Coronary Heart Disease (CHD) Coronary heart disease Alcohol consumption <=1 drink per day (women) or 2 drinks per day (men) standard drinks per day Blood Pressure target: < Cholesterol/Lipids Target: Develop chest pain action plan Develop healthy eatting pattern with low fat diet Diabetes target: HBA1C <= Exercise Target: At least 30 minutes walking or equivalent 5 or more days per week Improve knowledge of condition Manage depression Medication management - use of ACE inhibitors Medication management - use of Anticoagulants Medication management - use of antiplatelet agents Medication Management - use of Beta-blockers Medication Management - use of Statins Medication review to ensure correct use of medications, minimise side effects Reduce social isolation Smoking cessation Target BMI < or = 6 monthly BP check 0 Practice nurse 3 Annual cholesterol check 0 G.P. 1 Aspirin (unless contraindicated) 0 G.P. 1 Education about diabetes 0 Practice nurse 3 Education about heart condition 0 G.P. 1 GP & patient agree on written action plan on use of anti-anginals and when to ring the ambulance 0 G.P. 1 Improve social support eg referral to support group 0 G.P. 1 Medication or cognitive behaviour therapy. 0 G.P. 1 Medication Review 0 G.P. 1 Monitor BP 0 Practice nurse 3 Patient education on healthy diet 0 Practice nurse 3 Reduce alcohol intake 0 Patient 2 Smoking cessation strategy - Medication 0 G.P. 1 Smoking cessation strategy - Quit 0 Patient 2 Warfarin if high risk of thromboembolism post-myocardial infarction 0 G.P. 1