Key Factors for A Successful Telemedicine Solution for Cardiovascular Diseases: A Systematic Review

1. Introduction

In recent years, the adoption of telemonitoring systems in cardiology has shown significant potential in improving the management of chronic cardiovascular diseases [1]. Telemedicine, defined as using technology to provide healthcare services remotely [2], has become crucial in treating conditions such as hypertension, atrial fibrillation, and heart failure. This approach allows for constant monitoring of patient’s vital parameters, enhancing the timeliness and effectiveness of care.

The benefits of telemonitoring have been documented in various systematic reviews [3,4], which have highlighted how the implementation of such technologies can lead to a significant reduction in hospitalizations and mortality rates, as well as an overall improvement in patient quality of life. However, it is important to note that this systematic review does not include a meta-analysis but focuses on the qualitative analysis of available studies.

The universal definitions of the diseases considered in this review are crucial for contextualizing the results and effectively comparing studies. Hypertension is commonly defined as a systolic blood pressure of at least 140 mmHg and/or a diastolic pressure of at least 90 mmHg [5]. Heart failure is characterized by the heart’s inability to pump sufficient blood to meet the body’s needs [6,7], while atrial fibrillation is a cardiac arrhythmia that results in an irregular and often rapid heartbeat [8].

The rapid development of telemedicine has been further accelerated by the COVID-19 pandemic, highlighting the need for innovative and remote healthcare solutions [9]. During this period, a significant increase in telemedicine services was observed, making it essential to evaluate the effectiveness and efficiency of these interventions in emergency health contexts. Telemedicine facilitated the continuity of care during the pandemic and opened new perspectives for managing chronic diseases, reducing the need for in-person visits, and improving accessibility to healthcare services [10].

The primary objective of this systematic review is to assess whether the use of telemonitoring systems for patients with chronic cardiovascular diseases can improve their quality of life, including psychological and physical health, and increase their awareness of the disease and management methods. Specifically, the focus is on the effectiveness of these systems in improving disease-specific parameters, quality of life, and patients’ ability to self-manage their condition.

In this context, telemonitoring presents a promising solution to address the challenges posed by cardiovascular diseases. Several studies [11,12,13,14,15,16] have demonstrated that using remote monitoring devices and mobile applications can lead to better blood pressure control, reduced heart failure symptoms, and improved patients’ quality of life. Moreover, the real-time monitoring of vital parameters allows physicians to intervene promptly in case of a deterioration in the patient’s condition, thereby enhancing the effectiveness of prescribed therapies.

Despite the numerous advantages, there are still some barriers to the widespread adoption of telemedicine, including the need for adequate technological and secure infrastructure, training of medical personnel, and resistance to change from older patients [17,18,19]. However, with continuous technological advancement and the increasing integration of these solutions into healthcare systems, telemonitoring will likely become an integral part of cardiovascular disease management in the near future.

This systematic review aims to provide a comprehensive overview of the current state of telemonitoring for cardiovascular diseases. It analyzes the results of recent studies and identifies best practices and areas needing further research. The ultimate goal is to provide evidence-based recommendations for effectively implementing these technologies to improve clinical outcomes and the quality of life for patients with chronic cardiovascular diseases.

2. Materials and Methods

This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework [20,21,22]. The review aims to answer the following research question: does the use of telemonitoring systems for patients with chronic cardiovascular diseases (CVD) allow for improving their living conditions, including psychological and physical health, and improve their awareness of the disease and management methods?

2.1. Eligibility Criteria

As observed in other studies [23], the PICOS (Population, Intervention, Comparator, Outcomes, Study design) [24] strategy was adopted to perform the research and the selection of the studies to determine the inclusion criteria of articles in the review. In the following subsections, the eligibility criteria for each of the categories of the PICOS strategy are explained in detail.

2.1.1. Population

All studies between 2020 and 2024 analyzing the effects of a telemedicine intervention on patients aged 18 years or older were considered eligible for inclusion if they had one or more of the following cardiovascular diseases: hypertension, heart failure, or atrial fibrillation.

2.1.2. Intervention

The considered trials concerned the use of systems enabling medical practitioners to remotely monitor disease-specific parameters of intervention group participants. Only trials in which patients in the intervention group received a telemonitoring device to collect disease-related parameter values or a smartphone app to send their data to the medical center were included. The remote patient monitoring devices must be able to transmit the collected data to the medical team so that the latter can make appropriate changes to the therapy.

2.1.3. Comparator

Studies in which the usual care (UC) or a more limited intervention (e.g., a version of the app with fewer functionalities concerning the app used in the intervention) was used in the control group were considered eligible for inclusion in the systematic review.

2.1.4. Outcomes

Consideration was given to trials in which the results being measured are related to the improvement of the patient’s living condition, understood both as physical or psychological health and as a better awareness of the disease and the techniques for managing it, i.e., improvement in quality of life, disease-specific parameters, ability to measure these parameters, self-care, etc.

2.1.5. Study Design

Only randomized controlled trials (RCTs) were included, while non-randomized or non-controlled trials, study protocols and designs, cross-sectional, retrospective, qualitative, observational, and pilot studies, conference proceedings, feasibility, cost, ancillary, and secondary analyses, and all studies not reporting the use of a telemonitoring system were excluded.

2.2. Search Strategy

The literature search covered articles in the PubMed, Scopus, and Web of Science databases and published in English from January 1st, 2020 to February 2nd, 2024. The choice to analyze the period between 2020 and 2024 is motivated by the significant increase in telemedicine services found during the COVID-19 pandemic [25,26,27]. It will be interesting to see whether this topic of research and application is exclusively related to the early times of pandemic-related emergencies or whether it has become common in healthcare. The Supplemental Appendix contains a description of the entire search approach and terms.

All records found were exported in Research Information Systems (RIS) formats, which are fed to EndNote 1, the reference manager used for this review.

All English-language studies were included. The terms used as keywords for the search were ’telemedicine’, ’heart failure’, ’hypertension’, ’atrial fibrillation’, and their synonyms and combinations obtained using Boolean operators. In particular, the following combination of terms was used: (“telemedicine*” AND (“hypertension*” OR “heart failure*” OR “atrial fibrillation*”)).

Prior to the screening stage by study title, all duplicate papers were eliminated via a reference management tool.

2.3. Study Selection

The studies were selected using the appropriate tool produced by Clarivate Analytics, EndNote. In the first step, the title and abstract of the papers from the database search were analyzed, eliminating all articles that did not meet the inclusion criteria. Subsequently, full texts were examined to exclude all articles that did not include remote monitoring of disease-specific parameters in their interventions.

2.4. Data Extraction

We performed independent data extraction and obtained the following information for each trial: authors, year, country, and reference; number of participants and their age and sex; health condition; type of intervention (how the data are transmitted, follow-up duration, etc.); comparator (usual care, different interventions, etc.); outcomes (primary and secondary); impact of telemonitoring intervention on outcomes, compared to the control group.

2.5. Risk of Bias Assessment

We performed an independent risk of bias assessment of all papers using the Cochrane Risk of Bias 2 [28,29], the standard de facto for the evaluation of bias in studies 2. All included studies were classified into five different domains according to three levels of bias: low, medium, and high. Some outcomes, such as hospitalizations and mortality, are unlikely to be influenced by the lack of blindness. In contrast, others, such as improvement in quality of life (QoL), disease-specific knowledge, or self-care, are likely influenced by patient subjectivity.

3. Results

3.1. Study Selection and Characteristics

There were 866 articles found in all. The remaining 831 records were assessed for inclusion/exclusion criteria based on their title and abstract after 35 duplicates were removed. According to this screening, 793 works that did not fit the inclusion requirements were dropped. After reading 38 whole texts in all, 22 of them [30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51] were considered appropriate after the selection process since they met all the standards (Figure 1).

Table 1, Table 2, and Table 3 show the characteristics of the studies included in the analysis, respectively, for the three diseases reviewed, i.e., hypertension, atrial fibrillation, and heart failure. Less than 100 patients were included in each arm of a large number (12/22, 54.5%) of RCTs, and sample sizes range from 40 [49] to 3628 [38]. Most of the included studies were carried out in China (5/22, 22.7%), with a smaller number of studies carried out in Sweden, Germany, and the USA (2/22, 9.1%). Additionally, 4.5% (1/22) of the investigations were conducted in each of the following nations: Iran [31], Jordan [36], Spain [37], UK [45], Greece [41], South Korea [32], Denmark [33], Belgium (in combination with Italy) [34], Australia [35], Singapore [39] and Argentina [49]. The average age ranged from 48 to 80, with a greater percentage of males. Patients in the majority of trials (16/22, 72.7%) were followed for fewer than a year, and follow-up time ranges from 8 weeks [36] to 24 months [37,40]. The variables that were most frequently monitored were blood pressure, quality of life (9/22, 40.91%), self-care (6/22, 27.27%), and hospitalization (4/22, 18.2%). In particular, QoL was measured through SF-36 (consisting of MCS and PCS) [52], EQ-5D-5L [53], MLHFQ [54], AFEQT (2/22, 9.1%) [55], SF-12 [56] and MacNew Heart Disease HRQoL (1/22, 4.5%) [57]. Furthermore, current European recommendations [58] state that a mean office systolic blood pressure (SBP) of at least 140 mmHg and/or a diastolic blood pressure (DBP) of at least 90 mmHg constitute uncontrolled blood pressure. Manual input was the most common data entry method (14/22, 63.6%). At the same time, eight of the strategies under study (36.36%) stated automatic interface using external devices that were wirelessly connected (e.g., scales, blood pressure monitors, etc.). Most trials (18/22, 81.8%) compared the intervention with standard care, which included in-person meetings with general practitioners or the hospital care team and routine visits (outpatient clinics).

3.2. Interventions

For hypertension, Andersson et al. [30] provided participants with a Microlife BP A6 BT monitor and nightly reminders to measure and report blood pressure and other vital signs via a web portal accessible to both patients and healthcare providers. Bozorgi et al. [31] used an app for blood pressure logging, medication reminders, and informational support, alerting family and clinicians if readings were abnormal. Dwairej et al. [36] also offered an app for blood pressure recording and access to educational materials, with data available to clinicians through a web tool. Echeazarra et al. [37] implemented a Telegram bot for twice-daily blood pressure reminders and recording, with data available to healthcare providers. Leupold et al. [42] used a BOSO medicus family 4 monitor, an app, and an online eLearning system for data transmission and graphical analysis. Liu et al. [43] provided an app for logging blood pressure and other health metrics, such as heart rate and medication intake, viewable by healthcare providers. McManus et al. [45] had participants measure blood pressure with an Omron M3 monitor twice each morning for a week each month, with out-of-range values alerting clinicians via email. Meng et al. [46] equipped participants with a sphygmomanometer that automatically uploaded readings to an app accessible by patients and clinicians. Yuting et al. [50] provided a wrist blood pressure monitor that sent daily readings via Bluetooth to a website. Zhang et al. [51] used a Sanjian Tech Co. digital bracelet and app for patients and healthcare providers to log and monitor data automatically.

In atrial fibrillation studies, Guo et al. [38] used an app and photoplethysmography (PPG) smart devices for heart rhythm monitoring, allowing remote or hospital-based management of critical events. Lazaridis et al. [41] had both intervention and control groups use an app to log heart rate, with the intervention group logging additional parameters like blood pressure, weight, glucose levels, oxygen saturation, and therapy adherence. Marcus et al. [44] provided an app for selecting and statistically analyzing triggers for atrial fibrillation episodes, offering probabilistic feedback on potential triggers.

For heart failure, Choi et al. [32] offered an app for daily logging of blood pressure, weight, medication, meals, and exercise, including informational content and direct Q&A with clinicians. Cichosz et al. [33] provided a Samsung Galaxy Tab2, a UA-767 blood pressure monitor, and a precision scale, with data transmitted to a central system and alerts for out-of-range values. Clays et al. [34] used a comprehensive system with a blood pressure monitor, scale, pill organizer, and wristband sensor, with data processed by a decision support system and displayed via a smartphone app installed on a Nokia 6 TA-1021 smartphone. Ding et al. [35] used a digital scale and Samsung Galaxy Tab A to transmit weight data to an online decision support system, generating six possible alerts about weight fluctuation or low-level battery. Jiang et al. [39] combined educational and self-management toolkits with three home visits and an app, only available for experimental group B, for reminders, symptom logging, and communication with medical staff. Koehler et al. [40] provided devices for collecting blood pressure, weight, and electrocardiogram (ECG), which were connected via Bluetooth to a digital assistant transmitting data to a medical center. Sahlin et al. [47] offered the OPTILOGG device, a tablet connected to a scale featuring symptom monitoring, interactive education, and diuretic adjustments, with data shareable to medical practitioners at the patient’s discretion. Upshaw et al. [48] used an app for daily logging of weight, heart rate, blood pressure, and symptoms, with healthcare provider alerts for concerning data. Yanicelli et al. [49] provided a system that included an app for daily logging of health metrics, processing data online, and sending risk alerts to medical staff, with additional educational features and interactive content.

3.3. Risk of bias assessment

Each included study’s RoB2 domain scores are displayed in Supplemental Figure 1. Twenty-one (95.5%) RCTs raised at least some concerns about bias. At the same time, only one (4.5%) was classified as having minimal risk of bias [51].

In particular, two studies (9.1%) showed some concerns about bias in the randomization process. Because of the deviations from the intended interventions, most of the findings (19/22, 86.36%) either raised some concerns or demonstrated a significant risk of bias. Due to incomplete outcome data, three RCTs (13.6%) had problems or a high risk of bias. Of the 22 studies, thirteen (59.1%) have some issues or a significant risk of bias in measuring outcomes. Lastly, only a small number of RCTs (5/22, 22.73%) revealed significant issues or a high risk of bias in the reported outcome selection.

3.4. Outcomes

Most of the involved studies in blood pressure (8/9, 88.9%) showed a positive effect of telemonitoring intervention on the BP control ratio of patients. Concerning quality of life, it must be remembered that the studies do not use a unique metric to measure it, so it is impossible to compare the various trials objectively. However, four out of nine studies (44.4%) monitoring QoL show improvements compared to the control group due to the telemedicine intervention. Most studies (5/6, 83.3%) focusing on self-care demonstrate increases in this variable due to the telemedicine intervention with the control group. Finally, studies concerning hospitalization showed, for the biggest part (3/4, 75%), a positive impact of telemedicine on these outcomes when compared to the control patients.

4. Discussion

4.1. Principal Findings

The impact of telemonitoring methods with mobile applications on patients with chronic cardiovascular illnesses was assessed in this systematic review. Using them enhances self-care and blood pressure control ratios. Some effects varied between the RCTs concerning quality of life. The majority of studies raised at least some bias-related issues. For some of the papers analyzed, the analysis of the risk of bias raised discordant opinions among reviewers and was, therefore, subject to further evaluation.

Most studies showed that telemonitoring helped CVD patients maintain their blood pressure. These results imply that telemonitoring can be very helpful in controlling blood pressure and possibly lowering complications associated with hypertension. Improvements in quality of life were found in four out of nine trials (44.4%), suggesting that telemonitoring approaches could benefit patients’ mental and emotional health. In 83.3% of the trials, improved self-care abilities were observed, highlighting the potential of telemonitoring to enable patients to manage their health conditions better.

4.2. Comparison with Prior Works

Our results are consistent with earlier studies showing the advantages of telemonitoring in treating chronic illnesses. We discovered substantial improvements in blood pressure control [4,12,13,14], and capacity for self-care [15,16], which is in agreement with the findings reported by other authors. Our research reveals a significant influence on quality of life, in contrast to certain previous studies [3,4], and suggests that recent developments in telemonitoring technology may contribute to these good outcomes.

4.3. Strengths and Limitations

This review’s inclusion of a broad range of research from various geographic regions and healthcare settings is one of its strongest points; it offers a thorough summary of the current state of telemonitoring in CVD management. This review does have some limitations, though. Doing a meta-analysis was challenging due to the heterogeneity of the interventions and outcomes measured across trials. Furthermore, there might have been a language bias due to the reliance on studies published in English.

4.4. Practical Implications and Future Developments

Our findings indicate that integrating telemonitoring systems into routine care for patients with CVD could improve disease management and patient outcomes. Healthcare providers should consider adopting telemonitoring technologies to empower patients to manage their conditions more effectively. Policymakers should support the inclusion of telemonitoring into healthcare policies and funding models in order to ensure that patients have access to these beneficial interventions.

Future research should aim to standardize telemonitoring intervention and outcome measures to facilitate meta-analyses and more robust conclusions. It is necessary to lead long-term studies to assess the sustained impact of telemonitoring on patient outcomes. Furthermore, the next studies should focus on the cost-effectiveness of telemonitoring systems to inform policy decisions and healthcare funding allocations, and they could include other RCTs that may have been published after our article’s research.

Further research should ensure greater blindness among healthcare practitioners to reduce bias and improve the reliability of the results. The absence of a substantial number of papers on atrial fibrillation highlights the need for more RCTs focused on this condition to provide a clearer understanding of the benefits and limitations of telemonitoring in this specific patient group.

5. Conclusions

In summary, the findings from this systematic review highlight the considerable benefits of using telemonitoring systems in managing chronic cardiovascular conditions. The evidence points towards notable improvements in patients’ ability to manage their disease, including better control of disease-specific parameters, enhanced quality of life, and stronger self-care practices. Integrating telemonitoring into routine care practices can enhance patient outcomes and support chronic disease management significantly. It is essential for future research to explore further and leverage the full potential of these technologies to maximize their benefits for patients and the healthcare system at large.