Beyond geography: one remote monitoring program, two Frances in heart failure care

Background Heart failure (HF) telemonitoring is increasingly implemented across diverse healthcare settings. In France, overseas territories (DOM) face distinct demographic, epidemiological, and organizational constraints compared with metropolitan France. Whether these contextual differences translate into distinct patient profiles, care pathways, and treatment patterns within a single national telemonitoring program remains insufficiently described. Objectives and Methods We conducted a retrospective comparative analysis of HF patients enrolled in a remote monitoring program (from August 2018 to December 2025). Two cohorts were defined according to the follow-up center: overseas territories (3 DOM; nine centers, n=706; figure 1) and metropolitan France (all other centers, n=26,029). Demographics, functional status, left ventricular ejection fraction (LVEF), etiologies and comorbidities, follow-up organization, and guideline-directed medical therapy (GDMT) exposure were compared. Categorical variables were analyzed using chi-square or Fisher’s exact tests, and continuous variables using Welch’s t-test or Mann–Whitney U test, as appropriate. Statistical significance was set at p<0.05. Results DOM patients were significantly younger than metropolitan patients (mean age 65.2±14.2 vs 76.4±12.9 years; p<0.001) and were less frequently aged over 80 years (14.7% vs 43.4%; p<0.001). Among patients with available New York Heart Association (NYHA) class, DOM patients were more often NYHA II and less often NYHA III. DOM patients more frequently presented with reduced LVEF <40% (69.6% vs 43.7%; p<0.001), while preserved LVEF ≥50% was less common. Dilated HF etiology and diabetes were more prevalent in DOM, whereas atrial fibrillation was less frequent. Care organization differed substantially: patient-led follow-up and automatic monitoring frequency were more frequent in DOM, while nurse-led follow-up was less common. By 31 December 2025, a higher proportion of DOM patients remained under telemonitoring, and mortality was lower. GDMT implementation was more advanced in DOM, with higher use of ARNI and SGLT2 inhibitors, and a greater proportion of patients receiving full four-pillar therapy. Conclusion Within a single national HF telemonitoring program, overseas and metropolitan cohorts represent two distinct clinical and organizational realities. Despite younger age, DOM patients exhibited more severe systolic dysfunction but higher GDMT uptake, distinct follow-up models, and better retention. These findings highlight the need to consider regional context when designing and evaluating telemonitoring strategies, and support tailored approaches to optimize HF care across diverse healthcare settings.