Remote dielectric sensing-guided heart failure management in primary care: early lessons from a feasibility study

This invited commentary refers to ‘Feasibility of a heart failure management programme using Remote Dielectric Sensing technology for the non-invasive lung fluid monitoring in primary care: a mixed-methods study’, by M. Mattisson et al. https://doi.org/10.1093/eurjcn/zvag075. Heart failure is a common and increasingly prevalent public health problem associated with high morbidity, mortality, and recurrent hospitalization.1,2 Episodes of decompensated heart failure represent a further decline in an already serious condition and are associated with a poorer prognosis.3 Early identification of worsening heart failure is therefore crucial to permit timely treatment and avert overt decompensation. As more patients live longer with chronic heart failure, a growing share of care is delivered in the community, increasing the need for healthcare professionals in primary care to recognize early worsening.4 Yet this is challenging, as clinical signs are often insensitive and late, symptoms are frequently non-specific in older and multimorbid patients, natriuretic peptides may not always be readily available, and advanced monitoring strategies such as implantable haemodynamic sensors require specialist care and invasive procedures.5 Remote Dielectric Sensing (ReDS) is an emerging technology that could support earlier detection of decompensated heart failure and guide management in primary care.6 Rather than relying on indirect clinical signs, ReDS attempts to quantify pulmonary congestion through a rapid, non-invasive estimate of lung fluid content. Previous studies have shown that ReDS estimates of lung fluid correlate with pulmonary congestion assessed by chest CT7 and pulmonary capillary wedge pressure.8 Furthermore, in the randomized ReDS-SAFE HF trial, a ReDS-guided strategy was associated with fewer short-term heart failure events following hospitalization compared with usual care.9 However, whether the ReDS technology can be meaningfully integrated into primary care remains uncertain. In this issue of the European Journal of Cardiovascular Nursing, Mattisson and colleagues address that question in a 1-month, mixed-methods feasibility study of a ReDS-guided heart failure management programme in primary care.10 The study included an older, symptomatic heart failure population. Across the Bowen feasibility domains, acceptability and practicality were high, and both patients and clinicians perceived a need for the programme, particularly where access to laboratory testing and specialist care is limited. However, the most telling finding may be the reluctance of the healthcare professionals to follow the algorithm when elevated ReDS measurements were not accompanied by clinical symptoms or clear deterioration. Interestingly, mean ReDS measurements increased rather than decreased during follow-up. Taken together, these findings suggest that the main challenge in primary care may not be the feasibility of measuring congestion with ReDS, but rather how such information should be interpreted and acted on in practice. The study therefore highlights an often underappreciated issue in digital and physiological monitoring: new measurements are only clinically useful if they are linked to clear, credible, and actionable decision pathways.11 The decision to undertake a feasibility study before proceeding to a larger trial deserves particular emphasis. The implementation challenges identified in the present study should therefore not be interpreted as a failure, but rather as valuable insights that inform the design of future trials and care pathways. Another strength of the study is the nurse-led programme, reflecting the well-established role of specialist heart failure nurses in improving outcomes, reducing hospitalizations, and strengthening patient self-care.12,13 Beyond device feasibility, the more important question is whether the programme built around ReDS is clinically actionable. Before testing whether ReDS-guided care improves outcomes in primary care, it is necessary to clarify which ReDS measurements should trigger action. The thresholds used in the present study appear partly inspired by the ReDS-SAFE HF trial, in which ReDS guided decongestion during hospitalization and at a 7-day follow-up visit after discharge.9 However, in the primary care setting, elevated ReDS measurements often failed to trigger action when not accompanied by worsening symptoms.10 This suggests that thresholds developed for acute or recently decompensated heart failure populations may be less applicable in primary care, where patients may be more clinically stable and the implications of an isolated elevated ReDS measurement are less clear. That issue becomes particularly relevant in older, multimorbid patients, in whom pulmonary comorbidities such as emphysema or pulmonary fibrosis may influence ReDS measurements.14 In this context, serial trends in ReDS measurements may prove more clinically informative than isolated measurements interpreted against fixed thresholds. These considerations also matter for how ReDS-guided care should be organized in primary care. Repeated measurements and algorithm-driven follow-up may be difficult to sustain in routine practice. ReDS-guided management may therefore prove most valuable when targeted to higher-risk periods, such as after recent hospitalization or in response to worsening symptoms, rather than as routine monitoring across the broader heart failure population. The findings by Mattisson and colleagues should be interpreted in light of the study design. This was a small, short-term feasibility study in a selected heart failure population, and the organization of primary care varies substantially across healthcare systems. ReDS-guided diuretic adjustment should also be considered alongside overall heart failure optimization, as contemporary guideline-directed medical therapy was not fully implemented for all included patients.10 Nevertheless, the value of this study lies in revealing the practical barriers that may otherwise remain hidden until larger trials are undertaken. The ongoing randomized LiLAC-HF trial, conducted by the same group, will be an important next step. It will test a 3-month, nurse-led ReDS-guided programme against usual care and assess not only clinical outcomes, but also how such an approach can be implemented in routine primary care.15 Ultimately, the key question is not whether ReDS can measure pulmonary congestion, but for whom and how this information can be integrated into clinical workflows in a way that improves decision-making and patient outcomes in primary care. If these questions can be answered, ReDS may yet find a meaningful and pragmatic role within community-based heart failure care, supporting earlier detection of congestion and more proactive management in the outpatient setting. Anne Sophie Overgaard Olesen (Conceptualization, Visualization, Writing—original draft [lead], Writing—review & editing [equal]), and Kristina Miger (Conceptualization, Visualization [supporting], Writing—review & editing [equal]) The salary of ASOO is funded by a research grant from the Novo Nordisk Foundation (NNF22OC0079241) This commentary does not contain new data.