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From the patient’s perspective, a heart failure hospitalisation is associated with a permanent step-change in quality of life, functional capacity and independence. From a societal perspective, an unplanned admission is the costliest portion of heart failure care, forming a large proportion of overall healthcare expenditure given the current epidemic of heart failure. Although a heart failure hospitalisation is a sentinel event, following which ~25% are re-admitted within 30 days, and ~30% will die within 1 year, from the clinician’s perspective it is also an opportunity to rapidly optimise medical and device therapies for those at the greatest risk. These activities do not, however, require a patient be in a hospital bed. They merely require the ability to identify at-risk individuals and to coordinate care to prevent, delay or plan for the progression to an advanced heart failure syndrome.
Why have nearly all remote monitoring studies failed?
The numerous studies using data derived from cardiac implantable electronic devices or external devices have provided inconsistent results, even in higher risk individuals.1 The term ‘acute’ decompensated heart failure implies a process occurring rapidly, but in heart failure this is seldom the case, with the majority of admissions following gradual haemodynamic and symptomatic deterioration.2 Therefore, lack of time to intervene and prevent a decompensation is unlikely to be a significant barrier for remote monitoring strategies. More significant challenges are the specificity of a signal, having a clear therapeutic target, and consistency in the nature and efficacy of the response to an alert. Hence, the two aspects of the care pathway—the signal and our response to it—are inseparable, and both must be aligned to avoid neutral outcomes with increased costs.
Promise of invasive haemodynamic monitoring
Congestion is the most common reason for admission to hospital but has variable symptoms and clinical signs which are subjective, insensitive and take time to manifest. Invasive haemodynamic monitoring (IHM) promises …
Contributors Both authors have contributed equally to the manuscript, and both have reviewed the contents prior to submission.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests SS declares speaker’s fees and honoraria from Astra Zeneca. KKW declares speaker’s fees and honoraria from Medtronic, Abbott, Cardiac Dimensions, Novartis, Bayer and an unrestricted research grant from Medtronic.
Provenance and peer review Commissioned; internally peer reviewed.