Telemonitoring in heart failure: fact, fiction, and controversy

Figures & data

Table 1 Selected recent studies of telemonitoring in heart failure

Study	Participants and country	Intervention, comparison, and follow-up	Outcomes
TIM-HF^Citation29	710 stable chronic HF patients Mean age 66.9 years 81.3% male Eligibility criteria: NYHA Class II or III with LVEF ≤35% and HF decompensation in last 2 years or LVEF ≤20%. Germany	Intervention: electronic transfer of three-lead ECG, blood pressure, and weight daily. 24 hours per day, 7 days per week, physician-led medical support with capacity to initiate treatment response to transferred data. Comparison: usual care. Median follow-up was 26 months.	Primary end point was all-cause mortality. All-cause mortality (HR 0.97; 95% CI 0.67–1.41; P=0.87). Cardiovascular death or F hospitalization (HR 0.89; 95% CI 0.67–1.19; P=0.44).
TEHAF^Citation31	382 HF patients Mean age 71.5 years 59% male Eligibility criteria: NYHA Class II–IV, “…at least one episode of fluid retention requiring diuretics, either with an echocardiographic left ventricular ejection fraction ≤40% or a preserved ejection fraction with diastolic dysfunction ...”^31 The Netherlands	Intervention: health Buddy device electronically communicated patient responses regarding symptoms and health behaviors to heart failure nurse. Comparison: nurse-led usual care including oral and written educational information, and psychosocial support as needed. 12 months of follow-up.	Primary end point was time to first heart failure hospitalization. Mean time to first HF-related hospitalization was 161 days for the intervention group and 139 days for the comparison; hospitalizations occurred in 18 (9.1%) compared with 25 (13.5%) patients (HR 0.65, 95% CI 0.35-1.17; Ρ=0.151). No differences were found regarding secondary end points, except for the reduced number of face to face contacts with the heart failure nurse (P<0.001). Mortality was 18 (9.1%) in the intervention group and 12 (6.5%) in the usual-care group (P>0.05).
WISH^Citation30	319 HF patients following hospitalization Mean age 73 years 75% male Eligibility criteria: hospitalized for HF with NYHA class III-IV and treatment with diuretics and at least one other drug used in HF (ACE inhibitor, ARB, beta-blocker, an aldosterone antagonist, or digoxin) an impaired LVEF <50%. Sweden	Participants in both groups recommended to weigh themselves daily and contact the HF clinic if sudden weight gain >2 kg in 3 days. Weights of both the comparison and intervention groups were checked by the HF nurses on Mondays, wednesdays, and Fridays. Intervention: participants provided with an electronic scale, weight automatically transmitted to and monitored at the HF clinic. Comparison: participants recommended to weigh themselves daily and contact the HF clinic if sudden weight gain >2 kg in 3 days. 12 months of follow-up.	Primary end point was cardiac rehospitalization. No significant difference was found for cardiac rehospitalization (HR 0.90, 95% CI 0.65-1.26, P=0.54). No significant difference was found for the secondary end points; allcause hospitalization (HR 0.83, 95% CI 0.61-1.13, P=0.24), death from any cause (HR 0.57, 95% CI 0.19-1.73, P=0.32), or the composite end point of cardiac hospitalization and death from any cause (HR 0.90, 95% CI 0.65-1.26, P=0.54).
TEMA-HF 1^Citation32	160 CHF patients Mean age 77 years 65% male Eligibility criteria: hospitalized for fluid overload due to HF requiring an increase or initiation of diuretics and receiving ACE inhibitor or ARB and with a beta-blocker unless contraindicated Belgium	Intervention: participants were asked to measure weight, BP and heart rate daily, at a fixed time in the morning. Data were automatically forwarded. Prespecified alert limits were determined for weight, systolic BP, and heart rate. When recordings fell outside these limits for two consecutive days, the GP and HF clinic were alerted by email. The study protocol instructed the GP to visit or contact the patient and to adapt the treatment, if necessary. The HF nurse contacted the patient by telephone 1-3 days after the alert to check if the intervention was effective. Comparison: participants were followed up by their GP who could refer the patients to their cardiologist if needed. No intervention was provided by the study nurse or the HF clinic team. 6 months of follow-up.	Primary end point was all-cause mortality. All-cause mortality was significantly lower in the intervention group (5% versus 1 7.5%, P= 0.01). Secondary outcomes included a composite end point of total number of follow-up days lost to hospitalization, dialysis, or death and was significantly lower in the intervention group (13 versus 30 days, P=0.02).

Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor antagonist; BP, blood pressure; CHF, congestive heart failure; CI, confidence interval; ECG, electrocardiogram; GP, general practitioner; HF, heart failure; HR, hazard ratio; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association classification; TIM-HF, Telemedical Intervention Monitoring in Heart Failure study; TEHAF, Telemonitoring in Heart Failsure study; WISH, Weight Monitoring in patients with Severe Heart failure; TEMA-HF, Telemonitoring in the Management of Heart Failure study.

Koehler F, Winkler S, Schieber M, et al. Impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure: the Telemedical Interventional Monitoring in Heart Failure Study. Circulation. 2011;123(17):1873–1880.

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Boyne JJ, Vrijhoef HJ, Crijns HJ, De Weerd G, Kragten J, Gorgels AP; TEHAF investigators. Tailored telemonitoring in patients with heart failure: results of a multicentre randomized controlled trial. Eur J Heart Fail. 2012;14(7):791–801.

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Lyngå P, Persson H, Hägg-Martinell A, et al. Weight monitoring in patients with severe heart failure (WISH). A randomized controlled trial. Eur J Heart Fail. 2012;14(4):438–444.

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Dendale P, De Keulenaer G, Troisfontaines P, et al. Effect of a telemonitoring-facilitated collaboration between general practitioner and heart failure clinic on mortality and rehospitalization rates in severe heart failure: the TEMA-HF 1 (TElemonitoring in the MAnagement of Heart Failure) study. Eur J Heart Fail. 2012;14(3):333–340.

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