Action to improve secondary prevention in coronary heart disease patients: one-year follow-up of a shared care programme

Aims The aim of the study was to improve the treatment and prevention of risk factors in coronary patients at discharge from hospital and later on. Methods A network between hospital and primary care physicians was created to develop a local shared care programme to improve secondary prevention in our area. The group identified barriers that impede effective preventive measures and implemented a programme with specific recommendations and goals for secondary prevention. After agreement on the programme, 305 patients discharged during 1997 were included and 278 (91.1%) of them followed for one year. Results The intervention improved the situation of all risk factors. At the end of one year follow-up, only 3.6% of the total population still smoked, 90% of them reached the goals of blood pressure, glycemia and exercise. The correction of overweight was much less impressive but significant and there were also significant reductions of total cholesterol, LDL-cholesterol and triglycerides as well as an increase in HDL. The prescription of statins increased significantly during follow-up (from 28.9% at discharge to 62.2% at one year). The global risk of the total population diminished significantly. Conclusion Our programme showed that a reinforced action on risk factor control in coronary patients can be successful.