Review Article

Neth Heart J (2019) 27:5–15https://doi.org/10.1007/s12471-018-1202-5

Telemedicine in heart failure—more than nice to have?

C. G. M. J. Eurlings · J. J. Boyne · R. A. de Boer · H. P. Brunner-La Rocca

Published online: 10 December 2018© The Author(s) 2018

Abstract Telemedicine in chronic diseases like heartfailure is rapidly evolving and has two important goals:improving and individualising care as well as reducingcosts. In this paper, we provide a critical and an up-dated review of the current evidence by discussing themost important trials, meta-analyses and systematicreviews. So far, evidence for the CardioMEMS deviceis most convincing. Other trials regarding invasiveand non-invasive telemonitoring and telephone sup-port show divergent results, but several meta-analy-ses and systematic reviews uniformly reported a ben-eficial effect. Voice-over systems and ECG monitor-ing had neutral results. Lack of direct comparisonbetween different modalities makes it impossible todetermine the most effective method. Dutch studiesshowed predominantly non-significant results, mainlydue to underpowered studies or because of a highstandard of usual care. There are no conclusive re-sults on cost-effectiveness of telemedicine because ofthe above shortcomings. The adherence of elderly pa-tients was good in the trials, being essential for thecompliance of telemedicine in the entire heart failurepopulation. In the future perspective, telemedicineshould be better standardised and evolve to be morethan an addition to standard care to improve care andreduce costs.

Keywords Telemedicine · Heart failure · ehealth andtelehealth

C. G. M. J. Eurlings · J. J. Boyne · H. P. Brunner-La Rocca (�)Maastricht University Medical Center, Maastricht, TheNetherlandshp.brunnerlarocca@mumc.nl

R. A. de BoerUniversity Medical Center Groningen, Groningen, TheNetherlands

Key message

– Telemedicine in heart failure is rapidly evolving.– Evidence is conflicting, mainly due to a lack of

uniform methods/systems.– Direct comparison between different modalities

is lacking which impedes determination of themost effective method.

– Telemedicine should evolve into more than anaddition to standard of care.

Background

Heart failure (HF) is an increasingly prevalent disease,which affects approximately 1–2% of the total pop-ulation in Europe, despite a tendency towards lowerincidence in recent years [1, 2]. The high prevalence ismainly due to the ageing population as the prevalenceof HF exponentially increases with age. Not surpris-ingly, the complexity of the disease is increasing, aswell, and the majority of patients with HF suffer frommultiple comorbidities [1]. Therefore HF is charac-terised by highmorbidity andmortality, and prognosisimproved only slightly despite advances in treatment[3]. The high event rate, particularly repeated hospi-talisations, is the main driver of the enormous costsand a substantial reduction in quality of life. In orderto prevent these events and to reduce the burden ofHF, a multidisciplinary team approach has been advo-cated [2]. Multiple meta-analyses demonstrated thatsuch an approach indeed reduces the burden of HF[4]. Multidisciplinary treatment not only encompassesoptimal therapy of HF, but also involves patient edu-cation to improve compliance and self-monitoring bypatients. However, such an approach is quite labourintensive, requires many resources and monitoring by

Telemedicine in heart failure—more than nice to have? 5

Review Article

patients is often insufficient. Therefore, telemedicinehas been suggested to support patients at a distanceregarding both education and monitoring and to im-prove HF care. The implementation of these monitor-ing tools has been hypothesised to augment medicalcontrol of HF to prevent decompensation, to concur-rently gain time and resources when compared withtraditional care [5] and to maintain a good standardof care in the treatment of HF patients despite theincreasing prevalence.

Telemedicine or telehealth are multiform termsembracing the applications of telematics to medicineto enable diagnosis, monitoring and/or treatmentremotely by a variety of communication tools, whichmay include (smart)phones, mobile wireless devices,with or without a video connection, or implantabledevices (that are often part of another device suchas ICDs or pacemakers [6]). Until recently, digitalapplications in medicine were restricted to the use ofelectronic health records, but lately the technologicalcontext has notably expanded: the number of exist-ing internet-connected mobile devices has roughlydoubled every 5 years [5, 7].

Technology is rapidly evolving. There are a count-less number of apps available related to healthcare.New sensors have been developed and data exchangein real-time enables collection of large datasets. Al-though many issues are not yet resolved (e.g. datasafety), expectations are high and there are alreadyhealthcare insurers providing reduction in premiumsif e-Health technology is used for prevention or man-agement of diseases. However, the question ariseswhat the exact impact is of this technology on the carein HF, whether it improves quality of life and reducescardiovascular events, and if it may fulfil its expecta-tions.

Current evidence

Implantable devices

So far, the most convincing evidence for a telemoni-toring device relates to the implantable CardioMEMSdevice (Fig. 1; [8]). This device is implanted into thepulmonary artery (PA) and transmits PA pressures toa central service centre. The treating physician re-ceives the results, including the trends over time ofthese measurements. The physician is advised to re-act if PA pressure exceeds a certain threshold whichsuggests congestion, and when it is below the nor-mal range suggesting dehydration. The study was notpowered for mortality but showed significant reduc-tion in HF hospitalisation as a result of improved HFmanagement. This effect was maintained in the longterm [9]. A comparable rationale was studied in theCOMPASS-HF trial. A sensor on a transvenous leadwas positioned in the right ventricle (Fig. 2). The pri-mary endpoint rate was reduced by 21%, but this wasnot statistically significant. There were lower event

rates than expected which could make the study un-derpowered for the primary endpoint [10]. The majorlimitation of these studies was that the treatment rec-ommendation is very generic, with a plethora of in-terventions being used (diuretics, vasodilators), at thediscretion of the caring physician.

Another form of telemonitoring is part of ICD/CRTdevices. Such monitoring has not generated uniformresults. The IN-TIME trial reported improved clini-cal outcomes by using multi-parameter monitoringbased on information from an ICD device. By a dailycheck of several parameters summarised in Tab. 1,a composite clinical score indicating worsening ofHF was improved by 37% (odds ratio= 0.63, 95% CI0.43–0.90) as compared with usual care [11]. TheEFFECT study showed a similar effect with a clearreduction of the combined primary endpoint of all-cause mortality and cardiovascular hospitalisation[12]. Encouraging results were also found in theCOMMIT-HF trial, a matched cohort study, usingdifferent cardiac device brands for the telemonitor-ing. They observed a long-term effect of significantreduction in mortality (4.9% vs. 22.3%, p< 0.0001),but obviously, this was not a randomised trial [13].In contrast, The OptiLink HF study could not showany beneficial clinical outcome in advanced HF byusing fluid status telemedicine alerts (Fig. 2; [14]).Likewise, the positive effects on mortality and cardiachospitalisation were not supported in a meta-anal-ysis including 11 RCTs consisting of 5,703 patients;there was only a favourable effect on the number ofvisits, but no effects on hard clinical outcomes andan increase in unscheduled visits [15]. As to whetherthe differences can be explained by the use of dif-ferent devices or different interventions is currentlyunknown. Therefore, no general recommendation touse monitoring information from implantable devicescan at present be made.

Non-invasive monitoring

In general, individual trials of telemonitoring/tele-phone support compared with usual care did notconsistently report positive results on the primaryendpoints (Tab. 1). The large TELE-HF study didnot generate any clinical proof for the use of tele-monitoring (utilising a telephone-based interactivevoice response system collecting daily information onsymptoms and weight) [16]. A voice response systemwas used without direct contact between healthcareproviders, possibly resulting in the low adherenceof 14% never users and only about half of the pa-tients using the system more than three times perweek [16]. Unfortunately, there was no post-hocanalysis to determine if good adherence resulted inbetter outcomes. Also, the impact of weight changesfor monitoring may be overestimated as it was notdemonstrated to be effective as a predictive marker ofimpending decompensation [17]. This is supported

6 Telemedicine in heart failure—more than nice to have?

Review Article

Fig. 1 CardioMEMS, implantable haemodynamic monitoringsystem. a CardioMEMS sensor or transmitter. b Transcatheteris implanted into a distal branch of the descending pulmonaryartery. c The patient is instructed to take daily pressure read-ings from home using the home electronics. d Informationtransmitted from the monitoring system to the database is im-

mediately available to the investigators for review. e Trans-mitted information consists of pressure trend information andindividual pulmonary artery pressure waveforms. With permis-sion from Elsevier, original figure from Abraham et al. Lancet.2011;377:658–66

by the negative WISH trial that compared a self-measurement of patients’ weight or by an electronicscales with automatic transmission of the results tothe clinic. There was a solid mean of 75% (0–100%)of patient compliance, but there was no significantdifference in endpoints between the groups or in sub-groups [18]. Also the MCCD trial showed no benefitof telemonitoring despite very good adherence of theparticipants [19]. Again, the system was mainly basedon data transmission with very little direct contactwith the patients. Further, the TIM-HF group failed to

show a positive effect on the primary endpoint of all-cause mortality or composite endpoints comparingusual care with telemonitoring (Fig. 3), but the studywas not sufficiently powered [20]. In addition, theCHAT trial showed mixed results with positive effectson the secondary endpoints of all-cause mortalityand all-cause hospitalisation with telecommunica-tion, but not on the primary endpoint in HF patientsliving in rural areas [21]. Very recently, the largeTIM-HF2 study found more days alive outside thehospital with the use of structured remote patient

Telemedicine in heart failure—more than nice to have? 7

Review Article

Fig. 2 Examples of invasive monitoring. a OptiVOL ofMedtronic pacemaker/ICD devices. b Results presented forOptiVol with the thoracic impedance (ohms) measured andthe OptiVol fluid index, resulting from the difference of mea-sured thoracic impedance and reference thoracic impedance,with threshold. As the patient’s lungs become congested, in-trathoracic impedance tends to decrease. Similarly, an in-crease in intrathoracic impedance may indicate the patient’s

lungs are becoming more dry. c The Chronicle® ImplantableHemodynamic Monitor. d Results of Right Ventricle (RV) Sys-tolic Pressure measurements of a sensor on a transvenouslead positioned in the right ventricle and estimated pulmonaryartery diastolic (ePAD) pressures. With permission, original fig-ure A/B/C from source: Medtronic Inc. With permission fromElsevier, original figure D from Bourge et al. Am Coll Cardiol.2008;51:1073–9

management interventions as compared with usualcare (Tab. 1; [22]). Taken together, the inhomogeneityof the methods used, the devices applied, the patientsincluded and the intervention performed togetherwith the lack of sufficient statistical power may ex-plain the mixed findings of individual trials regardingthe use of telemonitoring. Moreover, there is a lackof direct comparison between different modalities,making it impossible to determine which may be themost effective method.

However, several recent meta-analyses and system-atic reviews reported that the use of telemonitoringmay improve outcomes [23–26]. As a consequence ofthe mixed trials, these meta-analyses included studieswith different inclusion criteria. Despite these differ-ences, all meta-analyses reported reduction inmortal-ity and HF-related hospital admissions. In addition,Kruse et al. concluded that telemedicine is effective in

customer satisfaction [25] and may increase the senseof security [27]. Also, some but not all studies re-ported positive effects on quality of life [9, 19, 28].Still, as many randomised trials were neutral, the rec-ommendation by the ESC HF guidelines is restrictive(i. e. recommendation IIB, level B) [2].

Dutch studies

In addition to research design, organisation of health-care may importantly influence outcomes of health-care interventions as telemonitoring. By comparingonly Dutch studies, we attempt to create a certainlevel of similarity, as organisation of care is com-parable in all parts of the Netherlands. The firstrandomised study including a significant number ofDutch patients was the TEN-HMS study [29], whichcompared telemonitoring with more traditional HF

8 Telemedicine in heart failure—more than nice to have?

Review Article

Table

1Sum

mariesof

differen

tinterna

tiona

ltelem

edicinestud

ies

Study

Design

NFU

inmonths

Intervention

Primaryendpoint

Outcom

e

TELE-HF(2010)

RCT

1,653

6TM

:readmission

forany

reason

ordeath

negative

2arms:

telephonebasedinteractivevoice-response

system

.Sym

ptom

sandweightdailycollected

(difference

0.8%

points;95%

CI–4.0–5.6;p

=0.75)

TMvs.U

C

WISH(2010)

RCT

344

12interventiongroup:

cardiacrehospitalisation

negative

2arms:

electro

nicscaleautomaticallytra

nsmitted

weight

(HR0.90;95%

CI0.19–1.73;

p=0.32)

TMvs.U

C

CHAM

PION

(2011)

prospectivesingleblind

multicentre

trial

550

15CardioMEM

S:wireless

implantable

haem

odynam

icmonitoringsystem

ofpulmonary

arterypressuresinadditionofstandardcare

HFrelatedhospitalisations

positive

(HR0.72;95%

CI0.60–0.85;

p=0.002)

2arms:

interventionvs.U

C

nodevice/system-related

complications

positive

(98.6%

;95%

CI99.3–100.0)

nopressure-sensorfailure

positive

(100%;95%

CI99.3–100.0)

TIM-HF(2011)

RCT

710

26TM

:Including

daily

ECG,

blood

mortality

negative

2arms:

pressure,bodyweight

(HR0.97;95%

CI0.67–1.41;

p=0.87)

TM+MTS

vs.U

C

INH(2012)

open

RCT

715

6HF

nurse:

combined:tim

etodeathor

rehospitalisation

negative

inhospitalcontact;teachingmaterials;UTS;

bloodpressure/heartrate;up-titratingmedication

(incooperationwith

GPs);w

eeklycontactfirst,

laterindividualised

2arms:

(HR1.02;95%

CI0.81–1.30;

p=0.89)

NTS+UC

vs.U

C

CHAT

(2013)

RCT

405

12TeleWatch

system

compositeofdeath;

HFhospitalisation;

withdraw

alfro

mstudydueto

worsening

HFandimprovem

ent

ofwell-b

eing

negative

2arms:

follow-upby

HFnurses

atleastm

onthly

regarding:

HFclinicalstatus;

medicalmanagem

ent;

socialrelevantquestions

(OR=1.02;p

=0.91)

UCvs.U

C+NT

S

Telemedicine in heart failure—more than nice to have? 9

Review Article

Table

1(Con

tinue

d)

Study

Design

NFU

inmonths

Intervention

Primaryendpoint

Outcom

eIN-TIME(2014)

RCT

664

12TM

byICD:

compositeofall-cause

death;

overnightH

Fhospitaladm

ission;

change

inNY

HAclassandchange

patientself-assessment

positive

2arms:

Tachyarrhythmia;low

%biv-pacing;increase

VES;decreasedpatientactivity;abnormal

intra

cardiacelectro

gram

(OR0.63;95%

CI0.43–0.90)

UC+TM

vs.U

C

MCC

D(2014)

RCT

204

26remotemonitoringof:

30-day

readmission

forthe

first

year

positive

2arms:

daily

weight;bloodpressure;heartrate;heart

rhythm

TMvs.U

C

all-cause

hospitalisation;Average

timetohospitalisation;Costs;

MortalityandQo

L

negative

EFFECT

(2015)

prospective,

non-random

ised

trial

987

12TM

byCIED

:combined:all-cause

mortality

andCV

hospitalisations

positive

studyprotocoldidnotm

andateanyspecific

device

programmingandwas

freetoenablethe

availablesystem

integrity

andclinicalalertsfor

automaticremotenotification

(0.15vs.0

.27events/year;

incidentrateratio,0.55;95%

CI,0.41–0.73;p

<0.001)

2arms:

UCvs.T

M+UC

OptiLinkHF

(2016)

RCT

1,002

22–23

TMby

CIED

:compositeofall-cause

deathand

CVhospitalisation

negative

2arms:

fluidstatus

alerts;autom

aticallytra

nsmitted

asinaudibletextmessage

totheresponsible

physician

(HR0.87;95%

CI0.62–1.28;

p=0.52)

UCvs.T

M+UC

COMMIT-HF(2017)

observationalprospectivecohort

study

822

36TM

byCIED

:all-cause

mortality

positive

automatictra

nsmission

ofdatafro

mthecardiac

device.D

ailycheckofthedataby

2physicians

and2EP

nurses

(HR0.187;95%

CI0.075–0.467,p=0.0003)

2arms:

USvs.T

M+UC

TIM-HF2

(2018)

RCT

1,571

Max

13daily

transmission

of:b

odyw

eight;blood

pressure;heartrate;heartrhythm

;SpO

2;Self-ratedhealthstatus

percentage

ofdays

lostdueCV

hospitalisations

orall-cause

death

positive

2arms:

(ratio

0.80;95%

CI0.65–1.00;p=0.0460)

UCvs.U

C+RP

M

Nnumberofparticipants,FUfollow-upm

RCTrandom

ised

controlledtrial,TMtelemonitoring;UC

usualcare;NT

Snursingtelephonesupport;MTS

medicaltelephonesupport;RP

Mremotepatientmanagem

ent;CIED

cardiac

implantableendovascular

device,VES

ventricular

extra

systole,EP

electro

physiology,H

Fheartfailure,TMtelemonitoring,OR

odds

ratio,H

Rhazard

ratio,C

Iconfidence

interval;PApulmonaryartery,H

Fheartfailure,C

Vcardiovascular;Q

oLQu

ality

ofLife.

10 Telemedicine in heart failure—more than nice to have?

Review Article

Fig. 3 Telemonitoring system for remote monitoring of ar-rhythmia and heart failure patients. Multi-parameter dataacquisition and transmission should be fully automatic withsmooth data flow to medical staff/arrhythmia and heart failuremonitoring centre. Optimised data workflow: normal data areautomatically stored in a patient’s electronic file without further

detailed evaluation. Alarm threshold crossing triggers detaileddata review and potential medical action. With permissionfrom Oxford University Press, original figure from Varma N,Ricci RP. Eur Heart J. 2013;34:1885–95 and reprinted/adaptedfigure in Hindricks G, Varma N. Eur Heart J. 2016;37:3164–6

care as nursing telephone support and usual care.Telemedicine did not differ from nursing telephonesupport except for prescription of medication, how-ever both had significantly better results comparedwith usual care for all endpoints (Tab. 2). The DutchTEHAF study [30] compared the results of using theHealth Buddy®, monitoring signs and symptoms, withusual care. HF hospitalisations and visits to the HFclinic decreased, but the primary endpoint of timeto first HF hospitalisation was not significantly im-proved. The IN-TOUCH study compared an ICT-guided disease management support and an ICT-guided support with additional telemedicine [31].No significant differences in outcome were found,possibly due to the lack of a usual care group. Thee-Vita study, a prospective three-arm study (usualcare; usual care plus the heartfailurematters.org web-site; these two plus an adjusted care pathway withan interactive platform for disease management (e-Vita platform), replacing routine outpatient consulta-tions with HF nurses), could not show any significantbenefit [32]. Lastly, an optimised care program usinga telehealth application in a pre-post design [33] dur-ing a 12-month follow-up found positive effects onmost outcomes. Due to the design and the limitedstudy population, the results should be interpretedwith caution.

Taken together, the Dutch studies follow the line ofthe overall evidence with mixed results, explained bythe low power of the studies. Endpoints mostly focuson mortality and care consumption, yet they were notpowered to detect differences. Possibly, the high stan-dard of usual care may have influenced the results.The challenge is to detect the important aspects ofthe systems and how to integrate the systems into thedaily care process.

Cost-effectiveness

There is limited evidence regarding cost-effectivenessof telemedicine. The reduction of hospitalisation andthe increased self-management of patients embodiesthe potential of cost reduction in healthcare [25]. Theincremental cost-effectiveness of the CardioMEMSdevice is estimated to be $ 13,979 per quality-ad-justed life year gained [8]. Klersy et al. describe intheir meta-analysis on telemonitoring by cardiac de-vices a reduction of 44% in hospital visits, withoutaffecting mortality, resulting 15–50% cost saving [15].In the long term, these interventions were calculatedto be cost-neutral [34].

Regarding non-invasive telemonitoring, the effectson costs are even less clear. Blum et al. showed nocost-reduction [19] as there was no positive effect inthe study (e.g. readmission/hospitalisation). In con-trast, Comín-Colet et al. found a significant reductionin HF and cardiovascular readmission with the use oftelemedicine, which resulted in a net decrease in di-rect hospital costs of � 3,546 per patient per 6 monthsof follow-up [35]. In the Dutch TEHAF study, the prob-ability of being cost-effective was only 48% (thresholdof � 50,000), possibly due to the divergence betweenparticipating institutions [36]. Because of the hetero-geneity of all the studies, populations and no uniformintervention it is difficult to be conclusive on cost-effectiveness.

Potential shortcomings and limitations

One of the shortcomings of telemedicine may be thatpatients need to be able to use modern technology.This may particularly apply to elderly patients, whousually have less exposure to ICT and may, therefore,

Telemedicine in heart failure—more than nice to have? 11

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Table 2 Summaries of different Dutch telemedicine studies

Study Design N FU inmonths

Intervention Primary endpoint Outcome

TEN-HMS study(2005)

RCT 426 14–15 TM: TM vs. NTS: negative

3 arms: electronic monitoring of weight;blood pressure; single lead ECG

days lost because of deathor hospitalisation

(difference –4 days; CI–15–6)UC; TM; NTS

NTS: (nursing telephone support) TM, NTS vs. UC: positive

days lost because of deathor hospitalisation

(difference 6 days;95% CI 1–11)

TEHAF (2010) RCT 382 12 Health Buddy: Time to first hospitalisation negative

2 arms: Monitoring signs & symptoms;Education; Support of self-care

(HR 0.65; 95% CI0.35–1.17; p= 0.151)

UC; TM

IN TOUCH(2016)

RCT 177 9 innovative ICT-guided-diseasemanagement support combinedwith TM

composite endpoint ofmortality, HF readmissionand change in health-relatedquality of life

negative

2 arms: (Mean difference 0.1;95% CI –0.67–0.82;p= 0.39)

innovative ICT-guidedsupport; InnovativeICT-guidedsupport+ TM

electronic monitoring of weight;blood pressure; ECG (used incase of start-up or up-titration ofbeta-blockers)

e-Vita (2018) RCT 450 12 heart Failure Matters website self-care negative

3 arms: care pathway on e-vita platform HFM vs. UC mean 72.1vs. 72.7, and EACP vs.UC 76.1 vs. 72.7,respectively (overallp= 0.184)

UC; UC+ HFM web-site; care path-way+ link to HFMwebsite

Hart MotiefStudy (2015)

pre-post design 102 12 Motiva telehealth system:providing educational material,reminders of medication andmotivational messages

no. of HF-hospitalisations positive

(rate ratio 4.1; 95%CI 2.8–6.3; p< 0.001)

N number of participants, FU follow-up, RCT randomised controlled trial, TM telemonitoring, UC usual care, NTS nursing telephone support, MTS medicaltelephone support, CIED cardiac implantable endovascular device, HF heart failure, TM telemonitoring. OR odds ratio, HR hazard ratio, CI confidence interval,PA pulmonary artery, HF heart failure, CV cardiovascular´, QoL quality of life

either be unable or unwilling to use this technology[37]. Still, a recent meta-analysis shows that patientswith a mean age of 70 years or more can quickly adopttelehealth, find its use an acceptable part of theirhealthcare routine and are able to maintain good ad-herence for at least 12 months with a beneficial effectin reducing the risk of all-cause mortality and HF-re-lated hospitalisations [38]. The same result is shown ina post hoc sub-analysis of a Cochrane analysis [26, 39].Still, it must be stressed that it is very likely, though notspecifically reported, that patients were selected andthese findings might not be applicable to all patientswith HF. This is in line with a recent finding that par-ticipants and non-participants of e-Health technologyin HF differed significantly, particularly regarding age[40]. Nevertheless, these findings are interesting andpromising that technology can developed in a waythat it is easy to use for a large proportion of HF pa-tients [38].

Another shortcoming is that the influence of re-imbursement adopted by the insurance companies isprobably significant but not yet tested. It is also un-clear if the reimbursement strategy results in a morestructured use of telemedicine. Also, the organisationof care may influence the effects of telemedicine. Forthis reason, the CardioMEMS system will only be re-

imbursed in the Netherlands within a prospective ran-domised study to test if the results of the CHAMPIONtrial also apply to the Dutch healthcare system.

Moreover, it may be argued that the effect oftelemedicine may be largest in rural areas whereaccess to good quality healthcare may be more dif-ficult. The current data do not clearly support thatnotion, but studies did not properly investigate theimpact of remoteness of access to care.

Finally, data safety will be an important issue,particularly for next generation devices that may in-clude data from electronic patient records. So far,telemedicine was used mainly as stand alone, limit-ing data safety issues but also enhanced functionality.Therefore, issues of data safety should be addressedmore extensively with further development of (new)devices.

Future perspectives

There are two main goals of telemedicine in HF: im-proving care and reducing costs. It is not necessar-ily required that telemedicine devices must strive toachieve both, but the present and future requirementsin healthcare will actually favour devices aiming todo so. It is important to much better define which

12 Telemedicine in heart failure—more than nice to have?

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goals are important to improve outcome, as high-lighted above.

Thus far, theoretical considerations have formedthe basis for developing telemedicine devices. Theseincluded the idea that monitoring patients regard-ing signs and symptoms, via haemodynamic moni-toring or as part of implantable devices such as ICDs(e.g. impedance, heart rate variability, activity levels)would result in a reduction in acute decompensation.This assumption is not sufficiently supported, and itis largely unknown what is required to achieve thebest outcome. Best results were achieved with theuse of invasive haemodynamic monitoring [8, 9], butthis is not applicable to the majority of patients andconfirmation in other healthcare systems than initiallytested is required [41, 42]. In addition, a similar kind ofdevice use (i. e. ICD/CRT-D devices for remote mon-itoring) resulted in mixed results [11, 43], which can-not be easily explained. Importantly, the exact ac-tion required based on the result of monitoring is leftto the care professionals in charge, which obviouslymay vary significantly. Therefore, there is an urgentneed for randomised controlled trials with a clear def-inition of both monitoring and intervention modali-ties, as well as collection of comprehensive data fromthe clinical use of telemedicine devices. Combiningsuch data based on different systems may help definewhich parts of monitoring and patient education aremost effective. However, there is also a great need tosufficiently record and analyse the therapeutic inter-vention done based on telemedicine systems. So far,there is a lack of such data in sufficiently large patientpopulations.

Telemedicine has also been advocated to reducecosts in HF care [35], mainly related to reduction inhospitalisation rate. However, there may be also a sig-nificant improvement in self-management in HF aswell as other chronic diseases [44], possibly result-ing in reduction of outpatient visits as shown for an-other chronic disease [45]. Current systems have lim-ited abilities to foster self-management by patients.Healthcare in Western countries requires a new inno-vative approach to address chronic diseases such asHF to provide sustainability of care and to limit theexcessive costs that may threaten the current system.Thus, changing the approach to care is important, notonly regarding adoption and smarter use of moderntechnology, but also regarding a new vision on bothcare and health [46]. Therefore, telemedicine shouldbe more than an addition to standard of care. Impor-tantly, chronic diseases usually do not occur in isola-tion. Most patients with chronic disease have multi-ple diseases [47]. Future telemedicine devices for HFshould consider comorbidities, not only for safety rea-sons, but to enable real patient self-management thatmay enable some substitution of traditional care.

Conclusions

Telemedicine is evolving fast, but lacks solid evi-dence on clinical outcomes and cost-effectivenessin trials, despite positive meta-analysis. The Car-dioMEMS device showed the most convincing results.For the future, sufficiently powered trials with cleardefinition of both monitoring and intervention areurgently needed. Telemedicine should evolve to bemore than an addition to standard of care. Only thenwill telemedicine be more than nice to have.

Acknowledgements Drs. Eurlings and Brunner-La Rocca aresupported by INTERREG-NWE (NWE702).

Dr. de Boer is supported by the Netherlands Heart Foun-dation (CVON DOSIS, grant 2014-40, CVON SHE-PREDICTS-HF, grant 2017-21, and CVON RED-CVD, grant 2017-11); andthe Innovational Research Incentives Scheme program of theNetherlands Organization for Scientific Research (NWOVIDI,grant 917.13.350).

Conflict of interest TheMUMC, which employs C.G.M.J. Eu-rlings, J.J Boyne and H.P. Brunner-La Rocca, has receivedresearch grants and/or fees from Novartis, Vifor, Abbott,Medtronic, Servier, Roche Diagnostics. They are collab-orating in a European project with Sananet, Exploris andNeurogames. Dr. Brunner-La Rocca received research grantsand/or fees from Roche Diagnostics, Novartis, Vifor, andServier. The UMCG, which employs R.A. De Boer, has re-ceived research grants and/or fees fromAstraZeneca, Abbott,Bristol-Myers Squibb, Novartis, Roche, Trevena, and Ther-moFisher GmbH. Dr. de Boer is a minority shareholder ofscPharmaceuticals, Inc. Dr. de Boer has received personalfees fromMandalMed Inc, Novartis, and Servier.

Open Access This article is distributed under the terms ofthe Creative Commons Attribution 4.0 International License(http://creativecommons.org/licenses/by/4.0/), which per-mits unrestricted use, distribution, and reproduction in anymedium, provided you give appropriate credit to the origi-nal author(s) and the source, provide a link to the CreativeCommons license, and indicate if changes were made.

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