Impact of telemonitoring-guided rapid guideline-directed medical therapy escalation on left ventricular reverse remodeling in new-onset acute heart failure with reduced ejection fraction
X Xiayan, H Z Yu, Z Y Yan, K Kam, P W Lee, B Yan, G M TanAbstract
Background
Left ventricular (LV) adverse remodeling is a key driver of heart failure (HF) progression. The post-discharge vulnerable phase represents a critical window for therapeutic intervention and rapid up titration of guideline-directed medical therapy (GDMT) has been shown to improve HF outcomes. Whether telemonitoring-guided accelerated optimization of (GDMT) translates into rapid LV reverse remodeling (LVRR) remains to be fully elucidated.
Purpose
To compare the impact of a telemonitoring-guided rapid GDMT up titration strategy on early LVRR and geometric transition versus usual care in patients with first-onset acute heart failure with reduced ejection fraction (HFrEF).
Methods
In this subanalysis of the prospective TOM-HF study, acute HFrEF patients received a mobile health-delivered, telemonitoring-guided titration strategy following hospital discharge, and were compared with a 1:2 propensity score–matched usual care cohort. Echocardiography was performed at discharge and at 90 days. The primary endpoint was LVRR at follow-up, defined as LV end-systolic volume reduction ≥15% with LVEF increase ≥10% at 90 days. As a structural correlate of remodeling, LV geometry was categorized into four patterns (normal, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy) based on LV mass index and relative wall thickness. Secondary endpoints included longitudinal changes in LV geometry distribution, LV and right ventricular (RV) function parameters, with between-group differences analyzed via multinomial logistic regression adjusted for baseline.
Results
A total of 60 patients with paired echocardiographic data were analyzed (TOM-HF n=20; usual care n=40). LVRR occurred more frequently in TOM-HF than usual care (84.2% vs 54.1%, P=0.039). At 90 days, the distribution of the four-class LV geometry differed significantly between groups after adjusting for baseline geometry (P=0.018), with TOM-HF group demonstrating a significant shift toward normal geometry (5% to 42%) and a dramatic reduction in eccentric hypertrophy (74% to 11%; Figure 1). Consistently, TOM-HF showed greater improvement in LV systolic function than usual care after baseline adjustment (stroke volume Adj diff +17.18 mL, P=0.002; LVEF Adj diff +10.17 percentage points, P<0.001), accompanied by smaller LV dimensions (LVIDs Adj diff −0.55 cm, P=0.009; LVIDd Adj diff −0.63 cm, P=0.045) and a favorable RV function signal (TAPSE Adj diff +0.21 cm, P=0.038; Table 1).
Conclusion
A telemonitoring-guided accelerated GDMT optimization strategy significantly promotes early LVRR and restores more favorable LV geometric patterns compared to usual care. Larger studies should evaluate whether this digital strategy translates into improved clinical outcomes.Figure 1