Remote Monitoring in Cardiology and Evidence From Trial Data
Remote Monitoring in Cardiology and Evidence From Trial Data
It is often not possible, or indeed necessary, to follow all patients with the same level of intensity. The period of greatest vulnerability remains the period immediately following hospital discharge. Only a minority of patients are readmitted, but it is best to schedule a review soon after hospital discharge and preferably within 10 days.
A major difficulty in establishing the frequency of subsequent follow-up is the substantial difference in the intensity of interventions in the studies demonstrating benefit from management programs, with follow-up varying from a single home visit, to weekly home visits for older or unstable patients in nurse-led heart failure management programs. The positive outcomes of the early studies were largely derived from trials in patients with left ventricular systolic dysfunction where 'usual' care was very poor. The generalizability to current patients, particularly where 'usual' care has improved, is unclear.
The COACH study, a multicenter study of over 1000 patients in The Netherlands, was designed to establish the optimal frequency of professional monitoring in a more general heart failure population. Patients were randomized to one of three groups: outpatient cardiologist clinic visit within 2 months of discharge and 6 monthly thereafter; the addition of nine outpatient nurse visits; or a total of four visits to the cardiologist and 20 contacts with the nurse (with the greatest intensity within the first month of hospital discharge), and multidisciplinary team contact for lifestyle advice. Patients were followed up for a period of 18 months. The study reported no difference in the risk of death or heart failure-related hospital admission between the groups. There was also no difference in the total number of days lost to death or all-cause hospitalization. Importantly, there was a substantial increase in contact with the secondary care heart failure team in all groups and this was frequently triggered by an increase in symptoms. The study has been interpreted as providing evidence that heart failure programs need to be adaptive to patient requirements, with an open access follow-up service, with varying levels of support.
Frequency of Monitoring
It is often not possible, or indeed necessary, to follow all patients with the same level of intensity. The period of greatest vulnerability remains the period immediately following hospital discharge. Only a minority of patients are readmitted, but it is best to schedule a review soon after hospital discharge and preferably within 10 days.
A major difficulty in establishing the frequency of subsequent follow-up is the substantial difference in the intensity of interventions in the studies demonstrating benefit from management programs, with follow-up varying from a single home visit, to weekly home visits for older or unstable patients in nurse-led heart failure management programs. The positive outcomes of the early studies were largely derived from trials in patients with left ventricular systolic dysfunction where 'usual' care was very poor. The generalizability to current patients, particularly where 'usual' care has improved, is unclear.
The COACH study, a multicenter study of over 1000 patients in The Netherlands, was designed to establish the optimal frequency of professional monitoring in a more general heart failure population. Patients were randomized to one of three groups: outpatient cardiologist clinic visit within 2 months of discharge and 6 monthly thereafter; the addition of nine outpatient nurse visits; or a total of four visits to the cardiologist and 20 contacts with the nurse (with the greatest intensity within the first month of hospital discharge), and multidisciplinary team contact for lifestyle advice. Patients were followed up for a period of 18 months. The study reported no difference in the risk of death or heart failure-related hospital admission between the groups. There was also no difference in the total number of days lost to death or all-cause hospitalization. Importantly, there was a substantial increase in contact with the secondary care heart failure team in all groups and this was frequently triggered by an increase in symptoms. The study has been interpreted as providing evidence that heart failure programs need to be adaptive to patient requirements, with an open access follow-up service, with varying levels of support.
