Download Best Practice - The Heart Foundation

GP management plan for
coronary heart disease (CHD)
Has been designed for patients with established coronary heart disease however it may be used for patients at high absolute
cardiovascular risk.
Doctor’s name: <DrName>
Patient’s name: <PtName>
Management plan history
(and team care arrangements):
 Past GPMP: <Past GPMP>
 Is this a review of a GPMP? <Is this
a review of a GPMP?>
 Past team care arrangement: <Past
team care arrangement>
 Health assessment: <Health
assessment>
 Home medicines review: <Home
medicines review>
D.O.B: <PtDoB> Medicare no: <PtMCNo>
Patient address: <PtAddress>
Age: <PtAge>
Address: <DrAddress>
Phone: <DrPhone>
Fax: <DrFax>
Date:
<TodaysDate>
Private health insurance details:
<PtHealthIns>
Telephone Home: <PtPhoneH>
Mobile: <PtPhoneMob>
Is the patient of Aboriginal or Torres Language spoken at home: <What language is spoken
Strait Islander origin? <Aborginal or
at home?>
Torres Strait Islander origin?>
Secondary prevention/cardiac
Chest pain action plan (yes/no):
(All patients must have a written action plan that they should follow in event of
rehabilitation program attended
chest pain.) <Chest pain action plan>
(yes/no): <Cardiac rehabilitation
program attended>
Allergies: <Reactions>
Family history: <FamilyHx>
Past medical history: <PMHAll>
Investigations: <Ix>
Medicines: <CurrentRx>
Note: the GP management plan for coronary heart disease (CHD) is provided by the Heart Foundation to health professionals as a tool
for CHD management in general practice. The sections recommendations and recommended targets should not be changed or altered
in any way. These recommendations are derived from Reducing risk in heart disease. An expert guide to clinical practice for secondary
prevention of coronary heart disease (Update 2012). Please see the Heart Foundation website at www.heartfoundation.org.au for Terms of Use.
GP management plan for coronary heart disease (CHD) (MBS Item No. 721)
© 2013 National Heart Foundation of Australia ABN 98 008 419 761
1
PRO-084-v2-BP
All rights reserved.
Medicine
Commenced/
Continued.
If no, what
reason
Yes
No
Medicines
Discussed
benefits
and side
effects?
Yes
Recommendation
Unless otherwise indicated, all recommendations
derived from National Heart Foundation of Australia and
the Cardiac Society of Australia and New Zealand
Reducing risk in heart disease. An expert guide to
clinical practice for secondary prevention of coronary
heart disease (Update 2012).
No
Antiplatelet agents
Use aspirin 75–150 mg/day for all patients
unless contraindicated. Clopidogrel can
be used where aspirin is contraindicated,
or with aspirin in patients who have
recurrent events or following treatment for
ACS (either fibrinolysis or stenting).
ACE inhibitors
(ACEI)/Angiotensin II
receptor antagonists
(ARA)
Recommended for all patients, especially
those at high risk of recurrent events,
unless contraindicated. Start early post
myocardial infarction (MI). Consider ARA
for patients who develop unacceptable
side effects on ACEI.
Beta-blockers
Recommended for all patients post MI,
unless contraindicated, and continued
indefinitely, especially in high-risk
patients.
(High-risk patients are defined as those with either
significant myocardial necrosis, left ventricular systolic
dysfunction, persistent evidence of ischaemia or
ventricular arrhythmia.)
Statins
Recommended for all patients, unless
contraindicated.
Anticoagulants
Use warfarin in patients at high risk of
thromboembolism due to AF post MI.
Aldosterone
antagonists
Epleronone may be used early (3-14days)
post MI in patients with left ventricular
systolic dysfunction and symptoms of
heart failure.
Medicine adherence
If poor adherence suspected, consider a
Home Medicine Review.
Short-acting nitrates
Recommended for all patients, unless
contraindicated, plus a written action plan
for chest pain.
Other
Note: the GP management plan for coronary heart disease (CHD) is provided by the Heart Foundation to health professionals as a tool
for CHD management in general practice. The sections recommendations and recommended targets should not be changed or altered
in any way. These recommendations are derived from Reducing risk in heart disease. An expert guide to clinical practice for secondary
prevention of coronary heart disease (Update 2012). Please see the Heart Foundation website at www.heartfoundation.org.au for Terms of Use.
GP management plan for coronary heart disease (CHD) (MBS Item No. 721)
© 2013 National Heart Foundation of Australia ABN 98 008 419 761
2
PRO-084-v2-BP
All rights reserved.
Risk factor
Smoking
Lifestyle/Psychosocial risk factors
Patient agreed
Current
goals and actions
Recommended targets
status
(how, who and by when)
<SmkStat
Complete cessation
us>
and avoidance of second-hand smoke.
Physical
inactivity
Progress, over time, to at least 30 minutes
of moderate-intensity physical activity on
most, if not all, days of the week (150
minutes per week minimum).
Nutrition
Establishment/
maintenance of healthy eating patterns,
with saturated fatty acid intake <7% and
trans fatty acid intake <1% of total energy
intake. Include 1g of eicosapentaenoic acid
(EPA) + docosahexaenoic acid (DHA) and
>2g of alpha linolenic acid (ALA) daily.
Limit salt intake to ≤4g/day (1550mg
sodium).
Healthy weight
Waist measurement
≤ 94 cm (males) or
≤ 80 cm (females);
BMI = 18.5-24.9 m2.
(Weight management goals based on studies of European
populations and may not be appropriate for all ages and
ethnic groups.)
Alcohol
Low risk alcohol consumption in people
who drink. ≤ 2 standard drinks per day or
≤ 1 standard drink per day for women with
high blood pressure or who are taking
antihypertensive medicine.
Depression
Assess all patients for co-morbid
depression. Initiate psychosocial and
medical management if appropriate.
Social support
Assess all patients for level of social
support and provide follow-up for people
considered at risk by referral to cardiac
rehabilitation and/or social worker or
psychologist.
Warning signs
of heart attack:
action plan
Provide written information and an action
plan for patients to follow in the event they
have warning signs of heart attack.
Other
Note: the GP management plan for coronary heart disease (CHD) is provided by the Heart Foundation to health professionals as a tool
for CHD management in general practice. The sections recommendations and recommended targets should not be changed or altered
in any way. These recommendations are derived from Reducing risk in heart disease. An expert guide to clinical practice for secondary
prevention of coronary heart disease (Update 2012). Please see the Heart Foundation website at www.heartfoundation.org.au for Terms of Use.
GP management plan for coronary heart disease (CHD) (MBS Item No. 721)
© 2013 National Heart Foundation of Australia ABN 98 008 419 761
3
PRO-084-v2-BP
All rights reserved.
Risk
factor
Lipids
Blood
pressure
Current
status
Biomedical risk factors
Patient agreed
goals and actions
Recommended targets
(how, who and by when)
LDL-C < 1.8 mmol/L; HDL-C > 1.0 mmol/L;
Triglycerides (TG)
< 2.0 mmol/L; non-HDL-C < 2.5 mmol/L.
BP < 130/80 mmHg including patients with
or without diabetes and/or stroke/TIA and/or
microalbuminuria.. Ambulatory BP
measurements: < 135/85 mmHg for daytime,
< 120/75 mmHg for night time, and < 130/80
mmHg for 24 hours.
(Microalbuminuria – men > 2.5 mg/mmol; women > 3.5
mg/mmol)
Diabetes
Identify undiagnosed type 2 diabetes;
maintain optimal BSL in those with diabetes
(HbA1c ≤ 7%).
Other
conditions




Other considerations
Implement a patient-centred approach, setting realistic goals and time frames in consultation
with the patient.
Consider strategies to support self-management, assess readiness for change and
explore barriers.
Provide written information and self-management resources, such as My heart for life and My
heart my life, that are available from the Heart Foundation.
Consider referral if appropriate.
For heart health information call 1300 36 27 87 or visit www.heartfoundation.org.au
Note: the GP management plan for coronary heart disease (CHD) is provided by the Heart Foundation to health professionals as a tool
for CHD management in general practice. The sections recommendations and recommended targets should not be changed or altered
in any way. These recommendations are derived from Reducing risk in heart disease. An expert guide to clinical practice for secondary
prevention of coronary heart disease (Update 2012). Please see the Heart Foundation website at www.heartfoundation.org.au for Terms of Use.
GP management plan for coronary heart disease (CHD) (MBS Item No. 721)
© 2013 National Heart Foundation of Australia ABN 98 008 419 761
4
PRO-084-v2-BP
All rights reserved.
Administration details
Date plan/service completed: <Date
Plan/Service Completed>
Proposed review date(s): <Proposed Review
Date>
Copy of CHD management plan offered to Copy of CHD management plan added to
patient? <Copy of CHD management plan patient’s records? <Copy of CHD management
offered?>
plan added to record?>
Other notes or comments:
Patient’s agreement
I agree with the goals of this plan and I understand the recommendations, including the costs
involved.
Patient’s signature: _______________________________________
Date: ______________
Patient’s name (in print): __________________________________________________________
I have explained the steps and any costs involved, and the patient has agreed to proceed with this
plan.
GP’s signature: __________________________________________
Date: _______________
Note: the GP management plan for coronary heart disease (CHD) is provided by the Heart Foundation to health professionals as a tool
for CHD management in general practice. The sections recommendations and recommended targets should not be changed or altered
in any way. These recommendations are derived from Reducing risk in heart disease. An expert guide to clinical practice for secondary
prevention of coronary heart disease (Update 2012). Please see the Heart Foundation website at www.heartfoundation.org.au for Terms of Use.
GP management plan for coronary heart disease (CHD) (MBS Item No. 721)
© 2013 National Heart Foundation of Australia ABN 98 008 419 761
5
PRO-084-v2-BP
All rights reserved.