Digital Health Strategies in Heart Failure: Effects of Telemedicine and Remote Monitoring on Clinical Outcomes—A Systematic Review and Meta-Analysis

Background/Objectives: Telemedicine and remote patient monitoring have emerged as promising strategies to improve outcomes in heart failure (HF), but prior meta-analyses reported conflicting results, partly due to insufficient differentiation between intervention modalities. This systematic review and meta-analysis evaluated the impact of distinct telemedicine strategies on clinically relevant outcomes in HF. Methods: Conducted according to PRISMA 2020 and a prospectively registered PROSPERO protocol (CRD420261355507), this analysis included randomized controlled trials (RCTs) comparing telemedicine-based strategies—non-invasive telemonitoring, structured remote patient management (RPM), or haemodynamic-guided monitoring—against standard care, identified through searches of PubMed/MEDLINE, Embase, and CENTRAL (inception to 15 March 2026). Random-effects meta-analyses (DerSimonian–Laird) were performed, with predefined subgroup, sensitivity, and publication bias analyses. Results: Sixteen RCTs (n = 8618) were included. Telemedicine significantly reduced all-cause mortality (RR 0.82, 95% CI 0.73–0.92; I2 = 34%; GRADE: moderate), all-cause hospitalization (RR 0.79, 95% CI 0.71–0.88; GRADE: moderate), HF-related hospitalization (RR 0.68, 95% CI 0.59–0.78; GRADE: high), and composite outcomes (RR 0.75, 95% CI 0.67–0.84; GRADE: moderate). A prespecified subgroup analysis revealed a significant mechanistic gradient (p for interaction = 0.008): haemodynamic-guided monitoring conferred the largest mortality reduction (RR 0.71), followed by structured RPM (RR 0.79), whereas non-invasive telemonitoring alone did not reach statistical significance (RR 0.93; p = 0.14). Conclusions: Telemedicine-based strategies yield clinically meaningful reductions in mortality and hospitalization in HF, but benefit is contingent upon intervention intensity and physiological specificity. Haemodynamic-guided monitoring and structured RPM provide robust outcome reductions, whereas passive telemonitoring alone is insufficient. These findings support consideration of structured remote patient management and haemodynamic-guided monitoring in appropriately selected patients and settings, while implementation and comparative effectiveness research remains necessary.