Cardiovascular and cerebrovascular diseases are the leading causes of death and disability globally, with existing management models facing challenges such as insufficient long-term intervention and limited effectiveness of comprehensive prevention and control. The traditional Chinese medicine (TCM) three-level prevention and control model establishes a multi-tiered system involving families, communities, and hospitals, combining health education, lifestyle intervention, and TCM-specific techniques to provide systematic and continuous management.

To evaluate the management effectiveness of the TCM three-level prevention and control model for patients with coronary heart disease (CHD) and stroke, aiming to optimize prevention strategies for cardiovascular diseases.

A prospective single-arm cohort study was conducted, enrolling 265 non-acute CHD and stroke patients from Tianjin Beichen District between October and December 2020. Using a TCM three-level prevention and control system centered on patients, with village/community physicians as executors and tertiary hospital specialists as leaders, comprehensive TCM health management interventions—including health education, lifestyle modification, risk factor control, medication guidance, and TCM techniques—were implemented. Patients were managed and followed up over a one-year period with biannual follow-up visits. Management effectiveness was assessed through comparisons of pre- and post-management data, including 1-year recurrence and progression rates, myocardial ischemia incidence, Seattle Angina Questionnaire (SAQ) scores, National Institutes of Health Stroke Scale (NIHSS) scores, cardiovascular prevention knowledge scores, cardiovascular risk factors, and lifestyle behavior indicators.

Among the 265 enrolled patients with coronary heart disease (CHD) and stroke, 214 were CHD patients (193 with angina pectoris and 21 in a stable state post-myocardial infarction or PCI) , and 51 were stroke patients (all ischemic stroke) . The cohort included 120 males and 145 females. By the end of the management period, 14 patients were lost to follow-up, including 4 CHD patients and 10 stroke patients, leaving 251 patients who completed the study and were included in the final analysis.The study demonstrated that after 12 months of management, the 1-year recurrence and progression rates of CHD and stroke significantly decreased compared to baseline (P<0.05) . For CHD management, the incidence of myocardial ischemia reduced significantly, with the most notable improvement observed at 6 months (P<0.05) . Additionally, patients’ scores in the Seattle Angina Questionnaire (SAQ) , including physical limitation, angina stability, angina frequency, treatment satisfaction, and disease perception, all significantly improved compared to baseline (P<0.05) . For stroke management, NIHSS scores significantly decreased compared to baseline (P<0.05) . Regarding disease awareness, the total scores of the cardiovascular prevention knowledge questionnaire significantly increased compared to baseline (P<0.05) . In terms of risk factor control, systolic blood pressure decreased significantly from baseline (P<0.05) , and no significant improvements were observed in other parameters (P>0.05) . In terms of lifestyle behavior, the proportions of individuals preferring sweet and oily foods significantly decreased (P<0.05) . Sleep quality, as indicated by PSQI scores, showed significant improvement (P<0.05) . But no significant improvements were observed in other parameters (P>0.05) .

The TCM three-level prevention and control model demonstrates significant management effectiveness in reducing 1-year recurrence and progression rates of CHD and stroke, enhancing disease awareness, improving unhealthy lifestyle behaviors, and partially controlling cardiovascular risk factors. These results suggest that the model effectively stabilizes disease conditions and improves the outcomes of secondary prevention for cardiovascular diseases, highlighting its potential for broader application.

心脑血管疾病是全球致死致残的主要原因，其管理模式仍面临长期干预不足及综合防控效果有限的挑战。中医三级防控模式通过构建"家庭-社区-医院"多层级体系，结合健康教育、生活方式干预及中医特色技术，为患者提供系统化、全周期管理。

评价中医三级防控模式对冠心病与脑卒中患者的管理效能，为优化心脑血管疾病的防治策略提供重要科学依据。

采用前瞻性单臂队列研究方法，于2020年10—12月入组天津市北辰区冠心病、脑卒中非急性期患者265例，通过"以患者为核心、村医/社区医师为执行主体、三级中医院专科医师为主导"的中医三级防控体系，给予患者包括健康教育、生活方式、危险因素、用药和中医适宜技术管理在内的中医健康管理措施，管理随访期共12个月，每6个月进行1次随访。从12个月内复发加重率、心肌缺血发生率、西雅图心绞痛量表（SAQ）得分、美国国立卫生研究院卒中量表（NIHSS）得分、心脑血管预防知识调查表得分、心脑血管危险因素相关指标、生活行为相关指标方面评价患者的管理效果。

265例患者中，冠心病患者214例（心绞痛193例，具有心肌梗死病史或经皮冠状动脉介入治疗术后稳定状态21例），脑卒中患者51例（均为缺血型脑卒中），男120例，女145例。在管理期结束后，共有14例患者脱落（冠心病患者4例、脑卒中患者10例），最终251例患者完成研究并纳入结果分析。管理12个月后，冠心病与脑卒中患者复发加重率较基线下降（P<0.05）。在冠心病管理方面，患者管理12个月的心肌缺血发生率较基线下降（P<0.05），管理6个月时效果最为明显（P<0.05）；患者管理12个月的SAQ躯体活动受限、心绞痛稳定性、心绞痛频率、治疗满意度、疾病感知维度得分均较基线有所增加（P<0.05）。在脑卒中管理方面，患者管理12个月的NIHSS评分较基线下降（P<0.05）。在疾病认知方面，冠心病与脑卒中患者管理12个月时心脑血管疾病预防知识调查表得分较基线升高（P<0.05）。在冠心病与脑卒中相关危险因素控制方面，患者管理12个月时收缩压较基线下降（P<0.05）；其余指标与基线比较，差异无统计学意义（P>0.05）。在生活行为改善方面，患者管理12个月时饮食偏甜率、饮食偏油腻率、匹兹堡睡眠质量指数（PSQI）得分较基线降低（P<0.05）；其余生活行为指标与基线比较，差异无统计学意义（P>0.05）。

基于三级防控的中医健康管理具有较好管理效能，可降低冠心病与脑卒中患者1年内复发加重率，帮助患者增强对疾病的认识、改善不良生活习惯、减少相关危险因素，使患者病情趋于稳定，可提高心血管疾病的二级预防效果。