[Remote monitoring for patients with cardiac implantable electronic devices and heart failure]

The digitalization in healthcare facilitates continuous monitoring of relevant medical parameters through internal and external sensors. For patients with heart failure and cardiac implantable electronic devices (CIEDs), telemedicine has the potential to improve patient care and reduce use of healthcare resources. Remote monitoring shortens the response time to a clinical event, reduces inappropriate shocks, and increases patient satisfaction. Despite some limitations, remote monitoring therefore represents a valuable addition to regular outpatient follow-up care.

Rationale and Design of the Personalized Therapy Study: Evaluating Real-World Performance of Two Automated Defibrillation Therapy Algorithms

BACKGROUND

Barriers to maximizing patient benefit with implantable defibrillation devices include limited ability to tailor antitachycardia pacing (ATP) therapy in real time and identify patients at risk of heart failure (HF) events early on. The Personalized Therapy study aims to evaluate the performance of 2 algorithms, intrinsic ATP (iATP) and TriageHF, to address these barriers in routine clinical practice.

METHODS AND RESULTS

The Personalized Therapy Study was designed as a prospective, multicenter, post-market registry study expected to enroll approximately 2200 patients meeting the following criteria: (1) implanted with a study-eligible device regardless of procedure type, (2) Medtronic CareLink Network enrolled, (3) TriageHF enabled within CareLink and High-Risk Alert notifications turned ON, and (4) iATP enabled. The primary study objectives are to demonstrate iATP effectiveness in the fast ventricular tachycardia zone and estimate the positive predictive value of TriageHF high-risk status for worsening HF. Additionally, objectives include characterizing iATP effectiveness in all ventricular detection zones and characterizing TriageHF-based clinical actions and related HF hospitalizations.

CONCLUSION

This study is expected to generate real-world evidence on the performance of the iATP and TriageHF algorithms, which aim to improve clinical practice by tailoring arrhythmia and HF therapies to individual patient disease states.

Implementation of a Cardiovascular Implantable Electronic Device Heart Failure Prediction Tool-Guided Management Pathway

Cardiovascular implantable electronic devices (CIEDs) monitor physiologic variables that could identify subacute heart failure (HF) decompensation and impending HF hospitalization. One such algorithm uses measurements from the previous 30 days of CIED remote monitoring data to predict low-, medium-, or high-probability of HF hospitalization in the next 30 days. We sought to understand how to prospectively implement the use of such algorithms in routine HF care. From January 18, 2024 to April 19, 2024, HF risk categories were predicted from scheduled remote transmissions every 30 days and from unscheduled transmissions for all patients at 2 distinct cardiology clinics. Clinicians contacted and assessed patients at high risk regarding symptoms and then provided an empiric 3-day diuretic intervention (initiation or dose augmentation), adjusted guideline-directed medical therapy, or performed other clinical action as appropriate. Among 358 patients with 1,140 remote transmissions, 72 (20%) had ≥1 transmission categorized as high-risk. The mean patient age was 72.8 years, 346 (97%) were male, and 221 (62%) had a pre-existing diagnosis of HF. Of these 72 patients, 67 (93%) were successfully contacted, 34 (51%) had no HF symptoms, 24 (36%) had mild to moderate symptoms, and 2 (3%) had severe symptoms. A total of 46 patients (69%) had clinical action taken, including 28 (42%) with a diuretic intervention and 12 (18%) with guideline-directed medical therapy augmented. In this implementation study, clinicians contacted and assessed nearly all patients at high risk for HF decompensation based on CIED remote monitoring data and intervened in more than 2/3s. A randomized clinical trial is needed to determine whether this algorithm and subsequent intervention improves clinical outcomes.

Telemonitoring for Chronic Heart Failure: Narrative Review of the 20-Year Journey From Concept to Standard Care in Germany

BACKGROUND

Chronic heart failure (CHF) is a major cause of morbidity and mortality worldwide, placing a significant burden on health care systems. The concept of telemedicine for CHF was first introduced in the late 1990s, and since 2010, studies have demonstrated its potential to improve patient outcomes and reduce health care costs. Over the following decade, technological advancements and changes in health care policy led to the development of more sophisticated telemedicine solutions for CHF, including remote patient management through invasive or noninvasive telemonitoring devices, mobile apps, and virtual consultations. Years of public funding in Germany have generated evidence that remote patient management improves outcomes for patients with CHF, such as quality of life, and reduces hospital admissions. Based on these data, the Federal Joint Committee (Gemeinsamer Bundesausschuss; G-BA) decided, independently of the current European Society of Cardiology recommendations, to incorporate telemedicine as a standard digital intervention for high-risk patients with reduced left ventricular ejection fraction in Germany in 2020.

OBJECTIVE

This review aims to illustrate the journey from the initial concept through pioneering studies that led to telemedicine's integration into standard care, and to share current experiences that have positioned Germany as a leader in cardiovascular telemedicine.

METHODS

We review and discuss existing literature and evidence on the development and implementation of telemonitoring for CHF in Germany over the past 20 years. Relevant studies, reports, and guidelines were identified through a comprehensive search of electronic databases, including PubMed, Google Scholar, and specialized journals focused on CHF telemonitoring.

RESULTS

Pioneering studies, such as the TIM-HF2 (Telemedical Interventional Management in Heart Failure II) and IN-TIME (Influence of Home Monitoring on Mortality and Morbidity in Heart Failure Patients with Impaired Left Ventricular Function) trials, demonstrated the effectiveness of remote patient management applications for patients with CHF in Germany and their applicability to current practices involving both invasive and noninvasive methods. Collaborations between researchers and technology developers overcame barriers, leading to sustainable improvements in patient care. Ongoing research on artificial intelligence applications for prioritizing and interpreting individual health data will continue to transform digital health care.

CONCLUSIONS

The establishment of telemedical care for patients with HF across Europe is likely to benefit from experiences in Germany, where significant improvements have been achieved in the care of patients with HF.

Biotronik Implantable Cardioverter Defibrillator for Measurement of Intrathoracic Impedance: A Report of Two Cases

OBJECTIVES

Two patients were received ICDs (Biotronic Iforia7 VR-TDX). Holter analysis revealed pacing spikes, which occurred regularly at 100 ms intervals following QRS complexes, with consecutive 1024 test pulses at hourly intervals during a specific time, and the VP was 0%.

METHODS

By analyzing the dynamic electrocardiogram and consulting relevant literature, it was found that this is a feature of the ICD that measures thoracic impedance.

RESULTS

This phenomenon is a special function for the purpose of transthoracic impedance measurement, which can monitor the heart failure.

CONCLUSIONS

This phenomenon should not be regarded as an interference signal or an abnormal sign of pacemaker malfunction.

Digital solutions to optimize guideline-directed medical therapy prescription rates in patients with heart failure: a clinical consensus statement from the ESC Working Group on e-Cardiology, the Heart Failure Association of the European Society of Cardiology, the Association of Cardiovascular Nursing & Allied Professions of the European Society of Cardiology, the ESC Digital Health Committee, the ESC Council of Cardio-Oncology, and the ESC Patient Forum

The 2021 European Society of Cardiology guideline on diagnosis and treatment of acute and chronic heart failure (HF) and the 2023 Focused Update include recommendations on the pharmacotherapy for patients with New York Heart Association (NYHA) class II-IV HF with reduced ejection fraction. However, multinational data from the EVOLUTION HF study found substantial prescribing inertia of guideline-directed medical therapy (GDMT) in clinical practice. The cause was multifactorial and included limitations in organizational resources. Digital solutions like digital consultation, digital remote monitoring, digital interrogation of cardiac implantable electronic devices, clinical decision support systems, and multifaceted interventions are increasingly available worldwide. The objectives of this Clinical Consensus Statement are to provide (i) examples of digital solutions that can aid the optimization of prescription of GDMT, (ii) evidence-based insights on the optimization of prescription of GDMT using digital solutions, (iii) current evidence gaps and implementation barriers that limit the adoption of digital solutions in clinical practice, and (iv) critically discuss strategies to achieve equality of access, with reference to patient subgroups. Embracing digital solutions through the use of digital consults and digital remote monitoring will future-proof, for example alerts to clinicians, informing them of patients on suboptimal GDMT. Researchers should consider employing multifaceted digital solutions to optimize effectiveness and use study designs that fit the unique sociotechnical aspects of digital solutions. Artificial intelligence solutions can handle larger data sets and relieve medical professionals' workloads, but as the data on the use of artificial intelligence in HF are limited, further investigation is warranted.

Personalized Intervention Strategy Based on a Risk Score Generated From Subcutaneous Insertable Cardiac Monitor: Results From Phase 1 of ALLEVIATE-HF

BACKGROUND

Diagnostic variables from insertable cardiac monitors may be useful in identifying patients at increased risk of heart failure (HF) events. High-risk alerts must be coupled with interventions to improve outcomes. We aim to assess the safety of a predefined protocolized intervention pathway activated by insertable cardiac monitor high-risk alerts.

METHODS AND RESULTS

ALLEVIATE-HF (Algorithm Using LINQ Sensors for Evaluation and Treatment of Heart Failure) Phase 1 was a randomized interventional study enrolling patients with New York Heart Association class II/III and a recent HF event. A HF risk score based on insertable cardiac monitor diagnostics, including impedance, respiration rate, atrial fibrillation burden, heart rate during atrial fibrillation, heart rate variability, and activity duration, was calculated. A protocolized intervention pathway was activated when high-risk scores were detected that involved physician-prescribed nurse-implemented uptitration of diuretic for 4 days, unless safety rule-out conditions were met. Interventions could be repeated if high-risk scores persisted and did not require worsening symptoms. In total, 59 patients were randomized (mean age 68.2±11.8 years; 59.3% male); 67.8% with ejection fraction ≥50%. The mean follow-up was 11.8±8.1 months. Overall, 146 high-risk scores were recorded in 33 patients and 118 interventions occurred in 75 (51.4%) high-risk alerts that did not meet safety rule-out criteria. There were no serious adverse events and 13 adverse events related to interventions. In patients with symptoms at intervention initiation, symptoms resolved in 37 interventions (80%) and worsened in 8 (17%). In asymptomatic patients, symptoms developed in 3 interventions (7%).

CONCLUSIONS

A personalized medication intervention based on insertable cardiac monitor risk score can be safely instituted in patients with HF, irrespective of symptoms.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique Identifier: NCT04452149.

Prediction of heart failure events based on physiologic sensor data in HINODE defibrillator patients

AIMS

Hospitalizations are common in patients with heart failure and are associated with high mortality, readmission and economic burden. Detecting early signs of worsening heart failure may enable earlier intervention and reduce hospitalizations. The HeartLogic algorithm is designed to predict worsening heart failure using diagnostic data from multiple device sensors. The main objective of this analysis was to evaluate the sensitivity of the HeartLogic alert calculation in predicting worsening heart failure events (HFEs). We also evaluated the false positive alert rate (FPR) and compared the incidence of HFEs occurring in a HeartLogic alert state to those occurring out of an alert state.

METHODS

The HINODE study enrolled 144 patients (81 ICD and 63 CRT-D) with device sensor data transmitted via a remote monitoring system. HeartLogic alerts were then retrospectively simulated using relevant sensor data. Clinicians and patients were blinded to calculated alerts. Reported adverse events with HF symptoms were adjudicated and classified by an independent HFE committee. Sensitivity was defined as the ratio of the number of detected usable HFEs (true positives) to the total number of usable HFEs. A false positive alert was defined as an alert with no usable HFE between the alert onset date and the alert recovery date plus 30 days. The patient follow-up period was categorized as in alert state or out of alert state. The event rate ratio was the HFE rate calculated in alert to out of alert.

RESULTS

The patient cohort was 79% male and had an average age of 68 ± 12 years. This analysis yielded 244 years of follow-up data with 73 HFEs from 37 patients. A total of 311 HeartLogic alerts at the nominal threshold (16) occurred across 106 patients providing an alert rate of 1.27 alerts per patient-year. The HFE rate was 8.4 times greater while in alert compared with out of alert (1.09 vs. 0.13 events per patient-year; P < 0.001). At the nominal alert threshold, 80.8% of HFEs were detected by a HeartLogic alert [95% confidence interval (CI): 69.9%-89.1%]. The median time from first true positive alert to an adjudicated clinical HFE was 53 days. The FPR was 1.16 (95% CI: 0.98-1.38) alerts per patient-year.

CONCLUSIONS

Results suggest that signs of worsening HF can be detected successfully with remote patient follow-up. The use of HeartLogic may predict periods of increased risk for HF or clinically significant events, allowing for early intervention and reduction of hospitalization in a vulnerable patient population.

Adequacy of Ambulatory Hemodynamic Assessments for Reducing All-Cause Mortality in Individuals With Heart Failure

Heart failure (HF) as a syndrome which is normally associated with significant reduction of cardiac output has evolved to include conditions such those of moderate and preserved ejection fraction. While the prevalence of HF in the population is increasing, it is not HF with reduced ejection fraction that is driving the trajectory upward for mortality. There is some evidence to suggest that a better understanding of the pathophysiology, novel pharmacological strategies, devices, as well as remote monitoring of the hemodynamics seem to account for a reduction in the cardiovascular mortality and re-hospitalization in some cohorts with HF. However, the all-cause mortality associated with HF has not been reduced significantly by the current interventions. To explore the potential approaches needed for the strategies and avenues to reduce all-cause mortality in patients with HF, it would be helpful to evaluate the evidence in the literature directed at the care of patients with chronic/acute decompensated HF. It is evident that ambulatory measurements of pressures and volume are pivotal in a better management of HF but unless the interventions extend to an improvement in the renal function, the chances of reducing all-cause mortality seems modest. Therefore, future directions of interventions must not only be directed at close monitoring of pressures and volume simultaneously in HF patients but also at improving renal function. Moreover, it is clear that venous congestion plays a detrimental role in the deterioration of renal function and until measures are in place to reduce it, all-cause mortality will not decrease.

[Telemedical care concepts for heart failure: status and future]

Telemedical care concepts provide opportunities to improve the care of patients with chronic heart failure (CHF). The current state of telemedical technologies enables the effective monitoring of the disease. Germany is one of the first European countries with an entitlement to telemedical supporting care for CHF patients. The decision of the German Federal Joint Committee in 2020 to introduce telemedical supporting care for CHF patients marks a milestone. For the first time, a digital care procedure was included in the benefits catalogue of the statutory health insurance funds due to its proven benefits in terms of morbidity and mortality. Privately insured CHF patients have been entitled to these benefits since January 2024. Future developments, particularly with respect to artificial intelligence procedures in telemedicine, are promising but require more evidence. Further research, technological innovation and supportive policy frameworks are needed to realize the full potential of these approaches. Continued collaboration between healthcare professionals, technology developers and policy makers will be crucial in sustainably improving the care of heart failure patients with telemedicine.

Remote monitoring of cardiac implantable electronic devices to predict acute clinical decompensation events

BACKGROUND

Heart failure (HF) patients are at constant risk of decompensation, and urgent hospital admissions can be life-threatening events. Monitoring biological variables has been proved to be an important mechanism to anticipate decompensations. TriageHF is a validated diagnostic algorithm tool available on Medtronic® cardiac implantable electronic devices that combines physiological data to stratify a patient's risk of HF hospitalization in the following 30 days in low, medium or high risk. We aimed to evaluate the utility of TriageHF algorithm to predict the occurrence of acute clinical decompensation events (ACDE), including HF and non-HF cardiovascular events, within a 30-day period in a population of HF patients with reduced ejection fraction.

METHODS

We reviewed the transmissions received by the Medtronic® Carelink™ Network between August 2022 and July 2023. The heart failure risk status (HFRS) and the device parameters contributing to that risk, from the previous 30 days, were collected, along with the occurrence of ACDEs within 30 days.

RESULTS

We retrospectively assessed 207 transmissions from the 64 patients included in the study. Among the 93 medium HFRS transmissions, 16 (17.2%) resulted in ACDEs. For the 21 high HFRS transmissions, 10 (47.6%) resulted in ACDEs. Considering the ACDEs, 60.7% were preceded by an alarm-initiated transmission. Except for heart rate variability, each diagnostic parameter demonstrated effectiveness in stratifying risk for ACDEs. Optivol® and the Combined Heart Rhythm showed independent association with ACDEs (p < .001). Patients with medium and high HFRS were, respectively, 8.6 and 29.1 times more likely to experience an ACDE in the next 30 days than low risk patients. A medium-high HFRS conferred a sensitivity of 92.9% and a NPV of 97.8% for an ACDE.

CONCLUSION

TriageHF is a useful method for predicting ACDEs and has the potential to trigger medical actions to prevent hospitalizations.

[Prognostic value of electrical bioimpedance measured with a portable and wireless device in acute heart failure]

INTRODUCTION AND OBJECTIVES

The current evaluation of acute heart failure (HF) does not allow an adequate prediction of its evolution. The electrical bioimpedance (BI) allows knowing the state of blood volume, until now only with fixed equipment. We have developed and validated a portable and wireless device to measure BI at the ankle (IVOL). The objective of the study is to know the long-term prognostic value of the point measurement of BI with IVOL in patients with acute HF.

METHODS

A prospective cohort study of unselected patients admitted for acute HF in a tertiary hospital. The association between BI and different clinical, analytical and echocardiographic variables on admission and clinical evolution were analyzed.

RESULTS

76 patients were included (mean age 66.1 years, 71.1% men, 68.4% hypertensive, 34.2% diabetic, mean NT-ProBNP: 7,103 pg / ml). Of these, 52.6% with non-preserved left ventricular ejection fraction (LVEF) (<50%) and 56.6% with right ventricular (RV) dysfunction. 26.3% died during a mean follow-up of 35.8 months. Survival in patients with BI≤21,8Ω was lower, globally and in the subgroups of patients without preserved LVEF and with RV dysfunction, P<.008). In the multivariate analysis, a BI≥21.8Ω was an independent survival factor (HR: 0.242; 95% CI: 0.86-0.681; P=.007).

CONCLUSIONS

BI values measured with IVOL may be an independent predictor of long-term mortality in patients hospitalized for acute HF. This prognostic value is maintained in patients without preserved LVEF function and with RV dysfunction.

CardioMEMS monitoring device migration: A rare complication

We present a rare case of CardioMEMS device migration six years post-implantation. Much is still being learned about endothelization of pulmonary vasculature and this case highlights the importance of device surveillance and device-related complications.

Efficacy of the Cardiac Implantable Electronic Device Multisensory Triage-HF Algorithm in Heart Failure Care: A Real-World Clinical Experience

Heart failure (HF) admissions are burdensome, and the mainstay of prevention is the timely detection of impending fluid retention, creating a window for medical treatment intensification. This study evaluated the accuracy and performance of a Triage-HF-guided carepath in real-world ambulatory HF patients in daily clinical practice. In this prospective, observational study, 92 adult HF patients (71 males (78%), with a median age of 69 [IQR 59-75] years) with the Triage-HF algorithm activated in their cardiac implantable electronic devices (CIEDs), were monitored. Following high-risk alerts, an HF nurse contacted patients to identify signs and symptoms of fluid retention. The sensitivity and specificity were 83% and 97%, respectively. The positive predictive value was 89%, and negative predictive value was 94%. The unexplained alert rate was 0.05 alerts/patient year, and the false negative rate was 0.11 alerts/patient year. Ambulatory diuretics were initiated or escalated in 77% of high-risk alert episodes. In 23% (n = 6), admission was ultimately required. The median alert handling time was 2 days. Fifty-eight percent (n = 18) of high-risk alerts were classified as true positives in the first week, followed by 29% in the second-third weeks (n = 9), and 13% (n = 4) in the fourth-sixth weeks. Common sensory triggers included an elevated night ventricular rate (84%), OptiVol (71%), and reduced patient activity (71%). The CIED-based Triage-HF algorithm-driven carepath enables the timely detection of impending fluid retention in a contemporary ambulatory setting, providing an opportunity for clinical action.

Remote monitoring of cardiac implantable electronic devices using smart device interface versus radiofrequency-based interface: A systematic review

Background

Guidelines recommended remote monitoring (RM) in managing patients with Cardiac Implantable Electronic Devices. In recent years, smart device (phone or tablet) monitoring-based RM (SM-RM) was introduced. This study aims to systematically review SM-RM versus bedside monitor RM (BM-RM) using radiofrequency in terms of compliance, connectivity, and episode transmission time.

Methods

We conducted a systematic review, searching three international databases from inception until July 2023 for studies comparing SM-RM (intervention group) versus BM-RM (control group).

Results

Two matched studies (21 978 patients) were retrieved (SM-RM arm: 9642 patients, BM-RM arm: 12 336 patients). There is significantly higher compliance among SM-RM patients compared with BM-RM patients in both pacemaker and defibrillator patients. Manyam et al. found that more SM-RM patients than BM-RM patients transmitted at least once (98.1% vs. 94.3%, p < .001), and Tarakji et al. showed that SM-RM patients have higher success rates of scheduled transmissions than traditional BM-RM methods (SM-RM: 94.6%, pacemaker manual: 56.3%, pacemaker wireless: 77.0%, defibrillator wireless: 87.1%). There were higher enrolment rates, completed scheduled and patient-initiated transmissions, shorter episode transmission time, and higher connectivity among SM-RM patients compared to BM-RM patients. Younger patients (aged <75) had more patient-initiated transmissions, and a higher proportion had ≥10 transmissions compared with older patients (aged ≥75) in both SM-RM and BM-RM groups.

Conclusion

SM-RM is a step in the right direction, with good compliance, connectivity, and shorter episode transmission time, empowering patients to be in control of their health. Further research on cost-effectiveness and long-term clinical outcomes can be carried out.

Contemporary Advances in Cardiac Remote Monitoring: A Comprehensive, Updated Mini-Review

Over the past decade, remote monitoring (RM) has become an increasingly popular way to improve healthcare and health outcomes. Modern cardiac implantable electronic devices (CIEDs) are capable of recording an increasing amount of data related to CIED function, arrhythmias, physiological status and hemodynamic parameters, providing in-depth and updated information on patient cardiovascular function. The extensive use of RM for patients with CIED allows for early diagnosis and rapid assessment of relevant issues, both clinical and technical, as well as replacing outpatient follow-up improving overall management without compromise safety. This approach is recommended by current guidelines for all eligible patients affected by different chronic cardiac conditions including either brady- and tachy-arrhythmias and heart failure. Beyond to clinical advantages, RM has demonstrated cost-effectiveness and is associated with elevated levels of patient satisfaction. Future perspectives include improving security, interoperability and diagnostic power as well as to engage patients with digital health technology. This review aims to update existing data concerning clinical outcomes in patients managed with RM in the wide spectrum of cardiac arrhythmias and Hear Failure (HF), disclosing also about safety, effectiveness, patient satisfaction and cost-saving.

Implementation of remote monitoring strategies to improve chronic heart failure management

PURPOSE OF REVIEW

The goal of this review is to describe the current evidence available for remote monitoring devices available for patients with chronic heart failure, and also detail practical clinical recommendations for implementing these tools in daily clinical practice.

RECENT FINDINGS

Several devices ranging from sophisticated multiparametric algorithms in defibrillators, implantable pulmonary artery pressure sensors, and wearable devices to measure thoracic impedance can be utilized as important adjunctive tools to reduce the risk of heart failure hospitalization in patients with chronic heart failure. Pulmonary artery pressure sensors provide the most granular data regarding hemodynamic status, while alerts from wearable devices for thoracic impedance and defibrillator-based algorithms increase the likelihood of worsening clinical status while also having high negative predictive value when values are within normal range.

SUMMARY

Multiple device-based monitoring strategies are available to reduce longitudinal risk in patients with chronic heart failure. Further studies are needed to best understand a practical pathway to integrate multiple signals of data for early clinical decompensation risk predictionVideo abstract: http://links.lww.com/HCO/A95.

Heart Failure Management through Telehealth: Expanding Care and Connecting Hearts

Heart failure (HF) is a leading cause of morbidity worldwide, imposing a significant burden on deaths, hospitalizations, and health costs. Anticipating patients' deterioration is a cornerstone of HF treatment: preventing congestion and end organ damage while titrating HF therapies is the aim of the majority of clinical trials. Anyway, real-life medicine struggles with resource optimization, often reducing the chances of providing a patient-tailored follow-up. Telehealth holds the potential to drive substantial qualitative improvement in clinical practice through the development of patient-centered care, facilitating resource optimization, leading to decreased outpatient visits, hospitalizations, and lengths of hospital stays. Different technologies are rising to offer the best possible care to many subsets of patients, facing any stage of HF, and challenging extreme scenarios such as heart transplantation and ventricular assist devices. This article aims to thoroughly examine the potential advantages and obstacles presented by both existing and emerging telehealth technologies, including artificial intelligence.

Telemedicine and patients with heart failure: evidence and unresolved issues

BACKGROUND

Heart failure is the leading cause of cardiac-related hospitalizations. Limited access to reevaluations and outpatient appointments restricts the application of modern therapies. Telemedicine has become an essential resource in the healthcare system because of its countless benefits, such as higher and more frequent appointments and faster titration of medications. This narrative review aimed to demonstrate the evidence and unresolved issues related to the use of telemedicine in patients with heart failure. No studies have examined heart failure prevention; however, several studies have addressed the prevention of decompensation with positive results. Telemedicine can be used to evaluate all patients with heart failure, and many telemedicine platforms are available. Several strategies, including both noninvasive (phone calls, weight measurement, and virtual visits) and invasive (implantable pulmonary artery catheters) strategies can be implemented. Given these benefits, telemedicine is highly desirable, particularly for vulnerable groups. Although some questions remain unanswered, the development of new technologies can complement remote visits and improve patient care.

Integration of implantable device therapy in patients with heart failure. A clinical consensus statement from the Heart Failure Association (HFA) and European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC)

Implantable devices form an integral part of the management of patients with heart failure (HF) and provide adjunctive therapies in addition to cornerstone drug treatment. Although the number of these devices is growing, only few are supported by robust evidence. Current devices aim to improve haemodynamics, improve reverse remodelling, or provide electrical therapy. A number of these devices have guideline recommendations and some have been shown to improve outcomes such as cardiac resynchronization therapy, implantable cardioverter-defibrillators and long-term mechanical support. For others, more evidence is still needed before large-scale implementation can be strongly advised. Of note, devices and drugs can work synergistically in HF as improved disease control with devices can allow for further optimization of drug therapy. Therefore, some devices might already be considered early in the disease trajectory of HF patients, while others might only be reserved for advanced HF. As such, device therapy should be integrated into HF care programmes. Unfortunately, implementation of devices, including those with the greatest evidence, in clinical care pathways is still suboptimal. This clinical consensus document of the Heart Failure Association (HFA) and European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC) describes the physiological rationale behind device-provided therapy and also device-guided management, offers an overview of current implantable device options recommended by the guidelines and proposes a new integrated model of device therapy as a part of HF care.

Multifaceted Strategy Based on Automated Text Messaging After a Recent Heart Failure Admission: The MESSAGE-HF Randomized Clinical Trial

Importance

Readmissions after an index heart failure (HF) hospitalization are a major contemporary health care problem.

Objective

To evaluate the feasibility and efficacy of an intensive telemonitoring strategy in the vulnerable period after an HF hospitalization.

Design, Setting, and Participants

This randomized clinical trial was conducted in 30 HF clinics in Brazil. Patients with left ventricular ejection fraction less than 40% and access to mobile phones were enrolled up to 30 days after an HF admission. Data were collected from July 2019 to July 2022.

Intervention

Participants were randomly assigned to a telemonitoring strategy or standard care. The telemonitoring group received 4 daily short message service text messages to optimize self-care, active engagement, and early intervention. Red flags based on feedback messages triggered automatic diuretic adjustment and/or a telephone call from the health care team.

Main Outcomes and Measures

The primary end point was change in N-terminal pro-brain natriuretic peptide (NT-proBNP) from baseline to 180 days. A hierarchical win-ratio analysis incorporating blindly adjudicated clinical events (cardiovascular deaths and HF hospitalization) and variation in NT-proBNP was also performed.

Results

Of 699 included patients, 460 (65.8%) were male, and the mean (SD) age was 61.2 (14.5) years. A total of 352 patients were randomly assigned to the telemonitoring strategy and 347 to standard care. Satisfaction with the telemonitoring strategy was excellent (net promoting score at 180 days, 78.5). HF self-care increased significantly in the telemonitoring group compared with the standard care group (score difference at 30 days, -2.21; 95% CI, -3.67 to -0.74; P = .001; score difference at 180 days, -2.08; 95% CI, -3.59 to -0.57; P = .004). Variation of NT-proBNP was similar in the telemonitoring group compared with the standard care group (telemonitoring: baseline, 2593 pg/mL; 95% CI, 2314-2923; 180 days, 1313 pg/mL; 95% CI, 1117-1543; standard care: baseline, 2396 pg/mL; 95% CI, 2122-2721; 180 days, 1319 pg/mL; 95% CI, 1114-1564; ratio of change, 0.92; 95% CI, 0.77-1.11; P = .39). Hierarchical analysis of the composite outcome demonstrated a similar number of wins in both groups (telemonitoring, 49 883 of 122 144 comparisons [40.8%]; standard care, 48 034 of 122 144 comparisons [39.3%]; win ratio, 1.04; 95% CI, 0.86-1.26).

Conclusions and Relevance

An intensive telemonitoring strategy applied in the vulnerable period after an HF admission was feasible, well-accepted, and increased scores of HF self-care but did not translate to reductions in NT-proBNP levels nor improvement in a composite hierarchical clinical outcome.

Trial Registration

ClinicalTrials.gov Identifier: NCT04062461.

Remote Monitoring Devices and Heart Failure

Remote patient monitoring (RPM) in patients with heart failure (HF) involves transmitting physiological data from devices to a health-care provider via a wireless connection with targeted interventions when values exceed the preset threshold. Devices used in telemonitoring range from weighing scales, blood pressure cuffs, and pulse oximeters to devices used to measure cardiac filling pressure and intrathoracic impedance using cardiac implantable electronic devices and wearables. Accordingly, RPM devices can potentially engage patients in their cardiovascular care and reduce the burden of HF in society.

Differences in management of telemedicine alerts on weekdays and public holidays: Results from the OptiLink heart failure trial

BACKGROUND

In the OptiLink heart failure study, timely and appropriate reactions to telemedicine alerts improved clinical outcomes in heart failure patients. This analysis investigates the relation between the weekday of alert transmission and the subsequent patient contact.

METHODS

In patients enrolled in the intervention arm of the OptiLink heart failure study (n = 505, age 66.1 ± 10.1, 77.2% male, left-ventricular ejection fraction 26.7% ± 6.1%), fluid index threshold crossing alerts were analysed according to the weekday of the transmission. Transmissions on Mondays-Thursdays were categorized as TD1, Fridays-Sundays as well as public holidays as TD2.

RESULTS

Of 1365 transmitted alerts, 867 (63.5%) were categorized as TD1 and 498 (36.5%) as TD2. Same day telephone contacts were more frequent in TD1 (46.2%) than in TD2 (18.3%; p < 0.001). Accordingly, the median time to contact was significantly longer in TD2 compared with TD1 (2(1-3) vs 0(0-1) days; p < 0.001). Rates of no telephone contact were no different between the groups (12.1% vs 12.4%; p = 0.866). Although signs of worsening heart failure were prevalent in 32.4% in TD1 versus 32.1% in TD2 (p = 0.996), initiation of a pharmacological intervention occurred more likely in TD1 compared with TD2 (27.9% vs 22.9%; p = 0.041). No differences existed concerning hospitalization for heart failure within 30 days after alert transmission (3.9% vs 3.4%; p = 0.636).

CONCLUSION

Alert transmissions during weekends and public holidays were less likely associated with timely patient contacts and initiation of pharmacological interventions than during the week. Telemedical centres providing 24/7 remote monitoring service and specific education programmes for physicians might help to optimize patient care.

New technologies for the diagnosis, treatment, and monitoring of cardiovascular diseases

Telemedicine enables the remote provision of medical care through information and communication technologies, facilitating data transmission, patient participation, promotion of heart-healthy habits, diagnosis, early detection of acute decompensation, and monitoring and follow-up of cardiovascular diseases. Wearable devices have multiple clinical applications, ranging from arrhythmia detection to remote monitoring of chronic diseases and risk factors. Integrating these technologies safely and effectively into routine clinical practice will require a multidisciplinary approach. Technological advances and data management will increase telemonitoring strategies, which will allow greater accessibility and equity, as well as more efficient and accurate patient care. However, there are still unresolved issues, such as identifying the most appropriate technological infrastructure, integrating these data into medical records, and addressing the digital divide, which can hamper patients' adoption of remote care. This article provides an updated overview of digital tools for a more comprehensive approach to atrial fibrillation, heart failure, risk factors, and treatment adherence.

Telemedicine for the treatment of heart failure: new opportunities after COVID-19

ABSTRACT

During the Coronavirus Disease 2019 (COVID-19) pandemic, the epidemiology of heart failure significantly changed with reduced access to health system resources and a worsening of patients' outcome. Understanding the causes of these phenomena could be important to refine the management of heart failure during and after the pandemic. Telemedicine was associated with an improvement in heart failure outcomes in several studies; therefore, it may help in refining the out-of-hospital care of heart failure. In this review, the authors describe the changes in heart failure epidemiology during the COVID-19 pandemic; analyse available evidence on use and benefit of telemedicine during the pandemic and prepandemic periods; and discuss approaches to optimize the home-based or outpatient heart failure management in the future, beyond the pandemic.

Heart failure management guided by remote multiparameter monitoring: A meta-analysis

BACKGROUND

Several implant-based remote monitoring strategies are currently tested to optimize heart failure (HF) management by anticipating clinical decompensation and preventing hospitalization. Among these solutions, the modern implantable cardioverter-defibrillator and cardiac resynchronization therapy devices have been equipped with sensors allowing continuous monitoring of multiple preclinical markers of worsening HF, including factors of autonomic adaptation, patient activity, and intrathoracic impedance.

OBJECTIVES

We aimed to assess whether implant-based multiparameter remote monitoring strategy for guided HF management improves clinical outcomes when compared to standard clinical care.

METHODS

A systematic literature research for randomized controlled trials (RCTs) comparing multiparameter-guided HF management versus standard of care was performed on PubMed, Embase, and CENTRAL databases. Incidence rate ratios (IRRs) and associated 95% confidence intervals (CIs) were calculated using the Poisson regression model with random study effects. The primary outcome was a composite of all-cause death and HF hospitalization events, whereas secondary endpoints included the individual components of the primary outcome.

RESULTS

Our meta-analysis included 6 RCTs, amounting to a total of 4869 patients with an average follow-up time of 18 months. Compared with standard clinical management, the multiparameter-guided strategy reduced the risk of the primary composite outcome (IRR 0.83, 95%CI 0.71-0.99), driven by statistically significant effect on both HF hospitalization events (IRR 0.75, 95%CI 0.61-0.93) and all-cause death (IRR 0.80, 95%CI 0.66-0.96).

CONCLUSION

Implant-based multiparameter remote monitoring strategy for guided HF management is associated with significant benefit on clinical outcomes compared to standard clinical care, providing a benefit on both hospitalization events and all-cause death.

Impedance-based remote monitoring in patients with heart failure and concomitant chronic kidney disease

AIMS

Remote monitoring (RM) of thoracic impedance represents an early marker of pulmonary congestion in heart failure (HF). Chronic kidney disease (CKD) may promote fluid overload in HF patients. We investigated whether concomitant CKD affected the efficacy of impedance-based RM in the OptiLink HF trial.

METHODS AND RESULTS

Among HF patients included in the OptiLink HF trial, time to the first cardiovascular hospitalization and all-cause death according to the presence of concomitant CKD was analysed. CKD was defined as GFR < 60 mL/min/1.73 m2 at enrolment. Of the 1002 patients included in OptiLink HF, 326 patients (33%) had HF with concomitant CKD. The presence of CKD increased transmission of telemedical alerts (median of 2 (1-5) vs. 1 (0-3); P = 0.012). Appropriate contacting after alert transmission was equally low in patients with and without CKD (57% vs. 59%, P = 0.593). The risk of the primary endpoint was higher in patients with CKD compared with patients without CKD (hazard ratio (HR), 1.62 [95% confidence interval (CI), 1.16-2.28]; P = 0.005). Impedance-based RM independently reduced primary events in HF patients with preserved renal function, but not in those with CKD (HR 0.68 [95% CI, 0.52-0.89]; P = 0.006).

CONCLUSIONS

The presence of CKD in HF patients led to a higher number of telemedical alert transmissions and increased the risk of the primary endpoint. Inappropriate handling of alert transmission was commonly observed in patients with chronic HF and CKD. Guidance of HF management by impedance-based RM significantly decreased primary event rates in patients without CKD, but not in patients with CKD.

Heart Failure Remote Monitoring: A Review and Implementation How-To

Heart failure (HF) is a significant clinical and financial burden worldwide. Remote monitoring (RM) devices capable of identifying early physiologic changes in decompensation have the potential to reduce the HF burden. However, few trials have discussed at length the practical aspects of implementing RM in real-world clinical practice. The present paper reviews current RM devices and clinical trials, focusing on patient populations, outcomes, data collection, storage, and management, and describes the implementation of an RM device in clinical practice, providing a pragmatic and adaptable framework.

2023 HRS/EHRA/APHRS/LAHRS expert consensus statement on practical management of the remote device clinic

Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.

Remote multiparametric monitoring and management of heart failure patients through cardiac implantable electronic devices

In this review we focus on heart failure (HF) which, as known, is associated with a substantial risk of hospitalizations and adverse cardiovascular outcomes, including death. In recent years, systems to monitor cardiac function and patient parameters have been developed with the aim to detect subclinical pathophysiological changes that precede worsening HF. Several patient-specific parameters can be remotely monitored through cardiac implantable electronic devices (CIED) and can be combined in multiparametric scores predicting patients' risk of worsening HF with good sensitivity and moderate specificity. Early patient management at the time of pre-clinical alerts remotely transmitted by CIEDs to physicians might prevent hospitalizations. However, it is not clear yet which is the best diagnostic pathway for HF patients after a CIED alert, which kind of medications should be changed or escalated, and in which case in-hospital visits or in-hospital admissions are required. Finally, the specific role of healthcare professionals involved in HF patient management under remote monitoring is still matter of definition. We analyzed recent data on multiparametric monitoring of patients with HF through CIEDs. We provided practical insights on how to timely manage CIED alarms with the aim to prevent worsening HF. We also discussed the role of biomarkers and thoracic echo in this context, and potential organizational models including multidisciplinary teams for remote care of HF patients with CIEDs.

Digital Transformation in the Diagnostics and Therapy of Cardiovascular Diseases: Comprehensive Literature Review

BACKGROUND

The digital transformation of our health care system has experienced a clear shift in the last few years due to political, medical, and technical innovations and reorganization. In particular, the cardiovascular field has undergone a significant change, with new broad perspectives in terms of optimized treatment strategies for patients nowadays.

OBJECTIVE

After a short historical introduction, this comprehensive literature review aimed to provide a detailed overview of the scientific evidence regarding digitalization in the diagnostics and therapy of cardiovascular diseases (CVDs).

METHODS

We performed an extensive literature search of the PubMed database and included all related articles that were published as of March 2022. Of the 3021 studies identified, 1639 (54.25%) studies were selected for a structured analysis and presentation (original articles: n=1273, 77.67%; reviews or comments: n=366, 22.33%). In addition to studies on CVDs in general, 829 studies could be assigned to a specific CVD with a diagnostic and therapeutic approach. For data presentation, all 829 publications were grouped into 6 categories of CVDs.

RESULTS

Evidence-based innovations in the cardiovascular field cover a wide medical spectrum, starting from the diagnosis of congenital heart diseases or arrhythmias and overoptimized workflows in the emergency care setting of acute myocardial infarction to telemedical care for patients having chronic diseases such as heart failure, coronary artery disease, or hypertension. The use of smartphones and wearables as well as the integration of artificial intelligence provides important tools for location-independent medical care and the prevention of adverse events.

CONCLUSIONS

Digital transformation has opened up multiple new perspectives in the cardiovascular field, with rapidly expanding scientific evidence. Beyond important improvements in terms of patient care, these innovations are also capable of reducing costs for our health care system. In the next few years, digital transformation will continue to revolutionize the field of cardiovascular medicine and broaden our medical and scientific horizons.

Telemonitoring for heart failure: a meta-analysis

AIMS

Telemonitoring modalities in heart failure (HF) have been proposed as being essential for future organization and transition of HF care, however, efficacy has not been proven. A comprehensive meta-analysis of studies on home telemonitoring systems (hTMS) in HF and the effect on clinical outcomes are provided.

METHODS AND RESULTS

A systematic literature search was performed in four bibliographic databases, including randomized trials and observational studies that were published during January 1996-July 2022. A random-effects meta-analysis was carried out comparing hTMS with standard of care. All-cause mortality, first HF hospitalization, and total HF hospitalizations were evaluated as study endpoints. Sixty-five non-invasive hTMS studies and 27 invasive hTMS studies enrolled 36 549 HF patients, with a mean follow-up of 11.5 months. In patients using hTMS compared with standard of care, a significant 16% reduction in all-cause mortality was observed [pooled odds ratio (OR): 0.84, 95% confidence interval (CI): 0.77-0.93, I2: 24%], as well as a significant 19% reduction in first HF hospitalization (OR: 0.81, 95% CI 0.74-0.88, I2: 22%) and a 15% reduction in total HF hospitalizations (pooled incidence rate ratio: 0.85, 95% CI 0.76-0.96, I2: 70%).

CONCLUSION

These results are an advocacy for the use of hTMS in HF patients to reduce all-cause mortality and HF-related hospitalizations. Still, the methods of hTMS remain diverse, so future research should strive to standardize modes of effective hTMS.

Remote monitoring of cardiac implantable electronic devices and disease management

This reviews the transition of remote monitoring of patients with cardiac electronic implantable devices from curiosity to standard of care. This has been delivered by technology evolution from patient-activated remote interrogations at appointed intervals to continuous monitoring that automatically flags clinically actionable information to the clinic for review. This model has facilitated follow-up and received professional society recommendations. Additionally, continuous monitoring has provided a new level of granularity of diagnostic data enabling extension of patient management from device to disease management. This ushers in an era of digital medicine with wider applications in cardiovascular medicine.

Independent prognostic value of the congestion and renal index in patients with acute heart failure

BACKGROUND

Clinical outcomes are poor if patients with acute heart failure (AHF) are discharged with residual congestion in the presence of renal dysfunction. However, there is no single indication to reflect the combined effects of the two related pathophysiological processes. We, therefore, proposed an indicator, congestion and renal index (CRI), and examined the associations between the CRI and one-year outcomes and the incremental prognostic value of CRI compared with the established scoring systems in a multicenter prospective cohort of AHF.

METHODS

We enrolled AHF patients and calculated the ratio of thoracic fluid content index divided by estimated glomerular filtration rate before discharge, as CRI. Then we examined the associations between CRI and one-year outcomes.

RESULTS

A total of 944 patients were included in the analysis (mean age 63.3 ± 13.8 years, 39.3% women). Compared with patients with CRI ≤ 0.59 mL/min per kΩ, those with CRI > 0.59 mL/min per kΩ had higher risks of cardiovascular death or HF hospitalization (HR = 1.56 [1.13-2.15]) and all-cause death or all-cause hospitalization (HR = 1.33 [1.01-1.74]). CRI had an incremental prognostic value compared with the established scoring system.

CONCLUSIONS

In patients with AHF, CRI is independently associated with the risk of death or hospitalization within one year, and improves the risk stratification of the established risk models.

Efficacy of sustained knowledge translation (KT) interventions in chronic disease management in older adults: systematic review and meta-analysis of complex interventions

BACKGROUND

Chronic disease management (CDM) through sustained knowledge translation (KT) interventions ensures long-term, high-quality care. We assessed implementation of KT interventions for supporting CDM and their efficacy when sustained in older adults.

METHODS

Design: Systematic review with meta-analysis engaging 17 knowledge users using integrated KT.

ELIGIBILITY CRITERIA

Randomized controlled trials (RCTs) including adults (> 65 years old) with chronic disease(s), their caregivers, health and/or policy-decision makers receiving a KT intervention to carry out a CDM intervention for at least 12 months (versus other KT interventions or usual care).

INFORMATION SOURCES

We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from each database's inception to March 2020.

OUTCOME MEASURES

Sustainability, fidelity, adherence of KT interventions for CDM practice, quality of life (QOL) and quality of care (QOC). Data extraction, risk of bias (ROB) assessment: We screened, abstracted and appraised articles (Effective Practice and Organisation of Care ROB tool) independently and in duplicate.

DATA SYNTHESIS

We performed both random-effects and fixed-effect meta-analyses and estimated mean differences (MDs) for continuous and odds ratios (ORs) for dichotomous data.

RESULTS

We included 158 RCTs (973,074 participants [961,745 patients, 5540 caregivers, 5789 providers]) and 39 companion reports comprising 329 KT interventions, involving patients (43.2%), healthcare providers (20.7%) or both (10.9%). We identified 16 studies described as assessing sustainability in 8.1% interventions, 67 studies as assessing adherence in 35.6% interventions and 20 studies as assessing fidelity in 8.7% of the interventions. Most meta-analyses suggested that KT interventions improved QOL, but imprecisely (36 item Short-Form mental [SF-36 mental]: MD 1.11, 95% confidence interval [CI] [- 1.25, 3.47], 14 RCTs, 5876 participants, I2 = 96%; European QOL-5 dimensions: MD 0.01, 95% CI [- 0.01, 0.02], 15 RCTs, 6628 participants, I2 = 25%; St George's Respiratory Questionnaire: MD - 2.12, 95% CI [- 3.72, - 0.51] 44 12 RCTs, 2893 participants, I2 = 44%). KT interventions improved QOC (OR 1.55, 95% CI [1.29, 1.85], 12 RCTS, 5271 participants, I2 = 21%).

CONCLUSIONS

KT intervention sustainability was infrequently defined and assessed. Sustained KT interventions have the potential to improve QOL and QOC in older adults with CDM. However, their overall efficacy remains uncertain and it varies by effect modifiers, including intervention type, chronic disease number, comorbidities, and participant age.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018084810.

2023 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Practical Management of the Remote Device Clinic

Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.

2023 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Practical Management of the Remote Device Clinic

Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.

Implantable Cardiovascular Devices: Current and Emerging Technologies for Remote Heart Failure Monitoring

Heart failure remains a substantial socioeconomic burden to our health care system. With the aging of the population, the incidence is expected to rise in the ensuing years. Standard heart failure management strategies have failed to reduce hospitalizations and mortality. In patients with heart failure, remote hemodynamic monitoring with implantable devices provides essential data, which can be used in unison with standard patient management to reduce heart failure hospitalizations. This review will chronicle the important clinical trials of various implantable devices and describe the emerging technologies in remote heart failure management. Cardiovascular implantable electronic devices, namely implanted cardioverter-defibrillator and cardiac resynchronization therapy devices with defibrillator, have evolved beyond sole resynchronization and currently can deliver real-time cardiac hemodynamics. Clinical data regarding hemodynamic monitoring with implanted cardioverter-defibrillator and cardiac resynchronization therapy devices with defibrillator have not consistently demonstrated a reduction in heart failure or mortality benefit. However, there is promise in the future with the application of multiparameter diagnostic algorithms with these devices. The most efficacious implantable device has been the pulmonary artery pressure sensor, CardioMEMS. This device has been proven to be safe and shown to reduce heart failure hospitalizations. Moreover, multiple newly developed devices are currently under investigation after successful first-in-man studies.

Clinical Pathways Guided by Remotely Monitoring Cardiac Device Data: The Future of Device Heart Failure Management?

Research examining the utility of cardiac device data to manage patients with heart failure (HF) is rapidly evolving. COVID-19 has reignited interest in remote monitoring, with manufacturers each developing and testing new ways to detect acute HF episodes, risk stratify patients and support self-care. As standalone diagnostic tools, individual physiological metrics and algorithm-based systems have demonstrated utility in predicting future events, but the integration of remote monitoring data with existing clinical care pathways for device HF patients is not well described. This narrative review provides an overview of device-based HF diagnostics available to care providers in the UK, and describes the current state of play with regard to how these systems fit in with current HF management.

Cardiovascular Implantable Electronic Devices Enabled Remote Heart Failure Monitoring; What We Have Learned and Where to Go Next

Despite recent developments, heart failure (HF) remains to be a great burden to the individual patient, entailing major morbidity and mortality. Moreover, HF is a great burden to overall healthcare, mainly because of frequent hospitalizations. Timely diagnosis of HF deterioration and implementation of appropriate therapy may prevent hospitalization and eventually improve a patient’s prognosis; however, depending on the patient’s presentation, the signs and symptoms of HF often offer too little therapeutic window to prevent hospitalizations. Cardiovascular implantable electronic devices (CIEDs) can provide real-time physiologic parameters and remote monitoring of these parameters can potentially help to identify patients at high risk. However, routine implementation of remote monitoring of CIEDs has still not been widely used in daily patient care. This review gives a detailed description of available metrics for remote HF monitoring, the studies that provide evidence of their efficacy, ways to implement them in clinical HF practice, as well as lessons learned on where to go on from where we currently are.

The patient perspective on remote monitoring of implantable cardiac devices

Aims

Remote monitoring for patients with cardiac implantable electronic devices (CIEDs) is well established in clinical routine and recommended by current guidelines. Nevertheless, data regarding patients' perceptions are limited. Therefore, this study aims to analyze the patient perspectives on the remote monitoring of cardiac devices in Germany.

Methods and results

Patients with CIEDs and remote monitoring of all current manufacturers from three German centers were asked to participate. The questionnaire consisted of 37 questions regarding the patients' individual use and perspectives on remote monitoring. Survey participation was anonymous and on a voluntary basis. A total of 617 patients (71.6% men) participated. Most patients reported feeling well informed (69.3%) and reported having unchanged or improved coping (98.8%) since the start of remote monitoring. At least 39.7% of patients experienced technical problems regarding the transmitter, whereas most patients (60.3%) reported that they never noted technical issues. Older patients had significantly less interest than younger patients in using their own smartphones for data transfer (p < 0.001).

Conclusion

Patients with remote follow-up of CIED reported that they felt well informed about the remote monitoring approach. Remote monitoring can support coping with their disease. With remote monitoring, patients experienced a prolongation of intervals of in-person follow-up visits, and especially younger patients would appreciate smartphone-based data transfer of their CIEDs.

Remote Monitoring of Cardiac Implantable Electronic Devices: What is the Evidence?

PURPOSE OF REVIEW

This review offers an overview of the evidence in diagnostic and therapeutic applications of remote monitoring implantable devices.

RECENT FINDINGS

Remote monitoring of cardiac implantable devices has become more and more popular in recent years as healthcare is moving towards a more patient centralized system. For heart failure patients with an ICD or pacemaker, there is controversial evidence regarding improvements in the clinical outcome, e.g., reduction of hospitalization rates or overall mortality. New developments as hemodynamic remote monitoring via measurement of the pulmonary artery pressure are promising technical achievements showing encouraging results. In cardiac remote monitoring of syncope and arrhythmias, implantable loop recorder plays an important role in diagnostic algorithms. Although there is controversial evidence according to remote monitoring of implantable devices, its use is rapidly expanding, giving healthcare providers the opportunity to react promptly to worsening of their patients. Adequate evaluation of the data created by remote monitoring systems remains an unsolved challenge of contemporary healthcare services.

Device-based remote monitoring strategies for congestion-guided management of patients with heart failure: a systematic review and meta-analysis

AIMS

Pre-clinical congestion markers of worsening heart failure (HF) can be monitored by devices and may support the management of patients with HF. We aimed to assess whether congestion-guided HF management according to device-based remote monitoring strategies is more effective than standard therapy.

METHODS AND RESULTS

A comprehensive literature research for randomized controlled trials (RCTs) comparing device-based remote monitoring strategies for congestion-guided HF management versus standard therapy was performed on PubMed, Embase, and CENTRAL databases. Incidence rate ratios (IRRs) and associated 95% confidence intervals (CIs) were calculated using the Poisson regression model with random study effects. The primary outcome was a composite of all-cause death and HF hospitalizations. Secondary endpoints included the individual components of the primary outcome. A total of 4347 patients from eight RCTs were included. Findings varied according to the type of parameters monitored. Compared with standard therapy, haemodynamic-guided strategy (4 trials, 2224 patients, 12-month follow-up) reduced the risk of the primary composite outcome (IRR 0.79, 95% CI 0.70-0.89) and HF hospitalizations (IRR 0.76, 95% CI 0.67-0.86), without a significant impact on all-cause death (IRR 0.93, 95% CI 0.72-1.21). In contrast, impedance-guided strategy (4 trials, 2123 patients, 19-month follow-up) did not provide significant benefits.

CONCLUSION

Haemodynamic-guided HF management is associated with better clinical outcomes as compared to standard clinical care.

Remote monitoring in patients with heart failure with cardiac implantable electronic devices: a systematic review and meta-analysis

BACKGROUND

Remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) is now the standard of care, but whether the demonstrated benefits of RM translate into improvements in heart failure (HF) management is controversial. This systematic review addresses the role of RM in patients with HF with a CIED.

METHODS AND RESULTS

A systematic search of the literature for randomised clinical trials in patients with HF and a CIED assessing efficacy/effectiveness of RM was performed using MEDLINE, PubMed and Embase. Meta-analysis was performed on the effects of RM of CIEDs in patients with HF on mortality and readmissions. Effects on implantable cardiac defibrillator (ICD) therapy, healthcare costs and clinic presentations were also assessed.607 articles were identified and refined to 10 studies with a total of 6579 patients. Implementation of RM was not uniform with substantial variation in methodology across the studies. There was no reduction in mortality or hospital readmission rates, while ICD therapy findings were inconsistent. There was a reduction in patient-associated healthcare costs and reduction in healthcare presentations.

CONCLUSION

RM for patients with CIEDs and HF was not uniformly performed. As currently implemented, RM does not provide a benefit on overall mortality or the key metric of HF readmission. It does provide a reduction in healthcare costs and healthcare presentations.

PROSPERO REGISTRATION NUMBER

CRD42019129270.

Interactive Remote Patient Monitoring Devices for Managing Chronic Health Conditions: Systematic Review and Meta-analysis

BACKGROUND

Telemedicine is an expanding and feasible approach to improve medical care for patients with long-term conditions. However, there is a poor understanding of patients' acceptability of this technology and their rate of uptake.

OBJECTIVE

The aim of this study was to systematically review the current evidence on telemonitoring in the management of patients with long-term conditions and evaluate the patients' uptake and acceptability of this technology.

METHODS

MEDLINE, Scopus, and CENTRAL (the Cochrane Central Register of Controlled Trials) were searched from the date of inception to February 5, 2021, with no language restrictions. Studies were eligible for inclusion if they reported any of the following outcomes: intervention uptake and adherence; study retention; patient acceptability, satisfaction, and experience using the intervention; changes in physiological values; all-cause and cardiovascular-related hospitalization; all-cause and disease-specific mortality; patient-reported outcome measures; and quality of life. In total, 2 reviewers independently assessed the articles for eligibility.

RESULTS

A total of 96 studies were included, and 58 (60%) were pooled for the meta-analyses. Meta-analyses showed a reduction in mortality (risk ratio=0.71, 95% CI 0.56-0.89; P=.003; I2=0%) and improvements in blood pressure (mean difference [MD]=-3.85 mm Hg, 95% CI -7.03 to -0.68; P=.02; I2=100%) and glycated hemoglobin (MD=-0.33, 95% CI -0.57 to -0.09; P=.008; I2=99%) but no significant improvements in quality of life (MD=1.45, 95% CI -0.10 to 3; P=.07; I2=80%) and an increased risk of hospitalization (risk ratio=1.02, 95% CI 0.85-1.23; P=.81; I2=79%) with telemonitoring compared with usual care. A total of 12% (12/96) of the studies reported adherence outcomes, and 9% (9/96) reported on satisfaction and acceptance outcomes; however, heterogeneity in the assessment methods meant that a meta-analysis could not be performed.

CONCLUSIONS

Telemonitoring is a valid alternative to usual care, reducing mortality and improving self-management of the disease, with patients reporting good satisfaction and adherence. Further studies are required to address some potential concerns regarding higher hospitalization rates and a lack of positive impact on patients' quality of life.

TRIAL REGISTRATION

PROSPERO CRD42021236291; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=236291.

Efficacy of ICD/CRT-D Remote Monitoring in Patients With HFrEF: a Bayesian Meta-analysis of Randomized Controlled Trials

PURPOSE OF REVIEW

To evaluate remote monitoring using implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D) devices as an adjunctive tool to the traditional care of patients with heart failure (HF).

RECENT FINDINGS

We included 11 trials encompassing 5965 patients. Absolute risk difference (ARD) with 95% credible interval (CrI) was estimated. Pooled (posterior) risk difference was computed using Bayesian hierarchical methods. The ARD for mortality was centered at - 0.01 (95% CrI: - 0.03; 0.01, Tau: 0.02), with an 82% probability of ARD of ICD/CRT-D remote monitoring with respect to control being less than 0. The ARD for cardiovascular mortality was centered at - 0.03 (95% CrI: - 0.11; 0.05, Tau: 0.10), with an 84% probability of ARD of ICD/CRT-D remote monitoring with respect to control being less than 0. ICD/CRT-D remote monitoring in patients with HF is associated with a higher probability of reduced all-cause and cardiovascular mortality compared with standard care alone.

Optimal effectiveness of heart failure management - an umbrella review of meta-analyses examining the effectiveness of interventions to reduce (re)hospitalizations in heart failure

Heart failure (HF) is a major health concern, which accounts for 1-2% of all hospital admissions. Nevertheless, there remains a knowledge gap concerning which interventions contribute to effective prevention of HF (re)hospitalization. Therefore, this umbrella review aims to systematically review meta-analyses that examined the effectiveness of interventions in reducing HF-related (re)hospitalization in HFrEF patients. An electronic literature search was performed in PubMed, Web of Science, PsycInfo, Cochrane Reviews, CINAHL, and Medline to identify eligible studies published in the English language in the past 10 years. Primarily, to synthesize the meta-analyzed data, a best-evidence synthesis was used in which meta-analyses were classified based on level of validity. Secondarily, all unique RCTS were extracted from the meta-analyses and examined. A total of 44 meta-analyses were included which encompassed 186 unique RCTs. Strong or moderate evidence suggested that catheter ablation, cardiac resynchronization therapy, cardiac rehabilitation, telemonitoring, and RAAS inhibitors could reduce (re)hospitalization. Additionally, limited evidence suggested that multidisciplinary clinic or self-management promotion programs, beta-blockers, statins, and mitral valve therapy could reduce HF hospitalization. No, or conflicting evidence was found for the effects of cell therapy or anticoagulation. This umbrella review highlights different levels of evidence regarding the effectiveness of several interventions in reducing HF-related (re)hospitalization in HFrEF patients. It could guide future guideline development in optimizing care pathways for heart failure patients.