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 The percentage of days lost due to unplanned cardiovascular hospitalizations and death from all causes was 4.88% in the remote patient management group and 6.64% in the usual care group (p = 0.04). Patients assigned to remote management lost an average of 17.8 days/year compared with 24.2 days/year among patients assigned to usual care. The hazard ratio (HR) for all-cause mortality was 0.70 (95%CI 0.50- 0.96; p = 0.0280) in favor of the teleconsultation group, but cardiovascular mortality was not significantly different between both groups (HR 0.671, 95%CI 0.45-1.01; p = 0.0560). 124 New devices to monitor intracardiac pressure present the most compelling evidence for the application of telemonitoring and use more advanced technologies. CardioMEMS is a device that is percutaneously implanted in the pulmonary artery to transmit central pressure values to a platform. When the pressure levels of the pulmonary artery rise above a certain threshold, the physician receives an alert and a statement indicating congestion or low output. Other devices for implantation in the right ventricle are being used experimentally. The study CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients) 125 evaluated patients with NYHA functional class III heart failure across 64 centers in the US. The patients were randomized by a centralized electronic system to a group of management by CardioMEMS or to a control group. In the monitoring group, the physicians used daily data from pulmonary artery pressure measurements to guide treatment. After a follow-up of 15 months, the monitoring group had a 37% reduction in hospitalizations related to heart failure compared with the control group. The long-term follow-up of this study, in which the control group was switched to receive pulmonary pressure monitoring, showed that these results remained significant and clinically relevant over time. 126 2.7.2. In Hypertension Telemonitoring strategies can also be applied for BP control, but they overlap the self- monitoring approach. In the TASMINH4 trial, 1,182 patients were randomized (1:1:1) to general titration of antihypertensive medication based on clinical readings by a generalist (usual care group), self- monitoring (self-monitoring group), or self-monitoring along with telemonitoring (telemonitoring group). The study found that the use of BP self-monitoring to titrate antihypertensive therapy in poorly controlled hypertension in primary care resulted in lower systolic BP without increasing the workload of the clinical team. After 1 year, patients who had the medications adjusted based on self-monitoring with or without telemonitoring had significantly lower systolic BP than those who had the treatment adjusted based on BP measured during consultations. The BP values in the telemonitoring group that received medication titration became lower faster (at 6 months) than in those in the self-monitoring group, an effect that is likely to further reduce cardiovascular events and improve long-term control. 127,128 Several studies also show that strategies for hypertension telemonitoring involving a clinical pharmacist lead to a beneficial impact on BP control in the short and medium term. Margolis et al. 129 evaluated the durability of the effect of such intervention after a follow-up of 54 months in a randomized cluster study among 16 primary care clinics and 450 patients (228 receiving telemonitoring and 222 on usual care). Intensive intervention based on telemonitoring maintained the effects for up to 24 months (12 months after the end of the intervention), but lost efficacy in the long term. 129 A prospective observational cohort study monitored the BP levels before and after an educational intervention and introduction to home BP monitoring (HBPM). In the intervention group, 484 patients were instructed to track their BP levels using a smartphone three to seven times a week. The mean BP levels improved from 42% to 67% among patients on HBPM compared with 59% to 67% among controls (p < 0.01). 130 The INTERACT study was a randomized clinical trial in which 303 patients using BP and/or lipid-lowering medications were randomized to receive or not receive text messages. The group that received text messages improved medication adherence at 6 months compared with the group that did not receive messages. The overall improvement in medication adherence was 16%. 129,131 A Cochrane systematic review 132 sought to establish the effectiveness of mobile phone-based interventions in improving adherence to medications prescribed for primary prevention of cardiovascular disease in adults. The participants in the trials were recruited from community- based primary care or outpatient clinics in high-income (Canada, Spain) and upper- to middle-income countries (South Africa, China), but the interventions varied widely. One trial evaluated an intervention focused on adherence to BP medication delivered exclusively by text messaging, while another trial involved BP monitoring combined with feedback delivered via smartphone. The authors considered the body of evidence for the effect of cell phone-based interventions on objective outcomes (BP and cholesterol) having a low quality. Of two studies that evaluated medication adherence along with other lifestyle modifications, one reported a small beneficial effect on lowering low-density lipoprotein cholesterol while the other found no benefit. Another trial (1,372 participants) on an intervention based on text messaging showed a small reduction in systolic BP in a group that delivered information-only text messages, but uncertain evidence of benefit in a second intervention group that provided additional interactivity. One study examined the effect of BP monitoring combined with smartphone text messaging and reported moderate intervention benefits to systolic and diastolic BP. There was conflicting evidence from trials targeting medication adherence along with lifestyle advice using multicomponent interventions. Another study found large benefits on BP levels, while another study showed no such effect. The authors of this Cochrane review concluded that there is low-quality evidence related to the effects of interventions delivered via mobile phone in increasing adherence to medications prescribed for primary prevention. The conclusion based on this review is that there is current uncertainty about the effectiveness of such interventions. 1027