应用心力衰竭清单对慢性心力衰竭患者进行社区管理的效果研究

背景　对于慢性心力衰竭患者给予积极治疗和良好的管理可避免心力衰竭加重。目前国内外没有统一、公众认可的心力衰竭管理模式。本课题拟应用心力衰竭清单方式对慢性心力衰竭患者进行统一的管理，旨在为我国探索社区管理模式提供参考。目的　应用心力衰竭清单对慢性心力衰竭患者进行社区管理，并评价此方法的效果，希望通过此研究探索一种简单易行的慢性心力衰竭社区管理模式并可进行推广。方法　选取2016-06-30至2017-06-30于首都医科大学附属北京朝阳医院心脏中心住院且明确诊断为慢性心力衰竭的患者200例。采用随机数字法将其分为管理组100例和对照组100例，管理组由全科团队采用心力衰竭清单对患者进行全方位管理，随访1次/月；对照组不应用心力衰竭清单，由全科团队进行常规门诊管理，随访1次/月，仅记录相关资料但不特别干预。查阅患者电子病例系统收集基线资料。随访6个月后，比较两组患者N末端脑钠肽前体（NT-proBNP）及心功能指标左心室射血分数（LVEF）、左心室舒张末期内径（LVEDD）、左心室收缩末期内径（LVESD）、慢性心力衰竭标准化药物使用率及心力衰竭再住院率和死亡率。结果　共176例患者完成随访，其中管理组89例，对照组87例。管理后，管理组NT-proBNP、心功能分级、LVEDD、LVESD均低于对照组，LVEF高于对照组（P<0.05）。管理组管理后血管紧张素转化酶抑制剂（ACEI）/血管紧张素Ⅱ受体拮抗剂（ARB）使用率高于管理前，螺内酯使用率低于管理前（P<0.05）。管理后两组β-受体阻滞剂、螺内酯使用率比较，差异无统计学意义（P>0.05）；管理组ACEI/ARB使用率高于对照组（P<0.05）。管理组心力衰竭再住院率〔11.2%（10/89）〕低于对照组〔29.9%（26/87）〕（χ2=9.404，P=0.002）。两组死亡率比较，差异无统计学意义〔9.0%（8/89）与11.5%（10/87），χ2=0.301，P=0.583〕。结论　全科医生应用心力衰竭清单管理慢性心力衰竭患者能明显提高管理效果，提示心力衰竭清单是一种简单易行的慢性心力衰竭社区管理模式。

Community-based Management of Chronic Heart Failure Patients Using Heart Failure Inventory Project

Background Active treatment and good management for patients with chronic heart failure(HF) can avoid exacerbation of the disease.But at present,there is no a unified,publicly recognized HF management model.Our research team used an HF inventory project to manage chronic HF patients in a unified way,aiming to provide a reference for the exploration of community-based management models of HF.Objective To evaluate the effect of community-based management of chronic HF patients with an HF inventory project,hoping to offer a basis for the development of a simple chronic HF management model that can be easily carried out and promoted.Methods We enrolled 200 HF inpatients from the Heart Center,Beijing Chaoyang Hospital,Capital Medical University during June 30,2016 to June 30,2017,and equally randomized them into the management group(n=100) and control group(n=100),treating with comprehensive management using an HF inventory project and follow-up once a month delivered by a general practitioner team,routine outpatient management without special interventions and follow-up once a month with recording of related data delivered by a general practitioner team,respectively.Intergroup comparisons were made in terms of baseline data obtained by searching the electronic medical record system,and NT-proBNP,left ventricular ejection fraction(LVEF),left ventricular end-diastolic diameter(LVEDD),left ventricular end-systolic diameter(LVESD),standard HF medication treatment,re-hospitalization rate and mortality rate at the end of 6-month follow-up.Results A total of 176 cases completed the follow-up(89 in the management group and 87 in the control group).At the end of 6-month follow-up,the management group showed lower mean NT-proBNP,NYHA class,LVEDD and LVESD,and higher mean LVEF compared with the control group(P<0.05).The use rates of ACEI/ARB increased while the use rate of spironolactone decreased significantly in the management group after intervention(P<0.05).After management,the utilization rate of ACEI/ARB in the management group was higher than that in the control group(P<0.05).However,there was no significant difference in the utilization rates of beta-blockers and spironolactone between the two groups(P>0.05).Furthermore,the management group showed a lower rehospitalization rate due to HF〔11.2%(10/89)〕vs〔29.9%(26/87)〕(χ~2=9.404,P=0.002),but a similar mortality rate〔9.0%(8/89)vs 11.5%(10/87),χ~2=0.301,P=0.583〕.Conclusion By using our HF inventory project,the management effect of HF patients is increased significantly,suggesting that this simple project is feasible for community-based management of chronic HF.