Home Monitoring for Heart Failure Management
This state-of-the-art paper reviews the published investigations of heart failure (HF) home monitoring and the benefits and weakness of the various strategies. Below are points to remember:
1. There are 1 million hospitalizations annually for HF, with an average readmission rate of 27% at 1 month.
2. HF management is challenged by a population of patients who tend to be older with multiple other health problems and educational barriers, as well as the need for frequent laboratory monitoring, medication changes, and the difficulty of detecting an HF exacerbation at a point where outpatient therapy interventions are likely to succeed.
3. ‘Self-care’ is defined by the American Heart Association as ‘the decision making process patients use to maintain physiologic stability,’ and includes components such as adherence to diet and medications and self-management of diuretics based on symptoms and weight.
4. Weight monitoring is an imperfect strategy, and a weight increase of >2 kg over 24-72 hours only offers 9% sensitivity for detecting clinical HF deterioration.
5. Studies on structured telephone HF support of ‘self-care’ have been equivocal, with some studies showing reduced HF readmissions and others showing increased readmissions and lengths of stay. A meta-analysis of telephone support suggests that HF rehospitalizations may be reduced by about 25%, but it has no impact on all-cause mortality.
6. It is unclear if the increased readmissions in telephone support studies are ‘false alarms’ or ‘pre-emptive admissions’ that may allow for shorter lengths of stay.
7. Telemonitoring allows transfer of physiologic data (weight, blood pressure, etc.) and patient symptoms, which may afford earlier detection of HF deterioration. Mortality reductions (17-47%) and reductions in HF readmissions (7-48%) have been noted on meta-analysis, but two large randomized controlled trials (TELE-HF and TIM-HF) failed to demonstrate benefit in either.
8. Patient adherence to telemonitoring data input may limit its success. In the TELE-HF study, 14% of patients input no data, and 45% were not regularly using the system at study end.
9. HF monitoring programs in implantable devices can detect arrhythmias, patient activity level, and changes in thoracic impedance, which may correlate with pulmonary edema. This information can be regularly sent to clinicians. While trials have demonstrated a reduction in ‘time to event diagnosis’ and ‘time to clinical decision making,’ data on hospitalization or mortality impact are lacking.
10. Other devices, including right ventricular pressure sensors, are under development and study for HF management assistance. All of these HF monitoring programs require substantial upfront costs, heavy data management and nursing resources, and a clinician to sift through data to find the useful information.
Keywords: Pulmonary Edema, Ventricular Pressure, Early Diagnosis, Body Weight, Diuretics, Disease Management, Blood Pressure, Weight Gain, Heart Diseases, Prostheses and Implants, Self Care, Patient Readmission, Heart Failure, Telemedicine, Diet, Hospitalization, Monitoring, Physiologic, United States
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