目的 基于旅程地图识别冠状动脉旁路移植术患者在心脏康复中的多维健康管理需求，为优化该人群的心脏康复全旅程提供参考依据。方法 采用描述性质性研究方法，于2025年5-8月在上海某三级甲等医院以最大差异化取样招募患者，开展半结构式面对面访谈，以主题分析法进行编码与归类，直至资料饱和，据此绘制旅程地图。结果 研究以院内康复期、院外早期康复期到院外长期康复期为时间横轴，以任务、情绪、痛点与机会点为项目纵轴绘制旅程地图，患者心脏康复管理需求包括术前预康复的“知行脱节”、多重症状困扰下的被动康复等20条主题。结论 冠状动脉旁路移植术患者的心脏康复健康管理旅程漫长且复杂，其需求动态变化且多维交织；未来心脏康复应聚焦于分阶段信息支持、院内院外康复衔接及心理与家庭支持的融入，以提升心脏康复依从性和患者生活质量。

Objective To identify the multidimensional health management needs of patients undergoing coronary artery bypass grafting (CABG) during cardiac rehabilitation based on a journey map, and to provide reference for optimizing the entire cardiac rehabilitation journey for this population.Methods A descriptive qualitative study was conducted. From May to August 2025, patients were recruited from a tertiary A hospital in Shanghai using maximum variation sampling. Semi-structured face-to-face interviews were conducted, and data were coded and categorized using thematic analysis until saturation was reached. A journey map was subsequently developed. Results The map was constructed with the timeline spanning the in-hospital rehabilitation phase, early out-of-hospital rehabilitation phase, and long-term out-of-hospital rehabilitation phase. The vertical axis comprised tasks, emotions, pain points, and opportunities. The health management needs of patients during cardiac rehabilitation included 20 themes, such as the “knowing-doing gap” in preoperative prehabilitation, and passive rehabilitation under the distress of multiple symptoms.Conclusions The cardiac rehabilitation health management journey for patients undergoing CABG is long and complex, with dynamic and multidimensional intertwined needs. Future cardiac rehabilitation should focus on phased information support, the coherence of in-hospital and out-of-hospital rehabilitation, and the integration of psychological and family support to enhance rehabilitation adherence and patients’ quality of life.

R473.54

上海市医院协会护理管理专业委员会立项课题（HLGL202510）；上海市浦东新区卫生系统重要薄弱学科建设项目资助（PWZbr2022-04）；上海市东方医院人才计划(DFRC2017017)