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

摘要： 背景　心力衰竭（简称心衰）是一种慢性、进展性自发性疾病，很难根治。对中重度慢性心衰患者进行医疗管理，能提高患者生活质量，延长生命，有效减少医疗资源的消耗。目前国际公认的最有效的人群健康服务模式是社区医疗管理。目的　探讨中重度慢性射血分数减低心力衰竭（HF-REF）患者在社区医疗管理下的诊疗效果。方法　选取2017年1—12月在内蒙古科技大学包头医学院第二附属医院心内科和急诊科诊治的美国纽约心脏病协会（NYHA）分级为Ⅱ~Ⅳ级的中重度HF-REF患者115例，根据患者意愿分组，同意回到社区与社区医生签约患者52例（社区组），无法回到社区和不愿意接受社区医生签约患者63例（区外组）。社区组医护学习《中国心力衰竭诊断和治疗指南2014》，并在技术层面和内蒙古科技大学包头医学院第二附属医院心内科、急诊科专科医生对本疾病的诊治达成一致，进行社区医疗管理模式。区外组患者如有医疗问题不在社区卫生服务中心、站诊治。两组患者出院后第6、12个月时本项目组成员对其进行电话随访，随访内容包括：一般情况〔症状加重、体征加重、药量增加、饮食减少、运动减少、社会活动减少、情感改变（烦躁/淡漠）、睡眠减少〕，“金三角”药物服药依从性及心衰不良事件（合并症增加、急性心衰再发、再次住院、手术、全因死亡）。“金三角”药物：是指血管紧张素转化酶抑制剂（ACEI）、β-受体阻滞剂和醛固酮受体拮抗剂合用，本研究主要观察这三个药物的服药依从性。结果　随访第6个月，社区组症状加重率、饮食减少率低于区外组（P<0.05）；随访第12个月，社区组症状加重率、社会活动减少率、睡眠减少率低于区外组（P<0.05）。随访第6、12个月，社区组β-受体阻滞剂、醛固酮受体拮抗剂服药依从性高于区外组（P<0.05）；随访第12个月，社区组急性心衰再发率低于区外组（P<0.05）。结论　社区医疗管理模式可以减缓中重度HF-REF疾病的进展，提高服药依从性，改善患者生活质量，减少心脏不良事件的发生。

关键词: 心力衰竭, 社区医学, 射血分数, 心血管疾病