ABC | Volume 113, Nº5, November 2019

Guidelines Guideline of the Brazilian Society of Cardiology on Telemedicine in Cardiology – 2019 Arq Bras Cardiol. 2019; 113(5):1006-1056 telediagnosis, and tele-education integrally applied to PHC and associated with tools like DSS can make a difference in the quality of care for cardiovascular diseases, especially hypertension, atrial fibrillation, heart failure, and AMI. Finally, teleregulation can offer support to PHC, in terms of solvability at this level, improving access to specialty care. 2.7. In Specialized Care 2.7.1. Heart Failure Extensive literature has examined the use of telemedicine strategies to monitor patients with heart failure with the objective of reducing hospitalizations associated with increased morbidity, mortality, and costs and improving patients’ adherence and participation. The interventions range from the application of traditional technologies like structured telephone support, telemonitoring using innovative technologies with implantable or wearable devices, DSS, and machine learning to predict complications. 115,116,117 The results are variable, but most demonstrate benefits. However, the use of these strategies in clinical practice is still very limited due to regulatory, logistics, and financial issues. 118 Telemonitoring may be invasive or noninvasive. Sensors are tools capable of detecting, recording, and responding to specific information, e.g., patients’ vital signs, and are increasingly embedded in smartphones and other mobile devices. Sensor logging can generate large data sets that may be transmitted in real time to health care professionals. 119 Since multiprofessional intervention programs often have geographical, economic, and bureaucratic barriers, telemonitoring can be a solution to promote care for patients with heart failure. 115 Evidence about structured telephone support and noninvasive telemonitoring in patients with heart failure has been summarized in a Cochrane systematic review of 41 studies. Structured telephone support reduced all- cause mortality (RR 0.87, 95%CI 0.77-0.98; n = 9,222) and heart failure-related hospitalizations (RR 0.85, 95%CI 0.77-0.93; n = 7,030), both with moderate-quality evidence. Telemonitoring reduced all-cause mortality (RR 0.80, 95%CI 0.68-0.94; n = 3,740) and heart failure-related hospitalizations (RR 0.71, 95%CI 0.60-0.83; n = 2,148), both with moderate-quality evidence. 119 Another meta-analysis 120 of 26 studies with 2,506 patients undergoing telemonitoring (including the transmission of vital signs) observed a time-dependent effect. Short-term follow-up (up to 180 days) had better results for hard outcomes (like mortality), which were not maintained during longer follow-up (1 year). Regardless of the follow-up duration, the strategy was unable to reduce hospitalization. An increase in emergency visits in the telemonitoring group raises the question of how an intervention that does not reduce hospitalization could reduce the mortality rate. Perhaps the early detection of signs of decompensation encourages a more frequent search for care and prompt treatment with diuretics and vasodilators without requiring intensive therapy. In the publication of one of its Clinical Protocols and Guidelines on Heart Failure, 121 the Ministry of Healthanalyzed several studies evaluating the benefits of telemonitoring based on telephone follow-up, recommending for health care services to consider follow-up using telephone support for patients with New York Heart Association (NYHA) functional class III to IV heart failure after hospital discharge. The analysis showed an 18% reduction in overall mortality with remote monitoring compared with usual care (RR 0.82, 95%CI 0.73-0.93). Telemonitoring also reduced by 23% (RR 0.77, 95%CI 0.68-0.88) the risk of hospitalization due to heart failure. Of note, this recommendation should be directed to patients with the potential of most benefits. There is no consensus on the intensity and frequency of monitoring, but they should be performed focused on clinical and educational guidance. Evidence regarding the duration of hospital stay is more fragile and controversial. Of seven studies on structured telephone support and nine on telemonitoring, only one on each type of intervention reported significantly decreased hospital stay. Additionally, nine of 11 studies on structured telephone support and five of 11 studies on telemonitoring reported significant improvements in quality of life. Three of nine studies on structured telephone support and one of six studies on telemonitoring reported reductions in cost, while two studies on telemonitoring reported increased costs due to expenses related to the intervention and increased medical management. Seven of the nine studies that assessed heart failure knowledge and self-care noted significant improvements. Despite acceptance by 76–97% of the participants, decreased adherence to the intervention over time can be challenging, and was reported in the review at 55.1–65.8%with structured telephone support and 75–98.5% with telemonitoring. 119 Machine learning techniques can be potentially valuable in remote monitoring of patients at high risk of heart failure. Individual characteristics of these patients obtained from the analysis of a large number of electronic medical records may help identify those at greatest risk of unfavorable outcomes who could benefit from individualized medical treatment. 122 The Seattle Heart Failure Model (SHFM), for example, is a machine learning framework for the calculation of mortality risk in heart failure. The model considers various clinical aspects obtained from electronic medical records to predict the prognosis of the disease and incorporates the potential impact of therapies on patients’ outcomes. This DSS was shown to be potentially useful in identifying patients with heart failure at higher risk of unfavorable outcomes, but met implementation barriers, as it was time consuming, expensive, required familiarity of the physician with computers, and failed to take into account other clinical variables that were not included in the collected data. 123 Evidence of the benefits of telemonitoring in heart failure has been recently confirmed with the publication of the Telemedical Interventional Management in Heart Failure II (TIM-HF2) study. This was a prospective, randomized, multicenter clinical trial including 1,571 patients with NYHA class II or III heart failure hospitalized due to heart failure within 12 months before the randomization and with an ejection fraction of 45% or lower. The patients were then randomized to remote management or usual care and followed up for up to 393 days. 124 1026