Remote monitoring of chronic heart failure patients: invasive versus non-invasive tools for optimising patient management

Feasibility of self-measurement telemonitoring using a handheld heart sound recorder in patients with heart failure - SELPH multicenter pilot study

BACKGROUND

Multi-parametric assessment, including heart sounds in addition to conventional parameters, may enhance the efficacy of noninvasive telemonitoring for heart failure (HF). We sought to assess the feasibility of self-telemonitoring with multiple devices including a handheld heart sound recorder and its association with clinical events in patients with HF.

METHODS

Ambulatory HF patients recorded their own heart sounds, mono‑lead electrocardiograms, oxygen saturation, body weight, and vital signs using multiple devices every morning for six months.

RESULTS

In the 77 patients enrolled (63 ± 13 years old, 84 % male), daily measurements were feasible with a self-measurement rate of >70 % of days in 75 % of patients. Younger age and higher Minnesota Living with Heart Failure Questionnaire scores were independently associated with lower adherence (p = 0.002 and 0.027, respectively). A usability questionnaire showed that 87 % of patients felt self-telemonitoring was helpful, and 96 % could use the devices without routine cohabitant support. Six patients experienced ten HF events of re-hospitalization and/or unplanned hospital visits due to HF. In patients who experienced HF events, a significant increase in heart rate and diastolic blood pressure and a decrease in the time interval from Q wave onset to the second heart sound were observed 7 days before the events compared with those without HF events.

CONCLUSIONS

Self-telemonitoring with multiple devices including a handheld heart sound recorder was feasible even in elderly patients with HF. This intervention may confer a sense of relief to patients and enable monitoring of physiological parameters that could be valuable in detecting the deterioration of HF.

Non-invasive heart failure monitoring: leveraging smart scales and digital biomarkers to improve heart failure outcomes

Heart failure (HF) is a significant global concern, impacting patient morbidity, mortality, and healthcare costs. Guideline-directed medical therapy and various preventive measures have proven effective in improving clinical outcomes and reducing HF hospitalizations. Recent data indicates that remote HF monitoring facilitates early detection of HF decompensation by observing upstream events and parameters before clinical signs and symptoms manifest. Moreover, these innovative devices have been shown to decrease unnecessary HF hospitalizations and, in some cases, provide predictive insights before an actual HF incident. In this review, we aim to explore the data regarding smart scales and digital biomarkers and summarize both FDA-approved devices and emerging technologies by assessing their clinical utility, mechanism of HF decompensation detection, and ongoing trials. Furthermore, we also discuss the future trend of integrating these devices into routine clinical practice to improve patient clinical outcomes.

Remote Monitoring of Cardiac Implantable Electronic Devices in Very Elderly Patients: Advantages and Specific Problems

Cardiac implantable electronic devices (CIEDs) offer the benefit of remote monitoring and decision making and find particular applications in special populations such as the elderly. Less transportation, reduced costs, prompt diagnosis, a sense of security, and continuous real-time monitoring are the main advantages. On the other hand, less physician-patient interactions and the technology barrier in the elderly pose specific problems in remote monitoring. CIEDs nowadays are abundant and are mostly represented by rhythm control/monitoring devices, whereas hemodynamic remote monitoring devices are gaining popularity and are evolving and becoming refined. Future directions include the involvement of artificial intelligence, yet disparities of availability, lack of follow-up data, and insufficient patient education are still areas to be improved. This review aims to describe the role of CIED in the very elderly and highlight the merits and possible drawbacks.

Implementation of an epicardial implantable MEMS sensor for continuous and real-time postoperative assessment of left ventricular activity in adult minipigs over a short- and long-term period

The sensing of left ventricular (LV) activity is fundamental in the diagnosis and monitoring of cardiovascular health in high-risk patients after cardiac surgery to achieve better short- and long-term outcome. Conventional approaches rely on noninvasive measurements even if, in the latest years, invasive microelectromechanical systems (MEMS) sensors have emerged as a valuable approach for precise and continuous monitoring of cardiac activity. The main challenges in designing cardiac MEMS sensors are represented by miniaturization, biocompatibility, and long-term stability. Here, we present a MEMS piezoresistive cardiac sensor capable of continuous monitoring of LV activity over time following epicardial implantation with a pericardial patch graft in adult minipigs. In acute and chronic scenarios, the sensor was able to compute heart rate with a root mean square error lower than 2 BPM. Early after up to 1 month of implantation, the device was able to record the heart activity during the most important phases of the cardiac cycle (systole and diastole peaks). The sensor signal waveform, in addition, closely reflected the typical waveforms of pressure signal obtained via intraventricular catheters, offering a safer alternative to heart catheterization. Furthermore, histological analysis of the LV implantation site following sensor retrieval revealed no evidence of myocardial fibrosis. Our results suggest that the epicardial LV implantation of an MEMS sensor is a suitable and reliable approach for direct continuous monitoring of cardiac activity. This work envisions the use of this sensor as a cardiac sensing device in closed-loop applications for patients undergoing heart surgery.

Evaluation of Ambient Sensor Systems for the Early Detection of Heart Failure Decompensation in Older Patients Living at Home Alone: Protocol for a Prospective Cohort Study

BACKGROUND

The results of telemedicine intervention studies in patients with heart failure (HF) to reduce rehospitalization rate and mortality by early detection of HF decompensation are encouraging. However, the benefits are lower than expected. A possible reason for this could be the fact that vital signs, including blood pressure, heart rate, heart rhythm, and weight changes, may not be ideal indicators of the early stages of HF decompensation but are more sensitive for acute events triggered by ischemic episodes or rhythm disturbances. Preliminary results indicate a potential role of ambient sensor-derived digital biomarkers in this setting.

OBJECTIVE

The aim of this study is to identify changes in ambient sensor system-derived digital biomarkers with a high potential for early detection of HF decompensation.

METHODS

This is a prospective interventional cohort study. A total of 24 consecutive patients with HF aged 70 years and older, living alone, and hospitalized for HF decompensation will be included. Physical activity in the apartment and toilet visits are quantified using a commercially available, passive, infrared motion sensing system (DomoHealth SA). Heart rate, respiration rate, and toss-and-turns in bed are recorded by using a commercially available Emfit QS device (Emfit Ltd), which is a contact-free piezoelectric sensor placed under the participant's mattress. Sensor data are visualized on a dedicated dashboard for easy monitoring by health professionals. Digital biomarkers are evaluated for predefined signs of HF decompensation, including particularly decreased physical activity; time spent in bed; increasing numbers of toilet visits at night; and increasing heart rate, respiration rate, and motion in bed at night. When predefined changes in digital biomarkers occur, patients will be called in for clinical evaluation, and N-terminal pro b-type natriuretic peptide measurement (an increase of >30% considered as significant) will be performed. The sensitivity and specificity of the different biomarkers and their combinations for the detection of HF decompensation will be calculated.

RESULTS

The study is in the data collection phase. Study recruitment started in February 2024. Data analysis is scheduled to start after all data are collected. As of manuscript submission, 5 patients have been recruited. Results are expected to be published by the end of 2025.

CONCLUSIONS

The results of this study will add to the current knowledge about opportunities for telemedicine to monitor older patients with HF living at home alone by evaluating the potential of ambient sensor systems for this purpose. Timely recognition of HF decompensation could enable proactive management, potentially reducing health care costs associated with preventable emergency presentations or hospitalizations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06126848; https://clinicaltrials.gov/study/NCT06126848.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/55953.

Prognostic value of signs and symptoms in heart failure patients using remote telemonitoring

INTRODUCTION

Heart failure is a serious burden on health care systems due to frequent hospital admissions. Early recognition of outpatients at risk for clinical deterioration could prevent hospitalization. Still, the role of signs and symptoms in monitoring heart failure patients is not clear. The heart failure coach is a web-based telemonitoring application consisting of a 9-item questionnaire assessment of heart failure signs and symptoms and developed to identify outpatients at risk for clinical deterioration. If deterioration was suspected, patients were contacted by a heart failure nurse for further evaluation.

METHODS

Heart failure coach questionnaires completed between 2015 and 2018 were collected from 287 patients, completing 18,176 questionnaires. Adverse events were defined as all-cause mortality, heart failure- or cardiac-related hospital admission or emergency cardiac care visits within 30 days after completion of each questionnaire. Multilevel logistic regression analyses were performed to assess the association between the heart failure coach questionnaire items and the odds of an adverse event.

RESULTS

No association between dyspnea and adverse events was observed (odds ratio 1.02, 95% confidence interval 0.79-1.30). Peripheral edema (odds ratio 2.21, 95% confidence interval 1.58-3.11), persistent chest pain (odds 2.06, 95% confidence interval 1.19-3.58), anxiety about heart failure (odds ratio 2.12, 95% confidence interval 1.44-3.13), and extensive struggle to perform daily activities (odds ratio 2.23, 95% confidence interval 1.38-3.62) were significantly associated with adverse outcome.

DISCUSSION

Regular assessment of more than the classical signs and symptoms may be helpful to identify heart failure patients at risk for clinical deterioration and should be an integrated part of heart failure telemonitoring programs.

Characteristics Associated With Telemonitoring Use Among Patients With Chronic Heart Failure: Retrospective Cohort Study

BACKGROUND

Chronic heart failure (HF) is a chronic disease affecting more than 64 million people worldwide, with an increasing prevalence and a high burden on individual patients and society. Telemonitoring may be able to mitigate some of this burden by increasing self-management and preventing use of the health care system. However, it is unknown to what degree telemonitoring has been adopted by hospitals and if the use of telemonitoring is associated with certain patient characteristics. Insight into the dissemination of this technology among hospitals and patients may inform strategies for further adoption.

OBJECTIVE

We aimed to explore the use of telemonitoring among hospitals in the Netherlands and to identify patient characteristics associated with the use of telemonitoring for HF.

METHODS

We performed a retrospective cohort study based on routinely collected health care claim data in the Netherlands. Descriptive analyses were used to gain insight in the adoption of telemonitoring for HF among hospitals in 2019. We used logistic multiple regression analyses to explore the associations between patient characteristics and telemonitoring use.

RESULTS

Less than half (31/84, 37%) of all included hospitals had claims for telemonitoring, and 20% (17/84) of hospitals had more than 10 patients with telemonitoring claims. Within these 17 hospitals, a total of 7040 patients were treated for HF in 2019, of whom 5.8% (409/7040) incurred a telemonitoring claim. Odds ratios (ORs) for using telemonitoring were higher for male patients (adjusted OR 1.90, 95% CI 1.50-2.41) and patients with previous hospital treatment for HF (adjusted OR 1.76, 95% CI 1.39-2.24). ORs were lower for higher age categories and were lowest for the highest age category, that is, patients older than 80 years (OR 0.30, 95% CI 0.21-0.44) compared to the reference age category (18-59 years). Socioeconomic status, degree of multimorbidity, and excessive polypharmacy were not associated with the use of telemonitoring.

CONCLUSIONS

The use of reimbursed telemonitoring for HF was limited up to 2019, and our results suggest that large variation exists among hospitals. A lack of adoption is therefore not only due to a lack of diffusion among hospitals but also due to a lack of scaling up within hospitals that already deploy telemonitoring. Future studies should therefore focus on both kinds of adoption and how to facilitate these processes. Older patients, female patients, and patients with no previous hospital treatment for HF were less likely to use telemonitoring for HF. This shows that some patient groups are not served as much by telemonitoring as other patient groups. The underlying mechanism of the reported associations should be identified in order to gain a deeper understanding of telemonitoring use among different patient groups.

Body composition, lipid profile and clinical parameters are predictors of prognosis in patients with heart failure: Two-year follow-up

BACKGROUND

Heart failure (HF) is a complex syndrome that leads to changes in body composition and eventually results in unfavorable outcomes.

AIM

This study aimed to evaluate body composition, lipid profiles and clinical parameters of patients with HF, and their associations with both survival and unfavorable clinical outcomes.

METHODS

This prospective cohort study included 94 adults and older people with HF. Body composition was assessed by bioelectrical impedance analysis (BIA). Anthropometric variables and lipid profile were also evaluated. Electronic medical records were checked to collect information on clinical outcomes (mortality and hospitalization), considering a follow-up period of 24 months. Survival was calculated using the Kaplan-Meier estimate, and the curves compared using Log-Rank. The death risk rate (Hazard Ratio, HR) was calculated using Cox's univariate models.

RESULTS

Mean age was 55.1 (13.9) years and there was a higher frequency of males. There was a predominance of HF with reduced ejection fraction, and ischemic etiology. Patients with New York Heart Association (NYHA) functional classification I/II had a better overall survival rate at 24 months than those with NYHA III/IV (univariate HR 4.93 (1.76-13.82); p = 0.001). Greater survival rates were found in patients without chronic kidney disease (CKD) (univariate HR 2.93 (1.59-5.39); p = 0.01). In the multivariate analyses, both dyslipidemia (adjusted HR 3.84 (1.22-12.00); p = 0.021) and increased fat mass index (FMI) were associated with overall survival rate (adjusted HR 3.59 (1, 10-11.74); p = 0.034).

CONCLUSION

The severity of HF symptoms and the presence of chronic kidney disease are associated with higher mortality. Increased fat mass index and dyslipidemia are predictors of favorable outcomes in this population.

Automated Assessment of the Quality of Phonocardographic Recordings through Signal-to-Noise Ratio for Home Monitoring Applications

The signal quality limits the applicability of phonocardiography at the patients’ domicile. This work proposes the signal-to-noise ratio of the recorded signal as its main quality metrics. Moreover, we define the minimum acceptable values of the signal-to-noise ratio that warrantee an accuracy of the derived parameters acceptable in clinics. We considered 25 original heart sounds recordings, which we corrupted by adding noise to decrease their signal-to-noise ratio. We found that a signal-to-noise ratio equal to or higher than 14 dB warrants an uncertainty of the estimate of the valve closure latencies below 1 ms. This accuracy is higher than that required by most clinical applications. We validated the proposed method against a public database, obtaining results comparable to those obtained on our sample population. In conclusion, we defined (a) the signal-to-noise ratio of the phonocardiographic signal as the preferred metric to evaluate its quality and (b) the minimum values of the signal-to-noise ratio required to obtain an uncertainty of the latency of heart sound components compatible with clinical applications. We believe these results are crucial for the development of home monitoring systems aimed at preventing acute episodes of heart failure and that can be safely operated by naïve users.

The kinocardiograph for assessment of changes in haemodynamic load in patients with chronic heart failure with reduced ejection fraction

Aims

The kinocardiograph (KCG) is an unobtrusive device, consisting of a chest sensor, which records local thoracic vibrations produced in result of cardiac contraction and ejection of blood into the great vessels [seismocardiography (SCG)], and a lower back sensor, which records micromovements of the body in reaction to blood flowing through the vasculature [ballistocardiography (BCG)]. SCG and BCG signals are translated to the integral of cardiac kinetic energy (iK) and cardiac maximum power (Pmax), which might be promising metrics for future telemonitoring purposes in heart failure (HF). As a first step of validation, this study aimed to determine whether iK and Pmax are responsive to exercise‐induced changes in the haemodynamic load of the heart in HF patients.

Methods and results

Fifteen patients with stable HF with reduced ejection fraction performed a submaximal exercise protocol. KCG and cardiac ultrasound measurements were obtained both at rest and at submaximal exercise. BCG iK over the cardiac cycle (CC) increased significantly (0.0026 ± 0.0017 to 0.0052 ± 0.0061 mJ.s.; P = 0.01) during exercise, in contrast to a non‐significant increase in SCG iK CC. BCG Pmax CC increased significantly (0.92 ± 0.89 to 2.03 ± 1.95 mJ/s; P = 0.02), in contrast to a non‐significant increase in SCG Pmax CC. When analysing the systolic phase of the CC, similar patterns were found. Cardiac output (CO) ratio (i.e. CO exercise/CO rest) showed a moderate, significant correlation with BCG Pmax CC ratio (r = +0.65; P = 0.008) and with SCG Pmax CC ratio (r = +0.54; P = 0.04).

Conclusions

iK and Pmax measured with the KCG, preferentially using BCG, are responsive to changes in the haemodynamic load of the heart in HF patients. The combination of the BCG and SCG sensor might be of added value to fully understand changes in haemodynamics and to discriminate between an HF patient and a healthy individual.

Clinical Update of the Latest Evidence for CardioMEMS Pulmonary Artery Pressure Monitoring in Patients with Chronic Heart Failure: A Promising System for Remote Heart Failure Care

The CardioMEMS pulmonary artery (PA) monitoring system placed in the left lower lobe pulmonary artery is capable of measuring pulmonary artery pressure remotely as a surrogate of intracardiac filling pressures and volume status. The technique is safe and reliable. By using remote PA monitoring for proactive medical interventions, there is a growing body of clinical evidence for a substantial, robust reduction in HF hospitalizations in various populations (clinical trial setting, post-marketing studies and real-world experiences). This review summarizes the clinical evidence, outlines future perspectives, and aims for remote patient care in heart failure using CardioMEMS.

Innovations in Cardiac Implantable Electronic Devices

Cardiac implantable electronic devices (CIEDs) are essential for the management of a variety of cardiac conditions, including tachyarrhythmias, bradyarrhythmias, and medically refractory heart failure (HF). Recent advancements in CIED technology have led to innovative solutions that overcome shortcomings associated with traditional devices or address unmet needs. Leadless pacemakers, subcutaneous implantable cardioverter defibrillators (ICDs), and extravascular ICDs eliminate lead-related complications common with conventional pacemakers or ICDs. Conduction system pacing (His bundle pacing and left bundle branch pacing) is a more physiologic method of pacing and avoids the deleterious consequences associated with long-term right ventricular pacing. For HF-related devices, cardiac contractility modulation is an emerging therapy that bridges a gap for many patients ineligible for cardiac resynchronization therapy and has been shown to improve HF symptoms and decrease hospitalizations and mortality in select patients. Implantable pulmonary artery pressure monitors help guide HF management and reduce hospitalizations. Lastly, new phrenic nerve stimulating devices are being utilized to treat central sleep apnea, a common comorbidity associated with HF. While further long-term studies are still underway for many of these new technologies, it is anticipated that these devices will become indispensable therapeutics in the expanding cardiovascular armamentarium.

The Future of Telemedicine in the Management of Heart Failure Patients

Telemedicine (TM) is potentially a way of escalating heart failure (HF) multidisciplinary integrated care. Despite the initial efforts to implement TM in HF management, we are still at an early stage of its implementation. The coronavirus disease 2019 pandemic led to an increased utilisation of TM. This tendency will probably remain after the resolution of this threat. Face-to-face medical interventions are gradually transitioning to the virtual setting by using TM. TM can improve healthcare accessibility and overcome geographic inequalities. It promotes healthcare system efficiency gains, and improves patient self-management and empowerment. In cooperation with human intervention, artificial intelligence can enhance TM by helping to deal with the complexities of multicomorbidity management in HF, and will play a relevant role towards a personalised HF patient approach. Artificial intelligence-powered/telemedical/heart team/multidisciplinary integrated care may be the next step of HF management. In this review, the authors analyse TM trends in the management of HF patients and foresee its future challenges within the scope of HF multidisciplinary integrated care.

Canadian Registry of Electronic Device Outcomes: remote monitoring outcomes in the Abbott battery performance alert-a multicentre cohort

AIMS

Cardiac implantable electronic devices with device advisories have the potential of device malfunction. Remote monitoring (RM) of devices has been suggested to allow the identification of abnormal device performance and permit early intervention. We sought to describe the outcomes of patients with and without RM in devices subject to the Abbott Premature Battery Depletion (PBD) advisory with data from a Canadian registry.

METHODS AND RESULTS

Patients with an Abbott device subject to the PBD advisory from nine implantable cardioverter defibrillator (ICD) implanting centres in Canada were included in the registry. The use of RM was identified from baseline and follow-up data in the registry. The primary outcome was detection of PBD and all-cause mortality. A total of 2666 patients were identified with a device subject to the advisory. In all, 1687 patients (63.2%) had RM at baseline. There were 487 deaths during follow-up. At a mean follow-up of 5.7 ± 0.7 years, mortality was higher in those without a remote monitor compared with RM at baseline (24.7% vs. 14.5%; P < 0.001). Pre-mature battery depletion was identified in 36 patients (2.1%) with RM vs. 7 (0.7%) without RM (P = 0.004). Time to battery replacement was significantly reduced in patients on RM (median 5 vs. 13 days, P = 0.001).

CONCLUSION

The use of RM in patients with ICD and cardiac resynchronization therapy under advisory improved detection of PBD, time to device replacement, and was associated with a reduction in all-cause mortality. The factors influencing the association with mortality are unknown and deserve further study.

Case Report: Ambient Sensor Signals as Digital Biomarkers for Early Signs of Heart Failure Decompensation

Home monitoring systems are increasingly used to monitor seniors in their apartments for detection of emergency situations. More recently, multimodal ambient sensor systems are also used to monitor digital biomarkers to detect clinically relevant health problems over longer time periods. Clinical signs of HF decompensation including increase of heart rate and respiration rate, decreased physical activity, reduced gait speed, increasing toilet use at night and deterioration of sleep quality have a great potential to be detected by non-intrusive contactless ambient sensor systems and negative changes of these parameters may be used to prevent further deterioration and hospitalization for HF decompensation. This is to our knowledge the first report about the potential of an affordable, contactless, and unobtrusive ambient sensor system for the detection of early signs of HF decompensation based on data with prospective data acquisition and retrospective correlation of the data with clinical events in a 91 year old senior with a serious heart problem over 1 year. The ambient sensor system detected an increase of respiration rate, heart rate, toilet use at night, toss, and turns in bed and a decrease of physical activity weeks before the decompensation. In view of the rapidly increasing prevalence of HF and the related costs for the health care systems and the societies, the real potential of our approach should be evaluated in larger populations of HF patients.

Wireless Hemodynamic Monitoring in Patients with Heart Failure

Purpose of Review

Wireless hemodynamic monitoring in heart failure patients allows for volume assessment without the need for physical exam. Data obtained from these devices is used to assist patient management and avoid heart failure hospitalizations. In this review, we outline the various devices, mechanisms they utilize, and effects on heart failure patients.

Recent Findings

New applications of these devices to specific populations may expand the pool of patients that may benefit. In the COVID-19 pandemic with a growing emphasis on virtual visits, remote monitoring can add vital ancillary data.

Summary

Wireless hemodynamic monitoring with a pulmonary artery pressure sensor is a highly effective and safe method to assess for worsening intracardiac pressures that may predict heart failure events, giving lead time that is valuable to keep patients optimized. Implantation of this device has been found to improve outcomes in heart failure patients regardless of preserved or reduced ejection fraction.

Transitioning Patients with Heart Failure to Outpatient Care

The transition from hospitalization to outpatient care is a vulnerable time for patients with heart failure. This requires specific focus on the transitional care period. Here the authors propose a framework to guide process improvement in the transitional care period. The authors extend this framework by (1) examining the role new technology might play in transitional care, and (2) offering practical advice for teams building transitional care programs.