关键词: 心力衰竭, 社区医学, 射血分数, 心血管疾病

Abstract: Background　Heart failure（HF） is a chronic，progressive and spontaneous disease，which is difficult to cure.Medical management can improve the quality of life，prolong life and effectively reduce the consumption of medical resources in patients with moderate-to-severe chronic HF.At present，community-based health care management is the most effective healthcare delivery mode that is recognized internationally.Objective　To investigate the effect of community-based management delivered by community physicians in patients with moderate-to-severe chronic HF with reduced ejection fraction（HF-REF）.Methods　115 moderate-to-severe HF-REF patients（NYHA classⅡ-Ⅳ） recruited from Cardiovascular Department and Emergency Department，the Second Affiliated Hospital of Baotou Medical College，Inner Mongolia University of Science & Technology during January to December 2017，including 52 who were willing to receive contracted healthcare services from community physicians（community group），and 63 who were unwilling to or could not go back to the community to receive such services（out-of-community group）.The community group received community-based management delivered by community physicians and nurses，who had learned Chinese Guidelines for Diagnosis and Treatment of Heart Failure 2014，had the same technique level as the cardiovascular and emergency physicians from the Second Affiliated Hospital of Baotou Medical College，Inner Mongolia University of Science & Technology，and followed the bilateral diagnostic and therapeutic agreement.The out-of-community group only sought healthcare for health problems in higher level medical institutions after discharge.All of them received two telephone-based follow-ups at 6 and 12 months after discharge，respectively，for collecting the following data：general conditions〔aggravation of symptoms，aggravation of signs，increase in dosage，decrease of diet，decrease of exercise，reduction in social activities，change in emotions（irritability/apathy），decrease in sleep〕，adherence to the "golden trigeminy"（ACEIs in combination with beta-blockers and aldosterone receptor antagonists） and HF-related adverse events.Results　Compared with out-of-community group，the community group showed lower aggravation rate of HF symptoms and reduction rate of diet，and higher adherence to beta blockers and aldosterone receptor antagonists at the 6th month after discharge（P<0.05）.Furthermore，the community group showed lower rates of HF symptoms，and reduction in social activities，and decrease in sleep，higher adherence to beta blockers and aldosterone receptor antagonists and lower recurrence rate of acute HF at the 12th month after discharge（P<0.05）.Conclusion　Effective community-based healthcare interventions could slow down the progress of moderate-to-severe HF-REF，improve the medication compliance and the quality of life，as well as reduce the incidence of adverse cardiac events in such patients.

Key words: Heart failure, Community medicine, Ejection fraction, Cardiovascular diseases