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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Patients discharged from the hospital after an acute decompensated heart failure &#40;HF&#41; event are at high risk for hospital readmissions and mortality in the subsequent months&#47;years&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Remote monitoring &#40;RM&#41; and mobile health technologies have been used as strategies to help HF patients remain free from rehospitalization&#46; These strategies are of particular relevance in environments where the patients have difficulties in accessing healthcare facilities&#44; such as those living in remote areas &#40;islands&#44; locations requiring long journeys to in person consultations with their health care providers &#40;HCPs&#41;&#41;&#44; or in the context of restrictions of different kinds on patients&#8217; visits to hospitals&#47;clinics&#44; for example&#44; during the current COVID-19 pandemic&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In fact&#44; the COVID-19 pandemic has led to the implementation of multiple telemonitoring programs for chronic conditions in general and for HF patients in particular&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Remote monitoring is a useful complement to usual HF care because it allows for early detection of worsened disease while the patient remains outside of the hospital&#44; thus giving HCPs the chance to intervene before another acute decompensation and&#44; at least theoretically&#44; to prevent hospital readmissions&#46; Despite these conceptual benefits&#44; RM for HF has shown mixed results in clinical trials&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Some good state-of-the-art reviews on this subject can be found in the literature&#44;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">6&#8211;9</span></a> including in previous issues of this Journal&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Remote monitoring tools often incorporate symptom monitoring and physiologic measures&#44; such as patient weight&#44; blood pressure&#44; and heart rate&#44; which have been shown to be associated with worsening HF&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Multiparameter monitoring with automatic transmission is useful for HF management&#46; Improved adherence to RM and an optimal algorithm for transmitted alerts and their management are warranted in the follow-up of HF patients&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">One of the most relevant discussions surrounding the telemonitoring of HF patients is for how long it should be continued to obtain relevant and positive outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> Also&#44; where the RM program requires non-invasive evaluation of physiological parameters&#44; this usually means the patients must have good adherence to the recommendations to use several wearables or other connected devices&#46; The failure&#44; by the patients&#44; to take these measurements at the designated time intervals can compromise the entire program and the respective individual and global long-term results&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">These difficulties led to the concept of using implantable devices with sensors that could monitor one or more parameters and be connected to communication systems&#44; that can send the data collect from the sensors remotely&#44; without the direct intervention of the patients&#44; to the healthcare providers responsible for the telemonitoring of the HF patients&#46; This long-lasting monitoring with implantable devices would solve the patient adherence issues&#44; in a way very similar to what is already usual practice with the monitoring of arrhythmias&#44; in patients carrying pacemakers and other implantable electronic devices&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">This was made feasible by technological advances in devices&#44; sensors and communication systems&#46; Constant advances in the miniaturization of the device batteries and sensors made them successively evolve from buildable to movable to carriable to wearable to insidable&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the past&#44; different approaches were tested&#44; with different implantable devices designed to monitor different hemodynamic and&#47;or rhythmic parameters&#46; From early detection of arrhythmias with cardiac implantable electronic devices &#40;e&#46;g&#46;&#44; implantable cardioverter defibrillators &#40;ICDs&#41;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> to measuring intrathoracic impedance by adding OptiVol&#8482; technology to either cardiac resynchronization &#40;CRTs&#41; or ICDs &#40;studied in the Medtronic Impedance Diagnostics in Heart Failure Patients &#40;MID-HeFT&#41; Study<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a>&#41;&#44; to different implantable hemodynamic monitors &#40;IHM&#41; with more or less success&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Different IHM have been designed to assess multiple or single parameters such as&#58;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Multiparameter monitoring</span><p id="par0065" class="elsevierStylePara elsevierViewall">The Chronicle&#8482; &#40;Medtronic Inc&#46;&#44; Minneapolis&#44; Minnesota&#41; is an example of an IHM that can continuously monitor and store heart rate&#44; body temperature&#44; patient activity&#44; right ventricular systolic and diastolic pressure&#44; maximal positive and negative rate of change in right ventricular pressure &#40;dP&#47;dt&#41;&#44; right ventricular pre-ejection and systolic time intervals&#44; and estimated pulmonary arterial diastolic pressure &#40;ePAD&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The COMPASS-HF &#40;Chronicle&#8482; Offers Management to Patients with Advanced Signs and Symptoms of Heart Failure&#41; study was a prospective&#44; multicenter&#44; randomized&#44; single-blind&#44; parallel-controlled trial of 274 New York Heart Association functional class III or IV HF patients who were randomized to a Chronicle&#8482; device &#40;n&#61;134&#41; or control &#40;n&#61;140&#41; group&#46; All patients received optimal medical therapy&#44; but the hemodynamic information from the monitor was used to guide patient management only in the Chronicle group&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Direct left atrial pressure monitoring</span><p id="par0075" class="elsevierStylePara elsevierViewall">Assessed in the prospective&#44; multicenter&#44; nonrandomized&#44; open-label feasibility clinical trial called Hemodynamically Guided Home Self-Therapy in Severe Heart Failure Patients &#40;HOMEOSTASIS I&#41;&#44; which was designed to assess the preliminary safety&#44; reliability&#44; and functionality of the permanently implantable LAP monitoring system &#40;HeartPOD&#8482;&#44; Savacor&#44; Inc&#44; a subsidiary of St Jude Medical&#44; Inc&#44; Minneapolis&#44; Minn&#41; in ambulatory patients with HF&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Pulmonary artery pressure monitoring</span><p id="par0080" class="elsevierStylePara elsevierViewall">The PAP monitoring system &#40;CardioMEMS Inc&#44; Atlanta&#44; GA&#41; consists of an implantable HF sensor&#44; a delivery catheter&#44; an electronic monitoring unit that contains a barometer to account for ambient atmospheric pressure changes&#44; and a secure Internet database that stores patient hemodynamic data and makes it available to the clinician&#46; The intermediate-term safety&#44; accuracy&#44; and feasibility of this system were assessed in a prospective&#44; nonrandomized&#44; single-arm trial l conducted at five sites that enrolled 17 patients between December 2006 and August 2007&#46; The results of this trial were published by Abraham et al&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">19</span></a> and an update on the CardioMEMS&#8482; PAP sensor experience was published by Ayyaduray et al&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The CardioMEMS&#8482; Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients &#40;CHAMPION&#41; trial tested the hypothesis that the management of HF using PAP monitoring would reduce the rate of HF-related hospitalizations&#46; CHAMPION was a prospective&#44; multicenter &#40;n&#61;64&#41;&#44; single-blind&#44; clinical trial undertaken in the USA&#46; The authors of this trial concluded that it was a positive trial&#44; &#8220;definitively showing a significant and large reduction in hospitalization for patients with NYHA class III HF who were managed with a wireless implantable hemodynamic monitoring system&#46; The addition of information about pulmonary artery pressure to clinical signs and symptoms allows for improved HF management&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The positive results obtained with the CardioMEMS&#8482; IHM device were recognized in 2014 by the US Food and Drug Administration&#44; by approving the device for clinical use in HF patients with preserved and reduced ejection fraction&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Although still very prudently &#8212; some might say conservatively&#41; &#8212; the 2021 European Society of Cardiology Heart Failure Guidelines kept a class IIb recommendation for &#8220;Monitoring of pulmonary artery pressure using a wireless hemodynamic monitoring system may be considered in symptomatic patients with HF in order to improve clinical outcomes&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In this issue of the Portuguese Journal of Cardiology&#44; Ferreira et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> present the initial experience of the Santa Marta Hospital in Lisbon&#44; Portugal with the implantable CardioMems&#8482; device&#46; Although their experience is still very limited and the follow-up of the study population was relatively short&#44; as the authors themselves acknowledged&#44; the results of this study corroborate other investigators&#8217; experience regarding the feasibility and safety of the procedure&#44; with relevant impact on the RM of HF patients&#44; particularly in the particular setting of the COVID-19 pandemic&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">A very comprehensive review of the different devices and sensors used in the RM of patients with HF was published recently by Radhoe and Veenis&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">We can anticipate that&#44; in a near future&#44; we shall witness the rise of increasingly sophisticated&#44; implantable devices with sensors that will be able to more accurately monitor these &#40;and other&#41; haemodynamic and rhythmic variables&#44; with the possibility of sending the data through more reliable and fast communication networks&#44; such as 5 G &#40;or even 6 G in a not so distant future&#41;&#44; to be incorporated into RM follow-up programs&#44; which most certainly result in measurable benefits to our HF patients and their healthcare systems&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Telemonitoring in heart failure: The rise of the insidables
Telemonitoração na insuficiência cardíaca: A ascenção dos insidables
Daniel Ferreira
Intensive Medicine, Department Hospital da Luz Lisboa, Lisboa, Portugal
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    "titulo" => "Telemonitoring in heart failure&#58; The rise of the insidables"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Patients discharged from the hospital after an acute decompensated heart failure &#40;HF&#41; event are at high risk for hospital readmissions and mortality in the subsequent months&#47;years&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Remote monitoring &#40;RM&#41; and mobile health technologies have been used as strategies to help HF patients remain free from rehospitalization&#46; These strategies are of particular relevance in environments where the patients have difficulties in accessing healthcare facilities&#44; such as those living in remote areas &#40;islands&#44; locations requiring long journeys to in person consultations with their health care providers &#40;HCPs&#41;&#41;&#44; or in the context of restrictions of different kinds on patients&#8217; visits to hospitals&#47;clinics&#44; for example&#44; during the current COVID-19 pandemic&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In fact&#44; the COVID-19 pandemic has led to the implementation of multiple telemonitoring programs for chronic conditions in general and for HF patients in particular&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Remote monitoring is a useful complement to usual HF care because it allows for early detection of worsened disease while the patient remains outside of the hospital&#44; thus giving HCPs the chance to intervene before another acute decompensation and&#44; at least theoretically&#44; to prevent hospital readmissions&#46; Despite these conceptual benefits&#44; RM for HF has shown mixed results in clinical trials&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Some good state-of-the-art reviews on this subject can be found in the literature&#44;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">6&#8211;9</span></a> including in previous issues of this Journal&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Remote monitoring tools often incorporate symptom monitoring and physiologic measures&#44; such as patient weight&#44; blood pressure&#44; and heart rate&#44; which have been shown to be associated with worsening HF&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Multiparameter monitoring with automatic transmission is useful for HF management&#46; Improved adherence to RM and an optimal algorithm for transmitted alerts and their management are warranted in the follow-up of HF patients&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">One of the most relevant discussions surrounding the telemonitoring of HF patients is for how long it should be continued to obtain relevant and positive outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> Also&#44; where the RM program requires non-invasive evaluation of physiological parameters&#44; this usually means the patients must have good adherence to the recommendations to use several wearables or other connected devices&#46; The failure&#44; by the patients&#44; to take these measurements at the designated time intervals can compromise the entire program and the respective individual and global long-term results&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">These difficulties led to the concept of using implantable devices with sensors that could monitor one or more parameters and be connected to communication systems&#44; that can send the data collect from the sensors remotely&#44; without the direct intervention of the patients&#44; to the healthcare providers responsible for the telemonitoring of the HF patients&#46; This long-lasting monitoring with implantable devices would solve the patient adherence issues&#44; in a way very similar to what is already usual practice with the monitoring of arrhythmias&#44; in patients carrying pacemakers and other implantable electronic devices&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">This was made feasible by technological advances in devices&#44; sensors and communication systems&#46; Constant advances in the miniaturization of the device batteries and sensors made them successively evolve from buildable to movable to carriable to wearable to insidable&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the past&#44; different approaches were tested&#44; with different implantable devices designed to monitor different hemodynamic and&#47;or rhythmic parameters&#46; From early detection of arrhythmias with cardiac implantable electronic devices &#40;e&#46;g&#46;&#44; implantable cardioverter defibrillators &#40;ICDs&#41;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> to measuring intrathoracic impedance by adding OptiVol&#8482; technology to either cardiac resynchronization &#40;CRTs&#41; or ICDs &#40;studied in the Medtronic Impedance Diagnostics in Heart Failure Patients &#40;MID-HeFT&#41; Study<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a>&#41;&#44; to different implantable hemodynamic monitors &#40;IHM&#41; with more or less success&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Different IHM have been designed to assess multiple or single parameters such as&#58;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Multiparameter monitoring</span><p id="par0065" class="elsevierStylePara elsevierViewall">The Chronicle&#8482; &#40;Medtronic Inc&#46;&#44; Minneapolis&#44; Minnesota&#41; is an example of an IHM that can continuously monitor and store heart rate&#44; body temperature&#44; patient activity&#44; right ventricular systolic and diastolic pressure&#44; maximal positive and negative rate of change in right ventricular pressure &#40;dP&#47;dt&#41;&#44; right ventricular pre-ejection and systolic time intervals&#44; and estimated pulmonary arterial diastolic pressure &#40;ePAD&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The COMPASS-HF &#40;Chronicle&#8482; Offers Management to Patients with Advanced Signs and Symptoms of Heart Failure&#41; study was a prospective&#44; multicenter&#44; randomized&#44; single-blind&#44; parallel-controlled trial of 274 New York Heart Association functional class III or IV HF patients who were randomized to a Chronicle&#8482; device &#40;n&#61;134&#41; or control &#40;n&#61;140&#41; group&#46; All patients received optimal medical therapy&#44; but the hemodynamic information from the monitor was used to guide patient management only in the Chronicle group&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Direct left atrial pressure monitoring</span><p id="par0075" class="elsevierStylePara elsevierViewall">Assessed in the prospective&#44; multicenter&#44; nonrandomized&#44; open-label feasibility clinical trial called Hemodynamically Guided Home Self-Therapy in Severe Heart Failure Patients &#40;HOMEOSTASIS I&#41;&#44; which was designed to assess the preliminary safety&#44; reliability&#44; and functionality of the permanently implantable LAP monitoring system &#40;HeartPOD&#8482;&#44; Savacor&#44; Inc&#44; a subsidiary of St Jude Medical&#44; Inc&#44; Minneapolis&#44; Minn&#41; in ambulatory patients with HF&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Pulmonary artery pressure monitoring</span><p id="par0080" class="elsevierStylePara elsevierViewall">The PAP monitoring system &#40;CardioMEMS Inc&#44; Atlanta&#44; GA&#41; consists of an implantable HF sensor&#44; a delivery catheter&#44; an electronic monitoring unit that contains a barometer to account for ambient atmospheric pressure changes&#44; and a secure Internet database that stores patient hemodynamic data and makes it available to the clinician&#46; The intermediate-term safety&#44; accuracy&#44; and feasibility of this system were assessed in a prospective&#44; nonrandomized&#44; single-arm trial l conducted at five sites that enrolled 17 patients between December 2006 and August 2007&#46; The results of this trial were published by Abraham et al&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">19</span></a> and an update on the CardioMEMS&#8482; PAP sensor experience was published by Ayyaduray et al&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The CardioMEMS&#8482; Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients &#40;CHAMPION&#41; trial tested the hypothesis that the management of HF using PAP monitoring would reduce the rate of HF-related hospitalizations&#46; CHAMPION was a prospective&#44; multicenter &#40;n&#61;64&#41;&#44; single-blind&#44; clinical trial undertaken in the USA&#46; The authors of this trial concluded that it was a positive trial&#44; &#8220;definitively showing a significant and large reduction in hospitalization for patients with NYHA class III HF who were managed with a wireless implantable hemodynamic monitoring system&#46; The addition of information about pulmonary artery pressure to clinical signs and symptoms allows for improved HF management&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The positive results obtained with the CardioMEMS&#8482; IHM device were recognized in 2014 by the US Food and Drug Administration&#44; by approving the device for clinical use in HF patients with preserved and reduced ejection fraction&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Although still very prudently &#8212; some might say conservatively&#41; &#8212; the 2021 European Society of Cardiology Heart Failure Guidelines kept a class IIb recommendation for &#8220;Monitoring of pulmonary artery pressure using a wireless hemodynamic monitoring system may be considered in symptomatic patients with HF in order to improve clinical outcomes&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In this issue of the Portuguese Journal of Cardiology&#44; Ferreira et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> present the initial experience of the Santa Marta Hospital in Lisbon&#44; Portugal with the implantable CardioMems&#8482; device&#46; Although their experience is still very limited and the follow-up of the study population was relatively short&#44; as the authors themselves acknowledged&#44; the results of this study corroborate other investigators&#8217; experience regarding the feasibility and safety of the procedure&#44; with relevant impact on the RM of HF patients&#44; particularly in the particular setting of the COVID-19 pandemic&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">A very comprehensive review of the different devices and sensors used in the RM of patients with HF was published recently by Radhoe and Veenis&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">We can anticipate that&#44; in a near future&#44; we shall witness the rise of increasingly sophisticated&#44; implantable devices with sensors that will be able to more accurately monitor these &#40;and other&#41; haemodynamic and rhythmic variables&#44; with the possibility of sending the data through more reliable and fast communication networks&#44; such as 5 G &#40;or even 6 G in a not so distant future&#41;&#44; to be incorporated into RM follow-up programs&#44; which most certainly result in measurable benefits to our HF patients and their healthcare systems&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Revista Portuguesa de Cardiologia
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