脑心同康的核心策略与数字健康技术赋能

doi:10.3969/j.issn.1673-5765.2025.11.005

摘要/Abstract

摘要： 脑心血管疾病存在高度共病关联，二者通过神经通路、压力感受性通路及生化通路相互影响。传统分科康复模式局限于单一器官系统，难以解决运动强度设定矛盾、患者依从性差等问题。基于神经心脏病学理论的脑心同康模式，依托神经科、心血管科、康复医学科等多学科协作，以“综合评估、风险分层、动态调整、个体化干预”为核心原则，构建覆盖综合评估、风险分层、个性化运动、神经康复与神经调控、心理康复、营养管理与危险因素控制、数字健康技术等多维度的“评估-分层-干预-再评估”闭环管理体系。应用个体化运动处方、神经发育疗法、经颅磁刺激、脑机接口及虚拟现实技术的综合康复措施以促进心脏和神经功能修复；借助可穿戴设备、移动健康应用、人工智能与大数据分析等数字健康技术，实现远程监测与动态方案调整，为脑心血管疾病共病患者提供精准、高效的整合康复方案。

文章导读： 本文根据脑心血管疾病的共同病理基础与康复共性，提出构建以“综合评估、风险分层、动态调整、个体化干预”为核心原则的脑心同康模式。该模式涵盖综合评估与风险分层、神经康复与神经调控、心理康复、营养管理与危险因素控制，以及数字健康技术，形成“评估-分层-干预-再评估”的闭环管理路径。

关键词: 脑心同康; 整合康复; 多学科协作; 数字健康

Abstract: Cerebrocardiovascular diseases exhibit a high degree of comorbidity, interacting through neural pathways, baroreceptor pathways, and biochemical pathways. The conventional department-based rehabilitation model is limited to a single organ system, making it difficult to address issues such as conflicts in exercise intensity setting and poor patient compliance. The co-rehabilitation of cerebrocardiovascular diseases model based on the theory of neurocardiology relies on the multidisciplinary collaboration of neurology, cardiology, and rehabilitation medicine. With “comprehensive assessment, risk stratification, dynamic adjustment, and individualized intervention” as its core principles, it builds a closed-loop management system of “assessment-stratification-intervention-reassessment”. This system encompasses multiple dimensions, including comprehensive assessment, risk stratification, individualized exercise, neurorehabilitation and neuromodulation, psychological rehabilitation, nutritional management and risk factor control, as well as digital health technologies. By integrating individualized exercise prescription with neurodevelopmental therapy, transcranial magnetic stimulation, brain-computer interfaces, and virtual reality technology, the model facilitates the repair of cardiac and neurological functions. With the support of digital health technologies, such as wearable devices, mobile health applications, and artificial intelligence-powered big data analysis, it enables remote monitoring and dynamic program adjustment, ultimately providing a precise and efficient integrated rehabilitation program for patients with comorbid cerebrocardiovascular diseases.

Key words: Co-rehabilitation of cerebrocardiovascular disease; Integrated rehabilitation; Multidisciplinary collaboration; Digital health

中图分类号:

周静, 袁健, 叶亮, 王玉龙. 脑心同康的核心策略与数字健康技术赋能[J]. 中国卒中杂志, 2025, 20(11): 1371-1379.

ZHOU Jing, YUAN Jian, YE Liang, WANG Yulong. Core Strategies and Digital Health Technology Empowerment for Co-Rehabilitation of Cerebrocardiovascular Diseases[J]. Chinese Journal of Stroke, 2025, 20(11): 1371-1379.

参考文献

[1] AN X Q，LIU Z Y，ZHANG L W，et al. Co-occurrence patterns and related risk factors of ischaemic heart disease and ischaemic stroke across 203 countries and territories：a spatial correspondence and systematic analysis[J/OL]. Lancet Glob Health，2025，13（5）：e808-e819[2025-10-21]. https://doi.org/10.1016/S2214-109X(25)00013-0.
[2] MARTIN S S，ADAY A W，ALLEN N B，et al. 2025 heart disease and stroke statistics：a report of us and global data from the American Heart Association[J/OL]. Circulation，2025，151（8）：e41-e660[2025-10-21]. https://doi.org/10.1161/cir.0000000000001303.
[3] Joint Committee for Comprehensive Risk Management Chart for the Prevention of Cerebro-Cardiovascular Diseases. Comprehensive risk management for the prevention of cerebro-cardiovascular diseases in Japan[J]. Clin Exp Nephrol，2017，21（5）：743-754.
[4] ROSSI A，MIKAIL N，BENGS S，et al. Heart-brain interactions in cardiac and brain diseases：why sex matters[J]. Eur Heart J，2022，43（39）：3971-3980.
[5] CHEN Z L，VENKAT P，SEYFRIED D，et al. Brain-heart interaction：cardiac complications after stroke[J]. Circ Res，2017，121（4）：451-468.
[6] SPOSATO L A，HILZ M J，ASPBERG S，et al. Post-stroke cardiovascular complications and neurogenic cardiac injury：JACC state-of-the-art review[J]. J Am Coll Cardiol，2020，76（23）：2768-2785.
[7] ARDELL J L，ARMOUR J A. Neurocardiology：structure-based function[J]. Compr Physiol，2016，6（4）：1635-1653.
[8] 李淑娟，马雅军. 树立“脑心同治”观念助力脑心共病诊断与治疗发展[J]. 中国现代神经疾病杂志，2024，24（2）：65-67.
LI S J，MA Y J. Establish the concept of“synchronous treatment for brain and heart”to help the comprehensive diagnosis and treatment of brain and heart comorbidity[J]. Chin J Contemp Neurol Neurosurg，2024，24（2）：65-67.
[9] 关于印发健康中国行动——心脑血管疾病防治行动实施方案（2023—2030年）的通知[EB/OL].（2023-10-30）[2025-10-21]. https://www.gov.cn/zhengce/zhengceku/202311/content 6915365.htm.
[10] VALENZA G，MATIĆ Z，CATRAMBONE V. The brain-heart axis：integrative cooperation of neural，mechanical and biochemical pathways[J]. Nat Rev Cardiol，2025，22（8）：537-550.
[11] SCHWAERZER G. Stroke alters the innate immune memory and drives inflammatory cardiac dysfunction
[J/OL]. Nat Cardiovasc Res，2024，3（8）：887[2025-10-21]. https://doi.org/10.1038/s44161-024-00526-9.
[12] MACHADO N，WINGFIELD M，KRAMER S，et al. Maintenance of cardiorespiratory fitness in people with stroke：a systematic review and meta-analysis[J]. Arch Phys Med Rehabil，2022，103（7）：1410-1421.
[13] ARNETT D K，BLUMENTHAL R S，ALBERT M A，et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease：a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines[J/OL]. Circulation，2019，140（11）：e596-e646[2025-10-21]. https://doi.org/10.1161/CIR.0000000000000678.
[14] BILLINGER S A，ARENA R，BERNHARDT J，et al. Physical activity and exercise recommendations for stroke survivors：a statement for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke，2014，45（8）：2532-2553.
[15] VISSEREN F L J，MACH F，SMULDERS Y M，et al. 2021 ESC guidelines on cardiovascular disease prevention in clinical practice[J]. Eur Heart J，2021，42（34）：3227-3337.
[16] CHO S H，CHOI K B. Guidelines for the evaluation of cardiorespiratory physiotherapy in stroke patients[J/OL]. Healthcare（Basel），2020，8（3）：222[2025-10-21]. https://doi.org/10.3390/healthcare8030222.
[17] DE RUBEIS G，CHATURVEDI S，KAMEL H，et al. Heterogeneity in measurement of NIHSS：a systematic review and meta-analysis[J/OL]. Neurol Sci，2025，46：227-237[2025-10-21]. https://doi.org/10.1007/s10072-024-07733-z.
[18] PRANGE-LASONDER G B，ALT MURPHY M，LAMERS I，et al. European evidence-based recommendations for clinical assessment of upper limb in neurorehabilitation（CAULIN）：data synthesis from systematic reviews，clinical practice guidelines and expert consensus[J/OL]. J Neuroeng Rehabil，2021，18：162[2025-10-21]. https://doi.org/10.1186/s12984-021-00951-y.
[19] HEIDENREICH P A，BOZKURT B，AGUILAR D，et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure：a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines[J/OL]. Circulation，2022，145（18）：e895-e1032[2025-10-21]. https://doi.org/10.1161/cir.0000000000001063.
[20] 中华医学会物理医学与康复学分会，四川大学华西医院. 中国冠心病康复循证实践指南（2024版）第二部分[J]. 中华物理医学与康复杂志，2024，46（7）：577-586.
Chinese Society of Physical Medicine and Rehabilitation，Chinese Medical Association；West China Hospital，Sichuan University. Chinese guidelines for evidence-based practice of coronary heart disease rehabilitation（2024 edition）：part 2[J]. Chin J Phys Med Rehabil，2024，46（7）：577-586.
[21] TAYLOR J L，MYERS J，BONIKOWSKE A R. Practical guidelines for exercise prescription in patients with chronic heart failure[J]. Heart Fail Rev，2023，28（6）：1285-1296.
[22] MACKAY-LYONS M，BILLINGER S A，ENG J J，et al. Aerobic exercise recommendations to optimize best practices in care after stroke：AEROBICS 2019 update[J]. Phys Ther，2020，100（1）：149-156.
[23] HANSEN D，BECKERS P，NEUNHÄUSERER D，et al. Standardised exercise prescription for patients with chronic coronary syndrome and/or heart failure：a consensus statement from the EXPERT Working Group[J]. Sports Med，2023，53（11）：2013-2037.
[24] SAUNDERS D H，SANDERSON M，HAYES S，et al. Physical fitness training for stroke patients[J/OL]. Cochrane Database Syst Rev，2020，3（3）：CD003316[2025-10-21]. https://doi.org/10.1002/14651858.CD003316.pub7.
[25] 贾凌云，刘丽旭. 脑心共患疾病的康复评定及治疗研究进展[J]. 中华脑血管病杂志（电子版），2025，19（3）：167-174.
JIA L Y，LIU L X. Research progress in rehabilitation assessment and treatment of brain-heart comorbidity diseases[J]. Chin J Cerebrovasc Dis（Electronic Edition），2025，19（3）：167-174.
[26] VEMURI A K，HEJAZIAN S S，SADR A V，et al. Adherence to physical activity recommendations among stroke survivors in the United States[J]. Stroke，2025，56（1）：113-121.
[27] MURIE-FERNÁNDEZ M，IRIMIA P，MARTÍNEZ-VILA E，et al. Neuro-rehabilitation after stroke[J]. Neurologia，2010，25（3）：189-196.
[28] LI K P，WU J J，ZHOU Z L，et al. Noninvasive brain stimulation for neurorehabilitation in post-stroke patients[J/OL]. Brain Sci，2023，13（3）：451[2025-10-21]. https://doi.org/10.3390/brainsci13030451.
[29] MESSINA G，MONDA A，MESSINA A，et al. Relationship between non-invasive brain stimulation and autonomic nervous system[J/OL]. Biomedicines，2024，12（5）：972[2025-10-21]. https://doi.org/10.3390/biomedicines12050972.
[30] SUN Z M，LIU L，PENG H J，et al. The efficacy of transcutaneous vagus nerve stimulation in heart failure management—a systematic review and meta-analysis[J/OL]. BMC Cardiovasc Disord，2025，25：481[2025-10-21]. https://doi.org/10.1186/s12872-025-04919-x.
[31] KIRTON A，METZLER M J，CRAIG B T，et al. Perinatal stroke：mapping and modulating developmental plasticity[J]. Nat Rev Neurol，2021，17（7）：415-432.
[32] MEKBIB D B，ZHAO Z Y，WANG J B，et al. Proactive motor functional recovery following immersive virtual reality-based limb mirroring therapy in patients with subacute stroke[J]. Neurotherapeutics，2020，17（4）：1919-1930.
[33] CASSANI R，NOVAK G S，FALK T H，et al. Virtual reality and non-invasive brain stimulation for rehabilitation applications：a systematic review[J/OL]. J Neuroeng Rehabil，2020，17：147[2025-10-21]. https://doi.org/10.1186/s12984-020-00780-5.
[34] SKI C F，TAYLOR R S，MCGUIGAN K，et al. Psychological interventions for depression and anxiety in patients with coronary heart disease，heart failure or atrial fibrillation[J/OL]. Cochrane Database Syst Rev，2024，4（4）：CD013508[2025-10-21]. https://doi.org/10.1002/14651858.CD013508.pub3.
[35] TERRILL A L. Mental health issues poststroke：underrecognized and undertreated[J]. Stroke，2023，54（6）：1528-1530.
[36] MORTENSEN J K，ANDERSEN G. Safety considerations for prescribing SSRI antidepressants to patients at increased cardiovascular risk[J]. Expert Opin Drug Saf，2022，21（4）：467-475.
[37] 中华预防医学会，中华预防医学会心脏病预防与控制专业委员会，中华医学会糖尿病学分会，等. 中国健康生活方式预防心血管代谢疾病指南[J]. 中国循环杂志，2020，35（3）：209-230.
Chinese Preventive Medicine Association；Branch of Heart Disease Prevention and Control，Chinese Preventive Medicine Association；Chinese Diabetes Society；et al. Chinese guideline on healthy lifestyle to prevent cardiometabolic diseases[J]. Chinese Circulation Journal，2020，35（3）：209-230.
[38] 中国医师协会睡眠医学专业委员会，中国医师协会神经内科医师分会睡眠学组. 中国成人失眠共病阻塞性睡眠呼吸暂停诊治指南（2024版）[J]. 中国全科医学，2025，28（11）：1289-1303.
Chinese Academy Society of Sleep Medicine，Chinese Medical Doctor Association；Sleep Medicine Group，China Neurologist Association. Chinese guideline for diagnosis and treatment of co-morbid insomnia and obstructive sleep apnea（2024）[J]. Chinese General Practice，2025，28（11）：1289-1303.
[39] 中国高血压防治指南修订委员会，高血压联盟（中国），中国医疗保健国际交流促进会高血压病学分会，等. 中国高血压防治指南（2024年修订版）[J]. 中华高血压杂志（中英文），2024，32（7）：603-700.
Writing Group of 2018 Chinese Guidelines for the Management of Hypertension，Chinese Hypertension League，Hypertension Branch of China International Exchange and Promotive Association for Medical and Health Care，et al. Chinese guidelines for the management of hypertension（2024 edition）[J]. Chin J Hypertens，2024，32（7）：603-700.
[40] 欧阳子祺，王剑，廖旭兴.“互联网+脑心同治”心脑血管疾病全生命周期健康管理新模式[J]. 中国临床神经外科杂志，2025，30（3）：177-180.
OUYANG Z Q，WANG J，LIAO X X. Internet+brain-heart co-treatment：a new model for whole life cycle health management of cardiovascular and cerebrovascular diseases[J]. Chin J Clin Neurosurg，2025，30（3）：177-180.
[41] MACKINNON G E，BRITTAIN E L. Mobile health technologies in cardiopulmonary disease[J]. Chest，2020，157（3）：654-664.
[42] THOMAS R J，BEATTY A L，BECKIE T M，et al. Home-based cardiac rehabilitation：a scientific statement from the american association of cardiovascular and pulmonary rehabilitation，the American Heart Association，and the American College of Cardiology[J/OL]. Circulation，2019，140（1）：e69-e89[2025-10-21]. https://doi.org/10.1161/cir.0000000000000663.
[43] MCDONAGH S T，DALAL H，MOORE S，et al. Home-based versus centre-based cardiac rehabilitation[J/OL]. Cochrane Database Syst Rev，2023，10（10）：CD007130[2025-10-21]. https://doi.org/10.1002/14651858.CD007130.pub5.
[44] OBERMEYER Z，EMANUEL E J. Predicting the future—big data，machine learning，and clinical medicine[J]. N Engl J Med，2016，375（13）：1216-1219.
[45] YE W X，GAN J，WANG M，et al. A combined-mode machine learning model for predicting stroke recurrence during hospitalization in patients with acute minor ischemic stroke[J/OL]. MedComm，2025，6（6）：e70234[2025-10-21]. https://doi.org/10.1002/mco2.70234.