Development of a Mobile Phone Application for Monitoring Cardiovascular Health
Article information
, Matheus Henrique Costa Xavier2, Iara Victoria dos Santos Moura2, Virna Anfrizio Souza2, Wictor Hugo de Souza Silva2, Renato Brito dos Santos Júnior2, Iris Tarciana de Freitas Cunha2, Ellen Natielly Fonseca de Jesus2, Adler Teixeira Machado Nissink Costa3, José Augusto Soares Barreto-Filho1,5,6
Abstract
Objectives
Cardiovascular diseases have been the leading cause of death worldwide. The American Heart Association defined eight metrics for cardiovascular health to reduce mortality. Mobile health tools can support shared clinical decision-making, provide tele-monitoring feedback, and improve patient adherence to medication regimens. This work aims to develop and implement the Cardiovascular Health application for mobile phones according to the parameters defined by the American Heart Association.
Methods
A user-centered design approach was employed using the Dart programming language, the Flutter framework, and a Firebase database.
Results
Each ideal parameter is evaluated as “good” when it meets the requirements, earning the patient one mark. Participants’ cardiovascular health is subsequently classified as “good,” “can be improved,” or “needs to be improved,” and PDF reports are generated.
Conclusions
The Cardiovascular Health application is built on a strong scientific foundation, given the high prevalence of individuals at risk for cardiovascular disease. It includes all components necessary to assess cardiovascular health and will enable physicians and other healthcare professionals to make more informed decisions regarding patient care.
I. Introduction
Cardiovascular disease (CVD) is the leading cause of death in low-income countries. Preventing CVD requires strict control of blood pressure, cholesterol, glucose, body mass index (BMI), physical activity, diet, and smoking cessation [1,2]. In 2010, the American Heart Association (AHA) defined seven specifications for cardiovascular health (CVH), classifying them as “ideal,” “intermediate,” or “poor” with the aim of reducing CVD mortality by 20% by 2030 [3]. In 2022, these metrics were updated to include sleep, evolving into “Life’s Essential 8” [4]. Studies have demonstrated that increasing the number of ideal metrics significantly reduces the risks of heart disease and stroke [5,6]. Although several applications for Android and iOS assess cardiovascular risk, not all incorporate all eight of Life’s Essential 8 metrics [7,8]. In this context, this article demonstrates the development and applicability of the “Cardiovascular Health” mobile application, which was designed to help healthcare professionals assess patients’ CVH according to the Life’s Essential 8 criteria.
II. Case Description
1. Study Design
This case report details the development of an application that will form the basis for a prospective cohort study, in which patients are monitored and assessed using the Cardiovascular Health application. A census of patients treated by healthcare professionals across Brazil will be established in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist for observational studies [9]. Currently, Brazil has 110,604,689 inhabitants aged over 18 [10], with 70% using the Unified Health System. Assuming a 20% attrition rate over 1 year, approximately 61,938,625 patients are expected to be followed during this period.
2. Inclusion and Exclusion Criteria
The inclusion criteria required that health professionals possess a valid registration issued by a professional association that regulates their activities. For patients, eligibility required being 18 years or older, registered, and receiving treatment at the health unit where the professional works. The exclusion criteria encompassed health professionals without valid registration and participants with physical impairments that compromise or interfere with the required physical examination.
3. Functionality
Health professionals using the Cardiovascular Health application must register by providing basic information such as their name, Regional Medical Association registration number, and a valid email address. To store additional information, ethical compliance is ensured by obtaining patient consent via a form provided directly through the application.
The data collected for analysis include smoking status, BMI, physical activity, blood pressure, total cholesterol, fasting blood glucose, diet, and sleep.
A review of the collected data will be conducted three months after project approval to verify alignment with the application’s objectives and to identify improvements. Subsequent reviews will occur every 6 months.
4. Application Development and Registration
The Cardiovascular Health application was developed using a user-centered design approach, which emphasizes meeting user needs [11]. The application was built with the Dart language, the Flutter framework, and utilizes Firebase as its database (Figure 1).
Model of the architecture of the Cardiovascular Health application.
The implementation began with launching Android Studio, an integrated development environment (IDE). Running the mobile application in the IDE involved using a smartphone emulator, which displayed the application’s screens in real time. This development workflow uses two screens: the IDE and the emulator, as illustrated in Figure 2. Real-time changes were facilitated by Flutter’s hot-reload function, which updated only the modified portions of the project.
Screenshot of the development environment.
Two user profiles were established: user and administrator. The user profile grants access to all operational functionalities and is intended for healthcare professionals during patient appointments. The administrator profile provides access to comprehensive reports containing all collected data, without personal identifiers.
5. Application Availability
The Cardiovascular Health application is registered with the National Institute of Industrial Property (INPI No. 922638390). It will be available for download on the Play Store. Data will be stored in real time on a Firebase cloud for 5 years, protected by passwords and accessible only to researchers involved in the development. Additionally, users must agree to a consent form outlining data security measures and research risks upon downloading the application. It should be noted that the application is still in its testing phase.
This application complies with Resolution no. 466/2012 of the National Health Council [12], the World Medical Association Declaration of Helsinki 2013 [13], and was approved by the Research Ethics Committee of the Federal University of Sergipe (No. CAAE 48614621.7.0000.5546).
6. Usability
It is important to clarify that this article is not intended as a tutorial on software development and therefore does not include the detailed code used in the project. The quality standards for the application will evolve as its use and operation progress.
After downloading the Cardiovascular Health application, users will view the application name, icon, version, and date. They will then create an account using their full name, association registration number, and email address. Following registration, navigation screens will appear, allowing the user or patient to review the informed consent form. Once consent is obtained, the patient’s sex and age will be recorded (Figure 3).
Visual outline of how to access the Cardiovascular Health application.
Subsequently, information regarding the eight metrics, known as “Life’s Essential 8,” will be entered based on physical examinations, laboratory tests, or patient self-report. For instance, patients will be asked to select the diet image that most closely represents their weekly eating habits (Figure 4).
Cardiovascular Health application navigation screens, showing diet components (breakfast, lunch, dinner and small meals).
Each parameter that meets the ideal criteria, earning between 5 and 8 points, results in a “good” classification (green). Scores between 3 and 4 points are classified as “can be improved” (yellow), while scores of 2 points or below are categorized as “needs to be improved” (red). These reports will display the results, offer patient guidelines, and include demographic variables alongside the cardiovascular health metric components (Figure 5). The reports will also be available for printing (Figure 6).
Cardiovascular Health application navigation screens, showing demographic variables and components of the cardiovascular health metrics.
Cardiovascular Health application PDF reports, with results of “good,” “can be improved,” and “needs to be improved.”
III. Discussion
Although new applications are frequently developed to assess and monitor cardiovascular health, no existing application has yet fully adopted the AHA’s Life’s Essential 8. The Cardiovascular Health application already incorporates all the elements necessary to assess these eight metrics.
Employing a user-centered design approach ensures that the application is developed through continuous user interaction, allowing end-users to directly influence every methodological step. This strategy reduces barriers to use and enables the conversion of gathered data into actionable solutions [11,14].
A systematic review of randomized clinical trials evaluating mobile applications on blood pressure monitoring, lifestyle changes, and medication adherence in hypertensive individuals analyzed eight studies with a total of 1,657 participants. The review found that interventions using mobile applications led to blood pressure reductions and improved medication adherence. These findings support the further study and implementation of technology-based medical interventions [15].
The Cardiovascular Health application is supported by a strong scientific rationale, considering the high prevalence of cardiovascular disease risk factors. Although some self-reported outcomes may be affected by memory bias, the objective measurement of CVH using established questionnaires has been validated in numerous studies. Additionally, after extensive testing and data analysis, the application is intended to serve the entire Brazilian territory with an objective assessment of CVH, and will include sleep as a modifiable risk factor when feasible [16–18].
The impact of the Cardiovascular Health application on clinical outcomes, such as stroke, acute myocardial infarction, and death, needs to be evaluated in a long-term prospective study, which was beyond the scope of the current article. Nevertheless, the application is expected to assist physicians and other healthcare professionals in monitoring CVH and developing effective interventions.
Notes
Conflict of Interest
No potential conflict of interest relevant to this article was reported.
Acknowledgments
We thank Marcelo Santos de Oliveira, for the revision and translation of the text.