Challenges in heart failure care in four European countries: a comparative study.

BACKGROUND: In Europe, more than 15 million people live with heart failure (HF). It imposes an enormous social, organizational and economic burden. As a reaction to impending impact on healthcare provision, different country-specific structures for HF-care have been established. The aim of this report is to provide an overview and compare the HF-care approaches of Germany, Ireland, the Netherlands and the UK, and to open the possibility of learning from each other's experience. METHODS: A mixed methods approach was implemented that included a literature analysis, interviews and questionnaires with HF-patients and caregivers, and expert interviews with representatives from healthcare, health service research and medical informatics. RESULTS: The models of HF-care in all countries analyzed are based on the European Society of Cardiology guidelines for diagnosis and treatment of HF. Even though the HF-models differed in design and implementation in practice, key challenges were similar: (i) unequal distribution of care between urban and rural areas, (ii) long waiting times, (iii) unequal access to and provision of healthcare services, (iv) information and communication gaps and (v) inadequate implementation and financing of digital applications. CONCLUSION: Although promising approaches exist to structure and improve HF-care, across the four countries, implementation was reluctant to embrace novel methods. A lack of financial resources and insufficient digitalization making it difficult to adopt new concepts. Integration of HF-nurses seems to be an effective way of improving current models of HF-care. Digital solutions offer further opportunities to overcome communication and coordination gaps and to strengthen self-management skills.

[Heart failure care in a digitalized future : A discourse on resource-sparing structures and self-determined patients]. / Herzinsuffizienzversorgung in einer digitalisierten Zukunft : Ein Diskurs zu ressourcenschonenden Strukturen und selbstbestimmten Patienten.

Digital health solutions, applications of artificial intelligence (AI) and new technologies, such as cardiac magnetic resonance imaging and cardiac human genetics are currently being validated in cardiac healthcare pathways. They show promising approaches for improving existing healthcare structures in the future by strengthening the focus on predictive, preventive and personalized medicine. In addition, the accompanying use of digital health applications will become increasingly more important in the future healthcare, especially in patients with chronic diseases. In this article, the authors describe a case of chronic heart failure (HF) as an example to provide an overview of how digitalized healthcare can be efficiently designed across sectors and disciplines in the future. Moreover, the importance of a self-determined patient management for the treatment process itself is underlined. Since HF is frequently accompanied by various comorbidities during the course of the disease that are often recognized only after a delay, the necessity for a timely simultaneous and preventive treatment of multiple comorbidities in cardiovascular diseases is emphasized. Against this background the currently separately applied disease management programs (DMP) are critically questioned. The development of a holistic DMP encompassing all indications for the treatment of chronic diseases may pave the way to a more efficient medical care system.

Outcomes of Patients in Long-Term Opioid Maintenance Treatment.

BACKGROUND: Despite the importance of duration of opioid maintenance treatment (OMT), only few studies have reported outcomes of long-term OMT. OBJECTIVES: To describe outcomes of long-term (> 5 years) OMT patients with respect to substance use, physical and mental health, and socioeconomic characteristics. METHODS: Patients (n = 160) were recruited from 15 OMT offices in different regions of Germany. Data were collected using a structured interview at baseline, and clinical recordings, including urine drug screenings, during 12 monhts follow-up. RESULTS: Patients had a mean age of 44 years. During follow-up, 23% of patients showed indications of an alcohol problem. Cannabis was used by 56%, often frequently. Heroin was used by 28%, mostly infrequently. Three quarters of patients either had a non-substance related mental disorder (48.1%, most frequently affective and anxiety disorders) or somatic diagnosis (61.3%, frequently hepatitis C, HIV, or cardiovascular diseases), or both. Unemployment rate was 43.1% at baseline (27% for patients without comorbidity) and remained generally stable during follow-up. No arrests or incarcerations were recorded. During follow-up, 2.5% of patients prematurely terminated OMT, 2.5% regularly completed OMT. CONCLUSIONS: The sample as a whole was characterized by stable living conditions, high unemployment, low illicit opiate use, and a high retention rate. Continuation of OMT could enable further treatment of comorbidity and prevent resumption of a drug-dominated lifestyle. But it may well be asked how within the context of OMT further improvements can be achieved, especially with regard to further decrease of alcohol use and the treatment of depression.

[Telemedicine for patients with cardiac implants : Insights into everyday practice of remote monitoring in Germany in 2022]. / Telemedizinische Versorgung von Patienten mit kardialen Implantaten : Einblick in die telekardiologische Versorgungsrealität in Deutschland im Jahr 2022.

BACKGROUND: As telemedical structures continues to be developed in the German healthcare system, remote monitoring is becoming increasingly important to ensure comprehensive, outpatient, and tailored care. The national quality assurance measure "DOQUVIDE-Documentation of quality in the assessment of vital parameters by implanted devices" is used to provide insight into everyday care for patients with telemedicine-enabled devices in Germany. METHODS: DOQUVIDE is a measuring instrument for recording outpatient remote monitoring for patients with implanted pacemaker, implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy with a pacemaker (CRT-P), CRT defibrillator (CRT-D) devices and event recorder. DOQUVIDE records telemedically measured vital signs as well as cardiac events and the associated procedures initiated by cardiologists using standardized forms. RESULTS: In 74 practices/clinics in 14 federal states, 6687 patients received telemedical care in 2022; 937 were newly enrolled. These (60% male) were on average 77.8 years old, mainly with New York Heart Association (NYHA) class II (62.6%). A total of 5801 electronic records were generated as a result of telecardiology events, of which 3590 were due to pathological atrial fibrillation and 1812 due to ventricular high-frequency episodes. 295 events were triggered by event recorders and 95 by device therapies. The main measures taken were telephone contacts or outpatient visits. CONCLUSION: Remote monitoring has become a reality in German healthcare. Standardized processes and the establishment of quality assurance measures enable the definition of common quality standards and the identification of the potential for further development and simplify implementation in day-to-day care for practices.

Costs and benefits of personalized healthcare for patients with chronic heart failure in the care and education program "Telemedicine for the Heart".

OBJECTIVE: A health economic analysis was conducted to evaluate the program "Telemedicine for the Heart," which the German Foundation for the Chronically Ill organizes for the Techniker Krankenkasse, one of the biggest German statutory health insurance funds. The program consists of nurse-calls to motivate patients to perform regular self-measurements (blood pressure, pulse, weight) with either their own or telemedical measuring devices provided by the program. In the case of measured values outside of set limits, calls to treating physicians were placed to allow for the initiation of therapy adjustments where applicable. MATERIALS AND METHODS: To evaluate the program, a retrospective matched-pairs analysis was performed. Program participants (n=281) and regularly insured patients (n=843) were matched for demographics and morbidity status and compared according to their use of resources. RESULTS: Significant cost differences in favor of the study group of up to 25% in relation to total costs could be detected, particularly in the group of New York Heart Association (NYHA) classification II patients (persons with mild symptoms and slight limitation according to the NYHA classification for the extent of heart failure). In the more severe NYHA stages III and IV the cost relation differed and showed a slight cost disadvantage for the program group. Mortality was 35.1% lower in the program group than in the control group. Quality of life measures were almost constant over the observation time, compatible with a positive impact of the program on the highly impaired patient group. CONCLUSIONS: The findings suggest that, besides a reduction of costs, by participating in "Telemedicine for the Heart" patients with chronic heart failure experienced a reduced number of hospital stays, optimized medical therapy, better quality of life, and reduced mortality.

[The wearable cardioverter defibrillator as diagnostic tool : Case report from remote monitoring daily practice]. / Der Wearable Kardioverter-Defibrillator als Diagnostikum : Fallbeispiel aus dem telemedizinischen Alltag.

Telemedical care can point out new applications of already established therapeutics such as a wearable cardioverter-defibrillator (WCD) and improve the quality of care for chronically ill patients with heart failure through improved management of data derived from this device. The current case report describes the clinical course of a 71-year-old man, who was treated with a WCD in accordance with the current guidelines until a final decision was made about ICD implantation, after acute cardiac decompensation and lately diagnosed severe decrease of left ventricular function in the context of ischaemic cardiomyopathy. The data collected by the WCD were evaluated in a structured way via a telemedicine centre (TMC) and recurrence of the previously known paroxysmal atrial fibrillation (AF) was discovered. This made it possible to treat the paroxysmal AF, before cardiac decompensation happened again by adjusting the medication and early initiation of pulmonary vein isolation (PVI). This case exemplifies the usefulness of structured telemedical intervention, which makes it possible to meaningfully supplement established concepts of patient care, improve existing concepts and significantly improve patient care.

[Artificial intelligence in cardiology : Relevance, current applications, and future developments]. / Künstliche Intelligenz in der Kardiologie : Relevanz, aktuelle Anwendungen und nächste Schritte.

Big data and applications of artificial intelligence (AI), such as machine learning or deep learning, will enrich healthcare in the future and become increasingly important. Among other things, they have the potential to avoid unnecessary examinations as well as diagnostic and therapeutic errors. They could enable improved, early and accelerated decision-making. In the article, the authors provide an overview of current AI-based applications in cardiology. The examples describe innovative solutions for risk assessment, diagnosis and therapy support up to patient self-management. Big data and AI serve as a basis for efficient, predictive, preventive and personalised medicine. However, the examples also show that research is needed to further develop the solutions for the benefit of the patient and the medical profession, to demonstrate the effectiveness and benefits in health care and to establish legal and ethical standards.

[Structural requirements and prerequisites for outpatient implantation of defibrillators, devices for cardiac resynchronization and event recorders]. / Strukturmerkmale und Voraussetzungen zur ambulanten Implantation von implantierbaren Defibrillatoren, Geräten zur kardialen Resynchronisation und Ereignisrekordern.

The possibility of outpatient implantation of defibrillators, devices for cardiac resynchronization, and event recorders (collectively called cardiac implantable electronic devices, CIEDs) is becoming increasingly important. In Germany, only a few options for outpatient implantation are currently realized. Furthermore, there is a lack of uniform, recognized, and binding quality criteria. This article provides insight into the current contract constellations for outpatient surgery and defines a first, holistic quality concept for outpatient implantations of CIEDs. The present works aims to initiate a discourse in the specialist society in order to define a coordinated, binding quality concept. Then, this should serve as the basis for future outpatient implantation services, enabling comparability and to contribute long-term evidence.

[Position paper on required competencies of nonphysician employees in telemedicine centers]. / Positionspapier zum Anforderungsprofil von nichtärztlichen Assistenzkräften in Telemedizinzentren.

The non-physician employees in telemedicine centers (TMC) play a decisive role in the care and treatment of patients with heart failure. For this reason, a holistic profile consisting of professional and methodological as well as social and personal competences is necessary, which should be built up or promoted in corresponding training concepts. This position paper underlines the urgency of appropriate and standardized further training of non-physician employees for quality assurance in TMCs and summarizes the requirements for the additional qualification of a telemedical assistant across the board.

[Present and future relevance of telemedicine in cardiac arrhythmia emergencies]. / Derzeitige und zukünftige Bedeutung der Telemedizin im Arrhythmienotfall.

BACKGROUND: The use of remote monitoring has increased due to recently published randomised studies. However, its benefit during acute rhythm disorders still remains controversial. OBJECTIVES: The current review describes the current status and highlights possible application of telemedicine during acute rhythm disorders. MATERIALS AND METHODS: The prerequisites, structural properties of the sender/patient and the receiver of the data/physician are examined and the results of the current literature are presented. RESULTS: Telemedicine during emergency rhythm disorders are normally reserved for specific scenarios. The lack of 24/7 staff of the receiver/hospital represents the main barrier. CONCLUSIONS: Remote medicine in the current form is not yet ready to be implemented for acute rhythm disorders. Expansion of currently existing chest pain units (CPUs) might enable this 24/7 service in the near future.

Artificial intelligence supported patient self-care in chronic heart failure: a paradigm shift from reactive to predictive, preventive and personalised care.

Heart failure (HF) is one of the most complex chronic disorders with high prevalence, mainly due to the ageing population and better treatment of underlying diseases. Prevalence will continue to rise and is estimated to reach 3% of the population in Western countries by 2025. It is the most important cause of hospitalisation in subjects aged 65 years or more, resulting in high costs and major social impact. The current "one-size-fits-all" approach in the treatment of HF does not result in best outcome for all patients. These facts are an imminent threat to good quality management of patients with HF. An unorthodox approach from a new vision on care is required. We propose a novel predictive, preventive and personalised medicine approach where patients are truly leading their management, supported by an easily accessible online application that takes advantage of artificial intelligence. This strategy paper describes the needs in HF care, the needed paradigm shift and the elements that are required to achieve this shift. Through the inspiring collaboration of clinical and high-tech partners from North-West Europe combining state of the art HF care, artificial intelligence, serious gaming and patient coaching, a virtual doctor is being created. The results are expected to advance and personalise self-care, where standard care tasks are performed by the patients themselves, in principle without involvement of healthcare professionals, the latter being able to focus on complex conditions. This new vision on care will significantly reduce costs per patient while improving outcomes to enable long-term sustainability of top-level HF care.

[Telemetry in the clinical setting]. / Telemetrie : Szenarien im klinischen Umfeld.

Telemetric cardiac monitoring was invented in 1949 by Norman J Holter. Its clinical use started in the early 1960s. In the hospital, biotelemetry allows early mobilization of patients with cardiovascular risk and addresses the need for arrhythmia or oxygen saturation monitoring. Nowadays telemetry either uses vendor-specific UHF band broadcasting or the digital ISM band (Industrial, Scientific, and Medical Band) standardized Wi-Fi network technology. Modern telemetry radio transmitters can measure and send multiple physiological parameters like multi-channel ECG, NIPB and oxygen saturation. The continuous measurement of oxygen saturation is mandatory for the remote monitoring of patients with cardiac pacemakers. Real 12-lead ECG systems with diagnostic quality are an advantage for monitoring patients with chest pain syndromes or in drug testing wards. Modern systems are light-weight and deliver a maximum of carrying comfort due to optimized cable design. Important for the system selection is a sophisticated detection algorithm with a maximum reduction of artifacts. Home-monitoring of implantable cardiac devices with telemetric functionalities are becoming popular because it allows remote diagnosis of proper device functionality and also optimization of the device settings. Continuous real-time monitoring at home for patients with chronic disease may be possible in the future using Digital Video Broadcasting Terrestrial (DVB-T) technology in Europe, but is currently not yet available.

[Current status and future of telemonitoring : Scenarios for telemedical care in 2025]. / Aktueller Stand und Zukunft des Telemonitoring : Szenarien für die telemedizinische Versorgung im Jahr 2025.

Telemonitoring is an already realized implementation of digital transformation in the healthcare system. It has the potential to support and secure a sustainable and comprehensive provision of healthcare for a rising number of chronically ill patients, e. g. patients with chronic heart failure. Remote regions in particular can profit from the benefits of telemonitoring; however, so far telemonitoring services have not become truly established in the German healthcare market. Together with experts from politics, science and practice, a scenario analysis "Health Care System 2025 - A Place for Telemonitoring?" was carried out with the aim to examine the future development of the healthcare market and to draw conclusions for providers of telemonitoring services or devices. The scenario analysis contained two workshops and an expert survey and was supported by a scenario software. The current drivers and barriers of the diffusion of telemonitoring were identified and the most relevant factors that influence the future development of the healthcare market were discussed. Based on those influencing factors, three different scenarios were determined: (1) administrating rather than shaping, (2) safely into the future and (3) interconnected and digital world. In the subsequent consequence analysis activities were defined, which describe the necessary infrastructure, software instruments, organizational structures and provision of services and discuss possible activities, which prepare telemonitoring solutions for the future.

A multiplex PCR strategy to screen for known mutations in families with sudden cardiac death burden.

Ventricular tachyarrythmia occurring in ischemic heart disease, dilated/hypertrophic cardiomyopathies or rare monogenic mutations of cardiac ion channels or associated proteins belong to the most frequent causes of sudden cardiac death (SCD). In further decades, next generation sequencing and bioinformatic analysis will become the gold standard of SCD risk stratification. At the moment, Sanger-sequencing is still obligatory in genetic diagnosis. A multiplex polymerase chain reaction (PCR) assay detecting eight SCD mutations in one reaction-tube was developed. To test the general validity of the assay, it was used with 12 patients, who had one or two of the eight mutations (LMNA, p.V256V; SCN5A, p.R1583C; RYR2, p.G1885E; MYH7, V606M; DSG2, p.T335A; KCNJ8, p.S422L; MYBPC, p.E441K; TNNT2, A38V). Thereafter, we tested the multiplex assay in a real diagnostic environment within a high risk family of several past SCD cases. This method allows efficient discrimination of multiple mutations by allele-specific PCR with standard PCR conditions. It relies on obtaining a PCR product specific to the mutation or wildtype-using primers that have the 3'end base complementary to the DNA template site, i.e. a specific primer only permits amplification to take place when its 3'terminal nucleotide matches with its target sequence. The PCR products are further analyzed by length, with Tape Station®(Agilent Technologies, Germany), a high-fidelity capillary chromatography test. The novel multiplex PCR assay strategy could be a good additional test used for SCD risk stratification. Advantages of the test are high velocity and ease of implementation, low price and flexibility of application within cardiomyopathy families for screening purposes.

General practitioners' adherence to chronic heart failure guidelines regarding medication: the GP-HF study.

AIMS: The adherence to the guidelines for pharmacotherapy of chronic heart failure (HF)-patients improves prognosis. Although general practitioners (GPs) treat the majority of HF-patients, information about GPs' current guideline adherence and their typical prescription rationales is sparse. METHODS AND RESULTS: A three-stage study design was employed. In Stage I, 206 patient records from 15 randomly chosen GP practices were analysed; 76 % of patients were prescribed ACE-inhibitors or angiotensin receptor blockers (ACEIs/ARBs), 73 % beta blocker (BBs), but only 18 % mineralocorticoid receptor antagonists (MRAs). ACEI doses were at 62 % of the guideline recommended target doses, BBs at 46 %, while MRAs were sufficiently highly dosed. The guideline adherence indicator (GAI-3) was only 22 %. In Stage II, GPs in all 15 practices were interviewed, and health record documentation deficits and patients' contraindications were taken into account. This increased the percentage of patients correctly prescribed ACEIs/ARBs to 87 %, BBs to 84 % and GAI-3 to 56 %. MRAs exhibited the most frequent contraindications, but remained underprescribed. Many GPs seemed not to be aware of the therapeutic value of MRAs or the need to reach target doses of the indicated drug classes. Patients-interviewed in Stage III-reported good tolerability of HF-drugs and generally good compliance, although 11 % discontinued HF-medication on their own. CONCLUSIONS: Guideline adherence of GPs was higher than expected from literature and might be further improved by highlighting MRAs as the third prognostically relevant drug class beside ACEIs/ARBs and BBs and stronger emphasis on target doses.

[Localization of the origin of idiopathic ventricular extrasystoles and tachycardia from the outflow tract]. / Ursprungslokalisation bei idiopathischen ventrikulären Extrasystolen und Tachykardien aus dem Ausflusstrakt.

Premature ventricular contractions (PVC) are a common cause for complaints. As a rule PVCs are not life-threatening if no structural heart disease is present; however, due to the symptoms treatment is often required using either antiarrhythmic drugs or more commonly catheter ablation. The surface electrocardiogram (ECG) is very helpful in localizing the origin of the arrhythmia, in particular for differentiating right from left ventricular sources.

[The Wearable Cardioverter-Defibrillator (WCD)]. / Der tragbare Kardioverter-Defibrillator.

While the implantable cardioverter-defibrillator (ICD) has been proven to be the best choice for patients with long-term risk for sudden cardiac arrest/sudden cardiac death (SCA/SCD), the question is how to manage patients with only temporary risk, e.g., during the guidelines-recommended waiting period until the decision for an ICD can be made. These patient groups should be monitored around the clock to guarantee a lifesaving shock within a few minutes, if necessary.These conditions can be accomplished by the wearable cardioverter-defibrillator (WCD) in the outpatient sector. The WCD is worn on the skin and consists of four nonadhesive ECG electrodes as well as three defibrillation electrodes-two at the back and one at the front-embedded in a garment. The defibrillation unit is connected via a cord and can be worn over the shoulder or on a belt. Cardiac events can be recorded and retrospectively analyzed by the treating physician.The WCD is a safe and effective measure to terminate potentially lethal ventricular tachycardia and ventricular fibrillation. It may be used early after myocardial infarction with reduced left ventricular ejection fraction (LVEF), as well as for patients with acute heart failure in nonischemic cardiomyopathy with uncertain cause and prognosis. In addition, it may be used for patients waiting for heart transplantation, for patients who cannot be implanted an ICD due to comorbidities, and for patients after explantation of their ICD, e.g., because of infection until reimplantation.One may expect that risk stratification of patients with the WCD will lead to even better selection for ICD use.

Prediction and personalised treatment of atrial fibrillation-stroke prevention: consolidated position paper of CVD professionals.

Atrial fibrillation (AF) is one of the major morbidity and health economic factors in Europe and often associated with several co-morbidities. This paper (1) underlines the importance of highly professional AF management utilising a multi-disciplinary expertise, especially considering the role of AF regarding the stroke risk and prevention, (2) demonstrates the consolidated position of CVD professionals and (3) emphasises those research aspects that could deepen the understanding of the emergence and the treatment of AF and therefore helps to provide a personalised preventive and more effective management of AF. Specialised calls are considered for that within the new European Programme 'Horizon 2020'.