冠心病患者介入术后随访管理对康复和预后的影响

目的通过对冠心病支架术后的患者进行电话追踪、专门门诊随访和健康教育指导等管理方式，探讨其对患者的预后及康复的影响。方法选择2008年3月至2010年3月在我院行冠状动脉支架置入的患者152例，随机分为生命网组和对照组。生命网组78例患者出院后加入生命网，由专人负责电话追踪、专门门诊随访和健康教育指导；对照组74例，出院后按照医嘱，由患者自己安排复诊，随访1年后观察两组患者的康复和预后情况。结果生命网组患者术后1年在高血压、高血脂、吸烟、超重等危险因素控制方面好于对照组，同时服药依从性高于对照组，1年内再发主要心脏不良事件如心脏性猝死、再发急性冠脉综合征、血运重建的概率明显降低，差异有统计学意义（P〈0．05）。结论加强对冠心病支架置入术后患者的随访和管理，可以改善冠心病患者治疗的依从性，增加药物治疗的规律性，减少冠脉事件的发生，促进术后康复。

Effect of by strengthened follow-up and management on the rehabilitation and prognosis of coronary heart disease patients with percutaneous coronary intervention

Objective To explore the effects of telephone follow-up, special clinic service and healthy education on the rehabilitation and prognosis of coronary heart disease （CHD） patients with percutaneous coronary intervention （PCI）. Methods A total of 152 consecutive CHD patients treated with primary PCI during March of 2008 to March of 2010 were randomly divided into the study group （78 cases） and control group （74 cases）. The study group was jointed into heart care network for telephone follow-up, special clinic service and healthy education. The control group only received the conventional follow-up. After one year, the rehabilitation and prognosis of two groups were observed. Results After follow-up for one year, the risk factors, such as hypertension, high blood lipid, smoking and overweight, in study group were controlled significantly better than those in control group. The rate of major adverse cardiac events （MACE） including cardiac death, non-fatal myocardial infarction or target vessel revascularization in control group was significantly higher than that in study group during one year follow-up （P〈0.05）. Conclusion The strengthened follow-up and management for CHD patients treated with primary PCI can improve the curative effects of CHD patients, reduce the incidence of coronary events and promote the rehabilitation of CHD patients treated with PCI.