脑心血管疾病共病的“四同”管理体系：从以器官为中心到系统整合

doi:10.3969/j.issn.1673-5765.2025.11.001

中国卒中杂志 ›› 2025, Vol. 20 ›› Issue (11): 1335-1343.DOI: 10.3969/j.issn.1673-5765.2025.11.001

脑心血管疾病共病的“四同”管理体系：从以器官为中心到系统整合

罗令夫^1*，樊燕琴^2，3*，曹黎明³，任力杰²（*第一作者）

1 深圳 518055 中国医学科学院阜外医院深圳医院心脏大血管外科
2 深圳大学医学部
3 深圳市第二人民医院（深圳大学第一附属医院）神经内科

收稿日期:2025-08-15 修回日期:2025-11-09 接受日期:2025-11-13 出版日期:2025-11-20 发布日期:2025-11-20
通讯作者: 任力杰 renlijie72@126.com
基金资助:
癌症、心脑血管、呼吸和代谢性疾病防治研究国家科技重大专项（2023ZD0504800；2023ZD0504802）
神经与肿瘤药物研发全国重点实验室开放课题重点项目（SKLSIM-F-202496）
深圳市神经系统疾病临床医学研究中心资助计划（LCYSSQ20220823091204009）
深圳市医防融合（神经系统疾病）项目（深卫健体改〔2019〕25号）

“Four-in-One” Management System for Comorbid Cerebrocardiovascular Diseases: from Organ-Centered to Systemic Integration

LUO Lingfu^1*, FAN Yanqin^2,3*, CAO Liming³, REN Lijie²(*contributed equally)

1 Department of Cardiac and Great Vessel Surgery, Fuwai Shenzhen Hospital, Chinese Academy of Medical Sciences, Shenzhen 518055, China
2 Shenzhen University Medical School, Shenzhen 518063, China
3 Department of Neurology, Shenzhen Second People’s Hospital (The First Affiliated Hospital of Shenzhen University), Shenzhen 518035, China

Received:2025-08-15 Revised:2025-11-09 Accepted:2025-11-13 Online:2025-11-20 Published:2025-11-20
Contact: REN Lijie, E-mail: renlijie72@126.com

摘要/Abstract

摘要： 脑心血管疾病作为全球重要的致死、致残病因，具有共同的动脉粥样硬化病理基础及高血压、糖尿病等血管危险因素，常以脑心血管疾病共病（简称脑心共病）的临床形式存在。传统分科诊疗模式导致脑心共病诊疗碎片化、医疗资源利用率低，限制了患者整体预后的改善。本文基于脑-心轴双向调控机制，系统提出脑心共病“同防、同检、同治、同康”的“四同”管理体系：同防聚焦全周期共同危险因素的防控，通过生活方式干预与危险因素管理，防患于未然；同检依托脑心联合多模态检查，实现脑心血管结构与功能的同步评估；同治以多学科协作为核心，制订协同治疗方案，破解治疗冲突及诊疗碎片化难题；同康构建脑心功能兼顾的一体化康复路径，实现脑心功能的相互促进与共同恢复。结合最新循证证据与我国医疗实践，本文论证该管理体系的科学性与必要性，剖析其落地挑战并提出发展方向，旨在为改善脑心共病患者预后及降低疾病负担提供理论依据与实践路径。

关键词: 脑心血管疾病; 统一管理; 多模态检查; 联合治疗; 整体康复

Abstract: As the leading cause of death and disability worldwide, cerebrocardiovascular diseases share the common pathological basis of atherosclerosis and vascular risk factors such as hypertension and diabetes mellitus. They often coexist in the form of comorbid cerebrocardiovascular diseases. The traditional department-based diagnosis and treatment model leads to fragmented prevention and treatment, low utilization efficiency of medical resources, ultimately limiting the improvement in patients’ overall prognosis. Based on the bidirectional regulation mechanism of the brain-heart axis, this paper systematically proposes a “Four-in-One” management system for comorbid cerebrocardiovascular diseases, which emphasizes co-prevention, co-screening, co-treatment, and co-rehabilitation. Co-prevention focuses on the whole-cycle prevention and control of common risk factors, and prevents diseases before they occur through lifestyle interventions and risk factor management; co-screening relies on cerebrocardiac combined multimodal examinations to achieve simultaneous assessment of the structure and function of the cerebrovascular and cardiovascular systems; co-treatment takes multi-disciplinary collaboration as the core, formulates coordinated plans, and resolves treatment conflicts and fragmented diagnosis and treatment; co-rehabilitation builds an integrated rehabilitation pathway that takes both cardiac and cerebral functions into account, realizing the mutual promotion and joint recovery of cardiac and cerebral functions. Combined with the latest evidence-based evidence and China’s medical practice, this paper demonstrates the scientificity and necessity of this system, analyzes the challenges in its implementation, and puts forward development directions. It aims to provide a theoretical basis and practical path for improving the prognosis of patients with comorbid cerebrocardiovascular diseases and reducing the disease burden.

Key words: Cerebrocardiovascular disease; Unified management; Multimodal examination; Combined treatment; Holistic rehabilitation

中图分类号:

罗令夫, 樊燕琴, 曹黎明, 任力杰. 脑心血管疾病共病的“四同”管理体系：从以器官为中心到系统整合[J]. 中国卒中杂志, 2025, 20(11): 1335-1343.

LUO Lingfu, FAN Yanqin, CAO Liming, REN Lijie. “Four-in-One” Management System for Comorbid Cerebrocardiovascular Diseases: from Organ-Centered to Systemic Integration[J]. Chinese Journal of Stroke, 2025, 20(11): 1335-1343.

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脑心血管疾病共病的“四同”管理体系：从以器官为中心到系统整合

“Four-in-One” Management System for Comorbid Cerebrocardiovascular Diseases: from Organ-Centered to Systemic Integration

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