Advances in continuity of care models for patients with acute myocardial infarction following percutaneous coronary intervention

1 Introduction

Acute myocardial infarction (AMI) is defined as myocardial necrosis resulting from acute or sustained ischemic hypoxia of the coronary arteries. AMI is characterized by sudden onset, rapid progression, and high mortality, ranking it among the most severe acute complications of coronary artery disease (1). According to the 2021 China Cardiovascular Health and Disease Report, the incidence and hospitalization rates of cardiovascular diseases in China have been increasing annually (2). Emergency percutaneous coronary intervention (PCI) is widely recognized as an optimal treatment for AMI, providing benefits such as minimal invasiveness, rapid recovery, and well-established efficacy (3). However, patients with AMI require lifelong management, including long-term oral medication and regular follow-up. Without structured nursing guidance, this may lead to increased complications and higher readmission rates (4). Post-PCI patients are also at risk of disease recurrence and complications due to postoperative emotional distress, limited self-care abilities, and insufficient disease awareness, all of which negatively impact prognosis (5). Existing studies indicate that post-PCI AMI patients receiving continuity of care demonstrate improved self-management awareness and skills, as well as a reduction in adverse symptom occurrence (6). Although continuity of care is still in the early stages of development domestically, its potential role in improving outcomes for AMI patients is receiving growing attention. This review aims to systematically summarize the application of continuity of care in post-PCI AMI patients, focusing on its definition, care models, and key components. It aims to provide guidance for developing scientifically sound and feasible postoperative care protocols, while highlighting current knowledge gaps and directions for future research.

2 Research methods

Relevant literature was retrieved from PubMed, Web of Science, CNKI, Wanfang, and VIP databases, covering the period from June 2015 to June 2025. The search strategy used combinations of the terms “acute myocardial infarction,” “percutaneous coronary intervention,” and “continuity of care”. This study was conducted as a narrative review. Retrieved records were initially screened based on titles and abstracts to identify studies relevant to continuity of care in patients with acute myocardial infarction following percutaneous coronary intervention. The full texts of potentially eligible studies were then reviewed to determine final inclusion. Only studies published in English or Chinese were included. A broad range of study designs—including randomized controlled trials, cohort studies, and descriptive studies—were considered, in order to comprehensively summarize existing continuity of care models and their reported outcomes in post-PCI acute myocardial infarction populations. The specific details are shown in Table 1.

Table 1. Summary of key studies on continuity of care interventions in Post-PCI AMI patients.

3 Definition of continuity of care

In 1989, Naylor et al. (7) from the Pennsylvania School of Nursing, USA, first proposed the concept of continuity of care, defining it as an adaptive discharge plan combined with a home follow-up program. Continuity of care refers to a set of service initiatives led and designed by healthcare professionals that guide patients through transitions across different care settings, ensuring coordinated and continuous healthcare delivery (8). As a novel nursing model, continuity of care was introduced relatively recently in China. Grounded in evidence-based medicine, this model led to the establishment of the 4C nursing system—characterized by comprehensiveness, collaboration, coordination, and continuity—which effectively prevents health deterioration in high-risk patients. This approach promotes favorable clinical outcomes and enhances patient satisfaction with nursing interventions (9).

3.1 Continuity of care model

Within the continuity of care framework, nursing continuity primarily encompasses three core dimensions: information continuity, management continuity, and relational continuity. Integrated medical and nursing care ensures management continuity by facilitating multidisciplinary collaboration and a clear division of responsibilities in clinical and nursing decision-making. Internet-based platforms allow dynamic sharing of patient information and follow-up feedback, thereby enhancing information continuity. Family involvement in care fosters relational continuity by providing stable caregiving relationships and emotional support. Collectively, these three models functionally complement one another, forming the core pathway for implementing continuity of care in post-PCI AMI patients.

3.2 Physician-nurse integration

The physician–nurse integration model is a continuity-of-care approach increasingly applied in cardiovascular disease management in recent years. Its core lies in breaking down traditional boundaries between physicians and nurses, achieving a high level of integration between clinical decision-making and nursing interventions through close collaboration (10). This patient-centered model emphasizes collaborative participation of healthcare professionals throughout the entire process of assessment, decision-making, implementation, and follow-up, thereby enhancing the continuity and comprehensiveness of nursing care. Among patients following percutaneous coronary intervention (PCI), the physician–nurse integration model has been shown to correlate closely with multiple prognostic outcomes. Randomized controlled trials indicate that at the 3-month follow-up, this model significantly improved patients' quality of life (SAQ total score), health-promoting behaviors (HPLP-II), and disease knowledge (CADE-Q SV), showing more pronounced improvements than the conventional care group (11). Its advantages extend beyond acute care to post-discharge continuity management. Unlike conventional multidisciplinary care models, integrated physician–nurse care does not involve parallel participation of multiple professions; rather, it operates through fixed physician–nurse teams as the basic unit, implementing continuous accountability for specific patients. Through real-time information sharing in daily practice, healthcare professionals collaboratively develop and dynamically adjust systematic treatment and care plans. This approach prevents information gaps and fragmented accountability, thereby enhancing intervention efficiency (12). Key components of the integrated model include unified responsibility assignment, where dedicated teams manage patients throughout their care journey; integrated treatment and nursing documentation to synchronize clinical information; joint physician–nurse rounds to collaboratively assess patient condition changes; coordinated health education to enhance patient disease awareness and self-management capabilities; and joint follow-up visits by healthcare providers to strengthen continuity of care post-discharge. Collectively, these measures form the practical foundation of the physician–nurse integration model in postoperative continuity care for AMI patients.

3.3 “Internet plus” platform

The “Internet Plus” continuity of care model has emerged in recent years for managing chronic and cardiovascular diseases. Its core lies in leveraging information technology to ensure continuity and accessibility of post-discharge nursing services. For patients following percutaneous coronary intervention (PCI), this model extends nursing services beyond hospital walls via internet platforms, overcoming the temporal and spatial limitations of traditional follow-up methods. By utilizing cloud computing, big data, and mobile communication technologies, it facilitates continuous interaction between nursing staff and patients through mobile applications, WeChat public accounts, or remote follow-up systems (13). Nursing staff can periodically monitor medication adherence, symptom changes, and psychological status, while providing targeted health education and rehabilitation guidance. Randomized controlled trials have shown that both SAS and SDS scores decreased in the observation group compared to pre-intervention levels, whereas CAS-R and self-efficacy scores increased. Moreover, post-intervention SAS and SDS scores in the observation group were lower than in the control group, CAS-R and self-efficacy scores were higher than in the control group, and the overall clinical treatment effectiveness rate was superior (all P < 0.05) (14, 15). These findings indicate that the “Internet+” health management intervention can alleviate adverse psychological emotions, enhance perceived control, improve self-efficacy, and achieve better clinical outcomes, highlighting its potential for clinical application. Compared to traditional follow-up methods, this model provides timely information delivery and sustained intervention continuity, reducing interruptions in nursing care. However, implementation challenges remain. First, privacy protection and information security for patients' health data require standardized management. Second, some elderly post-PCI patients have limited digital literacy, potentially impeding effective platform utilization. Finally, disparities in medical resources and informatization levels across regions may result in unequal access to nursing services (16). Therefore, it is essential to develop safer, more feasible, and equitable implementation pathways tailored to individual patient characteristics and healthcare system conditions.

3.4 Family-participatory approach

The family represents one of the most critical support systems during postoperative rehabilitation for patients with acute myocardial infarction (AMI). As primary caregivers, family members play a pivotal role in medication management, lifestyle interventions, and psychological support. The family-participatory nursing model integrates family members into the healthcare team, involving them in the ongoing care and management process after patient discharge, thereby enhancing continuity and coordination of care (17). Existing studies indicate that, post-intervention, the continuation group scored significantly higher than the control group on all dimensions of the ESCA scale (responsibility, self-care skills, health status) and the QOL scale (physical, psychological, and social function; P < 0.05). Moreover, the continuation group exhibited a markedly lower incidence of postoperative complications compared to the control group (P < 0.05), confirming that family-involved care can enhance self-efficacy and reduce readmission risk in post-PCI patients (18, 19). In AMI patients undergoing PCI, family-participatory care extends hospital nursing practices into the home environment, ensuring continuity in medication adherence, rehabilitation exercises, and lifestyle interventions. This approach improves recovery compliance, accelerates rehabilitation progress, and enhances long-term quality of life. However, high-quality research focusing on post-PCI AMI patients remains limited. Further studies are required to clarify specific implementation pathways and the long-term effects of family-participatory care.

4 Continuity of care components

4.1 Medication management

Percutaneous coronary intervention (PCI) is the primary treatment for acute myocardial infarction (AMI). However, post-PCI patients require lifelong or long-term medication regimens, including antiplatelet agents, cardiac function enhancers, and preventive lipid-lowering drugs to mitigate coronary atherosclerosis (20). Relevant studies indicate that medication adherence among coronary heart disease patients after PCI is only 58.59% (21). To ensure effective PCI outcomes, interventions aimed at enhancing medication adherence are essential. A randomized controlled trial demonstrated that continuous care interventions significantly improved medication adherence among post-PCI AMI patients while concurrently alleviating adverse emotional states, thereby promoting favorable post-PCI outcomes (22). Online platforms and software allow patients to log medication doses and monitor adherence, with weekly reminders and supervision provided by nursing staff. Related research indicates that such interventions can enhance patients' self-management capabilities, including medication adherence rates and completeness of medication records (23). Additionally, these interventions have been associated with improvements in treatment adherence, potentially leading to better clinical outcomes and prognosis. Concurrently, healthcare providers should strengthen disease education for patients and their families, emphasizing the importance of medication adherence, correct usage, and potential adverse reactions to support improved compliance and optimize treatment management.

4.2 Disease monitoring

Studies indicate that the recurrence of adverse cardiovascular events within 1 year after PCI is closely associated with multiple factors, including variations in drug metabolism, glycemic control, blood pressure and lipid management, as well as the patient's psychological status (24). Therefore, continuous and dynamic monitoring of patients after discharge is crucial for reducing the risk of adverse events, promoting recovery, and improving quality of life. In recent years, rapid advancements in digital technology have facilitated the use of wearable devices and remote monitoring tools. These technologies enable multidimensional tracking of vital signs, physical activity, sleep patterns, medication adherence, and lifestyle factors, providing novel approaches for continuous management of post-PCI patients (25). Qing Xiaotao et al. (26) suggested that mobile care models using smart bracelets and IoT technology allow real-time access to data such as blood pressure, blood glucose, and cardiac function for both patients and healthcare providers, thereby facilitating more systematic disease monitoring. However, current research primarily addresses technical feasibility and short-term efficacy, with limited focus on long-term clinical benefits, cost-effectiveness, and scalability across diverse healthcare settings. Furthermore, practical application may be affected by factors such as the acquisition and maintenance costs of wearable devices, patient acceptance of digital tools, and the IT support capabilities of primary healthcare institutions. Therefore, future studies should aim to ensure monitoring accuracy and safety while rigorously evaluating the economic feasibility, practicality, and clinical utility of digital disease monitoring models in post-AMI continuity care.

4.3 Lifestyle intervention

Percutaneous coronary intervention (PCI) is widely recognized as an effective reperfusion strategy for patients with acute myocardial infarction. However, evidence suggests that without sustained and standardized lifestyle management after discharge, cardiovascular risk factors may remain inadequately controlled, potentially increasing the risk of adverse cardiovascular events and hospital readmission. Compared with conventional inpatient cardiac rehabilitation, lifestyle interventions delivered within a continuity of care framework tend to emphasize longer-term follow-up, individualized guidance, and post-discharge behavioral monitoring.

Within more structured continuity of care models, healthcare providers may employ digital platforms, such as WeChat, to support ongoing follow-up and communication. Through these platforms, targeted guidance and supervision are provided on key lifestyle domains, including dietary modification (e.g., increased consumption of fresh fruits and vegetables, low-salt and low-fat diets), regular physical activity, smoking cessation, alcohol restriction, and medication adherence (27). Such approaches may help overcome temporal and spatial barriers to care delivery and support the transition from short-term health education to more sustained health-related behaviors. In a randomized controlled trial involving young and middle-aged patients after PCI, the intervention group received a 12-week home-based continuous care program incorporating both aerobic and resistance exercise. Compared with the control group, the intervention group demonstrated greater improvements in 6-min walk distance (6MWD; median difference: 50.0 m vs. 6.5 m, P < 0.001). Reductions in body mass index and lipid parameters (TG, TC, LDL-C) were also more pronounced in the intervention group (all P < 0.05), and a lower readmission rate was observed (2% vs. 16%). These findings suggest that home-based continuity of care programs integrating aerobic and resistance exercise may be associated with improvements in functional capacity, selected metabolic indicators, and short-term clinical outcomes among young and middle-aged post-PCI patients (28).

5 Shortcomings in continuity of care for patients after acute myocardial infarction in China

5.1 Lack of multidisciplinary specialists

Yan Li et al. (29) implemented a multidisciplinary, team-based continuity of care model for patients in the vulnerable phase of chronic heart failure. Their findings suggest that this intervention may effectively address patients' multifaceted care needs and lead to improvements in cardiac function indicators. Although this study was conducted in chronic heart failure patients rather than post-PCI AMI patients, it provides indirect evidence supporting the effectiveness of multidisciplinary continuity of care interventions. The core components—comprehensive assessment, coordinated care planning, and ongoing follow-up—are relevant to post-PCI AMI patients, who similarly require close monitoring of medication adherence, self-management behaviors, and prevention of adverse events. Continuity of care necessitates seamless collaboration among nursing, medical, rehabilitation, and nutrition disciplines. In China, continuity of care initiatives started relatively late, resulting in a shortage of multidisciplinary professionals. Consequently, developing continuity of care teams, cultivating multidisciplinary talent, and establishing specialized units are urgent priorities. Healthcare institutions should introduce dedicated continuity of care curricula to train professional reserves. Furthermore, enhancing skill training for healthcare personnel will provide robust support for continuity of care in post-PCI AMI patients, and the evidence from chronic heart failure patients indicates that similar interventions may be beneficial in improving patient outcomes in the post-PCI AMI population.

5.2 Lack of standardized, unified continuity of care models

Although continuity of care research has been increasingly conducted in China, the specific intervention content, implementation approaches, and outcome evaluation methods remain relatively underdeveloped, particularly in populations following PCI procedures (30). Existing evidence suggests that the lack of unified implementation standards and standardized continuity of care models may limit the comparability and generalizability of current findings. Within the current healthcare context, exploring and summarizing effective continuity of care interventions for post-PCI patients may contribute to the gradual development of more standardized and evidence-informed care pathways, which could, in turn, support improvements in the consistency and quality of nursing practice.

5.3 Lack of relevant policy framework

The development of continuity of care may be influenced by several systemic factors, including the absence of unified national policy guidance, the limited availability of dedicated continuity of care nursing positions within hospitals, shortages in the nursing workforce, and variability in professional competence and awareness of continuity of care among nursing staff (28). Existing literature suggests that supportive policy environments and organizational structures play an important role in facilitating the implementation of continuity of care services. Accordingly, it has been suggested that administrative authorities consider formulating and refining policies aimed at promoting continuity of care, strengthening the development of medical consortia, optimizing bidirectional referral mechanisms, and exploring information-based continuity of care service models (31). In addition, appropriate increases in investment in human, material, and financial resources may help improve healthcare personnel training and the infrastructure required for continuity of care delivery. The establishment of standardized subsidy mechanisms and supportive policy frameworks could further facilitate the gradual development and implementation of continuity of care services.

6 Conclusion

Continuity of care appears to play an important role in the long-term management of patients with acute myocardial infarction (AMI) following percutaneous coronary intervention (PCI). Existing evidence suggests that structured continuity of care may provide ongoing professional support for post-discharge health management and follow-up, which is associated with improved medication adherence, facilitation of healthy lifestyle behaviors, and a potential reduction in adverse cardiovascular events and hospital readmissions. However, as this study is a narrative review, the included literature shows substantial heterogeneity in study design, intervention components, and outcome indicators, which limits the robustness and comparability of the available evidence. Current research on continuity of care in post-PCI AMI patients remains limited by several factors, including a lack of high-quality, multicenter randomized controlled trials, generally short follow-up durations, insufficient evaluation of cost-effectiveness and implementation feasibility, and the absence of standardized intervention frameworks across different care models. Future research should place greater emphasis on post-PCI AMI populations and systematically examine the effectiveness, safety, and applicability of various continuity of care models. At the healthcare system level, further optimization of continuity of care mechanisms is warranted. This may include strengthening interprofessional collaboration, improving the continuity and integration of health information, enhancing family involvement, prioritizing the training of specialized nursing personnel, and exploring standardized continuity of care models supported by information technology and adapted to China's healthcare context. Such efforts may contribute to improving long-term management quality and overall prognosis in patients with AMI after PCI.

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Footnotes

Edited by: Ozgur Karcioglu, University of Health Sciences (Turkey), Türkiye

Reviewed by: Arezoo Monfared, Guilan University of Medical Sciences, Rasht, Iran

Eylem Ersan, Balikesir University, Türkiye