To investigate the adequate hypertension control rate and/or adequate glycemic control rate in hypertension and diabetic patients who are at high risk of atherosclerotic cardiovascular disease (ASCVD) but have good disease awareness and regular medication, and to explore the reasons for poor control, offering a theoretical basis for better prevention and control of ASCVD.

By use of cluster sampling, contracted patients with complete data of the China-PAR model who visited 10 community health centers in Shenzhen's Luohu District from August 2018 to April 2019 were selected, and received an assessment for screening the risk of 10-year ASCVD using the China-PAR model, and those with hypertension and/or diabetes who were at high risk of ASCVD (≥10 points) and volunteered to attend this study were further surveyed using a questionnaire developed by our research group. After that, those who were on regular medication with a good understanding of the threats of hypertension and/or diabetes, and targets for blood pressure control and/or fasting glycemia control, were finally enrolled. The rate of adequate hypertension control was compared between those with hypertension, the rate of adequate glycemic control was compared between those with diabetes, and the rates of adequate hypertension and glycemic control were compared between those with both hypertension and diabetes, by demographcihc factors. Then those who were found with inadequate hypertension and/or glycemic control were selected to attend an in-depth, semi-structured individual interview using a descriptive qualitative research design for understating the causes of inadequate hypertension and/or glycemic control. The contents of the interview were coded and categorized using NVivo 12, and were sorted, analyzed, and themes in which were identified using content analysis.

Totally 299 patients were finally enrolled, including 130 (43.5%) with hypertension, 9 (3.0%) with diabetes, and 160 (53.5%) with both hypertension and diabetes. Among the 290 hypertensive patients, 140 (48.3%) had adequate hypertension control. Among the 169 diabetics, 71 (42.0%) had adequate diabetes control. Among the 130 patients with simple hypertension, those with adequate hypertension control had older mean age than did those without (t'=3.758, P<0.001) . Among the 160 patients with both hypertension and diabetes, those with adequate hypertension control had older mean age than did those without (t'=2.203, P=0.031) . Among the 169 patients with diabetes, those with adequate control of fasting glycemia had lower rate of regular exercising (χ²=4.314, P=0.038) and shorter mean duration of diabetes (t=-3.180, P=0.002) , as well as lower mean frequency of blood glucose monitoring (Z=2.228, P=0.026) than did those without. Seven themes emerged from the interview: Patients did not feel compelled to reach the targets, feeling indifferent; Patients gave up after repeated treatments followed by failures to achieve the targets, feeling powerless; Patients took medicines regularly, but had problems in practical medication; Patients were restricted by various realistic factors; Patients were influenced by doctor-related factors, including doctors' irrelevant and ignorant attitudes; Patients had failures due to lack of self-control and unhealthy lifestyles; Other reasons, including unsuccessful medical insurance reimbursement, being afraid of over-control due to previous experiences of too low blood pressure or glucose, etc.

The high-risk population of ASCVD who had good disease awareness and took medications regularly still had low hypertension control rate and/or low glycemic control rate. Attention should be specially given to blood pressure levels in young hypertensive patients, and glycemic level in diabetic patients with regular exercising, a long history of diabetes, or frequent blood glucose monitoring. It is necessary to optimize the management of ASCVD in the community by encouraging patients to improve their mindset and change their unhealthy lifestyles, strengthening the promotion of standardized medication use, improving community health services, and improving patients' knowledge, beliefs and behaviors from the biopsychosocial perspective.

了解符合动脉粥样硬化性心血管疾病（ASCVD）高危人群判断标准的高血压和/或糖尿病患者在对所患疾病认知状况良好、规律服药背景下的血压和/或血糖控制达标情况，探索其血压和/或血糖控制不达标的原因，旨在为更好地防控ASCVD提供理论依据。

采用整群抽样法，选取2018年8月至2019年4月在深圳市罗湖区10家社区健康服务中心全科门诊就诊且10年ASCVD发病风险预测模型（China-PAR）资料完整的签约患者，采用China-PAR对其进行评估，以筛选ASCVD高危人群（China-PAR得分≥10分）。对符合ASCVD高危人群判断标准且自愿参与本研究的高血压和/或糖尿病患者，使用自设问卷对其进行调查，最终将知晓高血压和/或糖尿病的危害、血压和/或空腹血糖控制目标且规律服药者纳入本研究。以患病情况为分层依据，比较血压/空腹血糖控制达标组与未达标组的基本情况。采用描述性质性研究法，选取全体血压/空腹血糖控制未达标者为研究对象，对其进行一对一的半结构化深度访谈，了解其血压/空腹血糖控制未达标的原因。应用NVivo 12软件对访谈内容进行编码、归类；采用内容分析法对资料进行整理、分析，并提炼访谈主题。

本研究共纳入299例患者。其中130例（43.5%）为单纯高血压患者，9例（3.0%）为单纯糖尿病患者，160例（53.5%）为高血压合并糖尿病患者。290例患有高血压者中，140例血压控制达标，血压控制率为48.3%；169例患有糖尿病者中，71例空腹血糖控制达标，空腹血糖控制率为42.0%。对于130例单纯高血压患者而言，与血压控制达标组患者相比，血压控制未达标组患者年龄更小（t'=3.758，P<0.001）；对于160例高血压合并糖尿病患者而言，与血压控制达标组患者相比，未达标组患者年龄亦更小（t'=2.203，P=0.031）；对于169例患有糖尿病者而言，与空腹血糖控制达标组患者相比，空腹血糖控制未达标组患者规律运动率更高（χ²=4.314，P=0.038），糖尿病病程更长（t=-3.180，P=0.002），平素监测血糖的频率更高（Z=2.228，P=0.026）。访谈共提炼出7个原因：患者认为不必强求达标，持顺其自然的态度；经多次治疗，血压和/或血糖控制仍未达标后选择放弃，持无能为力的态度；虽规律服药，但在药物使用上存在问题；受各种现实条件的制约；受医生因素的影响，如医生认为无关紧要、"置若罔闻"等；缺乏自制力，不良的生活方式导致未达标；其他原因，如医保报销不顺利、曾出现血压/血糖过低导致不敢过分控制等。

患有高血压和/或糖尿病的ASCVD高危人群在疾病认知状况良好、规律服药的情况下，血压/血糖控制率仍较低。应密切关注年轻高血压患者的血压水平，以及规律运动、糖尿病病程较长或频繁监测血糖的糖尿病患者的血糖水平。通过鼓励患者调整心态、改变不良生活方式，加强对患者的规范用药宣传，提升社区卫生服务水平，从生物-心理-社会多层面改善患者的知信行等举措，优化社区ASCVD防治。