TIMELY: a Patient-centred Lifestyle Program for Patients With Coronary Artery Disease (TIMELY)

TIMELY: A Patient-centred Lifestyle Program to Support the Continuum of Care in Patients With Coronary Artery Disease Using eHealth and Artificial Intelligence

Study design: A randomized controlled trial will be used, where patients will be randomized (1:1) to either the control group receiving usual care or the intervention group in which patients will receive usual care in combination with the TIMELY intervention for a duration of 6 months.

Study sample: Female and male patients aged 18 years or over, with documented stable CAD and referred for cardiac rehabilitation (at > 2 weeks but <10 weeks after PCI or >4 weeks but <12 weeks after CABG or MI: STEM or non-STEMI), and/or having documented CAD by coronary angiography (stenosis in a major coronary artery >50%).

Intervention: Patients randomized to the intervention group will receive the TIMELY app on their phones or tablets for 6 months. Patients will also receive a wearable activity tracker that collects activity levels, heart rate and sleep characteristics. Based on patient's activity levels, self-reported momentary mental states, health-related behaviors and environmental and clinical background factors, the app will enable patient-tailored recommendations relevant to improving lifestyle behaviors during daily life. In addition, patients will receive a blood pressure monitor that measures hemodynamic parameters through pulse wave analysis and an easy-to-use ECG device which will be used to assess changes in heart rate and other cardiovascular measures at rest and with exercise.

Main study parameters/endpoints: The primary biomedical outcome is a change in the CoroPredict biomarker risk score from baseline (pre-randomization) to completion of the active intervention phase (6 months). The CoroPredict score is an indicator of the 10-year risk of mortality. The primary behavioral outcome is the change from baseline to 6 months in patients' functional status of fitness level (measured using the 6-minute walk test). The study further aims to improve secondary outcome measures: physical activity levels during daily life and cardiovascular responses to exercise, dietary habits, smoking behavior, medication adherence and perceived levels of psychological stress.

Study Overview

• Status: Completed
• Conditions: Myocardial Infarction; Coronary Artery Disease
• Intervention / Treatment: Other: TIMELY

Detailed Description

Background of the study:

Cardiovascular diseases (CVD) are the leading cause of death globally according to the WHO. The highest burden of disease among CVDs is caused by coronary artery disease (CAD). Ageing predisposes patients to a high incidence and prevalence of CAD, in both men and women. Older patients have the greatest mortality and morbidity risk attributable to Chronic Coronary Syndromes (CCS), partially due to the high prevalence of comorbidities. Secondary prevention through comprehensive cardiac rehabilitation (CR) has been recognized as the most cost-effective intervention to limit the physiological and psychological effects of CVDs and reduce the risk of future cardiovascular events.

Contrary to pharmacological or invasive interventions for CAD, CR is far from being well implemented in all European countries and participation rates in available programs range between 30-50% of eligible patients. The TIMELY platform has been developed to stimulate a healthy lifestyle after CR. Patient-related barriers for digital health mainly involve the usability of the CR platform, especially for older patients. Thus, TIMELY includes digital tools and interfaces that will not hinder senior citizens from using them, as patient co-design has guided the development. Since lifestyle changes are key in the prevention and self-management of CAD, the main component of the TIMELY platform will be an app built on behavioral change techniques and models to empower and motivate patients to adopt a healthy lifestyle. Artificial intelligence (AI) will be employed to adapt the platform to the most current needs of the patient. In addition to prevention and self-management, the TIMELY platform will constantly monitor and predict the individual risk for disease progression or serious events and complications using validated risk scores (CoroPredict®). TIMELY will become the first AI-powered, patient-centered eHealth platform that continuously adapts and customizes CR to meet the needs of patients.

Objective of the study:

1. To investigate whether the TIMELY intervention is superior to usual care in terms of A) reducing the CoroPredict risk score (indicating risk of 10-year mortality: primary biomedical outcome) from baseline to six months; and B) increasing functional fitness levels (6-minute walk test); primary behavioral outcome) from baseline to 6 months

Study design:

A randomized controlled trial study design will be employed, where patients will be randomized (1:1) to either the control group receiving usual care or the intervention group, where patients will receive usual care in combination with the TIMELY intervention.

Assessment will take place at 4 time points: baseline, 3, 6 and 12 months post inclusion.

Patients will be asked to fill out questionnaires at 4 timepoints: baseline, 3 months, 6 months and 12 months. Through the TIMELY-platform (app) patients in the intervention group will receive prompts to conduct and ECG and blood pressure measurement. Patient in the intervention group will be wearing a Garmin, which collects information about their physical activity patterns. Lastly, patients will receive physical assessments at three time points (baseline, 6 months and 12 months), namely an exercise test and bloodwork will be done.

Study population:

Patients with documented CAD and who have been referred to cardiac rehabilitation (at > 2 weeks but < 10 weeks after PCI or > 4 weeks but <12 weeks after CABG or MI: STEMI or non-STEMI), and/or have documented CAD by coronary angiography (stenosis in a major coronary artery > 50%) will be included. Recruitment will set special focus on women, recruiting racial/ethnic minorities, older adults, rural residents, and economically disadvantaged individuals.

Intervention:

1. Timely app:

   The TIMELY app will help patients adjust their lifestyle in order for them to become healthier. The TIMELY app is supported by artificial intelligence and is based on behavioral change techniques. Through the chatbots the messages aimed at changing the behavior of patients will be personalized. Specific attention will be given to promoting physical activity. Because the chatbots can take the (physical) context of the patient into account, the odds of success are higher.

2. Wrist-worn activity tracker:

   Patients will receive an activity tracker, which will collect physical measures, such as level of activity, heart rate and sleep.

3. Tel-O-Graph:

   Patients will receive a blood pressure monitor, the Tel-O-Graph. The device additionally measures other hemodynamic parameters through pulse wave analysis (PWA).

4. Net_ECG:

   Patients will receive an easy-to-use device capable of registering atrial fibrillation.

5. eConnect HUB: Patients will receive the eConnect HUB which will transfer all data from the Tel-O-Graph to the researchers.

Patients will complete questionnaires at 4 timepoints: baseline, 3 months, 6 months and 12 months. In addition, patients will have conversations with the chatbots in the app and, based on this, receive encouragement to perform certain behaviors (e.g., exercise more or eat healthier). Through the TIMELY platform (app), patients will receive messages to take their ECG and blood pressure readings. Furthermore, patients will wear a Garmin, which will collect information about their exercise behavior. Finally, at the three measurement moments, patients will receive an exercise test. Blood will also be drawn at these times.

• Study Type: Interventional
• Enrollment (Actual): 358
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Germany
  • Germany
    • Ennepetal, Germany, Germany, 58256
      • Klinik Königsfeld
• Netherlands
  • North Brabant
    • Tilburg, North Brabant, Netherlands, 5037 AB
      • Willem Johan Kop
• Spain
  • A Coruña
    • Santiago de Compostela, A Coruña, Spain, 15706
      • Hospital Universitario de Santiago de Compostela

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Age 18 years and over (there is no a priori upper age limit)
• Documented stable CAD and referred for cardiac rehabilitation (at > 2 weeks but < 10 weeks after PCI or > 4 weeks but <12 weeks after CABG or MI: STEMI or non-STEMI) and/or having documented CAD by coronary angiography (stenosis in a major coronary artery > 50%)
• Access and ability to operate a smartphone
• Able to speak the country's native language

Exclusion Criteria:

• Unable to fully understand the provided study information and consequences of participating in the study
• Presence of a physical impairment interfering with the use of the app or devices (e.g., blindness, wheelchair bound)
• Known diagnosis of an active malignant tumour (cancer) or any other medical condition associated with a life expectancy of less than one year
• Unstable cardiovascular, cerebrovascular or other unstable medical condition
• Refusal to informed consent
• Having a pacemaker

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: TIMELY intervention and care as usual; The intervention group will receive the TIMELY intervention including wearable monitoring devices and app in addition to care as usual for a duration of 6 months.	Other: TIMELY; The TIMELY app works with several devices, including a wearable activity tracker that collects activity levels, heart rate and sleep characteristics. Based on patient's activity levels, self-reported momentary mental states, health-related behaviours and environmental and clinical background factors, the app will enable patient-tailored recommendations relevant to improving lifestyle behaviours during daily life. In addition, patients will receive a blood pressure monitor that measures hemodynamic parameters through pulse wave analysis (PWA) and an easy-to-use ECG device which will be used to assess changes in heart rate and other cardiovascular measures at rest and with exercise.
No Intervention: Care as usual; The care as usual group will receive the standard care as they would receive without being enrolled in the current trial.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in functional fitness levels	Functional fitness levels will be assessed using the 6-minute walking test, using the number of meters walked as the outcome.	Baseline and 6 months
Change in risk of mortality	Risk of mortality will be determined using the validated biomarker risk score CoroPredict, indicating 10-year mortality probability.	Baseline and 6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in cardiovascular exercise tolerance	Measures of cardiovascular responses to exercise will be based on graded symptom-limited exercise tests, using maximum watt as the outcome	Baseline and 6 months
Change in weight	Weight will be measured in kilograms	Baseline and 6 months
Change in physical activity	Physical activity will be measured by the validated International Physical Activity Questionnaire (IPAQ), a total score of MET minutes can be calculated.	Baseline, 3 months and 6 months
Change in healthy dietary habits	Dietary habits will be assessed using the dietary questions from the validated Health Promoting Lifestyle Profiles-II questionnaire. Scores range from 9 to 36, with a higher score indicating better dietary habits.	Baseline, 3 months and 6 months
Change in smoking cessation	Smoking cessation will be assessed by the validated Fagerström test. Scores range from 0-10 with a higher score indicating higher nicotine dependence.	Baseline, 3 months and 6 months
Change in medication adherence	Medication adherence will be assessed using the validated Medication Adherence Report Scale (MARS-5) questionnaire. Scores range from 5 to 25, with a higher score indicating higher medication adherence.	Baseline, 3 months and 6 months
Change in psychological stress levels	Psychological stress will be measured using validated the Perceived Stress Score questionnaire (PSS-10). Scores range from 0 to 40, with a higher score indicating higher levels of perceived stress.	Baseline, 3 months, 6 months

Collaborators and Investigators

• Sponsor: Tilburg University
• Collaborators: Servicio Gallego de Salud; Klinik Königsfeld, Ennepetal, Germany
• Investigators: Principal Investigator: Jos Bosch, PhD, University of Amsterdam

Publications and helpful links

General Publications

• Habibovic M, Douma E, Schafer H, Sestayo-Fernandez M, Roovers T, Sun X, Schmidt H, Kotewitsch M, Widdershoven J, Cantarero-Prieto D, Mooren F, Pena-Gil C, Gonzalez Juanatey JR, Schmidt M, Malberg H, Tsakanikas V, Fotiadis D, Gatsios D, Bosch J, Kop WJ, Schmitz B. Patient-Centered Risk Prediction, Prevention, and Intervention Platform (TIMELY) to Support the Continuum of Care in Coronary Artery Disease Using eHealth and Artificial Intelligence: Protocol for a Randomized Controlled Trial. JMIR Res Protoc. 2025 Aug 14;14:e66283. doi: 10.2196/66283.

Helpful Links

• Official website of the TIMELY project

Study record dates

Study Major Dates

• Study Start (Actual): July 14, 2023
• Primary Completion (Actual): May 7, 2025
• Study Completion (Actual): May 7, 2025

Study Registration Dates

• First Submitted: July 13, 2023
• First Submitted That Met QC Criteria: July 13, 2023
• First Posted (Actual): July 21, 2023

Study Record Updates

• Last Update Posted (Estimated): August 27, 2025
• Last Update Submitted That Met QC Criteria: August 20, 2025
• Last Verified: August 1, 2025

More Information

Terms related to this study

• Keywords: Physical activity; Cardiac rehabilitation; Percutaneous coronary intervention; Coronary artery bypass graft; Lifestyle intervention; Lifestyle behaviour
• Additional Relevant MeSH Terms: Vascular Diseases; Cardiovascular Diseases; Pathologic Processes; Heart Diseases; Infarction; Necrosis; Arteriosclerosis; Arterial Occlusive Diseases; Coronary Disease; Myocardial Ischemia; Ischemia; Pathological Conditions, Signs and Symptoms; Behavior; Coronary Artery Disease; Myocardial Infarction; Motor Activity
• Other Study ID Numbers: NL82723.028.23

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: After trial completion, follow-up assessments, and main outcome analysis data will be (partly) available for other researchers.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No