Dr. Andrzej Gackowski
It is well known that patients with heart failure (HF) have poor prognosis and may die or decompensate if early signs of deterioration is not properly managed. Current technologies allow easy transmission of data from the patient’s home to a supervising team, and the concept of HF telemonitoring is a very promising way to improve patient care. Prof. J. Cleland (UK) pointed out the benefits of this approach documented in several small to medium size randomised trials and summarised by the Cochrane review published in 2010. It showed reductions of 34% and 9% in mortality and rehospitalisation rates respectively, when telemonitoring was compared to “usual care”. Significant benefits in terms of mortality and hospital admission rates were also shown in a recently published results of the Whole System Demonstrator Cluster Randomised Trial (N=3230) performed in 177 UK general practitioner offices, although the study included not only HF patients but also COPD and diabetic patients. Unfortunately, two large randomized trials: TIM-HF (Germany, N=700) and Tele-HF (US, N=1600) were neutral and did not show any significant benefits of telemonitoring. The Tele-HF trial used an automatic telephone-based interactive voice response system supervised during working hours, while the technology used in TIM-HF was much more advanced and provided medical assistance on a 24 hour basis. Prof. Cleland pointed out that HF telemonitoring remains a promising concept provided the systems are set not only to monitor but to promptly react, taking into account the complexity of the disease. Good organisation and supervision of the telemonitoring team of nurses and physicians is crucial. It is also important to define what is a control group in the specific trial – if the study is performed in a country with very well organised HF ambulatory “usual care”, the chance of showing a benefit of telemonitoring is much less. Prof. Abraham (US) showed that it is important which parameters are monitored (weight control has high specificity but low sensitivity in predicting decompensation). This is why chest impedance was proposed as a more sensitive tool. However, as pointed out by Prof. Conraads (BE), studies have shown that it had low specificity and provided data redundancy that was difficult to handle in everyday patient care. The invasively implanted pressure measurement devices make it possible to measure the LA or PA pressure and showed promising results in US studies where diuretics and vasodilators were adjusted according to pressure readings. Unfortunately, wide implementation of such technology is difficult. Patient compliance is also very important and the technology must be convenient for the patient to be accepted in the long-term. It should be semiautomatic, to limit the number of alarms received by the telemonitoring team. At the same time it should make the patient more systematic and teach self-management. However, the patient must not be isolated from the physician by the system. It is difficult to find one target and one way of HF telemonitoring and the approach will have to be individualised. Although controversial, one of the ways is perhaps not to avoid hospitalisations (end-point of the studies) but let the patient be admitted to solve the problem with the final aim of lowering mortality. Perhaps false remote patient reassuring in borderline or complex situations can cause adverse events. Not only the mortality/morbidity data but also quality of life is important and several trials have shown benefit in this field. Prof. Anker pointed out that there are unresolved legal issues concerning the medical and technical responsibility, ownership of the patient data etc. and this will have to be addressed in the future. Further studies are necessary to find optimal strategies of systems development and better define the HF subpopulations that may benefit. In the TIM-HF trial, a significant advantage of HF telemonitoring was shown in less sick patients (EF>25%, short history of HF), having no depression at inclusion. One of the concepts is that telemonitoring may be useful to maintain health rather than to avoid pending deterioration. Two large ongoing trials (TIM-HF2 and BEAT-HF) will give the answers to some of the above questions.
Telemonitoring in heart failure: is the concept proven?
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