高血压患者的适宜随访时间和频率

A Preliminary Investigation on the Appropriate Follow-up Cycle and Frequency for Hypertensive Patients

目的探索依托村医实施高血压规范管理的适宜随访时间和频率,为提出适宜的高血压管理模式提供依据.方法本研究利用“中国农村健康行动”在晋城市的2个县12个村接受规范化管理的所有463例高血压患者作为研究对象,分析其在干预期间血压水平和血压控制达标率随干预时间的变化情况.结果在干预后的不同时间,干预人群平均收缩压和血压控制率呈不同下降趋势.平均收缩压前3个月内下降迅速,从166.5mmHg(1mmHg =0.133kPa)降至139.5mmHg;第4~6个月缓慢下降,之后维持134mmHg左右水平.血压控制达标率前6个月上升明显,第6个月达63.2%;至第10个月达70.0%,之后基本稳定.结论初步建议在农村高血压规范化管理工作中,对于新纳入管理的高血压患者前3~6个月最好每个月随访1次,待血压达标并稳定之后每3个月随访1次即可.

Objective To explore the appropriate follow - up time and frequency of the standardized management of hypertensive patients depending on village doctors, and provide a foundation for proposing good hypertension management model. Methods Relying on“China Rural Health Initiative”, 463 hypertension patients undergoing standardized management from 12 villages of 2 counties in Jincheng City were selected into the study. The changes of blood pressure and the blood pressure controlling rate with intervention time during the standardized management were explored. Results The mean systolic pressure and the blood pressure controlling rate showed different decreasing trends during the different follow - up period. The mean systolic pressure was decrease rapidly with in the first 3 months, but was decreasing slowly during the 4th to 6th month, and then maintained at about 134 mmHg. The blood pressure controlling rate was increasing obviously in the first 6 months, and reached 63. 2% in the 6th month. After the 10th month of 70. 0%, the rate entered the plateau period. Conclusion It was recommended to follow up the new hypertensive patients in rural at least once a month for the first 3-6 months, then to follow up every three months when blood pressure was up to standard and stable.