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目的评价社区化管理模式在慢性左室射血分数下降的心力衰竭患者出院后管理中的应用效果,为慢性心血衰竭患者的治疗提供依据。方法对2012年1月至2014年12月期间在丽水市中心医院心内科住院治疗的纽约心脏病协会(NYHA)心功能分级为Ⅲ~Ⅳ级的1 273例丽水市莲都区户籍慢性心力衰竭患者进行超声心动图检查,采用改良的辛普森(Simpson)法测量左室射血分数(LVEF),发现LVEF<40%的患者共459例,从中选取405例慢性左室射血分数下降的心力衰竭住院患者为研究对象,并将其随机分为3组,A组为社区化管理组(134例),B组为电话随访组(136例),C组为自我管理组(135例)。所有患者均接受正规抗心力衰竭治疗。3组患者在出院后3个月、6个月及12个月各进行1次随访,用SPSS 23.0软件包对数据进行t检验和多组间比较的单因素方差分析。结果 A、B两组β受体阻滞剂与血管紧张素转化酶抑制剂或血管紧张素受体抑制剂(ACEI或ARB)类药物的用量均显著大于C组,且剂量逐渐递增,其中A组用量较B组更大,而C组却出现了β受体阻滞剂减量、ACEI或ARB类药物不再加量的现象。3组患者在治疗1年后血压及心率均较治疗前下降,6 min步行距离显著增高,血浆B型利钠肽(BNP)浓度显著下降,但只有A组患者治疗后LVEF水平较入组时明显升高(分别为32.18%±6.93%、31.45%±7.89%),差异有统计学意义(P<0.01),其余两组治疗后LVEF水平较入组时无显著改变。A组患者的血压、心率控制更满意,心功能改善最明显,1年内再住院率(9.92%)及病死率(7.44%)最低。C组患者的血压、心率控制最不满意,心功能改善最不明显,1年内再住院率(23.14%)及病死率(13.22%)最高。B组情况介于A、C两组之间。结论社区化管理模式和电话随访管理模式较患者自我管理模式能更好地提高患者服药的依从性,取得更好的疗效。社区化管理模式在药物的合理使用方面要更优于电话随访管理模式,取得的治疗效果也更好。
Objective To evaluate the effect of community-based management in the management of patients with heart failure after chronic left ventricular ejection fraction decline, and to provide evidence for the treatment of chronic heart failure patients. Methods From January 2012 to December 2014, 1,273 New York Heart Association (NYHA) patients who were hospitalized in Department of Cardiology, Lishui Central Hospital were enrolled in this study. Among them, 1 273 cases of chronic heart failure The patients underwent echocardiography. The modified Simpson method was used to measure the left ventricular ejection fraction (LVEF). A total of 459 patients with LVEF <40% were enrolled and 405 patients with chronic left ventricular ejection fraction (LVEF) Inpatients were randomized into three groups. Group A was a community management group (134 patients), group B was a telephone follow-up group (136 patients), and group C was a self-administered group (135 patients). All patients received formal anti-heart failure treatment. Three groups of patients were followed up at 3 months, 6 months and 12 months after discharge respectively. Data were analyzed by SPSS 23.0 software package and one-way ANOVA among the groups. Results The doses of beta blockers, angiotensin converting enzyme inhibitors and angiotensin receptor blockers (ACEIs or ARBs) in group A and group B were significantly higher than those in group C, and the doses gradually increased, with A Group B was larger than that of group B, but there was a decrease of β-blocker and no increase of ACEI or ARB in group C in group C. After 1 year of treatment, the blood pressure and heart rate of 3 groups decreased compared with those before treatment, and the distance of walking 6 min increased significantly. The concentration of plasma BNP decreased significantly, but only LVEF in group A was higher than that of group A (32.18% ± 6.93%, 31.45% ± 7.89%, respectively), the difference was statistically significant (P <0.01). The levels of LVEF in the other two groups had no significant change after treatment. A group of patients with more satisfactory blood pressure and heart rate control, the most obvious improvement of cardiac function, rehospitalization rate within 1 year (9.92%) and the lowest case-fatality rate (7.44%). Patients in group C had the most unsatisfied blood pressure and heart rate control, the least obvious improvement in cardiac function, and the highest rate of rehospitalization (23.14%) and mortality (13.22%) in 1 year. Group B situation between A, C between the two groups. Conclusion Community-based management and telephone follow-up management models are better than patient self-management in improving patient compliance and achieving better results. Community management mode in the rational use of drugs to be better than telephone follow-up management model, and achieved better treatment.