Post-myocardial infarction rehabilitation and secondary prevention in hospitals

Discussion

We found considerable variations between hospitals in discharge routines and the scope of cardiac rehabilitation for patients following myocardial infarction. A minority of hospitals used a standardised discharge summary template or arranged routine outpatient monitoring of patients. Most hospitals offered some form of systematic follow-up, but only 9 out of the 51 hospitals provided multidisciplinary comprehensive cardiac rehabilitation as recommended in the European guidelines (3).

A lack of risk factor control and a high incidence of new cardiovascular events in myocardial infarction patients highlight the need for closer secondary prevention follow-up (2, 4). In addition to changes in several recommended treatment targets and the development of new secondary prevention drugs, individualised treatment based on the patient's own wishes, age, comorbidities and risk profile is recommended to a greater extent than before (3). It can be argued that hospitals should also take greater responsibility for the follow-up of secondary prophylaxis after discharge. However, our study found that, although there is a documented beneficial effect on medication adherence and lifestyle changes (8), only a few hospitals offered routine outpatient post-myocardial infarction follow-up. Furthermore, general practitioners, who are primarily responsible for follow-up, are looking for more detailed information about treatment and expected follow-up (4). The use of standardised discharge summary templates can be an important tool in ensuring good transfer of information between the treatment levels.

Cardiac rehabilitation is associated with very favourable clinical and health economics effects and reduces total mortality by 20–60 % after a median follow-up of 24 months (5). Although most of the hospitals in our study reported that patients were referred for cardiac rehabilitation, the participation rate among patients in the NORSTENT study who underwent cardiac rehabilitation after percutaneous coronary intervention was only 28 % (6). This considerable divergence may be explained by long travelling distances, lack of provision or capacity, inadequate referral routines or low patient motivation. Vestfold Hospital has systematically referred patients to cardiac rehabilitation, with a participation rate of 75 % as a result (7).

Systemic barriers such as a lack of referral routines and low availability of provision are probably the main causes of the low participation rate in Norway. Only 18 % of hospitals offered multidisciplinary cardiac rehabilitation in line with European recommendations (3), while 27 % had 'heart school' classes without exercise training and 8 % had no provision for follow-up. Therefore, there is a clear need to expand the provision of cardiac rehabilitation at Norwegian hospitals. There is a need for further research into referral routines, barriers to participation, the content and quality of the various cardiac rehabilitation services, as well as evaluation of digital rehabilitation programmes. A registry to evaluate and improve cardiac rehabilitation is recommended (3), although not currently set up in Norway. Sweden has this type of registry, making it possible to evaluate the effect of the quality and availability of cardiac rehabilitation on new cardiac events, quality of life and survival (9).

This study used an interview guide that we developed ourselves with many closed questions and little room for elaboration of answers. Therefore, it is possible that important information about secondary prevention follow-up was not disclosed. The questions were not validated or used in previous studies. We did not manage to make contact with 11 of the heads of department. The study was conducted in autumn 2018, and the routines may have changed since then, but there is little reason to think that there have been any major changes apart from COVID-19 measures.