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  • br Does ambulatory monitoring prevent HF decompensation Whil

    2019-04-15


    Does ambulatory monitoring prevent HF decompensation? While vigilant monitoring of symptoms and signs (and BNP levels) is useful, it does not guarantee the accurate prediction of ADHF. On the other hand, frequent monitoring of some of these signs and symptoms and the use of external physiological (and implantable) data have been tested. A meta-analysis of both cohort (2354 patients) and randomized trials (6258 patients) [10], with 6–12 months of follow-up revealed a significantly lower rate of deaths and hospitalizations in patients receiving BNP-guided therapy than in those receiving conventional therapy. The Cochrane Database Systematic Review [11] examined 25 studies and 5 abstracts and has suggested that telephonic support and telemonitoring are effective in reducing all-cause mortality, HF-related hospitalization, and treatment cost; improving the QOL; and increasing the frequency of evidence-based prescription. The Randomized Trial of Phone Intervention in Chronic HF (DIAL) trial [12] randomized 1518 outpatients to either nurse-led, telephone-based intervention or conventional treatment. Weight, diet, and medication compliance were monitored, and nurse specialists adjusted the diuretics doses according to certain specified criteria. Patients were instructed to call 3 times at a frequency of once every 14 days and, thereafter, at a frequency depending on the severity of HF. This protracted study followed the patients for up to 3 years after trial completion. The primary endpoint (death or HF-related hospitalization) was lower in the intervention than in the conventional arm, with the main benefit being a hedgehog pathway in hospitalization (28.5% versus 35.1%, at 3 years). An educational effect and adherent to the above 3 supervised areas were considered the main reasons for improvement. The Telemedical Interventional Monitoring in HF (TIM-HF) trial [13] also randomized stable Class II or III HF patients with a history of HF-related hospitalization during the last 2 years to either conventional care or remote data monitoring (ECG, blood pressure, and body weight); the latter involved the transference of the collected data via a personal digital assistant to the monitoring center daily, followed by physician-led response. Over a median follow-up period of 26 months, there was no difference in the frequency of HF-related hospitalization or death, nor in the overall QOL score. However, physical functioning improved. The study documented an 81% compliance in ≥70% daily transmission of data. The Telemonitoring in Patients with HF (TELE-HF) trial [14] randomized 1653 patients who were recently admitted with ADHF. Daily telephone-based interactive voice-response systems on symptoms and weight were reviewed by the patients\' physicians. At the end of 180 days, there was no significant difference in the primary endpoint of death and HF-related hospitalization between the telephone-based intervention group and the conventional care group (52.3% versus 51.5%, respectively). Again, this study shows only a 55.1% adherence to interventional therapy at the end of 26 weeks among the 85.6% of patients who made at least 1 call.
    Monitoring of pathophysiological changes in HF Three possible pathophysiological areas for HF monitoring can be defined: monitoring of electrical remodeling, mechanical remodeling, and neurohormonal changes occurring with HF (Table 1). Electrical remodeling in either the atrium or ventricle will result in changes in the normal automaticity, conduction properties, and refractory period and predisposition to atrial fibrillation (AF) and ventricular tachyarrhythmias. The occurrence of arrhythmias is routinely monitored and treated by CIED, both by pacing and defibrillation. The effective refractory period (ERP) can be monitored by physician-activated electrical stimulation through a programmer. Intra- and inter-chamber conduction timings in HF are important; progressive PR and QRS duration prolongation occur with a worsening of HF [15]. A wide LBBB QRS complex is associated with ventricular dyssynchrony and impairs LV function.