Continuity of care in acute coronary syndrome: why dedicated clinics for post-acute coronary syndrome management make the difference

Acute coronary syndrome (ACS) requires comprehensive post-discharge management to improve outcomes and prevent recurrence. This study evaluates the effectiveness of a structured, multidisciplinary Diagnostic-Therapeutic Care Pathway implemented in the Local Health Unit of Brindisi n.1 compared to traditional outpatient management by general practitioners (GPs). A retrospective analysis was conducted on 200 patients discharged after ACS: 100 were managed through a structured post-ACS clinic (network group), and 100 were followed on demand by GPs (control group). Clinical variables, therapeutic adherence, and risk factor control were assessed over 12 months. The network group showed superior clinical outcomes. Low-density lipoprotein cholesterol targets (<55 mg/dL) were reached by 87% of network patients vs. 34% of controls. Blood pressure was controlled in 98% of the network group vs. 88% in controls. Glycemic control (hemoglobin A1c <6.5%) was achieved in 78% of diabetic patients in the network vs. 64% in controls. All network patients received dual antiplatelet therapy, compared to 56% in the control group. Smoking prevalence was lower in the network group (11% current smokers) vs. controls (31%). Despite a higher mean body mass index (28.5 vs. 27.8), the network group demonstrated better overall metabolic control. The integrated care model significantly improved adherence to evidence-based therapies and achievement of cardiovascular risk targets. These results support structured follow-up pathways as a superior strategy in secondary prevention of ACS, promoting continuity of care, patient education, and therapeutic optimization. Widespread implementation of similar models could enhance long-term cardiovascular outcomes and reduce healthcare burden.