Technology for Heart Health: Reducing hospitalizations in patients with Stage III/IV systolic heart failure

I. Overview:

Heart failure is a complex clinical syndrome that results from an underlying impairment of ventricular filling or ejection, which eventually culminates with the development of pulmonary congestion and peripheral edema (swelling). The cardinal manifestations of heart failure include dyspnea (shortness of breath) and fatigue, which often severally restrict a person’s daily activities and undermine his or her quality of life. The course may vary depending on individual patient’s age, sex, race, ethnicity, and previous medical history, but the common patient has a history of ischemic heart disease, hypertension, smoking, obesity, and/or diabetes [1].

Heart failure (HF) is a major public health issue. It affects over five million individuals in the United States alone[1], and the disease’s prevalence continues to rise due to the aging population and improved management of the condition leading to increased life expectancy. Over half a million new patients are diagnosed annually, and nearly 300,000 deaths are reported each year from heart failure [2,3]. HF is a chronic condition with no absolute cure; the goal of HF treatment is to control the disease’s progression, not to remove it entirely. For patients with severe Heart Failure (Stage III/IV), this often includes several hospitalizations to manage acute periods of symptom exacerbations known as decompensations. Heart failure is the most common source of hospital readmissions in the United States in individuals greater than sixty-five years of age [1,4]. Annual spending on HF-related care in the United States approaches thirty one billion dollars [5], and managing the costs of heart failure is a pivotal focus in the current healthcare environment both for the the financial, medical, and psychological costs associated with the condition.

II. Current Standard of Care

HF is a chronic condition with no absolute cure; the goal of HF treatment is to control the disease’s progression by stabilizing or slowing of myocardial function deterioration with the ultimate goal of reducing the risk of morbidity and mortality[6]. This process requires regular interactions between a person and his or her care team to address medication titration, changes in symptoms, or lifestyle assessment. Non-pharmacological care standards includes educating the patient and family about the disorder, and assessing if patient has social support to improve compliance. Correction of precipitating and exacerbating factors such as sodium load, anemia, and alcohol use is also generally done by monitoring and modifying diet and exercise. Current standards of pharmacological treatment include use and titration of ACE inhibitors, ARBs, Beta Blockers, Hydralazine, Isorobide dinitrate, Aldosterone Antagonists and Diuretics.



III. Outpatient Management

Although proper heart failure management requires extensive and intensive communication to help prevent decompensations, hospitalizations, and improve quality of life, the infrastructure for current HF outpatient management is neither robust nor efficient. Person-provider communication in the time between a clinic visits often requires dedicated staff to make semi-regular calls and for patients to recall ways of self-management without reminders. The current system, therefore, does not have an efficient mechanism in place to catch these decompensations. Mobile health has the potential to address this communication gap between patients and their providers and to serve as a crucial lever for higher quality medical care. Some trials to review the efficacy of digital health tools in HF management have already been completed (24-29), but the results are not conclusive. No single solution has been accepted, and more trials are still necessary to fully assess the therapy. If constructed properly, a heart failure mobile health system that leverages remote patient monitoring and patient-reported outcomes may reduce hospital readmissions, facilitate early intervention, prevent acute medical crises, and detect or avoid disease complications. All stakeholders–administrators, physicians, and patients–can benefit from investing in telemedicine methods with proven effectiveness.   

IV. A Simple Solution: Technology + Research

Through collaborative interviews with physicians, nurses, patients and medical students at Washinton University School of Medicine, Epharmix has a system to address these needs. EpxHeart Failure uses text messages and phone calls prompts patients to report their vital signs (body weight, blood pressure, and heart rate) as well as symptomatology (dyspnea, orthopnea, edema, and paroxysmal nocturnal dyspnea) via text messages. If the patient reports changes beyond set thresholds or worsening of symptoms, the provider receives an actionable alert encouraging patient follow up to address the issue and remotely alter the plan of care.

The system has been piloted with Washington University School of Medicine HF clinic with 10 adult patients and an ongoing cohort study is undergoing with difficult to manage patients to assess the impact of the system on hospitalizations, morbidity, and patient compliance. The system provides a way for patients to keep track of their health and communicate with their provider at their convenience while providers can remotely and efficiently monitor their patients with a system that automatically triages the patients to enable efficient use of time. Mobile health has the potential to alter the HF management landscape using smart outpatient-management tools. EpxHeart Failure provides a tool to do so, thereby helping to unburden the healthcare system from hospitalizations and empowering patients to take control of their health.

Guest Author, Kunjan Patel

Independent Clinical Researcher, Epx Research Center, Washington University in St. Louis School of Medicine

Saint Louis University School of Medicine, Class of 2019

Advisors: Dr. Gregory Ewald; Kelly Dodds, RN; Dr. Will Ross

Works Cited

1. Bui AL, Horwich TB, Fonarow, GC. Epidemiology and risk profile of heart failure. Nat Rev Cardiol. 2011; 8(1): 30-41.

2.  Packer M, Coats AJS, Fowler MB et al. for the Carvedilol Prospective Randomized Cumulative Survival Study Group. Effect of carvedilol on survival in severe chronic heart failure. N Engl J Med. 2001; 344: 1651–8.

3. The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med. 1991;325:293-302.

4. Roger VL. Epidemiology of heart failure. Circ Res 2013;113:646–59.

6. Chaudhry et al. (2010). Telemonitoring in Patients with Heart Failure. New England Journal Of Medicine, 363(24), 2301. doi:10.1056/NEJMoa1010029

7. Koehler F et al. (2011). Impact of Remote Telemedical Management on Mortality and Hospitalizations in Ambulatory Patients with Chronic Heart Failure: The Telemedical Interventional Monitoring in Heart Failure Study. Circulation, 2011 vol. 123 (17) p.1873-1880

8. Cowie et al. (2009). Rationale and Design of a Prospective Trial to Assess the Sensitivity and Positive Predictive Value of Implantable Intrathoracic Impedance Monitoring in the Prediction of Heart Failure Hospitalizations: The SENSE-HF Study. Journal of Cardiac Failure 2009 vol. 15(5) 394-400

9. Cleland et al. (2005). Noninvasive Home Telemonitoring for Patients With Heart Failure at High Risk of Recurrent Admission and Death. Journal of the American College of Cardiology, 2005 vol.45 (10) 1654-1664

10. Abraham et al. (2011) Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial. Lancet 2011; 377:658-66

11. Black et al. (2014). A remote monitoring and telephone nurse coaching intervention to reduce readmissions among patients with heart failure: study protocol for the Better Effectiveness After Transition – Heart Failure (BEAT-HF) randomized controlled trial. Trials. 2014 vol. 15(1) p.124-134