申请人前期参与研发了中国动脉粥样硬化性心血管疾病（Atherosclerotic Cardiovascular Disease，ASCVD）风险预测模型China-PAR，其预测价值良好，但在《中国心血管病风险评估和管理指南》中的推荐证据级别低，亟需随机对照试验研究证据。本课题采用整群随机对照现场试验，随机选择相距一定距离、能够有效避免沾染的三个社区，应用China-PAR预测模型，在三个社区的全部符合标准的研究对象中，筛查ASCVD高危人群，将社区随机分为对照社区、普通干预社区和强化干预社区。对照社区的研究对象接受常规诊疗，常规干预社区的研究对象接受常规诊疗和传统健康教育，强化干预社区接受常规诊疗、传统健康教育和基于移动健康技术（智能血压计、智能血糖仪、智能体脂分布测量仪、移动穿戴设备）的干预。通过与传统健康教育的干预措施和常规诊疗进行对比，基于移动健康技术对ASCVD高危人群开展为期三年的行为危险因素、血压和血糖水平的综合干预与管理，评估该干预方案对ASCVD发病风险、ASCVD相关心血管事件发生率等指标的改善程度，提高China-PAR预测ASCVD的证据级别，为心血管疾病的预防控制提供新的干预方案。

The principal investigator of this study participated in the development of the Atherosclerotic Cardiovascular Disease (ASCVD) risk prediction model-Prediction for ASCVD Risk in China (China-PAR), which was good to predict ASCVD risk for Chinese population. However, “China Cardiovascular Disease Risk Assessment and Management Guideline” suggests that the recommended level of evidence of this prediction model is relatively low. Randomized controlled trials are needed. This study used China-PAR to screen ASCVD high-risk populations. A three-year cluster randomized, controlled, on-site intervention trial was conducted to evaluate the effect of smart mobile health technology (i.e., smart blood pressure monitor, smart blood glucose meter, smart body fat distribution instrument and wearable device)-based intervention for behavior risk factors and the management of blood pressure and glucose among high-risk populations. Three eligible communities that are separated by a certain distance and can effectively avoid contamination are randomly selected and assigned into control group (usual care) and two different intervention groups (usual care and health education; usual care, health education and smart mobile health technology-based intervention). China-PAR is used to screen high-risk population in all three groups. Compared with traditional health education and usual care, the effect of smart mobile health technology-based intervention on cardiovascular disease related indicators such as ASCVD risk and the incidence of ASCVD-related cardiovascular events are assessed. This study is helpful to provide high-level evidence of China-PAR and develop a new intervention model for cardiovascular disease prevention and control.