三级医院心力衰竭门诊管理方案对患者预后的影响

Effects of integrated disease management program on the outcome of patients with heart failure

目的 探索结合心力衰竭（心衰）门诊、心衰教育和电话随访的心衰疾病管理方案的可行性,观察该方案对患者预后的影响.方法 入选住院的心衰患者145例,男91例,女54例,平均年龄（69.6±11.3）岁,纽约心功能分级（NYHA分级）Ⅱ-Ⅳ级,左室射血分数（LVEF）≤45%或LVEF〉45%时N末端B型利钠肽原〉1500 ns/L.根据个人意愿分为非疾病管理组和疾病管理组,疾病管理组进行一系列的干预措施,包括开展心衰教育、电话随访、定期心衰门诊就诊.于分组后10～12个月比较两组患者的结果.结果 基线时两组患者临床特征、LVEF及药物使用率、达标率差异无统计学意义.随访时,疾病管理组NYHA分级为（1.4±0.5）级,LVEF为40%±8%;非疾病管理组NYHA分级为（3.2±0.5）级,LVEF为31%±6%.疾病管理组自行监测体重、血压和脉搏的比例均显著高于非疾病管理组（P〈0.05）.在收缩性心衰患者中,疾病管理组40%患者的β受体阻滞剂达标剂量显著高于非疾病管理组的11%（P〈0.05）;疾病管理组66%患者的血管紧张素转换酶抑制剂/血管紧张素Ⅱ受体拮抗剂达标剂量高于非疾病管理组的37%,但差异无统计学意义（P=0.09）.非疾病管理组心血管病事件率为91.5%,疾病管理组心血管事件率为27.0%,两者差异有统计学意义（P〈0.05）.结论 结合心衰门诊、心衰教育和电话随访的心衰疾病管理方案可显著改善心衰患者的治疗依从性,增加有效药物的治疗剂量,改善患者的心功能并降低心血管病事件率.

Objective To investigate the feasibility and efficacy on the outcome of patients with heart failure of integrated disease management program with heart failure clinic, patient education and telephone follow-up. Methods A total of 145 hospitalized patients with chronic heart failure and LVEF≤ 45% or patients with LVEF 〉45% and NT-proBNP 〉 1500 ng/L were divided into conventional group （re = 71） and interventional group （n =74）. Patients were followed for 10 to 12 months. Results Baseline clinical characteristics, LVEF and dose of evidence-based medicine were similar between the 2 groups. During follow-up, the NYHA functional class was higher in conventional group than interventional group （3.2±0.5 vs 1.4±0.5, P 〈0.05） , and the LVEF deteriorated in the conventional group and improved from 34% to 40% in the interventional group. The proportions of self-monitoring of weight, blood pressure and pulse rate in the interventional group were significantly higher than those of conventional group （P 〈 0. 05）. Among patients with systolic heart failure, 40% patients in the interventional group and 11 % patients in the conventional group achieved the target doses of β-blockers （P〈0.05）. Cardiovascular event rate of conventional group and interventional group is 91. 5% and 27. 0% respectively （ P 〈 0. 05 ）. Conclusion Integrated disease management program with heart failure clinic, patient education and telephone follow-up can improve patient compliance to heart failure treatment, improve cardiac function and reduce cardiovascular event rate.