Abstract: Objective　To investigate the feasible management mode and effect of patients with coronary heart disease after percutaneous coronary intervention（PCI） and enhance the community physicans’ability for preventing the adverse events,and reduce the risk factors.Methods　In 2014,87 patients who were accepted PCI at Department of Cardiology，the Second Affiliated Hospital of Baotou Medical College and met the inclusion criteria were enrolled.These patients were divided into two groups:the intervention group （47） could return to community and accept the management of community doctors,and the control group （40） could not return to community and accept the management.After accepting training from the Cardiovascular Disease Prevention and Treatment Research Center of the former Ministry of Health,the experts of the study trained the community physicians to manage the intervention group.The intervention group accepted the management of community doctors,and the control group did not accet any intervention.All patients accepted phone-call follow up at 6 months and 12 months after PCI.The cardiovascular disease risk factors,drug use,lifestyle,and the major adverse cardiovascular events of the two groups were recorded.Results　The body mass index （BMI）,systolic blood pressure （SBP） and triglyceride （TG） in the intervention group were significantly lower than those in the control group at 6 months and 12 months after PCI（P<0.05）.There were statistically significant differences in the usage of calcium ion antagonist （CCB） and nitrate between the two groups at 6 months after PCI（P<0.05）.There were statistically significant differences in the usage of CCB,β-blockers and statins between the two groups at 12 months after PCI（P<0.05）.Logistic regression analysis showed that the group was the influencing factor for sleep qulity,irritability and depression at 6 months after PCI（P<0.05）;and group was the influencing factor for regular exercise >2 times/week and >30 min/time,fasting food > 3 times/week,drinking <22 g/time,and sleep qulity at 12 months after PCI（P<0.05）.There was statistically significant difference in the incidences in myocardial infarction between the two groups at 6 months after PCI（P<0.05）.There were statistically significant differences in the incidence of myocardial infarction and TLR between the two groups at 12 months after PCI（P<0.05）.Conclusion　The community as a unit to file management is beneficial to the secondary prevention of coronary heart disease after PCI.Effective management of patients after PCI by community doctors can reduce adverse cardiovascular events and risk factors.

Key words: Angioplasty,balloon,coronary, Community health education, Major adverse cardiovascular events, Cardiovascular diseases, Risk factors

摘要： 目的　探讨经皮冠状动脉介入治疗（PCI）后适宜的社区管理模式及管理效果，提高社区医生对冠心病患者PCI后不良心血管事件的防治能力，减少其危险因素。方法　选择2014年在包头医学院第二附属医院心内科诊治的符合入选标准的PCI后患者87例，其中回到社区接受社区医生管理者为干预组（47例），无法回到社区接受社区医生管理者为对照组（40例）。项目专家组成员接受原卫生部心血管病防治研究中心的培训后，再对具体管理干预组患者的社区医生进行培训。社区医生对干预组患者进行管理，对照组患者不予任何管理。项目专家组成员在两组患者PCI后6、12个月时进行电话随访，记录两组患者心血管病危险因素、服药情况，评估患者生活方式、主要不良心血管事件。结果　PCI后6、12个月时，干预组体质指数（BMI）、收缩压（SBP）和三酰甘油（TG）均较对照组下降（P<0.05）。PCI后6个月时，两组钙离子拮抗剂（CCB）、硝酸盐类药物服药率比较，差异均有统计学意义（P<0.05）；PCI后12个月时，两组CCB、β-受体阻滞剂、他汀类药物服药率比较，差异均有统计学意义（P<0.05）。Logistic回归分析显示，组别是PCI后6个月睡眠、烦躁、抑郁的影响因素，组别是PCI后12个月规律运动>2次/周并>30 min/次、吃快餐次数>3次/周、饮酒<22 g/次、睡眠的影响因素（P<0.05）。PCI后6个月时，两组心肌梗死发生率比较，差异有统计学意义（P<0.05）；PCI后12个月时，两组心肌梗死、靶目标血运重建（TLR）发生率比较，差异有统计学意义（P<0.05）。结论　以社区为单位开展PCI后建档管理，有利于冠心病的二级预防。社区医生对PCI后患者的有效管理可以减少不良心血管事件及其危险因素。

关键词: 血管成形术,气囊,冠状动脉, 社区健康教育, 主要不良心血管事件, 心血管疾病, 危险因素