Abstract: Objective To explore and establish a new mode of secondary prevention of coronary heart disease with assistant general practitioners as the main body, community health service centers and patients' family members conducting continuous management of coronary heart disease discharged patients, which is suitable for the current rural grassroots medical and health conditions. Methods A total of 100 cases of coronary heart disease patients diagnosed in Beijing Yanqing district hospital from June 2016 to June 2017 were selected as experimental group into "the integration of community and family management" model for secondary prevention of coronary heart disease management and follow-up of 12 months. A review was made of 100 cases of coronary heart disease (CHD) patients with secondary prevention effect 1 year earlier (from June 2015 to June 2016) treated in Beijing Yanqing district hospital who was selected as the control group. A comparative analysis was made regarding to coronary heart disease knowledge awareness (questionnaire) and evidence-based medicine compliance (families of patients with medication type and number of records), coronary heart disease risk factors (every 3 months 1 time of blood pressure measurement), the control of blood glucose, lipids, body weight and smoking cessation rate and the incidence of adverse cardiovascular events. Results Via the "integration of community and family management" model for secondary prevention of coronary artery disease patients, 74% (control, 38%) for coronary heart disease knowledge rate, medication adherence by 88% (control, 46%) were significantly increased (P<0.05); smoking, control weight and lifestyle improvement were not obvious (P>0.05); low density lipoprotein, blood pressure, blood glucose were significantly improved (all P<0.05). There was no significant difference in the incidence of adverse cardiovascular events between the two groups(P>0.05). Conclusion The "integrated community and family management" mode of secondary prevention of coronary heart disease ensures the continuous management of discharged patients, significantly improves the awareness of patients with coronary heart disease, effectively controls the risk factors of coronary heart disease, and improves the compliance of evidence-based drug treatment.