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Prof. Martin R. Cowie, Imperial College, London, United Kingdom
“Good heart failure management does require a team approach”, Cowie tells. A nurse-led multidisciplinary programme could be of added value to patients. The first studies, looking at the impact of a multidisciplinary team in heart failure, date back about 15 years. A US study showed a dramatic reduction in the risk of re-hospitalization. Also another trial from the U.K. showed an positive impact. However, a Dutch study published just two years ago compared normal cardiology follow-up with nurse input, but found no difference between those approaches. “I suspect the reason for that was that care was already so good, that it is difficult to improve on that.”
Telemonitoring has been shown to reduce mortality and hospitalization in the early studies, but larger studies from the past 12 months were neutral. Finally, Cowie talked about implanted devices, which information can be transmitted back to the hospital.

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Evidence HF management, monitoring

Is there evidence for heart failure management programmes and monitoring?
Prof. Martin Cowie - London, United Kingdom

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Is there evidence for heart failure management programmes and monitoring? - Prof. Martin Cowie

The median age of presentation of heart failure in the UK is 76 years old. With an aging population, the prevalence of this condition is increasing whilst survival is also improving: as a result, there are more and more people living in the community with chronic heart failure. Such patients may frequently deteriorate requiring hospital admission. Strategies are therefore required in order to reduce re-admission rates.
In a nurse-led multi-disciplinary programme in the U.S. cost savings along with a 44% relative risk reduction in re-admission rates were achieved. Encouraging results were also found in a similar UK study. However, a multi-centre Dutch study compared basic or intensive heart failure nurse specialist support with cardiology consultant follow-up only: this showed no significant difference in the primary end-point of death or heart failure re-admission. This suggests that if background therapy is already good, then there is little extra benefit to be gained from intensive nurse-led management programmes: a more “tailored” approach is therefore required. Remote monitoring is a possible strategy to achieve this: this may involve telephone contact with a nurse, patient self monitoring of variables such as weight, pulse oximetry and blood pressure or automatic monitoring from an implanted device. The actions resulting from monitoring can include lifestyle advice, adherence reinforcement, diuretic adjustment, GP/clinic review or “no action needed”.
There is evidence to show that frequent monitoring of weight, symptoms and blood pressure results in a 34% reduction in all cause mortality, 21% reduction in heart failure admission and 9% reduction in all admissions. However the TIM-HF trial, in which patients were asked to telemonitor their own weights and blood pressures, did not show any difference in the rates of all cause death, cardiovascular death or heart failure hospitalisations. This may have been as these patients had long-standing heart failure (mean duration 6.7 years) and were already well managed on ACE inhibitors (95%) and beta-blockers (92%). This suggests that monitoring may be most useful in those at higher risk. This theory was explored in the Partners-HF trial which measured a number of key parameters from implanted devices whilst tracking patients for heart failure-related adverse events. Here the trans-thoracic impedance, which is correlated to the amount of fluid on the lungs, was shown to be a useful predictor of outcome. This is important, as it suggests a role for early intervention after the trans-thoracic impedance has crossed a certain threshold. Implantable devices can also be placed into the pulmonary artery enabling the pulmonary artery pressure to be monitored: the value of this was investigated in the CHAMPION trial which demonstrated a 36% relative risk reduction in rates of hospitalisation.

Patients are generally receptive to remote monitoring as it supports self care and helps them to gain confidence. As a result, certain patients may be able to manage their own care and only contact a doctor or nurse as needed. Consequently, “face-to-face” time can be reduced, hence resulting in cost savings: this is particularly important in the current climate.