关键词: 心力衰竭, 疾病管理, 全科医生, 死亡率, 影响因素分析

Abstract: Objective　To analyze the death of chronic heart failure（CHF）patients during 2-year-integrated management，to observe the outcome of integrated management，and to analyze the influence factors for death.Methods　A total of 381 CHF patients who arrived at Yuetan Community Health Service Center or Fuxing Hospital at least once medical consultation every 3 months from 2012 to 2013，were divided into management group（194 cases） and control group（187 cases）according to random principle and the patients’ desire.Patients in management group received the comprehensive management，which included patients self-management，management by GPs，and regular instruction by specialists.Patients in control group received routine treatment.Patients were followed up for 2 years，the death and cause of death were recorded，Cox proporational hazards regression model was used to analyze influence factors for death.Results　There were significant differences in history of renal insufficiency，levels of Cr，eGFR，albumin，TC and TG at baseline，taking rates of ACEI/ARB and β-receptor blocking agent at follow-up between two groups of patients（P<0.05）.During the follow-up period，130 cases（67.0%）in management group completed 2-year-follow-up，39 cases（20.1%）died，among whom 13 cases died from cardiac diseases，11 cases died from infectious diseases，15 cases died from other causes；104 cases（55.6%）in control group completed 2-year-follow-up，56 cases（29.9%）died，among whom 18 cases died from cardiac diseases，25 cases died from infectious diseases,13 cases died from other causes.There was significant difference in all-cause mortality between two groups（χ2=7.36，P=0.007），and there was significant difference in infection-induced mortality between two groups（χ2=8.47，P=0.004）.However，there were no significant difference in cardiac and other causes mortality between two groups（χ2=2.15，χ2=0.03，P>0.05）.According to Cox proporational hazards regression model analysis，the independent factors for cardiac mortality included aged，lower LVEF level，higher FPG level，lower HDL-C level at baseline and no use of β-receptor blocking agent during follow-up（P<0.05）；the independent factors for infection-induced death included non-comprehensive management,aged，COPD，history of cerebrovascular disease，and higher Cr level at baseline（P<0.05）；aged and lower LVEF level at baseline were independent factors for other causes mortality（P<0.05）.Conclusion　Non-cardiac mortality is more common among CHF patients.CHF management can reduce all-cause mortality，mainly can reduce infection-induced mortality.To reduce mortality，comprehensive management for CHF patients should be carried out.

Key words: Heart failure, Disease management, General practitioners, Mortality, Root cause analysis