Acute Myocardial Infarction – Allied Health-Oriented, Patient-Centred and Digitally Enabled Care (AMI-HOPE)
16 July 2026
AMI-HOPE is a post-discharge care programme that supports patients recovering from acute myocardial infarction (AMI) – commonly known as a heart attack – to transition safely from hospital to primary care through remote monitoring, allied health-led follow-up, and digitally enabled lifestyle coaching. This approach improves recovery, reduces readmissions, and enables smoother, earlier transitions back to primary care.
MOHT partnered with the National University Health System (NUHS), NHG Health, SingHealth, the Health Promotion Board and Synapxe to design, implement and evaluate the care model. MOHT contributed to programme design, developed a personalised, AI-enabled digital coaching strategy, and led the design and implementation of the supporting technology platform.
Aim Statement
To improve post-AMI clinical outcomes by enabling safe transition of suitable patients to primary care within 6-12 months, enhancing patient self-management through AI-enabled digital coaching, and optimising specialist outpatient capacity for complex cases to enhance system efficiency and sustainability.
Why It Matters
Cardiovascular disease is Singapore’s leading cause of death, with rising AMI cases and poorer outcomes than peer countries. The immediate post-discharge period is high-risk, yet patients often wait months for specialist follow-up. Traditional care keeps even stable patients in specialist clinics for a year or longer, straining resources. AMI-HOPE provides closer follow-up, earlier intervention, and faster transition to primary care – delivering safer, continuous care closer to home while easing specialist demand. This improves patient safety, outcomes, and system efficiency.
Summary
Population: Patients recovering from AMI
Intervention: Allied health support, remote monitoring, medication titration, and personalised lifestyle guidance via digital tools
Comparator: Standard specialist outpatient care
Outcomes: Improved cardiovascular risk factor control, earlier transition to primary care, reduced avoidable readmissions and better use of specialist outpatient capacity
Key Results To Date
Scale and implementation:
Rolled out across all 3 clusters, implemented at 7 hospitals and 19 polyclinics, with over 1,600 patients enrolled
Clinical outcomes and impact:
Demonstrated significant improvements in medication optimisation, risk factor control (LDL, HbA1c, blood pressure), smoking cessation, and reduced long-term readmissions, while maintaining low mortality and reducing specialist outpatient burden
Care model and workflows:
Pharmacist-led workflows integrated with digital tools via HD+, with shift of follow-up care from specialists to allied health and digital monitoring, freeing specialist outpatient capacity
Programme progress and completion:
All control patients have completed 12 months; 697 intervention patients have completed 6 months, and 391 have completed 12 months
Clinical effectiveness:
Improved BP control at 6 months (86% vs 62% historical benchmark)
LDL trends show statistically significant treatment effect from month 1 to month 12 for all patients
HbA1c trends show statistically significant improvement from month 3 to month 10, with continued improvement at months 11-12 (statistical significance not reached yet due to smaller sample size of those who have completed interventions)
Adoption and system maturity:
Strong provider acceptance and cross-site collaboration reported, alongside refined protocols and escalation logic, and real-world pharmacist workflow adoption supporting more reliable and consistent patient follow-up experiences