In a new episode of Cadence Conversations, Dr. Theodore Feldman, Chief Medical Officer at Cadence, sat down with Dr. Marat Fudim, an advanced heart failure specialist and cardiologist at the Duke University Medical Center, to discuss the role that Remote Patient Monitoring (RPM) plays in treating heart failure and how this technology can be used to benefit both cardiologists and patients.
The conversation was released as the third episode of Cadence's new podcast Cadence Conversations, featuring health care executives, technology leaders, and policymakers discussing how technology is transforming the future of healthcare.
Previous episodes of the podcast include Dr. Omar Lateef discussing how virtual care technology can promote better outcomes for patients, and a star-studded panel of healthcare leaders in Nashville discussing remote patient monitoring, including Dr. Toby Cosgrove, David Dill, Dr. David Shulkin, and Dr. Lynn Simon.
Over the course of the latest podcast episode, Dr. Feldman, who has more than 35 years of experience as a cardiologist and specializes in the prevention, diagnosis, and treatment of complex cardiovascular disease and its risk factors, discussed a host of hot topics related to remote patient monitoring with Dr. Fudim, including: what the data currently shows around how RPM technology improves outcomes for heart failure patients, the biggest questions facing cardiologists around how RPM can help transform their practice, as well as what the future will look like for cardiologists powered by new technologies.
"We will not get around introducing remote monitoring," Fudim said. "I'm also confident that the healthcare of the future will be that centers that don't get on the train right now of remote monitoring will be outpaced and will be providing sub-perfect care compared to the competing systems. And I don't think we should be doing this."
During the conversation, Fudim and Feldman specifically addressed cardiologists who may be skeptical of RPM technology, saying that although there is admittedly limited data currently available showing the outcomes of RPM on heart failure patients, RPM should not be held to the same standard as, for example, pharmaceutical drugs when evaluating its effectiveness.
Instead, Fudim pushed cardiologists to look at surrogate metrics and compare those to traditional care metrics to assess the effectiveness of RPM. "If I can titrate medications at a greater rate, at a faster pace, and get to a higher dose in a shorter time frame using RPM versus the normal standard of care, that should count," said Fudim.
"We need to cut remote monitoring a little bit of a break, and accept the fact that if we can get patients on the right drugs, at a fast pace, and keep them at a lower heart rate … then we don't have to maybe show all those hard outcomes."
Speaking about his predictions for the future, Fudim painted a picture in which much of the care that is currently taking place inside of hospitals will transition to the home.
"One of the buzzwords of the future is the hospital at home model," he said. "Advanced academic and non-academic centers, large centers, are going to be caring primarily for very sick patients, but if you have this infection that really just needs some surveillance on a daily basis or every few hours, we will outsource those things to where patients can designate their home to be a home monitoring system, a mini hospital, where all they need is maybe some remote monitoring tools."
Listen above to the entire conversation and be sure to subscribe to Cadence Conversations wherever you get your podcasts in order to listen to future episodes.
Also read the full transcript of the conversation below:
Transcript for Ep 03: RPM and the future of cardiovascular health with Dr. Marat Fudim
Table of Contents:
- Specializing in Cardiology with a Focus on Heart Failure
- Challenging Conventional Perspectives on the History of Heart Disease
- The Use of Remote Patient Monitoring in Patients with Heart Failure
- Standing Up the Four Pillars of GDMT for Heart Failure
- Is it Possible to Treat Heart Failure without Remote Patient Monitoring?
- The Efficacy of RPM Technology in Cardiology
- Embracing RPM Technology as the Standard of Care
- Managing CHF and Chronic Conditions Through Connected Care
- Using Technology to Deliver Care to Rural Areas
Welcome to Cadence Conversations, where we're talking with prominent physicians, healthcare leaders, and tech entrepreneurs about their experiences driving innovation and progress.
This week, Dr. Ted Feldman, Chief Medical Officer at Cadence, spoke with Dr. Marat Fudim,
an advanced heart failure specialist and cardiologist at the Duke University Medical Center.
They focused their conversation on the role that Remote Patient Monitoring plays in heart failure patients and what future platforms can do to help cardiologists. So let's get to this week's Cadence Conversation.
Dr. Ted Feldman (TF): Thanks so much for joining us on this latest episode of Cadence Conversations. With me today is Dr. Murat Fudim, an advanced heart failure specialist and cardiologist at the Duke University Medical Center. He's one of the leading experts on remote patient monitoring and heart failure, and I'm very excited to be speaking with him today.
Dr. Marat Fudim (MF): Thanks for having me.
Specializing in Cardiology with a Focus on Heart Failure
TF: So Dr. Fudim, give us a little background: Why did you specialize in cardiology and why heart failure?
MF: First, it's a very exciting field. It's closely connected to hemodynamics, and one cool thing about cardiology is that it's all about physiology and, believe it or not, cardiology is a lot more complex than just the heart itself. As you well know, since you're a cardiologist yourself, we deal with the vascular system, and we deal with it all. There are a lot of co-morbidities in the cardiovascular space and when you drill it down, it came down for me to the decision to go into heart failure because heart failure is the sum of many different disease states. It's coronary artery disease, it's obesity, diabetes — all of those diseases at the end.
In heart failure, all roads lead to Rome because heart failure is the end stage form of many cardiovascular diseases. And that fascinated me because unlike many other disease states, for example, coronary artery disease, the incidents of coronary disease requiring treatment are going down. That's due to the success of drugs like aspirin and statin.
Having said that, the incidence of heart failure is only rising. For example, HFpEF heart failure with preserved ejection fraction — currently making 50% of the population of heart failure, and around 3 million in the United States — will explode to being 6, 7 million people in 10, 20 years from now alone.
So I think this is a massive, under-recognized tidal wave rolling towards us. And to date, it already makes up one of the most common types of diagnoses in the United States leading to hospitalization. So the number one cause of hospitalization in the United States today is heart failure. But typically, in the population of Medicare patients 60 and greater, 65 or so, we are already having this massive problem. So you can only imagine how this is going to change when heart failure incidents only increase.
Challenging Conventional Perspectives on the History of Heart Disease
TF: You mentioned that heart failure really is the combination of many diseases that come together: diabetes, coronary artery disease, hypertension, obesity, etc. Could you comment on how we got into this natural history of heart disease? Whereas you've said we've done a great job in standing up coronary artery disease and acute myocardial infarction through the statins and aspirin, how have we had this resurgence of HFpEF? Are we just getting older?
MF: So from a research standpoint, you hit exactly on what I'm doing at my institution. The majority of my time in doing research is thinking about how the body manages volume. And at the end of the day, HFpEF, HFrEF, and other disease states are coming down to how we manage volume — whether we are able to control the homeostasis of volume.
This is intravascular and extravascular — so total body volume and intravascular volume. And whether certain conditions lead us to accumulate too much volume and certain other conditions, we just redistribute the volume. I'm going to give you examples.
So, your white-haired professors and the textbooks have taught us that heart failure is driven by salt and water retention, i.e. we eat too much salt, we eat too much pizza, we drink too much food. And we blame that bad patient that he/she was non-compliant.
But actually, at the end of the day, that does not seem to be the case. And the reason for that is this dogma was challenged over the last 20 years through studies which showed that if you follow a patient's perspective with weight scales alone, that you see that in about 50% of cases, there is no significant weight gain preceding a hospital hospitalization.
So what is the number one way we track our patients right now? We tell patients to call us, do whatever you want to, and don't eat too much salt. Don't drink much water, but call us when your weight goes above three pounds, and that's it. And then we go off to the other hundred patients we have to see that day. That model has failed us pretty well.
So you need to be quite more aware because the problem with weight is that it's a) insensitive, and in 50% of the population, that seems to be applied to the decompensation. Do those patients without weight gain present with elevated filling pressures in the heart or elevated neck pains? Absolutely. And that's what we have been seeing in the past, where we know the patient does not seem to be particularly volume overloaded, the rejection fraction is preserved, so how do we explain that?
We can explain that because the heart is stiff. It does not tolerate any additional redistribution of blood volume from the periphery centrally. How does this occur? Through basic constriction. Mental and physical stress states induce that we basically constrict arteries and veins, and by doing so, you actually centralize blood volume. You shift it out of the periphery through the stress state, centrally, and the heart is stiff and says, "No way I will accept any incoming fluid."
What happens? The pressure in the tank rises.
I don't want to get too technical with the audience, but it speaks to compliance. The vascular compliance is this holy grail of the ability to handle blood volume. Think of it as a very stretchy balloon. That stretchy balloon can handle any influx volume, aka, you will not become short of breath with influx of volume. But if you have a very, very small or very, very stiff balloon or chamber, any shifts of blood volume into that chamber will result in high pressures in that tank. So that is how we now think about people without obvious weight gain.
Why am I making this point? Because we now know that HFpEF more likely than HFrEF meets that definition of a small, stiff tank where a little volume addition results in high filling pressure. So it doesn't take that much to decompensate. Weight scales won't necessarily pick up on that. So you need to have a vigilant, multi-sensor technology usually to pick up on that, or, frequent supervision with physicians, etc.
The Use of Remote Patient Monitoring in Patients with Heart Failure
TF: You've done quite a bit of research and have published several articles on remote monitoring technologies. Can you set the stage and tell us what remote monitoring technologies you believe are useful as it relates to heart failure?
MF: When I was thinking, what am I going to do clinically, I think the most impact can be made on our population when we transfer care away from the hospital, away from the clinics and bring it back home to the patients. Period.
The future patient will be all lined up and hooked up with fancy devices. And, the fanciest device we carry is our iPhones and Samsung devices. They already have a lot of sensor technology that will only exponentially change to where we have wearable sensor technology. To date, the technology's no longer the limiting factor in what we can manage and monitor.
So, no aspect of human and heart failure life will become unobserved. Now, in my opinion, is the workforce, who's going to manage all that data? And to make it even more complicated, who's going to act on the data? Because data you don't act on is worthless to the patient and worthless to the managing provider.
So I've made it my mission to think of protocols, think of ways, to design clinical studies to manage those patients remotely with the available technologies and future technologies, to be able to devise protocols to act on the data. And it has two-fold implications: As a pure red flag state, we want to flag patients that are in trouble — whether that's somebody who has an increase in weight, increase in blood pressure, whatever technology you use. It's a warning system. So that works to prevent compensation, remote monitoring technology is very good for that. For that, you don't have to rely on the patient to call you when he or she is too late and too far along the disease course.
The second reason why monitoring is so important is the world has gotten more complex and more populated. We have, I don't know exactly how many, but we have a few thousand heart failure providers in the United States. But I just said we have 6 million patients with heart failure. So clearly, heart failure doctors cannot see all heart failure patients, which is why the majority of heart failure patients are seen by general cardiologists, by medicine doctors, hospitalists. So we have a very strong variability in care provided to those patients. And to make things even worse, the patients that I might care for, I would love to see every other week. That would provide them the optimal care and get them on the medication they need.
To date, the government, via the NIH and all the other funding agencies, are funding what we call implementation science. It's not about discovering new drugs. It's about getting the drugs that are known to work to patients that would benefit from them. How do we do that? I would have to see a patient quite frequently in the clinic to get them the drugs that need to be on. And that is simply not possible. We have too many patients we have to see already as is. Wait times to see a cardiologist are sometimes many weeks to months.
Rather, we should divert that care monitoring to the home environment and titrate medications remotely and get them on all the good medications. We talk about the four or five pillar therapy and guideline-directed medical therapies, GDMT. So getting them on that medication would be ideal. Seeing the patients every week would be ideal. So what's the solution for that? Remote monitoring. We use that as a tool or means to contact the patients in greatest need to give us the safety assurance that when we titrate medication, they remain in a good zone — that we are titrating and the heart rate and blood pressure doesn't go too low or too high.. So I think that is sort of the framework in which we are seeing those two things: red flag and titration of medications.
Standing Up the Four Pillars of GDMT for Heart Failure
TF: At Cadence, we've set up a Care Delivery Team with some of the best advanced heart failure specialists to help manage and add capacity to those frequent and necessary visits. As you said, to stand up the four pillars of GDMT. Help me a little bit understand this sort of transformation over the past months to years, this sort of imperative to stand up four pillars of GDMT quickly. The early training was start low, go slow, there's no rush, this is a disease over a lifetime and the most important thing is to prevent people from getting side effects. And then all of a sudden over the last couple of years, some papers, some important research came out that it's not just about getting people on the drugs, but it's getting people on the maximum dosage of drugs. Help me and the audience understand a little bit better that sort of time imperative to get people on the four pillars of GDMT quicker, rather than slower.
MF: I think this all is grounded on the fact that heart failure is not just one of the most prevalent cardiovascular diseases, but it's also one of the primary, top three, top four killers in the United States. So what do we have today? The last 30, 40 years of research have ushered in an era of us having four or five drugs available that can lower the morbidity — so less heart failure hospitalization, lower the heart failure mortality, and can improve quality of life. As a matter of fact, those drugs act in a time-dependent manner.
If you started to date the average time to benefit on quality of life and/or reduction of heart failure hospitalization — We call it splitting up the curves, where you compared to a placebo pill, a sugar pill, will see a benefit. That occurs as early as two to four weeks after initiating a drug. This is not necessarily something you only see as a benefit in appropriately large sized studies at six to 12 months, you can see those benefits in the first weeks, to months where a patient feels better.
We also know that starting those medications in the hospital setting or shortly thereafter, tends to portend a better outcome, not only on the patient's outcomes, morbidity, mortality, but also once you started earlier in the hospital setting, you're more likely to stay on the drug.
Because patients, once they leave the hospital, think they are now invincible and often don't start a drug, forget to take the drug, and they're back in the same conundrum they were in before. So starting it early is important because you are now — when you use four pillar drug therapy, the GDMT therapy — you can gain yourself several, about a little less than a handful years of extra life, compared to not using the current gold standard medications. So getting them on as quickly as possible will save lives, will keep people out of hospital, will make them feel better, so why wait on that?
But the other thing is that this concept of treating people, the urgency to treat is actually not new. I remember publishing maybe, seven years ago, a paper called, "Urgency to Treat Hypertension." That same concept applies to hypertension, to diabetes. Time in uncontrolled status of whatever disease that is will accrue you side effects. And you can choose to accrue side effects or you can choose to treat. And we know that in treating hypertension, you split the curves very early on within a few weeks of seeing benefits on stroke rates and heart attack rates. Heart failure is just as much about managing comorbidities, meaning the COPD, the high blood pressure, diabetes, as it is about managing their volume status alone.
Interlude: At Cadence, we have a world-class Care Delivery Team who serve as an extension of our hospital system partners and help manage patients' care on a daily basis. In Care Delivery Stories, we'll hear from one of our team members about the impact Cadence is having on their patients.
Ana Patsiornik: This is Ana Patsiornik, an Advanced Heart Failure Nurse Practitioner here at Cadence. We recently had a heart failure patient enroll with Cadence. Their first vitals signs revealed a blood pressure of 201/100, which is way too high!
After 8 different clinician phone calls with the Cadence Care Delivery team and 3 medication titrations, we recently had a call to celebrate their blood pressure now being 113/70, just 3 weeks after they were hospitalized with heart failure exacerbation and uncontrolled blood pressure.
This is an incredible example of how RPM platforms like Cadence can make a meaningful impact on patients' lives.
Is it Possible to Treat Heart Failure without Remote Patient Monitoring?
TF: Do you think a cardiologist, general cardiologists, general internist who often winds up getting the lateral back when the patient is discharged from the hospital, can really monitor and treat and evaluate patients with congestive heart failure to the standard of care in 2022 without remote patient monitoring?
MF: So I can tell you, with an army of staff members, a nurse and advanced practice practitioners, yes, you could do that. That's how we do it in the majority of the country. And so an aging population, a growing population, and increased complexity of care, this becomes increasingly harder.
If you would ask the average internist and/or cardiologist, they would say, "Yeah, I can." That doesn't mean they are doing a good job. Unfortunately in the space of medicine, we're often quite confident people. Having said that, I'm the first to admit that I can alway provide better care to my patients with the right tools in hands. And I do personally believe that remote monitoring, when applied the right way and with the right resource in place, will be able to surveil your patient to a greater degree. And when the right flags are in place, we can flag them when they're at risk. And then with the right strategy in place, we can titrate the right drug.
So I think we will not get around introducing remote monitoring. And I'm also confident that the healthcare of the future will be that centers that don't get on the train right now of remote monitoring will be outpaced and will be providing sub-perfect care compared to the competing systems. And I don't think we should be doing this. We should not be trying to do traditional medicine when everybody around us is surrounded by technology all day, every day. We should leverage that.
The Efficacy of RPM Technology in Cardiology
TF: It's very clear that the rubber hits the road in medicine based upon outcomes. We're always talking about outcomes. One of the issues around RPM to date is that there's not been enough utilization to really be able to show on a consistent basis that RPM can impact on outcomes. Can you talk a little bit about current data about the success of remote monitoring within the cardiovascular space, and in particular, CHF?
MF: If you look into the summary of remote monitoring technologies to date, you will find that very few studies were able to significantly move the needle to benefit the patients in those remote monitoring trials.
And in the majority of those studies, you had either a single device that was applied with a standardized management system around it. And this either did result, as in the case of pressure sensors, CardioMEMS in a measurable benefit to patients. But in other strategies where it was multi-sensor technologies, we have not been able to find those benefits. And those were care systems where you actually had applied weight scales and blood pressure cuffs. And what people often say in the setting is that remote monitoring does not work. The problem is that it's actually not the remote monitoring, it's not the tools that don't work. It's actually the care plan that is often insufficient to derive the benefits.
So let me tell it to you in a different way: Don't blame the scale if you're not losing weight. It's the strategy that leads to weight loss that is not successful. So we often are rushing too fast to blame the technology at hand and say, oh, that technology doesn't work. And I think it's actually the way that humans are acting.
And I think your company is working to a great degree in advancing this field in this way to find ways to act on data and devising care management pathways that can line things up. So we act on the benefit of the data to the benefit of the patient, as opposed to relying blindly on data and having the data in some studies we wanted the data to guide the patient to have better benefits. But at the end of the day, it's about how we act on the data as clinicians to guide the patient to better outcomes. At the end of the day, it will come down to what management plans we are putting into place.
Embracing RPM Technology as the Standard of Care
TF: There are still so many cardiologists that remain skeptical about the role of RPM in the management of CHF and hypertension and other places. Speak directly to your colleagues. Try to convince a skeptical cardiologist out there that the time is now to embrace RPM technology.
MF: I do have this daily battle in my clinic with my partners. And I hope none of them is listening right now, but they would hear the same story.
The arguments I make are the following: We, in cardiology, are spoiled rotten. By large multicentered, gigantic mega trials with thousands of patients where we see a small benefit in the reduction of heart failure hospitalization or death. And it might be 10, 20, 30 percent of relative risk reduction, which in absolute terms is actually not that much. So the expectation is that any future treatment strategy — remember we are not a treatment. RPM is not a treatment. It's a strategy. So you would have to devise a strategy trial to show benefits we see with treatment strategies, such as a drug. We would have to devise large multi-thousand patient trials. If we have a similar treatment effect.
That is really hard to do. Those studies are very expensive. RPM companies usually do not have the dollars of Pharma off the Pfizers and the Novartis to do this type of studies. So I think we need to acknowledge that we need to settle on surrogates.
Let me tell what those surrogates might be. If I can titrate medications at a greater rate, at a faster pace, and get to a higher dose in a shorter time frame using RPM versus the normal standard of care, that should count. Why? Because we know unequivocally that higher rates and higher doses of GDMT are associated with outcomes. So if you, for whatever way, whether it's guilting them into it or calling them every day or showing up at the doorstep, if that's the means by which you can improve compliance and increase use of GDMT, you should win on that term alone.
Improvement of GDMT, improvement of some soft metrics such as quality of life, functional testing, biomarkers, should become eligible just to allow us to advance this field further — not having such a high bar.
We need to cut remote monitoring a little bit of a break, and accept the fact that if we can get patients on the right drugs, at a fast pace, and keep them at a lower heart rate because we watch them, keep them less congested, then we don't have to maybe show all those hard outcomes that, a significant P value that many people expect in our community and want to see that New England Journal of Medicine paper with a P value of less than 0.05. I think we need to be a little more cognizant that it's hard to do those types of studies.
Managing CHF and Chronic Conditions Through Connected Care
TF: Cadence is currently scaling up to partner with hospital systems and physicians all over the U.S. to manage a variety of chronic conditions, in addition to CHF, such as COPD, hypertension, and type two diabetes. When you think about the impact we here at Cadence can have, both for physicians and patients, what gets you excited?
MF: What gets me excited is that if I want to take on remote monitoring right now at my institution, no matter if you're at Duke or a smaller facility, the startup energy, the activation energy, to set up a program for remote monitoring is years worth of development work.
And then the problem becomes that it's years worth of work at every little institution that needs reproducing. It's reinventing the wheel at each institution. And why, is because we're relatively early into the era.
So what's maybe the most exciting about platforms such as yours is you invented it once, you might iterate it along the way, but you can now apply it to other institutions without having to be physically present there. And maybe it's something that can be outsourced.
I personally believe that in the future, institutions should not be inventing and building infrastructure for remote monitoring at each institution to the same degree zero to a hundred, which will take years, and miss out on all the opportunities that could be maybe just simply outsourced for some components.
At the end of the day, in order to stay profitable, you need to turn certain things to industry, you need to perfectionize the workflow and in an academic and non-academic settings, this is not always that easy to perfectionize and make processes, go very frictionless.
Using Technology to Deliver Care to Rural Areas
TF: Keeping your medical futurist hat on, help us paint this picture: What are the biggest advancements we're likely to see as it relates to cardiology, remote patient monitoring and virtual care, and what are some of the other new technologies that get you excited in this space?
MF: I think any effort to keep patients far away from hospitals even though they need medical care is exciting — whether that's enhanced by remote device technology, which I think is the case.
I think one of the buzzwords of the future is the hospital at home model. The idea that advanced academic and non-academic centers, large centers, are going to be caring primarily for very sick patients. But if you have this infection that really just needs some surveillance on a daily basis or every few hours, maybe something that doesn't even require a doctor to see you in person. We will outsource those things to where patients can designate their home to be a home monitoring system, a mini hospital, where all they need is maybe some remote monitoring tools, whether it's a remote scale, remote blood pressure cuff, heart rate sensors, and all they need to do is check in with a video visit or phone visit.
You know, the government recognized this as a target and is reimbursing some of those services. And I think the future is heading the way that we will outsource care to where patients don't have to travel three to four hours on average to see their provider when they live rurally. The majority of the United States is rural. You've got to deliver the care where it's needed. And it's mostly at patients' homes. And where we don't have to force them to come to that one hospital and eat our terrible food, but eat their good food at home.
TF: We'll leave it there. Dr. Fudim thanks so much for joining us today. It's been great speaking with you and thanks for enlightening us. And we look forward to our future conversations with Cadence.
MF: Thank you.