SMART-HF: structured management approach to remote treatment of heart failure. Guiding best practices

Responses to remote pulmonary artery pressure data vary across providers, days, and institutions, and only a minority of patients with elevated pressures reach targets linked to survival under ad hoc management. We evaluated SMART-HF, a structured pulmonary artery diastolic pressure (PAD)-guided workflow, in a community heart failure cohort. We retrospectively analyzed 37 adults (mean age 75.1±10.4 years; 17 [45.9%] female; left ventricular ejection fraction ≥50% in 23 [62.2%]; atrial fibrillation or flutter in 24 [64.9%]; hypertension in 32 [86.5%]; mean eGFR 54.9±21.3 mL/min/1.73 m2; median NT-proBNP 1846 [IQR 813-4036] pg/mL) with an implanted pulmonary artery pressure sensor managed with SMART-HF. PAD was averaged over prespecified 14-day windows at baseline, 90 days, and 6 months. Two prespecified hemodynamic management performance indices (HMPI) were defined: the 90-Day Target HMPI (PAD ≤20 mmHg at 90 days) and the 6-Month Delta HMPI (PAD reduction >2 mmHg from baseline). Thirty-six patients had paired 90-day and 29 had paired 6-month windows. Mean PAD decreased from 18.3±7.0 to 16.1±6.3 mmHg at 90 days (change −2.1±3.3 mmHg; 95% CI −3.2 to −1.0; P<0.001) and from 18.8 ± 6.8 to 15.5 ± 5.8 mmHg at 6 months (change −3.3±4.3 mmHg; 95% CI −4.9 to −1.7; P<0.001). The 90-Day Target HMPI was met in 26/36 (72.2%; 95% CI 54.8–85.8; P=0.011) and the 6-Month Delta HMPI in 19/29 (65.5%; 95% CI 45.7–82.1). Nineteen patients (51.4%) had baseline PAD >20 mmHg; in this subgroup PAD fell by −2.9±3.6 mmHg at 90 days (n=19; P=0.002) and −4.9±4.9 mmHg at 6 months (n=15; P=0.002), with the 6-Month Delta HMPI met in 12/15 (80.0%; P=0.035) − approximately double the 24% target-attainment rate reported for comparable patients under ad hoc management. No serious adverse events or heart-failure hospitalizations occurred. Seven patients required management for electrolyte derangements and eight met KDIGO criteria for acute kidney injury during decongestion; in five, transmitted pressure waveforms revealed occult paroxysmal atrial fibrillation, and after successful restoration of sinus rhythm, all five continued to decongest safely. SMART-HF was associated with improved ambulatory pulmonary artery pressures in patients with either elevated or controlled baseline averages and a reassuring safety profile supportive of additional large-scale research.