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目的：：建立慢性心力衰竭患者出院后的疾病管理方案，观察疾病管理对患者预后的影响。方法：入选慢性心衰力竭急性加重住院患者207例，出院后随机分为研究组103例和对照组104例，研究组采取疾病管理方案，对照组仅进行常规门诊随访，比较两组出院后1年时的临床随访结果。结果：排除失访患者，共188例获得完整资料，其中研究组98例，对照组90例，两组基线临床特征差异无统计学意义(P >0.05)。随访结果显示，与对照组比较，研究组出院后6个月内再入院率、多次再入院率、再入院或死亡联合事件发生率均明显降低(P <0.05)。研究组心功能 I 或 II 级患者所占百分比、左室射血分数均高于对照组(P <0.05)，左室舒张期末径小于对照组(P <0.05)。研究组明尼苏达心衰生活质量评分优于对照组(P 0.05 ).Follow-up results showed that compared with that in the control group,within the six months after discharged,the readmission rate,the multi-ple readmission rate,and the readmission or death joint events rate in the study group decreased significantly (P <0.05).The percentage of cardiac function NYHA class I to II and the left ventricular ejection fraction in the study group were higher than that in the control group (P <0.05),and the left ventricular end-diastolic diameter was in contrast (P <0.05).The score of Minnesota Living with Heart Failure Questionnaire in the study group was superior to that in the control group (P <0.05 ). Conclusions:The implementation of post-discharge disease management for the patients with chronic heart failure can signifi-cantly reduce the risk of the readmission,the multiple readmission,and the readmission or death joint events within the six months after discharge,and improve the patients’cardiac function and quality of life.