【摘要】 目的 了解随访管理对高血压患者血压控制及全因、心脑血管疾病和慢性肾病死亡的影响，探究患者参与随访管理依从性的影响因素，为高血压综合防控提供科学依据。方法 该研究数据来源于福建省2016—2023年心血管病高危人群早期筛查与综合干预项目，对25 812名高血压患者基线及随访管理信息进行分析。研究包含问卷调查、体格检查、实验室检测，随访管理包括生活方式干预、用药指导等。患者的死亡信息通过福建省死因监测系统获取，截至2024年2月28日。采用R 4.2.2软件进行秩和检验、χ²检验、多因素Cox回归分析、多因素logistic回归分析。结果 19 343名参与随访管理的高血压患者随访管理后，收缩压中位数从162.0 mmHg(P₂₅～P₇₅:148.5～169.0 mmHg)降低到143.5 mmHg(P₂₅～P₇₅:131.5～157.5 mmHg)，舒张压中位数从92.5 mmHg(P₂₅～P₇₅:84.0～101.0 mmHg)降低到84.0 mmHg(P₂₅～P₇₅:76.5～92.0 mmHg)，高血压治疗率从49.2%提高到60.5%，控制率从6.7%提高到36.5%，均有统计学意义（P<0.01）。多因素Cox回归分析结果显示，与未参与随访组相比，随访管理高频组的全因死亡（HR=0.07）、心脑血管疾病（HR=0.06）和慢性肾病（HR=0.09）死亡风险均降低，均有统计学意义（P<0.05,P<0.01）。多因素logistic回归分析结果显示，已婚（OR=1.02）、高中及以上学历（OR=1.05）、超重（OR=1.02）、高血压知晓（OR=1.03）、血脂异常（OR=1.02）的高血压患者更倾向于参与随访管理，女性（OR=0.98）、65～75岁年龄组（OR=0.96）、农事从业者（OR=0.97）、饮酒（OR=0.98）、低体质量（OR=0.93）、患糖尿病（OR=0.97）的高血压患者更倾向于不参与随访管理；城市（OR=1.15）、已婚（OR=1.03）、有医保（OR=1.12）、高血压治疗（OR=1.03）的患者更倾向于参与高频随访管理，女性（OR=0.97）、家庭年收入5万元及以上（OR=0.97）、农事从业者（OR=0.94）、饮酒（OR=0.97）、吸烟（OR=0.97）、低体质量（OR=0.94）、高血压知晓（OR=0.95）的患者更倾向于参与低频随访管理（P<0.05,P<0.01）。结论 积极参与随访管理，对高血压患者的血压控制以及降低全因死亡、心脑血管疾病和慢性肾病死亡风险均有显著效果。同时，鼓励女性、农事从业者、低体质量、饮酒等高血压人群积极参与随访管理。更多还原

【Abstract】 Objective To understand the effects of following-up management on blood pressure control and the death of all-cause,cardio-cerebrovascular disease and chronic kidney disease in hypertensive patients,and explore the influencing factors of patients compliance with following-up management,and provide the scientific basis for the comprehensive prevention and control of hypertension. Methods The data were from "Early Screening and Comprehensive Intervention Program in Population at High Risk for Cardiovascular Diseases" in Fujian Province from 2016 to 2023,the investigation for 25 812 hypertension patients baseline and following-up manegement was performed with questionnaire,physical examination and laboratory tests;following-up management included the life style intervention,medication guidance. The death information of patients were from Fujian Province Mortality Surveillance System. The end date was February 28,2024. Rank sum test,χ²test,multivariate Cox regression analysis,and multivariate logistic regression analysis were used to analyze the data.The used software was R 4.2.2. Results After 19 343 cases paticipated the following-up manegement of hypertension patients,the median of systolic blood pressure decreased from 162.0mmHg(P₂₅-P₇₅:148.5-169.0 mmHg) to 143.5 mmHg(P₂₅-P₇₅:131.5-157.5 mmHg) and the median of diastolic blood pressure decreased from 92.5 mmHg(P₂₅-P₇₅:84.0-101.0 mmHg) to 84.0 mmHg(P₂₅-P₇₅:76.5-92.0 mmHg);the treatment rate of hypertension increased from 49.2% to 60.5%;the control rate of hypertension increased from 6.7% to 36.5%,P<0.01. Multivariate Cox regression analysis showed that as compared with the non-participation group,the death risk of all cause death（HR=0.07）,cardio-cerebrovascular disease（HR=0.06）,chronic kidney disease（HR=0.09） in the high-frequency follow-up management group decreased significatly（P<0.05 or P<0.01）. Multivariate logistic regression analysis showed that hypertension patients with married（OR=1.02）,high school and above（OR=1.05）,overweight（OR=1.02）,hypertensive aware（OR=1.03）,and dyslipidaemic（OR=1.02） had the trend to paticipate the following-up management;hypertension patients with female（OR=0.98）,65-75 years old group（OR=0.96）,agricultural workers（OR=0.97）,alcohol drinking（OR=0.98）,those with a low BMI（OR=0.93）,and diabetes（OR =0.97） had the trend not to paticipate the following-up management;hypertension patients with urban area（OR =1.15）,married（OR=1.03）,medically insured（OR=1.12）,and hypertensive treatment（OR=1.03） were more inclined to participate in high-frequency following-up management;hypertension patients with female（OR =0.97）,family annual income ≥50 000 yuan（OR =0.97）,agricultural workers（OR =0.94）,alcohol drinking（OR =0.97）,smoking（OR =0.97）,low BMI（OR =0.94） and hypertensive aware（OR =0.95） were more inclined to participate in low-frequency following-up management（P <0.05）.Conclusion Active participating in following-up management has the significant effects on controlling blood pressure and reducing all cause death,the death risk of cardio-cerebrovascular disease and chronic kidney disease. Meanwhile,hypertension patients with females,agricultural workers,low BMI,and alcohol drinkers are encouraged to participate in the following-up management.更多还原