Device-based Strategies for Monitoring Congestion and Guideline-directed Therapy in Heart Failure: The Who, When and How of Personalised Care.

Despite therapeutic and technological advances, the prognosis for patients with heart failure (HF) remains poor. One reason for this poor prognosis lies in the limited usage of disease-modifying therapies, such as β-blockers, renin-angiotensin system inhibitors, mineralocorticoid receptor antagonists and sodium-glucose cotransporter 2 inhibitors, namely guideline-directed medical therapy (GDMT). Concurrently, technological advances have led to the development of numerous strategies for both invasive and non-invasive telemonitoring of HF patients, potentially intercepting a phase of decompensation before its overt clinical manifestation. As clinical guidelines and the healthcare landscape continue to evolve, HF management is increasingly focusing on integrating advanced technologies and empowering patients and care teams. Traditionally, diuretics have been the cornerstone of preventing HF decompensation because of their decongestive effects. However, emerging evidence suggests that the components of GDMT also exert decongestive effects, alongside their broader positive prognostic impact. The synergistic relationship between GDMT and telemonitoring devices offers a promising approach to congestion management. By adopting protocols that leverage both the pharmacological and non-pharmacological mechanisms of GDMT, care teams can maximise patient outcomes while addressing therapeutic inertia. This narrative review explores the potential for a paradigm shift, emphasising the early and consistent implementation of GDMT, supported by digital health solutions, to improve outcomes from the early stages of HF decompensation.