冠心病患者出院后随访管理对其用药依从性与再住院风险的前瞻性研究-现代医学

冠心病患者出院后随访管理对其用药依从性与再住院风险的前瞻性研究

单位：南京脑科医院心血管内科, 江苏南京 210000

分类号：R541.4

出版年·卷·期（页码）：2026·54·第二期（273-280）

摘要：

目的： 评估为期36个月的系统化、多学科随访管理对冠心病患者出院后长期用药依从性及心血管再住院风险的影响。方法： 采用前瞻性随机对照设计，选取2020年1月至2022年8月出院的确诊冠心病患者280例作为研究对象，随机分为干预组(n=140)与对照组(n=140)。对照组接受常规出院指导，干预组在常规基础上接受为期36个月的系统化电话随访，内容涵盖用药指导、症状监测、生活方式干预及心理支持。主要结局为Morisky用药依从性量表(MMAS-8)得分表和心血管相关再住院率。计量资料采用t检验，计数资料采用χ²检验或Fisher确切概率法进行组间比较。采用Kaplan-Meier法绘制生存曲线估算生存概率，采用Log-rank检验比较两组的心血管相关再住院率差异。为直观展示事件的累计负担，计算并绘制了累计发生率曲线。通过单因素及多因素Cox比例风险回归模型，分析随访管理对再住院风险的影响。结果： 两组基线资料均衡可比(均P > 0.05)，经过36个月随访，干预组和对照组的高依从率分别为83.3%(110/132)和49.2%(63/128)。与对照组相比，干预组用药依从性更高，各时间点MMAS-8得分及高依从性患者比例均更高(均P＜0.001)。干预组的心血管病相关再住院率(19.7% vs. 39.1%)、全因再住院率(26.5% vs. 48.4%)及主要不良心血管事件发生率(23.5% vs. 42.2%)均显著低于对照组，差异均有统计学意义(均P＜0.05)。Kaplan-Meier分析显示，干预组的无心血管再住院生存率更高(P＜0.001)。多因素Cox回归分析表明，随访管理与再住院风险降低独立相关(HR=0.48,95%CI 0.31-0.74, P=0.001)。结论： 系统化、多学科的随访管理能有效提升冠心病患者的用药依从性，降低心血管病再住院风险，是改善冠心病患者远期预后的有效二级预防策略。

Objective: To evaluate the impact of a 36 months systematic, multidisciplinary follow-up management program on long-term medication adherence and the risk of cardiovascular readmission in patients with coronary artery disease after hospital discharge. Methods: This prospective randomized controlled trial consecutively enrolled 280 coronary artery disease patients discharged between January 2020 and August 2022. Patients were randomly allocated to either an intervention group(n=140) or a control group(n=140). The control group received routine discharge instructions, while the intervention group received an additional 36 months systematic telephone follow-up program, which included medication guidance, symptom monitoring, lifestyle intervention, and psychological support. The primary outcomes were the Morisky Medication Adherence scale(MMAS-8) score and the cardiovascular-related readmission rate. Continuous variables were compared using the t-test, and categorical variables were analyzed using the χ² test or Fisher's exact test. Kaplan-Meier survival curves were constructed to estimate event-free survival, and differences between groups were assessed using the log-rank test. Cumulative incidence curves were plotted to illustrate the overall burden of events; Cox proportional hazards models were used to evaluate the association between follow-up management and rehospitalization risk. Results: Baseline characteristics were comparable between the two groups(all P>0.05). After 36 months of follow-up, the high adherence rate was 83.3%(110/132) in the intervention group compared to 49.2%(63/128) in the control group. The intervention group demonstrated significantly higher medication adherence, with higher Morisky scores and a greater proportion of patients with high adherence at all follow-up time points(all P＜0.001). Furthermore, the intervention group experienced significantly lower rates of cardiovascular-related readmission(19.7% vs. 39.1%, P＜0.001), all-cause readmission(26.5% vs. 48.4%, P＜0.001), and major adverse cardiovascular events(23.5% vs. 42.2%, P=0.001). Kaplan-Meier analysis revealed a significantly higher event-free survival rate from cardiovascular readmission in the intervention group(Log-rank P＜0.001). Multivariable Cox regression analysis showed that the follow-up management program was independently associated with a lower risk of readmission(HR=0.48, 95% CI 0.31-0.74, P=0.001). Conclusion: A 36 months systematic, multidisciplinary follow-up management program can significantly and sustainably improve medication adherence and reduce the risk of cardiovascular readmission by 52% in patients with CAD after discharge. This program represents an effective secondary prevention strategy for improving long-term prognosis.

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