The Salent–ima Prevention Network: Organizational Model for Continuity of Care Between Hospital and Territory

Introduction Since 2010, we have established a secondary prevention clinic for ischemic heart disease (IHD) dedicated to patients discharged after percutaneous myocardial revascularization, whether for elective PTCA or acute coronary syndrome (ACS) with or without ST–segment elevation (STEMI/NSTEMI). Materials & Methods Patients attending the clinic are stratified based on their thrombotic risk and risk of left ventricular dysfunction and followed with a specific diagnostic and therapeutic pathway, including monitoring adherence to including monitoring adherence to prescribed therapy and implementation of recommended lifestyle changes. Once the patient has been correctly stratified and the therapeutic targets required by the guidelines for proper secondary prevention have been reached, they are referred to the Community Cardiology Unit of the facility or of the relevant districts through a scheduled appointment with an exclusive booking diary. Results 1,093 patients were followed (899 men, 194 women; mean age 65.46 years). Of these, 22.6% had a history of chronic ischemic heart disease. The rehospitalization rate, to our unit or other departments in the Province, of the 1,054 patients who completed follow–up at the hospital outpatient clinic was 1.9% one year after the acute event. Furthermore, 89% of patients continuing follow–up at the Community Cardiology units continue to have LDL cholesterol levels within target range, according to the ESC Guidelines. Conclusions Given the results obtained, we believe the time has come to consider coronary revascularization as the initial therapeutic approach for acute coronary syndrome (ACS). This treatment must be complemented by ongoing stratification of the patient‘s residual risk, risk factor management, and lifestyle modification.