【摘要】 老年心房颤动（简称房颤）作为高发病率、高致残率的慢性疾病，其综合管理对基层医疗体系提出了严峻挑战。世界卫生组织提出的慢性病创新照护（ICCC）框架，分别从宏观、中观和微观3个层面为老年房颤的全科管理模式提供了理论基础。房颤的全球发病率持续上升，中国老年房颤患者的患病负担与卒中风险问题突出。全科医生作为基层健康管理核心，承担筛查、治疗及患者管理等职责，但现有管理模式仍面临筛查效率不足、资源分配不均及患者健康意识差等问题。本文基于ICCC框架，从3个层面探讨老年房颤患者的全科管理模式。首先，宏观层面需加强政策支持和引导，积极鼓励各地区在合理分配医疗卫生资源的基础上，开展老年房颤患者的个体化全科管理；其次，中观层面应构建以全科医生为核心的多学科团队，完善双向转诊机制，并利用人工智能技术提升治疗的精准性，提高资源的有效利用；最后，微观层面强调老年房颤患者及家庭的健康教育，通过家庭支持、生活方式干预及自我监测等手段，加强患者的自我管理。未来需进一步完善筛查的管理、基层能力的提升，以及生活方式的干预等，为老年房颤患者提供更高效、更全面的全科管理服务。更多还原

【Abstract】 As a chronic disease with high morbidity and disability rates,atrial fibrillation(AF)presents a significant challenge to the primary healthcare system in elderly populations. The Innovative Care for Chronic Conditions(ICCC)framework proposed by the World Health Organization provides a theoretical basis for developing a general practice management model in elderly patients with AF,addressing macro,meso,and micro levels. The global incidence of atrial fibrillation continues to rise,and in China,the disease burden and stroke risk among elderly patients with atrial fibrillation are particular pressing concerns. General practitioners,as the core of community-level health management,are responsible for screening,treatment,and patient management. However,the current management model still faces challenges such as insufficient screening efficiency,unequal resource distribution,and poor health awareness of patients. Based on ICCC framework,this paper discusses the general practice management model for elderly patients with atrial fibrillation across three levels. Firstly,it is necessary to strengthen policy support and guidance at the macro level,encouraging all regions to carry out individualized,practice-wide management approaches supported by the allocation of health resources.Secondly,at the meso level,a multidisciplinary team led by general practitioners should be built to improve the bidirectional referral mechanism. Integrating artificial intelligence technology can further improve the accuracy of treatment and the effective use of resources. Finally,at the micro level,health education for elderly patients with atrial fibrillation and their families should be prioritized,and with a focus on empowering patients through family support,lifestyle intervention,and self-monitoring. In the future,improvements in the management of screening,primary care capacity,and the intervention of lifestyle are necessary to provide more efficient and comprehensive general practice management services for elderly patients with atrial fibrillation.更多还原