Self-care Management of Heart Failure

Practical Recommendations From the Patient Care Committee of the Heart Failure Association of the European Society of Cardiology

Mitja Lainscak; Lynda Blue; Andrew L. Clark; Ulf Dahlström; Kenneth Dickstein; Inger Ekman; Theresa McDonagh; John J. McMurray; Mary Ryder; Simon Stewart; Anna Strömberg; Tiny Jaarsma

Disclosures

Eur J Heart Fail. 2011;13(2):115-126. 

In This Article

Remote Patient Monitoring

Rationale

While disease management programmes are effective in improving outcomes in patients with HF,[8] it might prove even better to provide a component of remote monitoring and support in patients' homes. Although the optimal model and minimal components required for success have not been determined, they have been successfully applied in several countries.

Evidence

Systematic reviews have suggested that there are benefits associated with a range of remote telemonitoring interventions, without providing definitive evidence in favour of this approach to management.[24,25] For example, a recently completed Cochrane systematic review[96] examined the outcomes of 25 randomized controlled trials (16 involving structured telephone support, 11 involving telemonitoring, and 2 evaluating both) involving a total of 8323 patients. Overall, telemonitoring was found to reduce the risk of all-cause mortality by 34% (RR 0.66, 95% CI 0.54–0.81), while structured telephone support resulted in a more modest (and non-significant) reduction in 12%, relative to usual care. The combination of both approaches significantly reduced the risk of a HF-related hospitalization by 21–23% with improvement in the quality-of-life and reduction in health care costs.[97] These analyses need to be interpreted with some caution given a recently reported trial of 1653 hospitalized patients, with heart failure randomized to telemonitoring (826 patients) or usual care (827 patients), found no difference between groups in respect to recurrent hospitalization or death.[98]

Similarly, the TIM-HF trial[99] showed no reduction of all-cause mortality (HR 0.87, 95% CI 0.47–1.41) in patients receiving remote telemedical management (N = 354) when compared to usual care (N = 356).

Current Guidelines

Remote monitoring may decrease health-care use through fewer hospitalizations for chronic HF, fewer HF-related re-admissions, and more efficient device management.

Clinical Practice

Telemonitoring has mainly featured in research trials but is increasingly becoming integrated into every day HF practice, enabling a higher proportion of people with HF to be monitored by specialist services. It is particularly helpful for those living in remote and rural areas, the elderly and frail who are housebound, and those at high risk of clinical deterioration.

Future Research

The Cochrane review[96,97] is the strongest evidence in support of remote management (particularly telemonitoring) applied to those patients not able to access face-to-face management. More research in a number of areas is needed before it becomes widely incorporated into routine practice.[100] We need to find out which components make a programme effective, the optimal duration and intensity of monitoring, and which patients benefit most from monitoring compared with face-to-face programmes. In addition, the value in different ethnic and socioeconomic groups and geographical locations needs to be worked out as well as the experiences of users and health professionals. A key issue, as the volume of data derived from telemonitoring increases, is the sensitivity and specificity of responding to monitored events that may (or may not) lead to a morbid or fatal event.

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