INTRODUCTION
Hyperlipidemia is an important modifiable risk factor for the development of atherosclerotic cardiovascular (CV) disease. (1,2) In clinical practice, it is not regarded simply as an abnormality in laboratory values but as a condition that may contribute to the development and progression of CV disease over the long term. (2) Elevated concentrations of atherogenic lipoproteins, particularly low-density lipoprotein cholesterol (LDL-C), play an important role in the development and progression of atherosclerosis. (3,4) Due to the well-established association between LDL-C and atherosclerotic disease, LDL-C control represents one of the foundations of CV prevention. (3,4)
Cardiovascular diseases remain a major public health issue worldwide, including in Croatia. (5,6) Their substantial health burden further emphasizes the importance of timely identification and management of modifiable risk factors. (5,6) LDL-C treatment targets are determined according to overall CV risk and are lower for patients at high and very high risk. (1,7) In such patients, it is especially important to approach treatment as a long-term process involving pharmacological therapy, lifestyle modification, and regular follow-up. (1,7)
Treatment success therefore depends not only on the prescribed therapy but also on the patient’s ability to incorporate it into daily life over the long term and implement recommended lifestyle changes. (1,7-9) Medication adherence is a complex process that may be influenced by disease-related knowledge, motivation, daily responsibilities, and various barriers encountered by patients. (8,9) Therefore, patient education should not be limited to the provision of information, but should also help patients understand and apply the recommendations they receive in the context of their individual circumstances. (8,9)
As part of this process, nurses may play an important role in patient education, counseling, and follow-up. Structured counseling may include explaining lipid profile results, discussing dietary habits and physical activity, assessing medication adherence, and identifying barriers that make it difficult for patients to follow recommendations. Previous studies have shown that nurse-led interventions may contribute to improved control of CV risk factors. (10-12) The meta-analysis by Yang et al. further supports the potential value of nurse-led interventions in patients with coronary artery disease (CAD). (10) The importance of continuous nursing follow-up was also demonstrated in the NAILED-ACS study, in which telephone-based follow-up was associated with better control of CV risk factors over an extended period. (11) Similarly, Ruiz-Bustillo et al. reported improved attainment of lipid targets following a more intensive intervention coordinated by nurses. (12) These findings do not imply that every nurse-led counseling intervention necessarily results in improved lipid levels, but they do indicate that nurses can play an active role in long-term patient care and support. (11,12)
Coronary angiography is an important diagnostic procedure for the assessment of CAD. (13) Patients undergoing this procedure represent a clinical population in which the assessment and management of CV risk factors are particularly important. (7,13)
The aim of this study was to investigate the associations between lifestyle habits, adherence to prescribed therapy, knowledge of hyperlipidemia, and attitudes toward nurse-led counseling, and the lipid profiles of patients with hyperlipidemia who underwent coronary angiography.
PATIENTS AND METHODS
A cross-sectional observational study was conducted at the Department of Cardiology, Merkur University Hospital, Zagreb, Croatia, from June 10 to December 20, 2025. The study included 29 (out of a total of 60) eligible adult patients with hyperlipidemia who had undergone coronary angiography, had an available lipid profile, and agreed to participate. A convenience sampling method was used. Patients were excluded if their lipid profile was unavailable, if they had incompletely answered questionnaire items relevant to the analysis, if they were unable to understand the questionnaire, or if they declined or discontinued participation.
Data were collected using an anonymous, investigator-developed questionnaire entitled “Nurse-Led Counseling in Hyperlipidemia Management” and from information obtained from medical records. The questionnaire was developed specifically for this study with the goal of assessing several aspects of daily life and treatment relevant to hyperlipidemia management. It comprised 28 statements rated on a five-point Likert scale (1 = “strongly disagree”; 5 = “strongly agree”) as well as questions regarding previous experience with nurse-led counseling. The statements covered dietary habits (6 items), physical activity (5 items), medication adherence (4 items), knowledge of hyperlipidemia (5 items), and attitudes toward nurse-led counseling (8 items). Reverse scoring was applied to negatively worded items. Sum scores and mean scores were calculated for each domain, as well as a total score for all 28 items and its corresponding mean on a scale ranging from 1 to 5. The complete questionnaire is available to interested researchers upon request by email.
Total cholesterol, high-density lipoprotein cholesterol (HDL-C), LDL-C, triglyceride, and non-HDL-C levels were analyzed using follow-up lipid profile results obtained 3–6 months after coronary angiography, with all values expressed in mmol/L. When a non-HDL-C value was unavailable, it was calculated as total cholesterol minus HDL-C. Laboratory-measured non-HDL-C values were available for 25 participants, whereas calculated values were obtained for all 29 participants; laboratory-measured values from the 25 participants were used in the correlation analysis.
Categorical variables were presented as frequencies and percentages, while numerical variables were summarized using means and standard deviations. Associations were assessed using Pearson’s correlation coefficient, with p < 0.05 considered statistically significant. Data were collected and analyzed using Microsoft Excel.
Participation was voluntary and anonymous, and participants were free to withdraw without any consequences for their subsequent care. The study was approved by the Ethics Committee of the Merkur University Hospital on June 10, 2025.
This article is based on research previously presented in the master’s thesis entitled “Nurse-Led Counseling in Hyperlipidemia Management,” which was defended at the University of Zagreb School of Medicine in 2026. (14) In this article, the study findings are further examined in the context of lifestyle habits, lipid profiles, and the role of nurse-led counseling in the care of patients with hyperlipidemia.
RESULTS
A total of 29 participants were enrolled in the study. Men constituted the majority of the sample, accounting for 24 participants (82.8%). The mean age of the participants was 63.17 ± 10.83 years.
The mean body mass index (BMI) was 28.11 ± 4.02 kg/m2. Overweight (BMI 25–29.99 kg/m2) was observed in 14 participants (48.3%), whereas obesity (BMI ≥ 30 kg/m2) was recorded in 8 participants (27.6%). The remaining 7 participants (24.1%) had a BMI below 25 kg/m2.
Among the participants, 7 were current smokers (24.1%), 14 were former smokers (48.3%), and 8 had never smoked (27.6%). Comorbid chronic conditions were present in 21 participants (72.4%). The most common comorbidity was arterial hypertension, reported in 19 participants (65.5%), followed by type 2 diabetes mellitus, which was present in 11 participants (37.9%). Both conditions were present concurrently in 9 participants (31.0%). Mean lipid profile values are presented inTable 1.
Across the domains assessed, the highest mean scores were observed for attitudes toward nurse-led counseling (4.77 ± 0.27) and medication adherence (4.65 ± 0.53). The mean score for physical activity was 3.83 ± 0.76, followed by knowledge of hyperlipidemia (3.49 ± 0.95) and dietary habits (3.43 ± 0.76). The overall mean score across all Likert-scale items was 4.07 ± 0.38 (Table 2).
According to self-reported data, 23 participants (79.3%) agreed or strongly agreed with the statement that they regularly walked or engaged in light physical activity for at least 30 minutes per day, whereas 14 participants (48.3%) agreed or strongly agreed that they engaged in moderate or vigorous physical activity at least three times per week. Twelve participants (41.4%) agreed or strongly agreed with the statement that they engaged in physical activity regularly, while 7 (24.1%) agreed or strongly agreed that they spent most of their days sitting. All 29 participants (100.0%) agreed or strongly agreed that physical activity was important for their health. Eight participants (27.6%) had previously received nurse-led counseling, whereas 20 (69.0%) had not, and 1 participant (3.4%) could not recall whether they had received it. Among participants with previous experience of nurse-led counseling, its perceived usefulness was rated at a mean of 4.25 ± 1.17 out of 5 (Table 2).
Correlation analysis revealed no statistically significant associations between the individual questionnaire domains and either LDL-C or non-HDL-C levels. The strongest negative correlations were observed between the overall mean questionnaire score and LDL-C (r = −0.301; p = 0.113) and between the overall mean questionnaire score and non-HDL-C (r = −0.318; p = 0.121). In contrast, a statistically significant positive correlation was identified between knowledge of hyperlipidemia and dietary habits (r = 0.584; p < 0.001) (Table 3).
DISCUSSION
The findings of this study provide an interesting picture of the relationship between patients’ knowledge, their perceptions of their own lifestyle habits, and their previous exposure to nurse-led counseling. The highest mean scores were observed for attitudes toward nurse-led counseling and self-reported medication adherence, whereas scores for dietary habits and self-assessed knowledge of hyperlipidemia were somewhat lower. Despite the highly positive attitudes toward nurse-led counseling, only 27.6% of participants had previously received such counseling. Among those who had received it, perceived usefulness was rated highly. These findings suggest that patients may be interested in this form of support, support, although only a minority had previously received such counseling.
This discrepancy represents one of the more clinically relevant findings of the study, as it may indicate an opportunity for more systematic involvement of nurses in the education and follow-up of patients with hyperlipidemia. Previous research, including the study by Yang et al., has shown that structured nurse-led interventions may contribute to improved control of cardiovascular (CV) risk factors in patients with coronary artery disease (CAD). (10-12) In a qualitative study, Parvizey et al. identified post-discharge follow-up, the use of reminders, improved patient education, enhanced patient support, and organizational changes in healthcare delivery as potential strategies for improving medication adherence. (15) These approaches may provide a basis for developing more structured forms of nurse-led counseling tailored to the needs of patients with hyperlipidemia. A similar approach was implemented in the NAILED-ACS study. After as little as one year of nurse-led telephone follow-up, Huber et al. reported favorable outcomes in secondary prevention. (16) Subsequent follow-up of the same cohort demonstrated improved control of LDL-C and blood pressure over a longer period. (11) The study by Ruiz-Bustillo et al. also demonstrated higher rates of lipid target attainment following a more intensive nursing intervention. (12) Nurse-led dietary interventions were further examined by Yar et al., whose systematic review and meta-analysis reported favorable changes in lipid profiles and adherence to dietary recommendations among patients with CAD. (17) These findings further emphasize the importance of dietary education, particularly given that the scores for dietary habits in the present sample were lower than those for medication adherence and attitudes toward nurse-led counseling. Nevertheless, these studies included interventions, and thus their effects cannot be directly compared with the findings of the present observational study.
Studies conducted in Croatia have also indicated challenges in achieving lipid control. Pintarić et al. described difficulties in attaining LDL-C target levels among patients at very high and extremely high CV risk. (18) Jurišić et al. identified shortcomings in the implementation of secondary prevention during the first year after myocardial infarction. (19) Additionally, the European EUROASPIRE V study also documented deviations from recommended prevention targets among patients with CAD. (20)
A systematic review by Ellis et al. demonstrated that structured education for patients with CAD may improve disease-related knowledge and certain health outcomes. (21) A meta-analysis by Alzhanova et al. also suggested potential benefits of nurse-led programs in controlling certain CV risk factors. (22) These findings provide further scientific support for considering the educational role of nurses in the care of patients with hyperlipidemia.
Another finding warranting attention is the statistically significant positive correlation between self-reported knowledge of hyperlipidemia and dietary habits. Given the cross-sectional study design, it is not possible to determine whether greater knowledge leads to healthier dietary habits or whether patients who pay greater attention to their diet also tend to assess their knowledge of the disease more favorably. Nevertheless, the observed association emphasizes the importance of the educational component of patient care. In clinical practice, this may mean that discussions about the disease may become more effective and valuable when linked to specific, achievable changes in diet and other lifestyle behaviors.
The high self-reported medication adherence score should also be interpreted with a certain amount of caution. Participants assessed their own behavior, and their responses may therefore have been influenced by recall bias or social desirability bias. Nevertheless, the high adherence score still represents valuable data because it shows how participants perceive their own involvement in treatment. The importance of long-term medication adherence is further supported by the study by Mazhar et al., which included 20,490 patients with CAD and found that better adherence to lipid-lowering therapy was associated with a lower risk of major CV events. (23) Unlike the self-assessment approach used in the present study, Mazhar et al. assessed adherence using medication dispensing records.
The mean LDL-C level in the present study was 2.08 mmol/L, but individual values should always be interpreted in the context of the patient’s overall CV risk and the treatment targets applicable to that particular patient. (1,7) In the present study, no statistically significant associations were identified between the questionnaire domains and either LDL-C or non-HDL-C levels. This does not mean that knowledge, lifestyle habits, or medication adherence are unimportant for hyperlipidemia management, but rather that their statistical associations with the lipid parameters examined could not be established in this sample. The small sample size, together with the numerous other factors that influence lipid levels, may have contributed to this finding. Although most correlations were negative, this trend cannot be interpreted as evidence that the factors examined affect lipid status.
The findings should also be considered in light of the study’s limitations. The sample was small and based on convenience sampling, the study was conducted at a single clinical center, and the cross-sectional design did not allow changes over time to be assessed. Some data were self-reported, and the questionnaire developed specifically for this study had not undergone separate psychometric validation. Consequently, the domain scores should be interpreted with caution. Furthermore, no intervention was implemented, and no measurements were obtained before and after nurse-led counseling; therefore, its direct effect could not be evaluated. These findings may serve as a basis for future prospective or interventional studies in which structured nurse-led counseling would be evaluated over time, in order to determine its association with changes in knowledge, lifestyle habits, medication adherence, and lipid status.
CONCLUSION
The findings of this study show that patients had highly positive attitudes toward nurse-led counseling and high levels of self-reported medication adherence, although only a minority had previously received this form of counseling. This discrepancy clearly shows an opportunity for further evaluation of the role of nurses in patient education and the long-term follow-up of patients with hyperlipidemia.
No statistically significant associations were identified between the questionnaire domains and LDL-C or non-HDL-C levels. However, a positive correlation was observed between knowledge of hyperlipidemia and dietary habits, further supporting the value of patient education, although the study design does not permit conclusions regarding a causal relationship between the two.
The findings do not establish a direct effect of nurse-led counseling on lipid levels, but they show that patients recognize and respond positively to this form of support. Future studies should investigate whether structured, individualized, and continuous nurse-led counseling can contribute to improved disease-related knowledge, healthier lifestyle habits, and long-term control of hyperlipidemia.