This study aims to evaluate the effect of an AI-assisted "Smart family doctor" digital health management tool on improving the control rates of hypertension, diabetes, and dyslipidemia in post-revascularization patients. A randomized controlled trial design will be used, involving approximately 10-20 hospitals and 951 participants. Eligible participants are adults aged between 18 and 80 years, post-CABG or post-PCI patients with hypertension, diabetes, and dyslipidemia.
Age 18-80 years.
Underwent CABG or PCI more than 3 months prior and have concurrent hypertension, diabetes, and dyslipidemia.
Systolic blood pressure no less than 130 mmHg or diastolic blood pressure no less than 80 mmHg
HbA1c no less than 7%
History of heart failure or severe arrhythmias.
Presence of other severe underlying conditions such as cancer or liver and kidney insufficiency.
Pregnancy, lactation, or plans for pregnancy within the next year.
Cognitive, communication impairments, or limitations in daily activities.