Proactive Measures in Chronic Disease Management: Self-Prevention and Management Goals and Digital Monitoring for Patients with Hypertension, Hyperlipidemia, and Hyperglycemia

Self-management of patients with hypertension, hyperlipidemia, and diabetes. I. Purpose of Self-Management. The fundamental purpose of managing hypertension, hyperlipidemia, and diabetes is to prevent cardiovascular and cerebrovascular events (myocardial infarction, stroke, etc.). Therefore, the goal of self-management is comprehensive management, not only of the primary diseases, but also of all major risk factors related to cardiovascular and cerebrovascular diseases, including: blood pressure, blood lipids, blood sugar, metabolic syndrome, coronary heart disease, cerebrovascular disease, carotid artery stenosis, and lower extremity arterial disease, to promptly identify and prevent problems.

II. Self-management of comprehensive prevention and control. Patients should regularly measure the required parameters for hypertension, hyperlipidemia, and diabetes, and record changes and control status of their condition; non-pharmacological interventions and lifestyle changes; drug treatment and adverse reactions, evaluate drug efficacy and adjust medications promptly; cooperate with doctors for relevant examinations, regularly check blood lipids, blood glucose and other related indicators according to the condition, and evaluate target organ damage and coexisting diseases.

Third, apply comprehensive prevention and management software for cardiovascular and cerebrovascular diseases for health education. This helps patients and their families understand their condition, including its relationship with blood pressure, blood sugar, blood lipids, and other risk factors, the overall risk and prognosis of cardiovascular and cerebrovascular diseases, and to understand individualized treatment goals for blood pressure, blood sugar, and blood lipids, as well as individualized core treatment plans. It also enables individualized self-monitoring and management. "Experience makes one a better doctor," and this is the fundamental way to improve the prevention and control level and efficiency of hypertension, hyperlipidemia, and hyperglycemia, and to reduce the incidence of cardiovascular and cerebrovascular accidents.

(I) Basis of the Comprehensive Prevention and Management Software for Cardiovascular and Cerebrovascular Diseases. In order to improve the level and efficiency of prevention and management of more than 300 million people with hypertension, hyperlipidemia, and diabetes in China, the Expert Committee on Prevention and Management of Cardiovascular and Cerebrovascular Diseases of the China Association of Senior Professors designed and compiled an integrated software system for implementing the guidelines for cardiovascular and cerebrovascular diseases based on the relevant guidelines of the Ministry of Health.

(II) How Patients Use the Comprehensive Prevention and Management Software for Cardiovascular and Cerebrovascular Diseases. Patients can conveniently and quickly log in to the website of the Expert Committee on Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases of the China Association of Senior Professors. After entering their personal medical history, the software provides the following: 1. Risk Factor Analysis. Based on the "Guidelines" and recognized risk analysis methods, the data is analyzed, graded, and stratified for comprehensive risk factors; 2. Multifactorial Risk Assessment of Cardiovascular and Cerebrovascular Diseases. Primarily based on Framingham's risk assessment, combined with the risk factor risk assessment methods of various "Guidelines," allowing patients to understand their risk (%) of developing myocardial infarction or stroke within 10 years; 3. Analysis of Main Treatment Target Values, Initiating Values, and Achievement Status. This includes commonly used blood lipid series, blood glucose, blood pressure, weight, BMI, waist circumference, metabolic syndrome, and coronary heart disease, cerebrovascular disease, and lower extremity arterial disease; 4. Core Treatment Plan Analysis. An individualized ABCDE core drug treatment plan is developed according to the requirements of the "Guidelines" and the patient's condition; 5. Core Treatment Plan and Prediction of Prevention and Treatment Effects. Incorporating more evidence-based medicine and guidelines in recent years to analyze and predict patient treatment and efficacy, the main purpose is to increase patients' understanding of their condition, recognize the significance of each treatment, and improve their confidence and adherence. 6. Analysis of risk factor monitoring and testing protocols. Based on guidelines and individual circumstances, recommendations for monitoring and testing of important risk factors are provided. 7. Popularization of guidelines, individualized guidance, and education programs. Based on patient data and relevant guidelines, targeted interpretations are provided using a combination of text and graphics, covering key prevention and control points, risk factor analysis and comprehensive risk assessment, treatment initiation values, treatment goals, non-pharmacological and pharmacological treatment principles, the importance of treatment, expected treatment effects, key points of monitoring and testing, and important precautions. Popularization of guidelines and individualized guidance improve doctor-patient communication efficiency, increase patients' understanding of the disease, treatment, and testing, encourage active patient participation, and improve treatment adherence. 8. Targeted follow-up management. This concise and dynamic individualized follow-up management form provides information on risk factor clustering, risk assessment, individualized treatment goals, core treatment plans, expected treatment outcomes, and key examination items. It facilitates healthcare professionals' understanding of patients' progress and adherence to treatment protocols, enabling adjustments to treatment plans and targeted reinforcement of education. Through in-depth, standardized, and individualized public education on the prevention and treatment of cardiovascular and cerebrovascular diseases, it improves prevention and control effectiveness, effectively improving patients' health. It also helps improve quality of life, control medical costs, and reduce the burden on society, families, and patients.

(III) How to do a good job of monitoring and recording the course of the disease. 1. Patient self-monitoring. Comprehensive and detailed monitoring records are necessary so that doctors and patients can understand the condition well and make it easier to adjust the treatment plan. 2. Main contents of disease course monitoring. The main observation contents and time should be recorded. It is best to use a standardized form for monitoring and recording. Generally, the following should be recorded: (1) Time: the date and time of the monitoring to understand the specific time period of blood pressure fluctuations each day. When the condition is unstable, blood pressure should be measured at least three times a day. After the condition is stable, the number of measurements should be reduced as appropriate, but at least 1 or 2 times a week should be measured. (2) Non-drug treatment: daily life, three meals a day, try to arrange low-oil, low-salt and low-fat foods, weight changes; smoking cessation and alcohol limitation; exercise. Continuously improve a healthy lifestyle. (3) Drug treatment: understand the drug application, whether there is a reduction, discontinuation or change of drugs, what adverse reactions the drugs have, and evaluate the drug treatment effect. Doctors can adjust the treatment plan in a timely manner according to the monitoring records, which is conducive to improving the patient's treatment compliance. (4) Relevant laboratory tests: According to the condition, relevant tests should be performed regularly so that doctors can detect target organ damage and coexisting diseases in a timely manner, and provide timely treatment and referral.

IV. Points to Note During Follow-up Visits. Patients should go to the hospital for follow-up visits as needed. During the follow-up visit, please describe the following points to the doctor in detail: Have you improved your lifestyle, such as eating less oil and salt, eating more fruits and vegetables, and increasing physical activity? Have you consumed excessive alcohol? Do you experience any mental stress or psychological imbalance, and is your sleep good? Have you taken your medication as prescribed by the doctor, including the type of medication, the time of administration, frequency, and dosage? Have you experienced any adverse reactions after taking the medication? What medications are you currently taking? Have you experienced any new symptoms, such as palpitations, chest tightness, waking up at night feeling suffocated, shortness of breath, blurred vision, eye pain, numbness or weakness in the limbs, lower limb edema, or lower limb pain when walking?