Study: NCT04409210

Intervention type: BEHAVIORAL
Group type: EXPERIMENTAL
Intervention: Establishment of individual health records
Description: Patients could upload self-test data (such as blood pressure, blood glucose, heart rate and weight) and medical institution examination data (such as blood lipids, ECG, echocardiography, etc.) through App. AND then the App can automatically generate health reports to reflect the dynamic changes of the data in the form of charts and whether the data is normal or not. It is convenient for patients to have a clear understanding of their health management, and if there are outliers, they can intervene in time.

Intervention type: BEHAVIORAL
Group type: EXPERIMENTAL
Intervention: Cardiovascular risk assessment
Description: The China-PAR risk prediction tool can be used to stratify the 10-years atherosclerotic cardiovascular disease (ASCVD) risk. Those with predicted risks of \<5%, 5-10%, and ≥10% could be classified into categories of low-, moderate-, and high-risk for ASCVD, respectively. It is a risk prediction tool for Chinese developed by the team of Professor Gu Dongfeng of Fuwai Hospital of the Chinese Academy of Medical Sciences. When patients are aware of their risk of cardio-cerebrovascular diseases, it is helpful for patients to take the initiative to manage their cardio-cerebrovascular health.

Intervention type: BEHAVIORAL
Group type: EXPERIMENTAL
Intervention: Popularization of medical knowledge
Description: Health education is divided into nine modules, such as introduction of cardio-cerebrovascular diseases, diet, exercise, sleep, psychology, medicine, cardiopulmonary resuscitation and cardiac self-rescue technology. The presentation of health education includes three modules: text, video and voice. Video and voice modules are more suitable for illiterates or people are inconvenient to read text. It mainly takes into account the fact that most of the high-risk population of cardio-cerebrovascular diseases are the elderly.

Intervention type: BEHAVIORAL
Group type: EXPERIMENTAL
Intervention: Personalized Reminders
Description: 1. Abnormal data reminder App can automatically judge whether the data is normal. If abnormal data is found, it will inform the patient in red font and remind the patient to consult the doctor in time. Patients can consult their family doctors directly online through App or go to the hospital.~2. Medication reminder After patients upload their own medication information, the App will automatically generate a medication alarm clock to remind patients to take the drugs.~3. Follow-up reminder According to the clinical diagnosis and conditions of patients, make personalized follow-up time. Family physicians could use the App to remind patients to fill in the follow-up form or go to the hospital.

Intervention type: DRUG
Group type: OTHER
Intervention: Routine treatment
Description: Family physicians conduct the corresponding treatment and management according to the diagnosis and conditions of the patients.

Intervention type: DRUG
Group type: EXPERIMENTAL
Intervention: Routine treatment
Description: Family physicians conduct the corresponding treatment and management according to the diagnosis and conditions of the patients.