关键词: 心力衰竭, 社区管理, 心力衰竭清单, 心脏不良事件

Abstract: 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）〕（χ2=9.404，P=0.002），but a similar mortality rate〔9.0%（8/89）vs 11.5%（10/87），χ2=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.

Key words: Heart failure, Community management, Heart failure checklist, Adverse cardiac events