Zhou Zhaoyuan, Gao Xiaotong, Jiang Meichen, Wang Jiachun, Zhang Qiang, Wang Zhen, Yan Zhe, Yu Kai, Chen Xinyue, He Xiaoqing, Wang Shuang
Department of General Practice, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China.
Front Med (Lausanne). 2025 Jul 8;12:1593238. doi: 10.3389/fmed.2025.1593238. eCollection 2025.
We aimed to explore the benefits of the "Digital and Intelligent Patient-centered Integration of Treatment and Prevention for Cardiovascular Diseases in the Community" (DITP), which is a new model for managing cardiovascular disease risk factors in high-risk elderly stroke patients.
A total of 338 elderly high-risk stroke patients were included and subjected to a 6-month self-controlled DITP study.
The five chronic diseases with the highest prevalence rates were hypertension (89.94%), dyslipidemia (73.37%), overweight (65.70%), diabetes (52.96%), and atrial fibrillation/valvular heart disease (2.07%). Moreover, 86.7% of patients had two or more simultaneous chronic diseases, and 27.22% had a history of smoking. After 6 months of intervention, (1) with respect to the control of multiple risk factors, there were improvements in blood pressure and blood lipid compliance rates. The blood glucose compliance rate (50.30% preintervention vs. 62.43% postintervention) and the optimal risk factor control rate (3.85% preintervention vs. 8.88% postintervention) were significantly improved (P < 0.05). (2) Regarding physiological indicators, fasting blood glucose (7.44 ± 2.37 mmol/L preintervention vs. 6.99 ± 2.15 mmol/L postintervention), cholesterol (5.56 ± 1.3 mmol/L preintervention vs. 5.20 ± 1.22 mmol/L postintervention), and low-density lipoprotein cholesterol levels significantly decreased ( < 0.05). (3) The proportions of patients with good medication adherence scores for hypoglycemic (6.76 ± 1.76 preintervention vs. 7.19 ± 1.24 postintervention), lipid-lowering (6.80% preintervention vs. 15.09% postintervention), and antiplatelet (4.73% preintervention vs. 7.69% postintervention) drugs significantly increased ( < 0.05). (4) The activation score and the proportion of the highest activation level significantly improved ( < 0.05). (5) Regarding major adverse cardiovascular events, 2 (0.59%) and 13 (3.85%) patients experienced myocardial infarction and cerebral vascular ischemia events, respectively. (6) Univariate analysis revealed that employment status, per capita monthly family income, hypertension status, diabetes status, family history of stroke, and hypoglycemic and lipid-lowering treatment had significant effects on the optimal risk factor control rate ( < 0.05). Multivariate logistic regression analysis revealed that employment status, nondiabetes status, a family history of stroke, and receiving lipid-lowering treatment were associated with better control.
This DITP model will help actively improve the health of elderly high-risk stroke patients in the long term and should be further applied and promoted in primary healthcare in the future.
我们旨在探讨“社区心血管疾病治疗与预防的数字化和智能化以患者为中心的整合”（DITP）的益处，这是一种管理高危老年中风患者心血管疾病风险因素的新模式。
共纳入338例老年高危中风患者，并进行了为期6个月的DITP自我对照研究。
患病率最高的五种慢性病为高血压（89.94%）、血脂异常（73.37%）、超重（65.70%）、糖尿病（52.96%）和心房颤动/瓣膜性心脏病（2.07%）。此外，86.7%的患者同时患有两种或更多种慢性病，27.22%的患者有吸烟史。干预6个月后，（1）在多重危险因素控制方面，血压和血脂达标率有所改善。血糖达标率（干预前50.30% vs. 干预后62.43%）和最佳危险因素控制率（干预前3.85% vs. 干预后8.88%）显著提高（P < 0.05）。（2）关于生理指标，空腹血糖（干预前7.44±2.37 mmol/L vs. 干预后6.99±2.15 mmol/L）、胆固醇（干预前5.56±1.3 mmol/L vs. 干预后5.20±1.22 mmol/L）和低密度脂蛋白胆固醇水平显著降低（<0.05）。（3）降糖（干预前6.76±1.76 vs. 干预后7.19±1.24）、降脂（干预前6.80% vs. 干预后15.09%）和抗血小板（干预前4.73% vs. 干预后7.69%）药物的良好用药依从性评分患者比例显著增加（<0.05）。（4）激活评分和最高激活水平比例显著改善（<0.05）。（5）关于主要心血管不良事件，分别有2例（0.59%）和13例（3.85%）患者发生心肌梗死和脑血管缺血事件。（6）单因素分析显示，就业状况、家庭人均月收入、高血压状况、糖尿病状况、中风家族史以及降糖和降脂治疗对最佳危险因素控制率有显著影响（<0.05）。多因素logistic回归分析显示，就业状况非糖尿病状态、中风家族史以及接受降脂治疗与更好的控制相关。
这种DITP模式将有助于长期积极改善老年高危中风患者的健康状况，未来应在基层医疗保健中进一步应用和推广。
