Introduction: Management of patients affected both from heart failure (HF) and Chronic Kidney Disease (CKD) is a well-known issue. The latest ESC 2023 Heart Failure Guidelines recommend the use of four classes of drugs to reduce mortality and hospital admissions due to HF. CKD represents one of the most frequently reported factors underlying the failure to prescribe or to titrate recommended treatments. New telemonitoring techniques can be useful in the detection of signs of decompensation and achievement of therapeutic targets.
Methods: Our project aims at optimizing the management, treatment and follow-up of patients with HF, thanks to multidisciplinary management and an accurate and easy-to-use home telemonitoring equipment provided to patients.
Patients will be divided into two groups based on a high (group A) or medium/low risk (group B) profile. Remote monitoring will last 3 weeks, before the first clinical control in out-patient HF clinic. Once the inclusion and exclusion criteria have been assessed, the patient will be enrolled in one of the two groups.
The home telemonitoring equipment allows the detection of different clinical parameters (oximetry, blood pressure, heart rate, 6-lead EKG, body weight) and the visualization of blood test reports. Data are recorded on a tablet connected to a cloud server. A questionnaire is provided to the patient aimed at understanding his/her symptoms and quality of life. Data are sent daily to all the healthcare professionals involved in the project.
Group A: High risk patients. The patient will be trained on the operation of the remote monitoring equipment. Daily self-measurement of parameters for 3 weeks after discharge.
GROUP B: Low-medium risk patients. Weekly measurement of the parameters by the community nurse for 3 weeks after discharge.
In case of signs of congestion and clinical HF decompensation patients from both groups could be treated with diuretic infusion at home or in community out-patient clinics (Case di Comunità).
Expected results: Reducing mortality and re-hospitalization for decompensated HF, achievement of the pharmacological treatment targets recommended by the ESC guidelines, reducing renal disease progression, building a multi-professional HF support-team, testing a community telemonitoring programme based on the cloud.
Preliminary data: preliminary data will be available on May 2024.