Abstract: Objective To evaluate the long-term effectiveness of a remote case management model in the post-discharge follow-up for patients with coronary heart disease （CHD） after percutaneous coronary intervention （PCI）. Methods A total of 200 CHD patients who underwent PCI at the First Affiliated Hospital of Jinan University were selected as study participants. 100 patients enrolled in 2021 were assigned into the control group and received conventional discharge guidance and outpatient follow-up, while 100 patients enrolled from February to June 2023 were assigned into the intervention group and received a remote case management model supported by a multidisciplinary team （including comprehensive assessment, individualized planning, telephone/WeChat follow-up, and specialized nursing clinics）. After 12 months of intervention, comparisons were made between the two groups regarding metabolic indicators （blood lipids, blood glucose, renal function, etc.）, left ventricular ejection fraction （LVEF）, medication adherence （MMAS-8 scale）, and the incidence of major adverse cardiovascular events （MACE）. Results After 12 months of intervention, patients in the intervention group showed significantly better outcomes than their counterparts in the control group in fasting blood glucose （5.59±1.22） vs. （6.01±1.63） mmol/L, P = 0.040, glycated hemoglobin （5.97±0.74）% vs. （6.34±1.10）%, P = 0.006, total cholesterol （3.26±0.77）vs.（3.55±0.99） mmol/L, P = 0.019, triglycerides （1.32±0.81） vs. （1.73±1.14）mmol/L, P = 0.004, low-density lipoprotein （1.64±0.55） vs. （1.84±0.76）mmol/L, P = 0.036, uric acid （396.24±93.91） vs. （434.48±113.74）μmol/L, P = 0.010, and creatinine （84.15±26.29）μmol/L vs. （97.76±50.18）μmol/L, P = 0.017. In the intervention group, the medication adherence score was significantly higher （7.04±0.85）μmol/L vs. （6.52±0.94）μmol/L, P < 0.001, and the incidence of MACE was significantly lower （6.0% vs. 16.0%, P = 0.024） compared with those in the control group. No significant differences were observed in LVEF and high-density lipoprotein levels between two groups （both P > 0.05）. Conclusions The implementation of a remote case management model for CHD patients after PCI can improve medication adherence, optimize risk factors such as glucose and lipid metabolism, and reduce the incidence of MACE. It is an effective secondary prevention management strategy worthy of clinical promotion and application.