title: A multi-layer monitoring system for clinical management of Congestive Heart Failure.
abstract: BACKGROUND
  Congestive Heart Failure (CHF) is a serious cardiac condition that brings high risks of urgent hospitalization and death. Remote monitoring systems are well-suited to managing patients suffering from CHF, and can reduce deaths and re-hospitalizations, as shown by the literature, including multiple systematic reviews.
  
  
  METHODS
  The monitoring system proposed in this paper aims at helping CHF stakeholders make appropriate decisions in managing the disease and preventing cardiac events, such as decompensation, which can lead to hospitalization or death. Monitoring activities are stratified into three layers: scheduled visits to a hospital following up on a cardiac event, home monitoring visits by nurses, and patient's self-monitoring performed at home using specialized equipment. Appropriate hardware, desktop and mobile software applications were developed to enable a patient's monitoring by all stakeholders. For the first two layers, we designed and implemented a Decision Support System (DSS) using machine learning (Random Forest algorithm) to predict the number of decompensations per year and to assess the heart failure severity based on a variety of clinical data. For the third layer, custom-designed sensors (the Blue Scale system) for electrocardiogram (EKG), pulse transit times, bio-impedance and weight allowed frequent collection of CHF-related data in the comfort of the patient's home. We also performed a short-term Heart Rate Variability (HRV) analysis on electrocardiograms self-acquired by 15 healthy volunteers and compared the obtained parameters with those of 15 CHF patients from PhysioNet's PhysioBank archives.
  
  
  RESULTS
  We report numerical performances of the DSS, calculated as multiclass accuracy, sensitivity and specificity in a 10-fold cross-validation. The obtained average accuracies are: 71.9% in predicting the number of decompensations and 81.3% in severity assessment. The most serious class in severity assessment is detected with good sensitivity and specificity (0.87 / 0.95), while, in predicting decompensation, high specificity combined with good sensitivity prevents false alarms. The HRV parameters extracted from the self-measured EKG using the Blue Scale system of sensors are comparable with those reported in the literature about healthy people.
  
  
  CONCLUSIONS
  The performance of DSSs trained with new patients confirmed the results of previous work, and emphasizes the strong correlation between some CHF markers, such as brain natriuretic peptide (BNP) and ejection fraction (EF), with the outputs of interest. Comparing HRV parameters from healthy volunteers with HRV parameters obtained from PhysioBank archives, we confirm the literature that considers the HRV a promising method for distinguishing healthy from CHF patients.
authors.forename: Gabriele
authors.initials: G
authors.lastname: Guidi
authors.forename: Luca
authors.initials: L
authors.lastname: Pollonini
authors.forename: Clifford C
authors.initials: CC
authors.lastname: Dacso
authors.forename: Ernesto
authors.initials: E
authors.lastname: Iadanza
mesh_terms: D020000:Decision Support Systems, Clinical; D019468:Disease Management; D006333:Heart Failure / Q000175:diagnosis / Q000628:therapy*; D006339:Heart Rate / Q000502:physiology*; D006801:Humans; D008991:Monitoring, Physiologic / Q000379:methods*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity