GP management plan for 
coronary heart disease (CHD)

Applies to acute coronary syndromes, myocardial infarction, coronary angioplasty with/without stenting, and bypass surgery.

<DrDetails>	Date: 
<TodaysDate>	Management plan history 
(and team care arrangements):
•	Past GPMP:      
•	Is this a review of a GPMP?      
•	Past team care arrangement:      
•	Health assessment:      
•	Home medicines review:      	
Patient’s name:  <PtName>
Patient address:  <PtAddress>
Telephone:  <PtPhoneH>	D.O.B: 
<PtDoB>

Age: <PtAge>	Medicare no:      
Private health insurance details: 
	
Is the patient of Aboriginal or Torres Strait Islander origin?    
	Language spoken at home: 
     	
Ongoing prevention/cardiac rehabilitation program attended (yes/no):     
	Chest pain action plan (yes/no): 
(All patients must have a written action plan that they should follow in event of chest pain.)     	
Allergies:
<Reactions>     
	
Family history:
<FamilyHx>     
	
Past medical history:
<PMHAll>     
	
Investigations: 
<Ix>     
	
Medicines:
<CurrentRx>     

Medicine	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 2008.)	My role in this care plan  and Lifestyle changes 	
Who will do this?	
Antiplatelet agents 	Use aspirin 75–150 mg/day for all patients unless contraindicated.	     	     	
ACE inhibitors (ACEI)/Angiotensin II receptor antagonists (ARA)	Consider ACEI in all patients, especially those at high risk, unless contraindicated. Start early post myocardial infarction (MI). Consider ARA for patients who develop unacceptable side effects on ACEI.	     	     	
Beta-blockers	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	For all patients with CHD, unless contraindicated.	     	     	
Anticoagulants	Use warfarin in patients at high risk of thromboembolism 
post MI.	     	     	
Aldosterone antagonists	Epleronone may be used early post MI in patient with left ventricular systolic dysfunction and symptoms of 
heart failure.	     	     	
Medicine adherence	If poor adherence suspected, consider a Home Medicine Review.	     	     	
Other	
	     	     	

Lifestyle/Psychosocial risk factors	
Risk factor	Recommendations
and targets			
Smoking	Complete cessation 
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 and trans fatty acid intake ≤ 8% of total energy intake.	     	     	
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 (males) or < 1 standard drink 
per day (females).	     	     	
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. 	     	     	
Other	     
	     	     

Biomedical risk factors	
Risk factor	Current status	Patient agreed 
goals and actions 
(how, who and by when)	Recommended targets	
Cholesterol/Lipids	     	     	LDL-C < 2.0 mmol/L; HDL-C > 1.0 mmol/L; Triglycerides 
< 1.5 mmol/L.	
Blood pressure	     	     	BP < 130/80 mmHg. For people with proteinuria  > 1 g/day (with or without diabetes): 
< 125/75 mmHg.
(National Heart Foundation of Australia. Guide to management of hypertension 2008.)	
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 Managing my heart health and My heart my life, that are available from the Heart Foundation.
•	Consider referral if appropriate.

For heart health information 1300 36 27 87 www.heartfoundation.org.au 

Administration details

Date plan/service completed: 

	Proposed review date(s): 
	
Copy of CHD management plan offered to patient? 	Copy of CHD management plan added to patient’s records? 
	
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: _______________