Influence of decompensated heart failure on cardiac acoustic biomarkers: impact on early readmissions

A scoping review on advancements in noninvasive wearable technology for heart failure management

Wearables offer a promising solution for enhancing remote monitoring (RM) of heart failure (HF) patients by tracking key physiological parameters. Despite their potential, their clinical integration faces challenges due to the lack of rigorous evaluations. This review aims to summarize the current evidence and assess the readiness of wearables for clinical practice using the Medical Device Readiness Level (MDRL). A systematic search identified 99 studies from 3112 found articles, with only eight being randomized controlled trials. Accelerometery was the most used measurement technique. Consumer-grade wearables, repurposed for HF monitoring, dominated the studies with most of them in the feasibility testing stage (MDRL 6). Only two of the described wearables were specifically designed for HF RM, and received FDA approval. Consequently, the actual impact of wearables on HF management remains uncertain due to limited robust evidence, posing a significant barrier to their integration into HF care.

The role of cardiac acoustic biomarkers in monitoring patients with heart failure: A systematic literature review

Heart failure (HF) creates a considerable clinical, humanistic and economic burden on patients and caregivers as well as on healthcare systems. To attenuate the significant burden of HF, there is a need for enhanced management of patients with HF. The use of digital tools for remote non-invasive monitoring of heart parameters is gaining traction, and cardiac acoustic biomarkers (CABs) have been proposed as a complementary set of measures to assess heart function alongside traditional methods such as electrocardiogram and echocardiography. We conducted a systematic literature review to evaluate associations between CABs and HF outcomes. Embase and MEDLINE databases were searched for recent studies published between 2013 and 2023 that evaluated CABs in patients with HF. Additional grey literature (i.e., conference, congress and pre-print publications from January 2021 to May 2023) searches were included. Two reviewers independently examined all articles; a third resolved conflicts. Data were extracted from articles meeting inclusion criteria. Extracted studies underwent quality and bias assessments using the Joanna Briggs Institute (JBI) critical appraisal tools. In total, 3074 records were screened, 73 full-text articles were assessed for eligibility and 27 publications were included. Third heart sound (S3) and electromechanical activation time (EMAT) were the CABs most often reported in the literature for monitoring HF. Fifteen publications discussed changes in S3 characteristics and its role in HF detection or outcomes: six studies highlighted S3 assessment among various groups of patients with HF; four studies evaluated the strength or amplitude of S3 with clinical outcomes; five studies assessed the relationship between S3 presence and clinical outcomes; and one study assessed both S3 presence and amplitude in relation to HF clinical outcomes. Eleven publications reported on EMAT and its derivatives: five studies on the relationship between EMAT and HF and six studies on the association of EMAT and HF clinical outcomes. Studies reporting the first and fourth heart sound, left ventricular ejection time and systolic dysfunction index were limited. Published literature supported S3 and EMAT as robust CAB measures in HF that may have value in remote clinical monitoring and management of patients with HF. Additional studies designed to test the predictive power of these CABs, and others less well-characterized, are needed. This work was funded by Astellas Pharma Inc.

Sex differences in achieving guideline-recommended heart rate control among a large sample of patients at risk for sudden cardiac arrest

Background

Despite known clinical benefits, guideline-recommended heart rate (HR) control is not achieved for a significant proportion of patients with HF with reduced ejection fraction. The wearable cardioverter-defibrillator (WCD) provides continuous HR monitoring and alerts that could aid medication titration.

Objective

This study sought to evaluate sex differences in achieving guideline-recommended HR control during a period of WCD use.

Methods

Data from patients fitted with a WCD from 2015 to 2018 were obtained from the manufacturer's database (ZOLL). The proportion of patients with adequate nighttime resting HR control at the beginning of use (BOU) and at the end of use (EOU) were compared by sex. Adequate HR control was defined as having a nighttime median HR <70 beats/min.

Results

A total of 21,440 women and a comparative sample of 17,328 men (median 90 [IQR 59-116] days of WCD wear) were included in the final dataset. Among patients who did not receive a shock, over half had insufficient HR control at BOU (59% of women, 53% of men). Although the proportion of patients with resting HR ≥70 beats/min improved by EOU, 43% of women and 36% of men did not achieve guideline-recommended HR control.

Conclusion

A significant proportion of women and men did not achieve adequate HR control during a period of medical therapy optimization. Compared with men, a greater proportion of women receiving WCD shocks had insufficiently controlled HR in the week preceding ventricular tachyarrhythmia/ventricular fibrillation and 43% of nonshocked women, compared with 36% of men, did not reach adequate HR control during the study period. The WCD can be utilized as a remote monitoring tool to record HR and inform adequate uptitration of beta-blockers, with particular focus on reducing the treatment gap in women.

Telemedical Intervention and Its Effect on Quality of Life in Chronic Heart Failure Patients: The Results from the Telemedicine and e-Health Solution Pilot Program

(1) Background: Heart failure (HF) is not only a common cardiovascular disease with a poor prognosis. Its prevalence in developed countries equals 1-2% of the general population of adults, while in Poland HF, patients constitute 3.2% of the total population. Modern heart failure treatment should be focused not only on reducing the risk of death and the number of readmissions due to HF exacerbation but quality of life as well. Telemedicine has been suggested as a viable tool for enhancing HRQL. Therefore, we present the results of telemedical intervention in a group of HF patients and its effect on quality of life in chronic heart failure patients from a pilot study dedicated to reducing social inequalities in health through the use of telemedicine and e-health solutions. (2) Method: The project was a multicenter, open, non-controlled trial conducted by the University of Rzeszów, Poland. The data points were collected in the June 2023-December 2023 period from fourteen primary care units from five voivodeships, mostly considered social exclusion areas. A total of 52.7% of the patients recruited were Podkarpackie Voivodeship inhabitants. The result and discussion are presented based on the Chronic Heart Failure Questionnaire (CHFQ) and the EuroQol Visual Analogue Scale (EQVAS). (3) Results: During the program, a total of over 100,000 telemedicine examinations were conducted in the form of body weight measurement, heart rate, blood pressure tests, and 7-day Holter or 14-day event Holter assessment. Over the course of this study, coordinating the pilot program medical staff has ordered 570 changes in the patient's pharmacotherapy, confirming the positive impact on quality of life in the study group. (4) Conclusions: A comprehensive telemedical intervention can contribute to an improvement in the quality of life of patients with HF beyond what was achieved with the basic standard of care in the group of HF patients from the social exclusion region. It is now unclear if the result of the basic telemedical intervention would be constant after discontinuation of the mentioned pilot program.

AI diagnosis of heart sounds differentiated with super StethoScope

In the aging global society, heart failure and valvular heart diseases, including aortic stenosis, are affecting millions of people and healthcare systems worldwide. Although the number of effective treatment options has increased in recent years, the lack of effective screening methods is provoking continued high mortality and rehospitalization rates. Appropriately, auscultation has been the primary option for screening such patients, however, challenges arise due to the variability in auscultation skills, the objectivity of the clinical method, and the presence of sounds inaudible to the human ear. To address challenges associated with the current approach towards auscultation, the hardware of Super StethoScope was developed. This paper is composed of (1) a background literature review of bioacoustic research regarding heart disease detection, (2) an introduction of our approach to heart sound research and development of Super StethoScope, (3) a discussion of the application of remote auscultation to telemedicine, and (4) results of a market needs survey on traditional and remote auscultation. Heart sounds and murmurs, if collected properly, have been shown to closely represent heart disease characteristics. Correspondingly, the main characteristics of Super StethoScope include: (1) simultaneous collection of electrocardiographic and heart sound for the detection of heart rate variability, (2) optimized signal-to-noise ratio in the audible frequency bands, and (3) acquisition of heart sounds including the inaudible frequency ranges. Due to the ability to visualize the data, the device is able to provide quantitative results without disturbance by sound quality alterations during remote auscultations. An online survey of 3648 doctors confirmed that auscultation is the common examination method used in today's clinical practice and revealed that artificial intelligence-based heart sound analysis systems are expected to be integrated into clinicians' practices. Super StethoScope would open new horizons for heart sound research and telemedicine.

Virtual healthcare solutions in heart failure: a literature review

The widespread adoption of mobile technologies offers an opportunity for a new approach to post-discharge care for patients with heart failure (HF). By enabling non-invasive remote monitoring and two-way, real-time communication between the clinic and home-based patients, as well as a host of other capabilities, mobile technologies have a potential to significantly improve remote patient care. This literature review summarizes clinical evidence related to virtual healthcare (VHC), defined as a care team + connected devices + a digital solution in post-release care of patients with HF. Searches were conducted on Embase (06/12/2020). A total of 171 studies were included for data extraction and evidence synthesis: 96 studies related to VHC efficacy, and 75 studies related to AI in HF. In addition, 15 publications were included from the search on studies scaling up VHC solutions in HF within the real-world setting. The most successful VHC interventions, as measured by the number of reported significant results, were those targeting reduction in rehospitalization rates. In terms of relative success rate, the two most effective interventions targeted patient self-care and all-cause hospital visits in their primary endpoint. Among the three categories of VHC identified in this review (telemonitoring, remote patient management, and patient self-empowerment) the integrated approach in remote patient management solutions performs the best in decreasing HF patients' re-admission rates and overall hospital visits. Given the increased amount of data generated by VHC technologies, artificial intelligence (AI) is being investigated as a tool to aid decision making in the context of primary diagnostics, identifying disease phenotypes, and predicting treatment outcomes. Currently, most AI algorithms are developed using data gathered in clinic and only a few studies deploy AI in the context of VHC. Most successes have been reported in predicting HF outcomes. Since the field of VHC in HF is relatively new and still in flux, this is not a typical systematic review capturing all published studies within this domain. Although the standard methodology for this type of reviews was followed, the nature of this review is qualitative. The main objective was to summarize the most promising results and identify potential research directions.

Changes in cardiac acoustic biomarkers before and after cardiac events in a patient with right-sided heart failure due to cor pulmonale

Chronic heart failure (HF) has various phenotypes. It is accompanied by repeated hospitalizations over a long period. Therefore, accumulating long-term observational data of patients with various backgrounds is important to establish a prediction technology for the exacerbation of HF. In a patient with chronic right-sided HF caused by cor pulmonale, heart sounds and electrocardiograms were recorded at home or our hospital twice a week for 7 months including the stable (31 days), pre-exacerbation (2 weeks just before the onset of exacerbation), and hospitalization periods and quantified as cardiac acoustic biomarkers (CABs) using AUDICOR technology (Inovise Medical, Inc., Portland, OR, USA). The relationship between the change in CABs and hospitalization events due to HF were investigated. During the pre-exacerbation period just before the onset of exacerbation of HF leading to hospitalization, inaudible changes in the third heart sound (S3) strength that were probably derived from the right heart were observed. Although the values of the fourth heart sound (S4) strength were high during the stable and pre-exacerbation period, values decreased markedly during hospitalization. These findings suggest that CABs including S3 and S4 are useful for the early detection of signs of HF exacerbation.

Learning Objective

In a case of chronic right-sided heart failure, the change in the third heart sound (S3) caused by the right ventricle could be detected using cardiac acoustic biomarkers in exacerbations of heart failure. Even if S3 is inaudible by auscultation, it is possible to observe its changes using quantification technology.

Relationship between Cardiac Acoustic Biomarkers and Pulmonary Artery Pressure in Patients with Heart Failure

Since an elevation of pulmonary artery pressure (PAP) often precedes clinical worsening of heart failure (HF), early and non-invasive detection of this sign is useful in HF care. This study aimed to assess whether cardiac acoustic biomarkers (CABs) are associated with the elevation of PAP in patients with HF. Patients with HF scheduled to undergo right heart catheterization were prospectively enrolled. CABs were concurrently recorded during catheterization at rest (baseline) and while applying a handgrip (exercise). Forty-nine patients were included in the analysis, and their mean PAP significantly increased after exercise compared to baseline. Several CABs correlated significantly with mean PAP by absolute values, among which S2 Width (r = 0.354; p = 0.014 and r = 0.363; p = 0.010) and S3 Strength (r = 0.375; p = 0.009 and r = 0.386; p = 0.007) were consistent throughout baseline and exercise. The response of CABs to exercise-induced PAP elevation was divided into two patterns: increasing and decreasing. The frequency of cardiac index below 2.2 mL/m2 was significantly higher in the decreasing pattern. CABs related to S2 and S3 showed significant correlations with absolute PAP values both at baseline and after exercise in patients with HF, but no significant correlations between their changes from baseline to post-exercise were observed in this study population. Further research is therefore needed to assess whether CABs can sensitively reflect changes in PAP according to HF status and underlying phenotypes.

Multiparameter Monitoring with a Wearable Cardioverter Defibrillator

A wearable cardioverter-defibrillator (WCD) is a temporary treatment option for patients at high risk for sudden cardiac death (SCD) and for patients who are temporarily not candidates for an implantable cardioverter defibrillator (ICD). In addition, the need for telemedical concepts in the detection and treatment of heart failure (HF) and its arrhythmias is growing. The WCD has evolved from a shock device detecting malignant ventricular arrhythmias (VA) and treating them with shocks to a heart-failure-monitoring device that captures physical activity and cardioacoustic biomarkers as surrogate parameters for HF to help the treating physician surveil and guide the HF therapy of each individual patient. In addition to its important role in preventing SCD, the WCD could become an important tool in heart failure treatment by helping prevent HF events by detecting imminent decompensation via remote monitoring and monitoring therapy success.

Influence of decompensated heart failure on cardiac acoustic biomarkers: impact on early readmissions

Aims

Preventing hospitalization by detecting early evidence of heart failure (HF) decompensation in an outpatient setting can improve patient's quality of life and reduce costs of care. The purpose of this study was to assess the value of cardiac acoustic biomarkers (CABs), a combination of cardiohaemic vibrations synchronized with ECG signals, and heart rate (HR) for detecting HF decompensation during first 3 months after hospital discharge for HF.

Methods and results

Patients with an ejection fraction ≤35% (HFrEF) and hospitalized for decompensated HF were enrolled in a prospective observational study. All subjects wore a wearable cardioverter‐defibrillator (ZOLL LifeVest^®, Pittsburgh, PA, USA) that is capable of recording CABs and HR. The primary endpoint of the study was the first HF event, defined as HF readmission or HF emergency room visit. From June 2017 through August 2019, 671 patients with HFrEF were enrolled. Eighty‐one patients (12.1%) had a total of 112 HF events. The algorithm detected HF events with a median of 32 days (interquartile range = 11‐45) in advance of the first HF event. The algorithm had a sensitivity of 69%, specificity of 60%, positive predictive value of 19%, and a negative predictive value of 94%. Of note, the baseline (first 7 days post‐enrolment) algorithm using CABs and HR was superior to New York Heart Association classification in detecting patients more likely to have HF decompensation (sensitivity and specificity of 61% and 68% vs. 46% and 55%, respectively).

Conclusions

This prospective international registry showed that an algorithm incorporating CABs and HR data detected HF events 30 days in advance of the event in patients with HFrEF during first 3 months after hospital discharge. Therefore, integrating CAB technology into clinical practice may prevent HF rehospitalizations.