• Remote monitoring programs (including telemonitoring or structured telephone support – see below) reduce the rates of admission to hospital for chronic HF and all-cause mortality.

• Most of the programs are cost-effective or cost-neutral.

Telemonitoring and telehomecare. Keeping patients in their own environment is preferable, and the use of telehomecare (follow-up by telephone) and telemonitoring (using wireless technology) has been developed with this aim in mind. Information such as daily weight, heart rate, blood pressure and adherence to treatment can be assessed over the telephone or transmitted wirelessly to allow rapid and serial review. The results from a number of studies looking at both intensive home-care assessment and remote analysis have been variable. In a Cochrane review of 25 studies involving more than 8000 patients, telemonitoring significantly reduced mortality and HF rehospitalization. However, other studies have indicated more neutral outcomes and, overall, current evidence does not support a strong effect on patient outcomes.

Although implantable devices, such as pacemakers and defibrillators, are capable of providing real-time information on a daily basis, such as heart-rate variability, patient-activity status and assessment of lung fluid volume, they have yet to provide sufficiently accurate predictive data. Newer devices currently under intensive study may be able to monitor hemodynamic changes either directly (left atrial pressures) or indirectly (via the pulmonary circulation or by transthoracic or intracardiac impedance). Early signs are promising but there is still too great a variation in outcome for results to be predictive.

General principles of non-pharmacological management

Self-care involves active participation in the maintenance and management of HF. Included within self-care maintenance are healthy lifestyle choices, treatment adherence and monitoring of behaviors. Self-care management is a cognitive process that involves the recognition of signs and symptoms of worsening HF, evaluation of the importance of a change in symptoms, implementation of a self-care strategy (such as increasing diuretic medication) and evaluating the effectiveness of any changes.

Patients and/or caregivers should understand the variable nature of HF symptoms and learn to recognize decompensation warning symptoms early in order to take appropriate action.

Patients should be encouraged to weigh themselves daily, each morning after emptying their bladder, in order to detect either rapid weight gain, which might indicate they are retaining too much fluid, or rapid weight loss of a similar amount in the same period, which might indicate dehydration. Ideally, these weights should be recorded in a weight diary so that trends can be monitored over time. This is also advantageous to those with cognitive impairment. Patients and their carers should be instructed to contact their healthcare practitioner or HF nurse if weight increases or decreases unexpectedly by more than 2 kg over 2 or 3 consecutive days as they may need further assessment or a change to their diuretic regimen.

If patients have demonstrated the ability to self-care, it may be appropriate for them to regulate their own diuretic dose based on daily weight monitoring and assessment of HF symptoms. Initially, the increased dose should be a single multiple of the previous dose (e.g. if the usual dose is 40 mg daily, the increase should be to 80 mg daily) for a period of 3 days or until euvolemia is achieved. If there is no change in status the patient should be encouraged to seek the assistance of the healthcare provider or HF nurse.

Patients with severe symptoms of HF should be encouraged to limit their fluid intake to 1.5–2 L/day (except in warmer weather), particularly if they have associated hyponatremia. There is no evidence to suggest fluid limitation is useful in patients with mild-to-moderate HF. Excessive dietary sodium intake contributes to fluid overload and is a major cause of preventable admission to hospital. It has been suggested that excessive sodium intake may also contribute to diuretic resistance. When combined with a diuretic regimen, a low-sodium diet can result in beneficial hemodynamic and clinical effects. In patients with mild symptoms, a sodium restriction to 3 g per day is sufficient to control extracellular fluid volume, while those with more severe symptoms should reduce sodium intake to 2 g/day.

Patients should be assessed on their knowledge of sodium content in the foods they consume and then educated on how to identify and measure sodium intake.

Physical activity. Multiple factors contribute to physical deconditioning in patients with HF. Effort-related dyspnea and fatigue dominate the clinical picture, thus reducing functional capacity. In general, exercise limitation is caused by a combination of low cardiac output and non-cardiac causes such as peripheral vasoconstriction/endothelial dysfunction, ventilatory limitation and skeletal muscle changes. The presence of multiple medical comorbidities (e.g. depression, sleep-disordered breathing, arthritis) further limits physical performance in this group.

Benefits of regular exercise. Physical activity has been shown to improve functional capacity, symptoms and neurohormonal abnormalities. Provisional evidence also suggests that regular exercise, which is considered a safe and cost-effective intervention, may reduce hospital admissions and improve survival. The benefits of regular exercise in patients with HF include peripheral adaptation of the skeletal muscles and autonomic nervous system, and a significant increase in exercise capacity (by about 15% maximum oxygen consumption [VO₂max]). Exercise also leads to improvement in overall quality-of-life scores.