Heart failure management programmes with dedicated multidisciplinary clinics have been shown to improve outcomes for heart failure patients. However, increasing prevalence of disease combined with an aging population may make it difficult for heart failure clinics to keep up with demand in years to come. This brings new challenges and a need to consider additional ways to deliver heart failure care. E-health encompasses the use of information and communication technologies (ICT) in the support of health and health related activity. ICT innovation has brought changes in practice including electronic medical records, e-referrals and e-prescribing, teleconsultation and tele monitoring.
Large randomised trials including BEAT-HF have evaluated whether telemonitoring using electronic equipment to collect daily information about blood pressure, heart rate, symptoms and weight provides benefit for patients with heart failure after discharge from hospital. (1) Most of these trials have failed to demonstrate benefit. BEAT-HF found that health coaching telephone calls and telemonitoring did not reduce 180-day readmissions. (1) Results from impedance monitoring have also been disappointing. (2) It was hypothesised that early recognition of heart failure decompensation would allow early intervention and improve outcomes. However, in patients with heart failure and intrathoracic impedance monitoring (available through implanted cardioverter-defibrillator or cardiac resynchronization therapy devices), audible patient alarms did not improve outcomes or reduce hospitalisations.
It is possible that increased intrathoracic impedance, weight gain and symptoms occur too late in the natural history of heart failure decompensation for intervention to be effective. Pressure changes occur earlier. The randomised CHAMPION trial evaluated pulmonary artery pressure (PAP) guided management compared with usual care in class III New York Heart Association (NHYA) heart failure patients with previous hospitalisation. PAP monitoring was achieved through an implanted pressure sensor which generated daily results. CHAMPION showed a significant reduction in hospital admissions for heart failure after six months which appeared to persist longer-term. (3) The challenge now will be to determine whether this invasive and expensive approach is cost-effective, although data from the United States suggests that within their healthcare system it is.
The future of heart failure care needs to evolve to cope with demand. Certainly, patient education and empowerment will be important. E-health may offer additional support when integrated into current heart failure programs. Telemonitoring, implemented early in the natural history of heart failure decompensation, has shown some benefit. Perhaps the future will also include virtual/video-linked consultations, particularly in countries with large geographical areas and remote populations.
- Ong MK et al. Effectiveness of remote patient monitoring after discharge of hospitalised patients with heart failure: the better effectiveness after transition – Heart Failure (BEAT-HF) randomised clinical trial. JAMA Intern Med 2016;176:310-8.
- Van Veldhuisen DJ et al. Intrathoracic impendance monitoring, audible patient alarms, and outcome in patients with heart failure. Circulation 2011;124:1719-26.
- Abraham WT et al. Sustained efficacy of pulmonary artery pressure to guide adjustment of chronic heart failure therapy: complete follow-up results from the CHAMPION randomised trial. Lancet 2016;387:453-61.