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................. symptoms, weight, heart rate, and BP, can be collected frequently, stored in an electronic health record and used to guide patients (directly or through a healthcare professional), to adjust therapy or to seek further advice. Home telemonitoring (HTM) can help maintain quality of care, facilitate rapid access to care when needed, reduce patient travel costs, and minimize the frequency of clinic visits.355 Enforced cessation of face-to-face consultations in many countries during the recent COVID-19 pandemic have highlighted some of the potential advantages of HTM.356 Trials of HTM are diverse. Patients are usually required to make measurements and, as for many other aspects of HF management, adherence may be incomplete. HTM may be provided as a local, regional, or national service. Systems that focus on optimizing management rather than detecting and managing medical emergencies need only to be staffed during standard working hours. Some systems are designed also to offer support at any time requested by the patient. The comparative effectiveness and cost effectiveness of each strategy is uncertain. Systems that focus on continuous optimization of care (a health maintenance approach) rather than trying to anticipate and manage episodes of worsening (a strategy that is plagued by a large number of false-positive alerts), appear more successful.357 HTM is an efficient method for providing patient education and motivation and aiding delivery of care, but it should be adapted to work in synergy with existing healthcare provision.358 A Cochrane systematic review conducted in 2017 identified 39 relevant trials of HTM, largely based on assessments of symptoms, weight, heart rate and rhythm, and BP and found that HTM was associated with a reduction in all-cause mortality of 20% and HF hospitalization of 37%.359 Since then, several neutral trials and at least one positive trial have been published.357,360364 These are unlikely to change the positive results of the systematic review. Importantly, if social distancing and the ‘green’ agenda are important, HTM only needs to show that it is not inferior to contemporary methods of delivering care to be an appropriate means of supporting care.356 Whether wearable technologies for monitoring heart rate and rhythm or lung congestion (bio-impedance or lung radar) offer additional benefits to conventional HTM described above is uncertain.365367 Many implanted therapeutic devices can provide, wirelessly and remotely, information either on the device itself (generator and lead function), arrhythmias, or on patient physiology (heart rate, activity, heart sounds, bio-impedance). There is strong evidence that monitoring can detect device malfunction earlier than by conventional monitoring and that it may be useful for detecting arrhythmias such as AF. However, there is little evidence that device monitoring reduces admissions for HF or mortality.368370,371 Devices that only provide a monitoring function are also available. Implantable loop-recorders can be injected subcutaneously and used to monitor heart rate and rhythm, activity, and bio-impedance. Monitoring devices can also be placed in the pulmonary artery to monitor pressure wirelessly, although the external reader required to detect the device signal is rather bulky and requires patient cooperation. A rise in diastolic pulmonary artery pressure may be one of the earliest signs of congestion. A preliminary, but fairly substantial, trial showed a reduction in the risk of recurrent HF hospitalization.372 A much larger trial has completed recruitment (GUIDE-HF).373 Thus, non-invasive HTM may be considered for patients with HF in order to reduce the risk of recurrent CV and HF hospitalizations and CV death; further evidence on management guided by implanted systems is awaited.374

10 Advanced heart failure

10.1 Epidemiology, diagnosis, and

prognosis Many patients with HF progress into a phase of advanced HF, characterized by persistent symptoms despite maximal therapy.375377 The prevalence of advanced HF is increasing due to the growing number of patients with HF, ageing of the population, and better treatment and survival of HF. Prognosis remains poor, with a 1-year mortality ranging from 25% to 75%.378380 The updated HFA-ESC 2018 criteria for the definition of advanced HF are reported in Table 13.376 A severely reduced LVEF is common but not required for a diagnosis of advanced HF as it may develop in patients with HFpEF as well. In addition to the reported criteria, extra-cardiac organ dysfunction due to HF (e.g. cardiac cachexia, liver or kidney dysfunction) or type II pulmonary hypertension may be present, but are not required for the definition of advanced HF.376 The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles, developed to classify patients with a potential indication for durable MCS devices, describes clinical parameters and characteristics consistent with a need for advanced therapies (Table 14).381 This classification has also been shown to be useful in estimating the prognosis of patients undergoing urgent heart transplantation382 or LV assist device (LVAD) implantation,383 and for risk assessment in ambulatory advanced HF patients.384 Prognostic stratification is important to identify the ideal time for referral to an appropriate centre (i.e. one capable of providing advanced HF therapies), to properly convey expectations to patients and families, and to plan treatment and follow-up strategies

Recommendations for telemonitoring

Recommendations Classa Levelb

Non-invasive HTM may be considered for patients with HF in order to reduce the risk of recurrent CV and HF hospitalizations and CV death.374 IIb B Monitoring of pulmonary artery pressure using a wireless haemodynamic monitoring system may be considered in symptomatic patients with HF in order to improve clinical outcomes.372 IIb B

CV = cardiovascular; HF = heart failure; HTM = home telemonitoring; LVEF = left ventricular ejection fraction. aClass of recommendation. bLevel of evidence. ESC 2021

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