ST-elevation myocardial infarction (STEMI). Patients who present to peripheral hospitals with a STEMI are sent to centres capable of percutaneous coronary intervention for management, and are often repatriated back to the periphery. Unfortunately, this system may be associated with fragmented care, inadequate follow-up, and suboptimal secondary prevention management. We implemented a Virtual STEMI Clinic (VSC) to facilitate early follow-up and identify gaps in care following a STEMI.
METHODS AND RESULTS: We referred all patients who were alive at discharge post-STEMI to the VSC, and prospectively included all patients who attended their appointment from November 9, 2023 to November 9, 2024. We pre-specified all data collection variables, which included demographics, STEMI characteristics, and cardiovascular risk factor assessment. Guideline-recommended targets were used to determine risk factor control. Our primary outcome was the number of new recommendations made at the VSC. Poisson and logistic regression analyses were used to determine the predictors most associated with new recommendations.
A total of 586 patients were seen in the VSC, of which 547 (93.3%) had a true STEMI and were included for further analysis. There were 733 STEMIs treated at our centre in the timeframe, indicating a follow-up rate of 74.6%. The mean follow-up took place within 4.30 (SD 1.77) weeks. Among the 547 patients, blood pressure control was deemed optimal in 520 (95.1%) patients, while lipid control was optimal in only 203 (55.2%) patients, and HbA1c was optimal in only 36 (25.1%) of 142 diabetic patients. Smoking cessation counselling was discussed in all of the 77 (14.1%) patients who were actively smoking. New Cardiac Rehab referrals were made for 166 (30.4%) patients. Altogether, 73.1% of patients had at least one intervention, 35.1% had at least two interventions, and 11.7% had at least three interventions. In regression analyses, the presence of anterior infarction, diabetes, and smoking were significantly associated with having at least one new recommendation. Similarly, diabetes and current smoking were significantly associated with an increase in the mean rate of new recommendations.
Conclusion: The VSC was able to systematically identify gaps in evidence-based secondary prevention care for patients discharged following a STEMI. This model provides a timely and patient-centered approach to bridging the fragmented transition of care from hospital to home. This simple and cost-effective virtual model holds promise for enhancing continuity of post-STEMI care at provincial and national levels.
