“四师共管”随访模式用于冠心病患者PCI术后危险因素控制和中期预后改善的效果探索  

Effect of"four-staff co-management"follow-up mode on the control of risk factors and medium-term prognosis improvement in patients with coronary heart disease after PCI

作　　者：张国明 戴翠莲 陈家进 欧尾妹 黄承敏 留志贤 金志远 林吉怡 王斌 葛晓峰 李穗吉 陈翔 王焱 Zhang Guoming;Dai Cuilian;Chen Jiajin;Ou Weimei;Huang Chengmin;Liu Zhixian;Jin Zhiyuan;Lin Jiyi;Wang Bin;Ge Xiaofeng;Li Suiji;Chen Xiang;Wang Yan(Emergency Department,Xiamen Cardiovascular Hospital of Xiamen University,School of Medicine,Xiamen University,Xiamen 361009,China;Department of Cardiology,Xiamen Cardiovascular Hospital of Xiamen University,School of Medicine,Xiamen University,Xiamen 361009,China;Institute of Cardiovascular Disease,School of Medicine,Xiamen University,Xiamen 361009,China;Xiamen Chest Pain Quality Control Center,Xiamen 361009,China)

机构地区：[1]厦门大学附属心血管病医院急诊科,厦门361009 [2]厦门大学附属心血管病医院心内科,厦门361009 [3]厦门大学医学院心血管病研究所,厦门361009 [4]厦门市胸痛质量控制中心,厦门361009

出　　处：《中华全科医师杂志》2025年第4期426-433,共8页Chinese Journal of General Practitioners

基　　金：科技部重点研发计划(2019YFE0113900);厦门市卫生健康委员会和厦门市科学技术局联合项目(3502Z20209007);福建省自然科学基金(2023J011676);厦门市科技局基金(3502Z20224ZD1182)。

摘　　要：目的探讨“四师共管”随访模式用于冠心病患者经皮冠状动脉介入治疗(PCI)术后危险因素控制和中期预后改善的效果。方法该研究为干预性试验。纳入2021年6月至2022年1月在厦门大学附属心血管病医院行PCI并顺利出院的冠心病患者。根据出院后随访模式不同分为传统随访组和“四师共管”随访组。“四师共管”随访模式即由三级甲等医院的专科医师、专病管理师和基层医院的全科医师、健康管理师共同负责PCI患者出院后随访。收集患者的基线临床资料。主要观察终点为术后12个月时两组患者冠心病危险因素控制达标率、计划外二次手术率以及中期主要不良心脑血管事件(MACCE)发生率。计划外二次手术包括症状驱使性二次手术和无症状复查二次手术。MACCE包括心肌梗死、心力衰竭住院、卒中、大出血、全因死亡以及包括上述事件的复合终点事件。结果共入选患者2181例,其中传统随访组1097例,年龄(64.65±11.67)岁,男性844例(76.94%),“四师共管”随访组1084例,年龄(64.23±11.68)岁,男性854例(78.78%)。基线时,两组患者的性别、年龄、出院诊断、合并疾病、超声心动图指标以及冠状动脉病变情况等差异均无统计学意义(均P>0.05);两组患者PCI支架总长度、支架最大内径、使用药物球囊者占比、住院期间计划内二次手术者占比、出院带药情况差异均无统计学意义(均P>0.05)。术后12个月,“四师共管”随访组患者糖化血红蛋白、低密度脂蛋白胆固醇降低幅度均大于传统随访组(均P<0.05),低密度脂蛋白胆固醇达标率高于传统随访组(P=0.001),但收缩压、舒张压和糖化血红蛋白达标率两组间差异无统计学意义(均P>0.05)。随访期间“四师共管”随访组患者症状驱使二次手术者占比低于传统随访组(P<0.001),无症状复查二次手术者占比两组间差异无统计学意义(P=0.191);“四师共管”�Objective To investigate the effect of"four-staff co-management"follow-up mode on risk factor control and medium-term prognosis improvement in patients with coronary heart disease after percutaneous coronary intervention(PCI).Methods This was a intervention study.Patients with coronary heart disease who were admitted to the Xiamen Cardiovascular Hospital of Xiamen University from June 2021 to January 2022 and successfully discharged after PCI were included.According to the different types of follow-up after discharge,patients were divided into the traditional follow-up group and the"four-staff co-management"follow-up group.The"four-staff co-management"follow-up mode means that specialists,specialist managers in third-level A hospitals and general practitioners and health managers in basic hospitals were jointly responsible for post-discharge follow-up of PCI patients.Baseline clinical data were collected.The primary endpoints were the rate of compliance of coronary heart disease risk factor control at 12 months after surgery,the rate of secondary surgery,and the incidence of mid-term major adverse cardiovascular and cerebrovascular events(MACCE).Unplanned secondary PCI included symptom-driven secondary PCI and asymptomatic secondary PCI.MACCE includes myocardial infarction,hospitalization for heart failure,stroke,major bleeding,all-cause death,and composite endpoints including these events.Results A total of 2181 patients were enrolled,including 1097 patients in the traditional follow-up group and 1084 patients in the"four-staff co-management"follow-up group.At baseline,there were no statistically significant differences in gender,age,discharge diagnosis,co-existing diseases,echocardiographic indexes,and coronary artery lesions between the two groups(all P>0.05).There were no significant differences between the two groups in total PCI stent length,maximum internal diameter of stent,proportion of patients using drug balloon,proportion of patients with a planned second surgery during hospitalization,and discharge w

关 键 词：冠心病 经皮冠状动脉介入治疗 随访 “四师共管”随访模式 

分 类 号：R541.4[医药卫生—心血管疾病]