Post-hospital management of acute myocardial infarction patients in Estonia today and tomorrow

Abstract In 2022, Estonian Society of Cardiologists, Estonian Society of Rehabilitation Physicians and Estonian Society of Family Doctors published a consensus document (CD) describing the principles of handling pt-s with acute myocardial infarction (MI) in the first year after illness, emphasizing the systematization and quality of decisions during follow up and prioritizing the referral of perspective pt-s to the rehabilitation program. After that, implementation results were analysed and used to create a national treatment pathway (NTP) in February 2025. Purpose: Describe the compliance of the management with the CD and the basic principles of the NTP developed based on it. Methods: Estonian Health Insurance Fund and Prescriptions databases were used to obtain anonymous aggregated data for pt-s hospitalised due to acute MI from 2022-07-01 to 2023-12-31. CD recommended: within 4-6 w after discharge visit to rehabilitation doctor (RD), after 3 m (+/- 1 w) visit to RD or high risk pt-s visit to cardiologist, at the end of 6 m (+/- 2 w) and after a year (+/- 2 w) visit the family doctor. For every visit specific tasks were listed (t.e. analyses, treatment plan and goals update, referrals criteria). Data were collected within a year of the index episode of pt-s discharged from the hospital alive (excl inpatient services during index episode) and compared to CD. Results: The sample consisted of 2807 pt-s (1778 men, 63.3%), the average age was 70.5 y, 321 (11,4%) pt-s died during 1 year. Within 4-6 w after discharge, the 235 (8.4%) pt-s visited a RD. After 3 m (+/- 1 w), the 872 (31.1%) pt-s visited a cardiologist and 147 (5.2%) pt-s RD. At the end of 6 m (+/- 2 w), the 833 (29.7%) pt-s and after a year (+/- 2 w), the 391 (13.9%) pt-s visited the family doctor, respectively. However, only 23 (0,8%) pt-s followed recommended pathway (visits at the right time and in the right order). Prescription data until the end of the follow-up period was available for 2458 pt-s. Lipid-lowering drugs were prescribed to 2342 pt-s (95.3%), beta-blockers to 2215 pt-s (90.2%), ACEi/ARB/ARNI to 2190 pt-s (89.1%), P2Y12 inhibitors to 2063 pt-s (84.0%), oral anticoagulants to 764 pt-s (31.1%), SGLT2 inhibitors to 798 pt-s (32.5%). Conclusions: Most pt-s were not handled according to the CD. To improve pt care a NTP was created which emphasizes the following critical deficiencies -1) Leaving the hospital (t.e. a quality treatment plan, referrals, reservations, cardiologist-RD-family doctor direction decision, nurse-counselor visit (mutual transfer begins); 2) Rehabilitation (MI patients are "taken over" from the ward as soon as possible, the RD is responsible for carrying out the program (incl control of risk factors), availability of rehabilitation choice (center-based, independent guide, remote service); 3) Development of national digital solutions (metrics, interactive medication chart, automatic notifications), funding of nurse-counselor positions.