The goal of this observational study is to evaluate the implementation of a structured, digital, nurse-led, remote monitoring care pathway for cardiovascular risk management (CVRM). Participants will receive this care as part of routine clinical practice. In addition to standard follow-up, participants will complete questionnaires on quality of life, medication adherence, system usability, and patient satisfaction.
CVRM is essential for patients at increased risk of cardiovascular disease (CVD) as well as for those with established atherosclerotic cardiovascular disease (ASCVD). Monitoring blood pressure and lipid profiles is crucial to achieving guideline-recommended targets. However, many patients fail to reach these targets despite the availability of effective therapies, resulting in an increased risk of recurrent events. Meanwhile, the burden of CVD continues to rise, creating significant pressure on healthcare systems. A digital care pathway may improve therapy adherence and outcomes by enabling personalized, data-driven care. This study evaluates the effectiveness of a nurse-led, telemonitoring pathway for CVRM in routine practice, where patients measure their blood pressure and LDL-c levels at home. The study aims to improve risk stratification, support earlier intervention, and optimize lipid and blood pressure control, ultimately leading to better patient outcomes.
Study Type
OBSERVATIONAL
Enrollment
750
Cardiology Centers of the Netherlands (CCN)
Amsterdam, North Holland, Netherlands
Number of patients on-target for LDL-c
Proportion of patients achieving guideline-recommended LDL-c targets
Time frame: Baseline and 1 year
Mean LDL-c
The mean of LDL-c values in mmol/L, measured at-home
Time frame: Baseline and 1 year follow-up
Number of patients achieving blood pressure control
Proportion of patients achieving guideline-recommended blood pressure targets
Time frame: Baseline and 1 year
Change in home-measured blood pressure values
Change in blood pressure values measured at home with telemonitoring in mmHg
Time frame: Baseline and 1 year
Number of medication changes
Changes in lipid-lowering and antihypertensive medications, defined as change in dose and change in medication type
Time frame: 1 year
5-item Medication Adherence Report Scale (MARS-5)
5 questions about medication adherence, with higher scores indicating better adherence
Time frame: Baseline and 1 year
Visual Analog Scale (VAS) for medication adherence
The scale ranges from 0% to 100%, with higher scores indicating better medication adherence
Time frame: Baseline and 1 year
Quality of life (QoL)
Using the EuroQoL-5D questionnaire
Time frame: Baseline and 1 year
Telehealth Usability Questionnaire (TUQ)
18 questions on patient satisfaction and usability, with higher scores indicating better satisfaction
Time frame: Baseline and 1 year
Hospitalization
Unplanned cardiovascular (re)hospitalization
Time frame: 12 and 24 months
MACE
Cardiovascular death, myocardial infarction, any documented stroke (ischemic or hemorrhagic), ischemia-driven revascularization
Time frame: 12 and 24 months
All-cause mortality
Total number of deaths from any cause
Time frame: 12 and 24 months
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