Abstract: Atrial fibrillation（AF） is one of the least manageable cardiovascular diseases in the 21st century. As a result of deepening understanding of AF，continuous promotion of the implementation of hierarchical medical system，and appropriately allocating medical resources to primary care gradually，a tertiary general hospital actively cooperates with a community hospital to carry out a new pattern for integrated management of AF has become an exploratory focus during the medical consortium development. AF，as a high-risk chronic disease，plays an important role in the cardiovascular disease continuum，given that hypertension is its high-risk factor and stroke is one of its complications. Therefore，in addition to managing patients with hypertension，it is necessary for community hospitals to early screen hypertension or stroke or other coexisting conditions in AF patients，and deliver a series of targeted comprehensive management accordingly. We introduced an example of comprehensive management of AF by West China Hospital，Sichuan University and Shuangliu District Xihanggang Community Hospital，a tertiary general hospital in combination with a community hospital. Specifically，by means mainly consist of providing online and offline precise trainings for community general practitioners by physicians from West China Hospital，providing AF-related health education and free consultations for contracted residents，and adopting a bi-directional referral pathway for AF patients，the two hospitals collaboratively managed AF dynamically and comprehensively based on the patient's conditions using integrated general care or/and specialty care in an exploratory way. By presenting a detailed analysis and concise summary of the collaborative experience of these two hospitals，we aimed to offer help for the development of a systematic and standard pattern for collaborative management of AF by a tertiary general hospital and a community hospital，and for the empirical exploration of new ways for the specific implementation of hierarchical medical system.

Key words: Atrial fibrillation；Regional cooperative healthcare；Hospital, general；Community health centers；Community hospital；Hierarchical medical treatment；Chronic disease management

摘要： 心房颤动（房颤）被称为21世纪心血管疾病领域最富挑战的心血管疾病之一。随着对房颤认识的不断加深、分级诊疗政策的不断推进、医疗资源不断下沉，三级综合医院主动协同社区医院开展房颤综合管理的新模式成为医联体建设中的一个探索热点。高血压是房颤的高危因素，卒中是高血压和房颤的重要并发症，房颤作为高危慢性病在整个心血管事件链中扮演了重要角色，故基于社区医院对高血压管理的同时，对房颤患者进行早期筛查，开展高血压-房颤-卒中系列综合管理具有重要意义。本文分享了四川大学华西医院协同成都市双流区西航港社区医院，通过全专联合的方式，动态匹配房颤综合管理要素，并对其协同路径进行探索与思考，通过三级综合医院医生对社区医院全科医师房颤知识的线上、线下精准培训，社区签约居民主题宣教和义诊，“医院-社区”转诊路径3个方面，系统总结和分析了“三级综合医院-社区医院”对房颤综合管理的实践经验，旨在为建立一套系统规范的社区医院房颤综合管理协同模式及落实分级诊疗政策的实证病例探索与思考做出贡献。

关键词: 心房颤动, 区域协同医疗, 医院, 综合, 社区卫生中心, 社区医院, 分级诊疗, 慢病管理