The heart attack may be over but the real danger begins at discharge, say cardiologists

Queensland’s cardiac experts have identified a critical fault line in the state’s health system. Patients leave the hospital treated and seemingly on the road to recovery, only to encounter a fragmented system precisely when preventing the next heart attack matters most.

A new roadmap developed by 14 Queensland cardiovascular experts is calling for a fundamental rethink of what happens after a cardiac event, arguing that the period between hospital discharge and ongoing community care has become one of the most consequential and neglected points in the patient journey.

The Queensland Cardiovascular Disease Expert Roundtable, convened by Amgen Australia with the Heart Foundation and Springfield Healthy Hearts, found that the state already possesses many of the clinical tools required to prevent repeat cardiac events. The problem is less an absence of health technologies and care models than an inability to consistently connect the patients, information and services required to deliver it.

For Sheree Hughes, General Manager of the Heart Foundation Queensland, the assumption that recovery ends when a patient walks out of hospital misses the most difficult part of the journey.

“Leaving hospital after a heart event isn’t the end of recovery – for most people, it’s actually where the hard work of rebuilding confidence and managing risk begins,“ said Hughes. “Right now, too many patients are falling through the gaps during that critical handover back to their GP. By partnering with experts, we’re building a practical roadmap to close those gaps, support families emotionally as well as physically, and ultimately help prevent the next heart attack. Local initiatives like Springfield Healthy Hearts are also helping to lead the way in showing how this can work.”

Around one in three heart attacks in Australia are repeat events. Cardiovascular disease contributes to one in four deaths and is responsible for almost 570,000 hospitalisations. Queensland has the country’s second-highest acute coronary syndrome admission rate and contains 12 of Australia’s 20 heart disease hotspots.

But the report’s most provocative finding is where it locates the opportunity to intervene. Across the discussion, the most fixable failure point was the transition from hospital to community care, particularly what is initiated in hospital, documented at discharge and subsequently acted upon by primary care and rehabilitation teams.

Patients are seeing the cracks. New consumer research commissioned by Amgen and conducted by YouGov gives that system-level concern a human dimension.

Among 506 Australian adults who had experienced one or more cardiac events, 41% reported problems with how information about their ongoing care was shared with their GP. Nine per cent (9%) said their discharge summary was not sent in a timely manner. More than a third struggled to access timely follow-up appointments, specialist cardiac care or rehabilitation. And while 79% reported mental or emotional health challenges after their cardiac event, 26% said they were offered no mental health support.

The findings expose a paradox at the heart of secondary prevention: patients are discharged with an urgent need for long-term risk management, yet the machinery responsible for delivering that care is fragmented and overwhelming to navigate.

Associate Professor David Colquhoun, Clinical Cardiologist, pointed to a disconnect between what medicine knows and what the health system is capable of delivering consistently.

“The clinical evidence is clear – addressing risk factors such as bad cholesterol and securing timely and co-ordinated follow-up care dramatically improves survival outcomes,” said Associate Professor Colquhoun. “But we cannot expect patients to manage this complex journey alone when the systems connecting their doctors are outdated.”

The report also flags an important equity consideration: women experience poorer cardiovascular outcomes than men, and the newly established Ministerial Expert Panel on Women’s Health is identified as a potential avenue for advancing cardiovascular prevention.

The experts have distilled their proposed fix into three recommendations.

First, Queensland should standardise and digitise cardiac discharge summaries, incorporating guideline-aligned prompts and risk-factor targets and making information easier to share across hospital, general practice and rehabilitation settings.

Second, continuity of care should be built into state-funded programs, with cardiologists, GPs, pharmacists, nurse practitioners and rehabilitation professionals working as a coordinated team rather than as disconnected parts of the patient’s journey.

Third, Queensland should develop an economic model capable of demonstrating what prevention actually saves, linking existing de-identified data to measure avoided hospitalisations and repeat cardiac events.

The experts point to cardiac rehabilitation as another piece of the puzzle, noting that services exist across Queensland but are not distributed or resourced equitably.

The roadmap therefore amounts to more than a plea for better discharge paperwork. It is also a proposal to change how governments measure the value of keeping people well enough to stay out of hospital.

A local experiment with a national ambition

The roadmap is closely linked to Springfield Healthy Hearts’ ambition for the Ipswich suburb of Springfield to become the “healthiest heart of the nation” by 2030.

But its architects are positioning the initiative as something larger than a local experiment. The report argues that the proposed model could be scaled across Queensland and potentially beyond, particularly because it focuses on changes to coordination, workforce utilisation, data and existing programs rather than creating an entirely new clinical pathway.

There is also an intriguing policy dimension.

Queensland already has initiatives aimed at improving cardiovascular risk management, including PHASES and the Queensland Pharmacy Chronic Conditions Management Pilot. The problem identified by the roundtable is that these programs largely operate within their own structures, with continuity between them relying heavily on broader systems such as My Health Record rather than being deliberately designed into the programs themselves.

The proposal, therefore, is not necessarily to start again. It is to make the pieces of an existing system behave more like a cohesive system.

For a health system under pressure from hospital demand, the argument is strikingly pragmatic. The next cardiac event may not be prevented by another dramatic intervention in the emergency department. It may be prevented by what happens after the patient leaves it.

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