OBJECTIVE To implement the “Healthy China 2030” strategy by constructing a whole-cycle closed-loop intelligent prevention and management system for stroke, which is based on the concept of “front-loading prevention” and tailored to China’s national context.

METHODS Using the close-knit medical consortium between Renji Hospital, Shanghai Jiao Tong University School of Medicine and Huamu Community Health Service Center as the platform, the intervention point was shifted forward to the carotid plaque stage. High-risk individuals were actively identified through artificial intelligence-assisted screening, community mobile screening, and retrospective ultrasound data tracing. A multidisciplinary team(neurology, general practice, pharmacy, etc.) was established to conduct pre-consultation assessments and risk stratification(high/medium/low). An intelligent platform(electronic health records, management application, and health groups) was utilized for stratified follow-up, targeted education, and medication management. Green channels for acute referral and downward referral for rehabilitation were established.

RESULTS From December 2023 to December 2024, 400 patients with carotid plaques were screened, of whom 169 were enrolled into the systematic management of the specialized clinic(95 high-risk, 39 medium-risk, 35 low-risk). Among them, 31 symptomatic patients were referred to Renji Hospital, Shanghai Jiao Tong University School of Medicine through the green channel, including 2 who underwent stenting and 1 whose new cerebral infarction was identified promptly during follow-up. Patient satisfaction reached 94.7%, and medication adherence in the high-risk group improved significantly.

CONCLUSION The “front-loading prevention”-based closed-loop intelligent management system constructed in this study effectively integrates hospital-community-family resources, achieves early identification, stratified management, and whole-cycle care for high-risk stroke populations, preliminarily verifying its feasibility and effectiveness. It provides a referential practical model for stroke prevention and control in China.