Is There a Role for Telemonitoring in Heart Failure?

Heart Failure/physiopathology; Telemonitoring; Hospitalization; Emergency Services

Heart failure (HF) is the leading cause of cardiovascular hospitalization in the world. Mortality rate ranges from 5% to 15%, and up to 50% of patients are readmitted in the emergency department in 90 days after discharge.¹ Different strategies have been implemented in recent years to avoid readmission, and telemedicine is a growing field in this scenario. The use of telecommunication technologies brings potential advantages when compared to in-person care, overcoming organizational and geographic barriers. However, divergent results in randomized trials evaluating the efficacy of telemedicine in reducing heart failure hospitalizations and mortality² discouraged the routine use of digital resources in clinical practice until the COVID-19 pandemic.

In this issue of Arquivos Brasileiros de Cardiologia, retrospective observational research evaluated the impact of an advanced telemonitoring program in a heart failure population.³ Thirty-nine patients were included, and the researchers compared the number of hospitalizations one year before the program, with hospitalizations during the program. The program used vital signs and variables such as heart rate, blood pressure, weight variation, peripheral blood oxygenation, temperature, and a seminal 3-derivation electrocardiogram. Thirty-four patients were included in the final analysis. The authors reported a 66% reduction in emergency department admissions and a reduction of 68% in heart failure hospitalizations, considering the patients themselves as controls.

The small number of participants, the retrospective observational nature of the study, and the absence of simultaneous control participants make these results only hypothesis generating results, but they do run in line with current literature. Although randomized controlled trials (RCTs) in the last decade showed divergent results regarding the efficacy of telemedicine in heart failure,² systematic reviews showed a reduction in hospitalizations and mortality among this population. A Cochrane systematic review in 2015, including only RCTs, evaluated the use

of structured telephone support or non-invasive home telemonitoring compared to standard practice for people with heart failure.⁴ This study showed that non-invasive telemonitoring reduced all-cause mortality (RR 0.80, 95% CI 0.68 to 0.94) and heart failure-related hospitalizations (RR 0.71, 95% CI 0.60 to 0.83). Another systematic review, also including only RCTs and 11,450 patients, published in 2020, confirmed similar results.⁵

Current guidelines also diverge in the class of recommendation on telemedicine with heart failure patients. The Guideline of the Brazilian Society of Cardiology on Telemedicine in Cardiology advise cardiologists to use noninvasive telemonitoring strategies with structured telephone support in heart failure to reduce hospitalizations (class IA recommendation) and mortality (class IIA recommendation),⁶ which is in alignment with the Emerging Topics Update of the Brazilian Heart Failure Guideline - 2021 (class IIA recommendation for mortality and hospitalizations).⁷ The European Society of Cardiology Heart Failure guideline, however, does not provide any recommendation on non-invasive remote monitoring,⁸ while the American Heart Association recommend effective systems to coordinate HF care to provide the guideline-recommended medical therapy and prevent hospitalizations (class I recommendation).⁹

This retrospective research does not clear doubts about efficacy of telemedicine in heart failure, however it draws attention to a relevant theme not only in heart failure, but in all clinical areas. In-person evaluation became limited in the healthcare system after the new coronavirus, leading to a growing need for alternative means of clinical evaluation.¹⁰ The COVID-19 pandemic boosted the development of remote monitoring tools, and new trials need to be designed to analyze the role of telemedicine after these global changes and to encourage the routine use of this tool in clinical practice.

Referências

• ¹
  Roger VL. Epidemiology of heart failure. Circ Res. Aug 30 2013;113(6):646-59. doi:10.1161/circresaha.113.300268.
• ²
  Veenis JF, Radhoe SP, Hooijmans P, Brugts JJ. Remote Monitoring in Chronic Heart Failure Patients: Is Non-Invasive Remote Monitoring the Way to Go? Sensors (Basel). Jan 28 2021;21(3)doi:10.3390/s21030887.
  » https://doi.org/10.3390/s21030887
• ³
  Cruz IO, Costa S, Teixeira R, Franco F, Gonçalves L.. Telemonitoring in Heart Failure – A Single Center Experience. Arq Bras Cardiol. 2022; 118(3):599-604.
• ⁴
  Inglis SC, Clark RA, Dierckx R, Prieto-Merino D, Cleland JG. Structured telephone support or non-invasive telemonitoring for patients with heart failure. Cochrane Database Syst Rev. Oct 31 2015;2015(10):Cd007228. doi:10.1002/14651858.CD007228.pub3.
• ⁵
  Ding H, Chen SH, Edwards I, Jayasena D, Doecke J, Layland J, et al. Effects of Different Telemonitoring Strategies on Chronic Heart Failure Care: Systematic Review and Subgroup Meta-Analysis. J Med Internet Res. Nov 13 2020;22(11):e20032. doi:10.2196/20032.
• ⁶
  Lopes M, Oliveira GMM, Ribeiro ALP, Pinto FJ, Rey HC, Zimmerman LI, et al. Guideline of the Brazilian Society of Cardiology on Telemedicine in Cardiology - 2019. Arq Bras Cardiol. Nov 2019;113(5):1006-1056. doi:10.5935/abc.20190205.
• ⁷
  Marcondes-Braga FG, Moura LAZ, Issa VS, Vieira J, Marcondes-Braga V, Simões MV, et al. Emerging Topics Update of the Brazilian Heart Failure Guideline - 2021. Arq Bras Cardiol. Jun 2021;116(6):1174-1212. Atualização de Tópicos Emergentes da Diretriz Brasileira de Insuficiência Cardíaca – 2021. doi:10.36660/abc.20210367. DOI: 10.2196/20032
• ⁸
  Ponikowski P, Voors AA, Anker SD, Cleland JGF, Coats AJS, Falk V, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. Jul 14 2016;37(27):2129-2200. doi:10.1093/eurheartj/ehw128.
• ⁹
  Yancy CW, Jessup M, Bozkurt B, Butler J, Casey Jr DE, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. Oct 15 2013;128(16):1810-52. doi:10.1161/CIR.0b013e31829e8807.
• ¹⁰
  Oseran AS, Afari ME, Barrett CD, Lewis GD, Thomas SS. Beyond the stethoscope: managing ambulatory heart failure during the COVID-19 pandemic. ESC Heart Fail. Apr 2021;8(2):999-1006. doi:10.1002/ehf2.13201.

• Short Editorial related to the article: Telemonitoring in Heart Failure – A Single Center Experience

Publication Dates

• Publication in this collection
  18 Mar 2022
• Date of issue
  Mar 2022