慢性心力衰竭出院患者的随访管理分析

The Follow-up of discharged patients with chronic heart failure

目的探讨慢性心力衰竭（CHF）出院患者随访管理的效果及其对预后的影响。方法选取两组患者，其中116例CHF出院患者（管理组）在住院期间由经治医生及责任护士进行相关院后规范治疗的宣教，出院后定期随访管理，另103例CHF出院患者（对照组）住院期间并未行相关院后规范治疗的宣教，出院后亦未作专门的随访管理。随访后对两组患者的症状、服药情况、药物不良反应、生活质量、运动耐量、药物依从性等指标进行比较分析。结果与对照组比较，管理组患者服药依从性及生活质量改善均明显提高（均P〈0.05），心功能恶化发生率、NYHA Ⅳ级患者所占比例、再次住院率及住院时间均明显降低（均P〈0．05）。结论对CHF出院患者进行定期随访管理，能有效提高治疗率，改善预后。

Objective To review of follow-up management for discharged patients with chronic heart failure （CHF）. Methods Two hundred nineteen discharged patients with CHF, were divided into two groups. In management group, 116 patients received health education during the hospitalization and regular management from designated physicians and nurses during the follow-up In control group 103 patients did not receive any special management during the follow-up. The symptoms, medication, drug adverse effect, quality of life, exercise tolerance, compliance and other indicators were compared between two groups. Results The medication compliance and the quality of life in the management group were significantly higher than those in the control group （P〈0.05）; the cardiac function deterioration rate, proportion of patients with NYHA Ⅳ class, readmission rate in the management group were significantly lower than those in the control group （P〈0.05）. Conclusion The regular follow-up management can increase the treatment rate and improve the prognosis in the post-hospital chronic heart failure patients.