关键词: 急性冠状动脉综合征；GRACE评分；分级转介照护模式；心脏康复

Abstract: Objective: To evaluate the effect of hospital-community-family graded referral care model among patients with Acute Coronary Syndrome (ACS) at different risk levels discharged from hospital. Methods: Global Registry of Acute Coronary Events (GRACE) were used to evaluate risk stratification of ACS. Hospital-community-family graded referral care model was applied to continuous cardiac rehabilitation management in 50 ACS patients at different risk levels. Before discharge and 3 months, 6 months and 1 years after discharge, the laboratory indicators, cardiac function and patient's self-efficacy were evaluated respectively. Results: The low density lipoprotein (LDL), fasting blood glucose and self-efficacy were improved with the prolongation of follow-up time, and the difference was statistically significant (P<0.05). In addition, the change of cardiac function index was not significant, and the difference was not statistically significant (P>0.05). Conclusion: The hospital-community-family graded referral care model based on GRACE risk stratification can effectively improve the clinical recovery of ACS patients and enhance patients' self-efficacy.

Key words: Acute Coronary Syndrome (ACS); GRACE Score; graded referral care model; cardiac rehabilitation