This study aims to evaluate the effect of an AI-assisted "Smart family doctor" digital health management tool on improving the control rates of hypertension, diabetes, and dyslipidemia in post-revascularization patients. A randomized controlled trial design will be used, involving approximately 10-20 hospitals and 951 participants. Eligible participants are adults aged between 18 and 80 years, post-CABG or post-PCI patients with hypertension, diabetes, and dyslipidemia.
Age 18-80 years.
Underwent CABG or PCI more than 3 months prior and have concurrent hypertension, diabetes, and dyslipidemia.
Systolic blood pressure no less than 130 mmHg or diastolic blood pressure no less than 80 mmHg
HbA1c no less than 7%
History of heart failure or severe arrhythmias.
Presence of other severe underlying conditions such as cancer or liver and kidney insufficiency.
Pregnancy, lactation, or plans for pregnancy within the next year.
Cognitive, communication impairments, or limitations in daily activities.
Parallel
Smart family doctor
BehavioralParticipants will be provided "Smart family doctor", which is an AI-assisted applications with personalized interactions. The content includes, but is not limited to: (1) General educational content, covering basic health knowledge on diseases, risk factors, and treatment methods; (2) Targeted health information, such as more specific guidance on blood pressure and blood sugar control, medication adherence, exercise, and smoking cessation; (3) Personalized disease management guidance, providing tailored reminders for patients regarding medication, diet, exercise, and medical visits. Patients can also directly report their latest self-measured blood pressure, blood lipid, blood sugar levels, and medication adherence to receive treatment and medication guidance from the 'Smart family doctor'.
Health manager
BehavioralParticipants will received 3-hour health management guidance from a health manager once a week, including guidance on healthy lifestyle, medication treatment, and rehabilitation advice.
Usual Care
BehavioralParticipants will receive usual secondary prevention management.
The control rates of hypertension, diabetes and hyperlipidemia
All cretria are meet: 1) Systolic blood pressure less than 130 mmHg and diastolic blood pressure less than 80 mmHg. 2) HbA1c less than 7%. 3) LDL-C less than 1.4 mmol/L.
Blood Pressure Control Rate
The proportion of patients with systolic blood pressure less than 130 mmHg and diastolic blood pressure less than 80 mmHg.
Blood glucose Control Rate
The proportion of patients with HbA1c less than 7%.
Blood lipid Control Rate
The proportion of patients with LDL-C less than 1.4mmol/L.
Systolic blood pressure
Systolic blood pressure measured at the local site.
Major adverse cardiovascular events (MACE)
The composite endpoint of cardiovascular death, myocardial infarction, stroke, or hospitalization due to cardiovascular disease.
BMI
Body mass index (BMI) is calculated as weights (kg) divided by the square of heights (meters).
Waist circumference
Waist circumference is measured at local site.
Rehospitalization rate
The proportion of patients who had hospitalization
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