Heart failure - REM-HF

The clinical question

Heart failure happens when the heart muscle has become weakened and isn’t able to pump blood around the body effectively. Many patients with heart failure have devices implanted into their chest to help manage their condition. For example, a pacemaker, which uses electrical impulses to maintain a normal heart rhythm. Or a defibrillator, which can shock the heart back into a normal rhythm if it stops beating correctly. 

Some of these devices can record information about how the heart is working. This information could help doctors decide if a patient’s treatment needs to be changed, or give an early warning of worsening heart failure or complications. Patients fitted with these devices will usually attend routine hospital appointments to assess any changes to their symptoms and to have their device readings checked.

Because of advances in technology, some devices now allow doctors to retrieve the information they record online, without patients having to go to hospital. This is done using a small monitor which sends the device data over a telephone line to a secure hospital server. This could allow clinical staff to check device data more regularly. But whether this is a cost effective way to improve the care of people with heart failure was unclear.

The BHF-funded ‘Remote Management of Heart Failure Using Implantable Electronic Devices’ (REM-HF) study, led by Professor John Morgan from the University of Southampton and Professor Martin Cowie from Imperial College London, was carried out to find out.

What did the study involve?

Between 2011 and 2014, the REM-HF trial recruited 1650 people with heart failure, who had an implanted device that could record information about their heart function. The trial took place across 9 UK hospitals. Participants were randomly assigned to either:

• Receive ‘remote monitoring’. Participants were shown how to download the information recorded by the device. They were asked to do this on a weekly basis. This information was reviewed by members of the research team. Where appropriate, this information was used to offer advice about medication changes, or to recommend that the patient visit their GP or hospital for a check-up.
• Receive ‘usual care’. This varied between hospitals, but generally meant that participants attended a device clinic for monitoring every 3 to 6 months.

What did the study show?

• A total of 79,325 downloads were reviewed by the research team.
• About 70% of patients in the remote monitoring group received advice or were asked to seek further medical attention as a result of their readings.
• However, after around 3 years’ follow-up, patients who were remotely monitored were no more or less likely to survive, or have an unplanned hospitalisation, than patients in the usual care group.

Why is the study important?

The results of REM-HF had important implications for clinical practice and health economics within the NHS. At the European Society of Cardiology Conference in Rome in 2016, where the trial reported its findings, Professor Cowie gave his thoughts on the results:

He added: "But it is possible that an effect could be demonstrated in health care systems with less well developed usual care, where patients are less-well treated and have more severe symptoms.”

Overall, the results of REM-HF suggest that routine use of currently available remote monitoring technology does not offer any benefits for people with heart failure. Current guidelines suggest that monitoring can be considered for people with severe heart failure or hard to manage symptoms. But these findings provide evidence that – for now - the NHS should not invest in making this monitoring more widely available.

Study details

"Remote Monitoring: an evaluation of implantable devices for management of Heart Failure patients- REM-HF."
Award reference:  SP/11/1/28479
Principal Investigator: Professor John Morgan, University of Southampton
Trial registration number: ISRCTN96536028

Publication details

Morgan JM, Kitt S, Gill J, et al. Remote management of heart failure using implantable electronic devices. Eur Heart J. 2017;38(30):2352-2360.