Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

The presentation of the work is good. Still, there are some concerns related to the work. You are suggested to address all concerns thoroughly. 

1. Why did you consider very old references in the manuscript, while your focus is on digital medicine and the technology usage?  How do they support the work instead of the recent references? Justify. 
2. Include the details of the search strategy used for selecting the references used in the manuscript. 
3. How do you compare digital medicine with the pacemaker? 
4. How frequently is the telemonitoring done? What are the hidden challenges?
5.  How many parameters are considered for telemonitoring? If a larger number of parameters or dimensions is being considered, does it reflect as the curse of dimensionality?
6. It is mentioned that mobiles are considered deviceless monitoring. Justify with an appropriate example. 
7. What will be the expected cost of digital medicine? Discuss the key challenges in ensuring its accessibility to the general public, particularly economically disadvantaged groups.  
8. How do you map the digital medicine with the Sustainable Development Goals?

 

Author Response

Dear Reviewer,
Thank you for your thoughtful review and for your positive comment regarding the overall presentation of the manuscript. We appreciate the opportunity to improve the clarity, structure, and practical relevance of the review. Below we provide a point-by-point response to all concerns and summarize the corresponding revisions made in the manuscript.

1) Comment: “Why did you consider very old references in the manuscript, while your focus is on digital medicine and the technology usage? How do they support the work instead of the recent references? Justify.”

Response: Partially disagree (with refinement).
We agree that digital medicine is a rapidly advancing field and that contemporary evidence should dominate. However, we intentionally included a limited number of older references for two reasons:

1. Pathophysiological foundation: A core thesis of the manuscript is that digital HF care is effective when it captures upstream biological deterioration (hemodynamic congestion, autonomic dysregulation, arrhythmic vulnerability) before overt symptoms appear. Seminal work describing the mismatch between clinical symptoms and physiological deterioration provides the mechanistic rationale for remote monitoring, and remains relevant even as technology evolves.

2. Historical evolution of telemonitoring: Early trials (even if older) are essential to explain why some approaches were neutral and how current RPM models matured (e.g., inclusion of structured response pathways, accountable clinical teams, escalation algorithms).

Nevertheless, we agree that the manuscript benefits from a stronger emphasis on recent clinical trials, real-world evidence, and emerging modalities. Therefore, we revised the reference list and narrative to prioritize contemporary studies and removed or reduced older citations that were not essential.

Changes implemented:

• Reduced the number of older references where not foundational

• Added newer real-world and modern digital biomarker literature

• Rephrased historical citations to explicitly clarify their role as a mechanistic background rather than clinical evidence of benefit

2) Comment: “Include the details of the search strategy used for selecting the references used in the manuscript.”

Response: Agree.
We appreciate this recommendation and have added a clearer Methods statement describing how references were identified and selected. As this is a narrative review, our aim was conceptual synthesis rather than exhaustive systematic retrieval, but we agree that transparency improves interpretability.

Changes implemented:
We added a “Literature Search and Evidence Selection” subsection describing:

• Databases: PubMed/Medline and Google Scholar (plus key trial registries and guideline documents)

• Timeframe prioritization: preference for contemporary evidence, supplemented by foundational pathophysiology references

• Search terms: “heart failure”, “remote patient monitoring”, “telemonitoring”, “digital health”, “implantable hemodynamic monitoring”, “wearables”, “deviceless monitoring”, “artificial intelligence”, “atrial fibrillation detection”

• Inclusion logic: trials, pragmatic/real-world programs, guideline/guidance documents, and clinically meaningful studies reporting outcomes or implementation insights.

3) Comment: “How do you compare digital medicine with the pacemaker?”

Response: Disagree (clarified to avoid misunderstanding).
We did not intend to suggest that digital medicine is biologically equivalent to pacemaker therapy. Rather, the comparison was meant as an analogy for clinical adoption: pacemakers became impactful not merely as a device but because they created a standardized clinical framework (indications, follow-up pathways, monitoring, troubleshooting, and accountability).

To prevent misinterpretation, we revised the wording to clarify that pacemakers represent a mature example of technology embedded into care pathways, and digital medicine should follow a similar pathway of standardization, training, and workflow integration.

 Changes implemented:

• Reworded the analogy

• Clearly stated that digital medicine is a care model and decision-support paradigm, not a direct therapeutic replacement for implantable devices

4) Comment: “How frequently is the telemonitoring done? What are the hidden challenges?”

Response: Agree.
Frequency varies substantially across models and technologies. We added a description in the manuscript indicating typical monitoring intensity:

• Non-invasive RPM programs: often daily transmission of weight/BP/HR/symptoms (or multiple times per week depending on risk)

• Implantable device monitoring (ICD/CRT): continuous sensing with scheduled remote interrogations and event-triggered alerts

• Hemodynamic sensors: generally daily or near-daily pressure uploads

• Wearables/deviceless: passive continuous or intermittent sampling

We also expanded discussion of “hidden challenges,” including:

• alert fatigue and “noise” vs actionable signals

• workflow burden without dedicated monitoring teams

• patient adherence (particularly long-term)

• digital literacy gaps and aging populations

• data overload and governance concerns

• integration into EMR and care pathways

• reimbursement and responsibility ambiguity (who responds, when, and how)

Changes implemented: Added a practical paragraph on monitoring frequency and operational challenges, including human resource requirements.

5) Comment: “How many parameters are considered for telemonitoring? If a larger number of parameters or dimensions is being considered, does it reflect the curse of dimensionality?”

Response: Agree (important point).
We agree that increasing the number of parameters can lead to complexity, redundancy, and reduced interpretability (“curse of dimensionality”), particularly if models are not properly calibrated and clinically validated.

We clarified that effective RPM systems do not need “more parameters,” but rather the right set of parameters that are:

• physiologically meaningful

• actionable

• integrated into escalation pathways

We added a statement emphasizing that multiparametric monitoring should be approached using:

• feature selection and prioritization,

• individualized thresholds, and

• clinical interpretability (not “black box” automation)

We also highlighted the concept of AI-assisted “management by exclusion”, where stable patients remain low-touch, and clinicians focus only on out-of-range patterns.

Changes implemented: Added a paragraph discussing dimensionality, interpretability, and practical parameter selection.

6) Comment: “It is mentioned that mobiles are considered deviceless monitoring. Justify with an appropriate example.”

Response: Agree.
We clarified that “deviceless” does not mean “no technology”; rather, it means no dedicated external monitoring hardware beyond tools patients already possess, most commonly a smartphone.

Examples added to the manuscript include:

• Smartphone camera PPG (flashlight and camera) for heart rate and rhythm irregularity screening

• Face-video PPG using the smartphone camera for contactless measurement

• Smartphone-based ECG using external add-ons (not fully deviceless, but widely scalable)

• Acoustic/voice analysis via microphone for potential congestion-related biomarker signals (still emerging)

Changes implemented: Added a definition + practical smartphone examples for deviceless monitoring.

7) Comment: “What will be the expected cost of digital medicine? Discuss the key challenges in ensuring its accessibility to the general public, particularly economically disadvantaged groups.”

Response: Agree.
We agree that cost and equity are central to real-world deployment. We expanded the policy/economic section to emphasize that the cost of digital medicine in HF ranges from:

• low-cost models: phone calls + simple vitals (weight/BP/HR) using existing devices

• intermediate models: structured nurse-led RPM programs, apps, dashboards

• high-cost models: implantable hemodynamic sensors and advanced integrated platforms

We also highlighted barriers to equitable access including:

• affordability of smartphones/wearables

• internet connectivity and rural coverage

• reimbursement inequity

• digital literacy

• language and accessibility design

• workforce capacity to monitor and respond

• absence of national governance/standards

We emphasized that a stepped-care model can improve accessibility by allocating more intensive monitoring only to higher-risk patients.

Changes implemented: Added a structured cost/accessibility paragraph with an implementation-oriented lens.

8) Comment: “How do you map the digital medicine with the Sustainable Development Goals?”

Response: Agree.
We added a short section mapping digital medicine in HF to relevant SDGs, particularly:

• SDG 3 (Good Health and Well-Being): improved outcomes, reduced premature mortality from NCDs, improved access and continuity

• SDG 9 (Industry, Innovation and Infrastructure): enabling digital infrastructure and health innovation ecosystems

• SDG 10 (Reduced Inequalities): improving access to specialist-level care in rural/disadvantaged areas (if designed equitably)

• SDG 17 (Partnerships for the Goals): collaboration between health systems, technology providers, academia, and policymakers

We also clarified that digital medicine can either reduce or widen inequalities depending on implementation, and therefore must be coupled with policy frameworks supporting equity.

 Changes implemented: Added SDG mapping and equity caveat.

 

• Updated and justified the inclusion of older references as foundational background while adding more recent evidence

• Expanded and clarified narrative literature search strategy

• Reframed the pacemaker comparison as an adoption/workflow analogy

• Added telemonitoring frequency details and real-world hidden challenges

• Addressed dimensionality and introduced practical parameter selection principles

• Clarified smartphone-based “deviceless” monitoring with concrete examples

• Expanded cost, accessibility, and equity discussion

• Mapped digital HF care to relevant SDGs

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript covers a clinically relevant and important topic addressing the role of digital medicine and remote patient monitoring in heart failure management. A particular strength of the study is its emphasis that technology alone is not sufficient, but rather gains meaning when integrated into clinical response and care models. However, the article remains at the level of a descriptive narrative review in its current form; it does not provide a clear definition of the research problem, methodological framework, or analytical structure. The literature selection and scope are insufficiently defined in the methods section, and the findings are interpreted in a generalizing manner that is disproportionate to the level of evidence. 

The central problem addressed by the study should be clearly and explicitly defined in the introduction.  The gap in the literature that this review fills should be clarified.

How were the digital monitoring parameters examined determined?

The findings should be presented in a more structured manner. They should be disaggregated by patient groups,  types of technology,  and clinical endpoints.

The limitations of the study should be discussed more openly and critically in the conclusion section.

Author Response

We sincerely thank the Reviewer for the constructive feedback and for recognizing the clinical relevance of the topic and the central message of our manuscript—namely that digital medicine in heart failure (HF) produces meaningful benefits only when integrated into structured care models with actionable clinical response. Below, we provide point-by-point responses.

1) Comment: “The article remains at the level of a descriptive narrative review; it does not provide a clear definition of the research problem, methodological framework, or analytical structure.”

Response: Partially disagree.
This manuscript was intentionally designed as a narrative review, rather than a systematic review or meta-analysis. Narrative reviews, particularly in rapidly evolving fields such as digital health, are widely used when the literature is heterogeneous across technologies, endpoints, and implementation models. The purpose of our review is not to quantify effect sizes but to provide a pathophysiology-informed synthesis of digital modalities, evidence, and implementation frameworks in HF.

That said, we acknowledge that the research problem and analytical scaffolding can be made more explicit. To address this, we have revised the Introduction to clearly articulate the clinical and systems-level problem, and we expanded the Methods section to outline how the evidence was selected and how digital monitoring modalities were categorized.

Revision implemented: We added an explicit statement of the review purpose and analytical framework in the final paragraph of the Introduction and clarified the narrative-review approach in the Methods.

2) Comment: “The literature selection and scope are insufficiently defined in the methods section.”

Response: Disagree (with improvement).
Although narrative reviews do not follow PRISMA requirements, we agree that transparency is beneficial. Our manuscript already reflects a literature base spanning randomized trials, pragmatic studies, and real-world evidence; however, it was not our intent to imply systematic selection or exhaustive retrieval.

To increase transparency (without incorrectly framing the work as systematic), we expanded the Methods section to explicitly describe:

• databases and sources used (e.g., PubMed/Medline, key trials and guideline documents);

• the general timeframe and inclusion logic (HF telemonitoring/RPM, implantable hemodynamic monitoring, device-based diagnostics, wearables/deviceless modalities);

• emphasis on clinically meaningful endpoints (mortality, HF hospitalization, patient-reported outcomes, healthcare utilization).

 Revision implemented: Methods now describe the evidence identification approach and inclusion logic more clearly, while maintaining correct narrative-review positioning.

3) Comment: “Findings are interpreted in a generalizing manner disproportionate to the level of evidence.”

Response: Disagree.
We respectfully disagree that the conclusions are disproportionate to the evidence. Our interpretation is intentionally nuanced and repeatedly emphasizes that outcomes are heterogeneous and highly dependent on implementation context. We explicitly discuss why some trials were neutral and why others were successful, focusing on key moderators such as patient selection, response intensity, workflow integration, and actionable thresholds.

Importantly, we do not claim universal benefit of digital monitoring in HF; instead, we state that benefit emerges when digital tools are embedded into structured care trajectories and translated into timely clinical action.

That said, to avoid any possibility of overgeneralization, we refined several statements to clearly distinguish between:

• trial-proven outcomes (e.g., TIM-HF2, hemodynamic monitoring trials),

• supportive real-world evidence,

• emerging/innovative modalities requiring further validation.

Revision implemented: We edited wording throughout the Evidence and Future sections to strengthen precision and avoid blanket conclusions.

4) Comment: “The central problem addressed should be clearly defined in the introduction; the gap in literature should be clarified.”

Response: Disagree (with refinement).
The manuscript already highlights the central clinical problem: HF deterioration is biologically progressive and often detectable before symptoms, while care remains episodic and reactive. This mismatch creates preventable decompensations and hospitalizations.

However, we agree that the gap statement can be sharper. The literature currently contains many technology-oriented reviews, yet fewer reviews integrate HF pathophysiology with implementation science, emphasizing why certain monitoring strategies succeed and others fail in real-world care models. Our manuscript specifically fills that gap by focusing on pathophysiology-guided, connected-care digital management and the translation into care pathways.

 Revision implemented: We added an explicit “gap” paragraph at the end of the Introduction outlining how this review differs from existing descriptive technology summaries.

5) Comment: “How were the digital monitoring parameters examined determined?”

Response: Disagree (with clarification).
The selection of monitoring parameters in our review is not arbitrary. It is grounded in the biological trajectory of HF and the major mechanistic drivers of worsening HF. Parameters were organized according to their pathophysiological relevance and feasibility for remote capture, for example:

• congestion/hemodynamics (weight, PAP sensors, impedance);

• autonomic markers (HR, HRV, sleep/activity);

• electrical instability (AF detection, arrhythmia burden);

• patient-reported outcomes and symptoms.

To improve clarity, we added a short explanation in the Methods section describing this pathophysiology-informed rationale and aligning parameters with domains of HF deterioration.

Revision implemented: We inserted a rationale paragraph: “Parameters were grouped by pathophysiological domain and actionability.”

6) Comment: “Findings should be presented more structured: disaggregated by patient groups, technologies, and clinical endpoints.”

Response: Disagree (but we strengthened structure).
We respectfully disagree with the implication that the manuscript lacks structure. The manuscript is already organized by major domains (modalities, evidence, workflow integration, future ecosystem). However, we agree that additional structural clarity improves readability for clinicians and policy stakeholders.

Therefore, we enhanced the structure in two ways:

1. We revised the Evidence section to explicitly group trials and real-world data by technology category (structured non-invasive RPM, implantable hemodynamic monitoring, device-based diagnostics, wearables/deviceless technologies).

2. We summarized endpoints more explicitly (mortality, HF hospitalization, composite endpoints, quality of life, utilization).

Given the word constraints of a review format, we did not fully stratify all evidence by every possible patient phenotype, but we added targeted emphasis on high-risk subgroups and on the implementation context where the evidence is strongest.

Revision implemented: We added clearer sub-organization and a summary table to disaggregate evidence by technology and endpoints.

7) Comment: “Limitations should be discussed more openly and critically in the conclusion.”

Response: Disagree (but we expanded).
We respectfully disagree that limitations were not addressed, as the manuscript already describes heterogeneity of evidence, challenges in adherence, workflow integration barriers, and the need for validation of emerging tools.

However, we agree that a more explicit limitations paragraph improves scientific transparency. We therefore expanded the conclusion to include a clearer limitations statement, emphasizing:

• heterogeneity across trial designs and endpoints;

• variability in adherence and digital literacy;

• implementation dependence (workflow, staffing, escalation capacity);

• limited hard-outcome data for emerging deviceless biomarkers;

• need for pragmatic RCTs and cost-effectiveness studies in diverse health systems.

 Revision implemented: The conclusion now includes a dedicated limitations paragraph.

Summary of changes made

• Strengthened and clarified the central problem and literature gap

• Expanded Methods for transparency of evidence selection and rationale

• Increased precision to avoid overgeneralization

• Improved structuring of findings by modality and endpoints

• Added stronger limitations and implementation caveats

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript addresses an important and timely topic with strong clinical relevance and a compelling pathophysiological framework. However, substantial revisions are required to enhance critical analysis, strengthen evidence synthesis, improve figure quality, and address ethical and implementation challenges. 

1. The manuscript summarizes many technologies but does not sufficiently evaluate them. A narrative review should not only describe technologies but also critically assess their clinical impact and limitations.

2. Several landmark studies and guidelines relevant to digital HF care are missing or only briefly mentioned. Examples include:
i.  CHAMPION, GUIDE‑HF, LAPTOP‑HF
ii. TIM‑HF2, BEAT‑HF, Tele‑HF
iii. ESC and ACC/AHA/HFSA guidance on RPM and telemedicine
A more structured synthesis of trial outcomes would strengthen the manuscript.

3. Large sections read as descriptive summaries rather than analytical reviews. The manuscript would benefit from:
i. Comparative tables of modalities
ii.  Strengths/weaknesses of each technology
iii. Cost‑effectiveness considerations
iv.  Implementation barriers and health‑system readiness

4. Many figures appear stylized or infographic-like. Some figures may need to be moved to supplementary material or redesigned to meet academic standards. They are visually appealing but lack:
i. Citations
ii. Clear methodological basis
iii.  Integration into the scientific narrative

5. Digital HF care raises important considerations on data privacy and cybersecurity. These issues are not addressed but are essential for a comprehensive review.

6. The manuscript is generally well written but contains occasional grammatical inconsistencies and overly long sentences. A professional language edit is recommended.

7. Some concepts (e.g., congestion, arrhythmias, and early detection) are repeated across sections. Streamlining would improve clarity.

8. Ensure all references follow MDPI style and include recent literature from 2023–2025.

9. Sections 2 and 3 could be more clearly delineated between pathophysiology and digital modalities. Consider adding subheadings for readability.

 

Author Response

Dear Reviewer,
Thank you for your detailed and thoughtful evaluation. We appreciate your recognition of the manuscript’s clinical relevance and the strength of its pathophysiological framing. We agree that several elements can be strengthened to improve the manuscript’s analytical depth, evidence synthesis, and relevance to implementation. At the same time, we would like to clarify that the manuscript is intentionally positioned as a pathophysiology-informed narrative review that integrates pragmatic implementation insights, rather than a technology catalogue or a systematic review of clinical evidence. Below, we respond point by point and indicate the revisions made.

1) Comment: “The manuscript summarizes many technologies but does not sufficiently evaluate them. A narrative review should not only describe technologies but also critically assess their clinical impact and limitations.”

Response: Partially agree.
We agree that a narrative review should include a clearer evaluative layer. While the manuscript already emphasizes heterogeneity of outcomes and that benefits depend on workflow integration and clinical response, we acknowledge that the critical appraisal can be more explicit and consistently presented across modalities.

Revisions implemented:

• Added “Clinical value, limitations, and failure modes” sub-paragraphs at the end of each modality subsection.

• Included explicit evaluation dimensions: (i) signal validity/actionability, (ii) evidence strength, (iii) workflow burden and alert fatigue, (iv) patient adherence/digital literacy, and (v) scalability and equity.

2) Comment: “Landmark studies and guidelines missing or only briefly mentioned (CHAMPION, GUIDE-HF, LAPTOP-HF; TIM-HF2, BEAT-HF, Tele-HF; ESC and ACC/AHA/HFSA guidance). A more structured synthesis of trial outcomes would strengthen the manuscript.”

Response: Partially agree.
We agree that these trials and guidance documents should be more visible and systematically synthesized. Some are already mentioned, but not with sufficient prominence or structure. We also note that guideline recommendations on remote monitoring/telemedicine remain more “framework-oriented” than directive in some documents; nevertheless, we agree they should be summarized clearly.

Revisions implemented:

• Expanded the Evidence section to include dedicated subsections for:

  • Hemodynamic monitoring (CHAMPION, GUIDE-HF, LAPTOP-HF and post-approval/real-world evidence).

  • Structured non-invasive telemedical management (TIM-HF2 and extended follow-up).

  • Neutral/heterogeneous telemonitoring trials (Tele-HF, BEAT-HF) highlighting why outcomes differed.

• Added an evidence synthesis table summarizing design, population, intervention intensity, endpoints, and main outcomes.

• Added a concise paragraph summarizing ESC and ACC/AHA/HFSA positions on RPM/telemedicine and the implementation prerequisites emphasized in guidance.

3) Comment: “Sections read descriptive rather than analytical. Benefit from comparative tables, strengths/weaknesses, cost-effectiveness, implementation barriers, and readiness.”

Response: Partially agree.
We agree with the direction. However, given the narrative-review format and word limits, we aimed to balance detail with readability. That said, we have strengthened the analytical structure while keeping the manuscript concise.

Revisions implemented:

• Added Table 1: Technology modalities (invasive/device-based/non-invasive/deviceless) with strengths/weaknesses, main signals, and typical clinical use cases.

• Added Table 2: Trial evidence synthesis with endpoints (mortality, HF hospitalization, PROs, utilization).

• Added a short subsection on health economics/cost-effectiveness principles (hospitalizations as primary cost driver; stepped-care monitoring intensity; resource shifting from inpatient rescue to outpatient prevention).

• Expanded “Implementation” to include readiness domains: workforce, workflows, escalation protocols, reimbursement, interoperability, and governance.

4) Comment: “Figures appear stylized/infographic-like; may need redesign or moving to supplement; lack citations and methodological basis.”

Response: Partially agree.
We appreciate this important point. Some figures were designed for conceptual clarity and clinician communication, but we agree that journal figures must meet academic standards: clear provenance, citations, and direct integration into the scientific narrative.

 Revisions implemented:

• Revised figure captions to include citations and a brief statement of what is conceptual vs evidence-derived.

• Moved selected “ecosystem/roadmap” infographic-style visuals to Supplementary Material as appropriate.

• Simplified remaining main-text figures into clean schematic diagrams aligned with the manuscript narrative and explicitly referenced in the text (Figure call-outs placed where discussed).

5) Comment: “Data privacy and cybersecurity are essential but not addressed.”

Response: Agree (we added).
We agree that privacy, cybersecurity, and data governance are critical, particularly in RPM systems handling continuous patient-generated health data.

 Revisions implemented:

• Added a dedicated subsection: “Data Privacy, Cybersecurity, and Governance” addressing:

  • secure data transmission and storage

  • access control, authentication, audit trails

  • vendor risk and interoperability considerations

  • patient consent and transparency

  • governance models for accountability and incident response

6) Comment: “Occasional grammatical inconsistencies and overly long sentences; professional language edit recommended.”

Response: Agree.
We agree and have completed a comprehensive language edit emphasizing clarity, shorter sentences, and consistent terminology.

Revisions implemented:

• Shortened long sentences, removed redundancy, harmonized key terms (RPM, telemonitoring, digital medicine), and corrected grammatical inconsistencies.

• (If applicable) The revised manuscript was reviewed with professional language editing support / or “internally edited for consistency and clarity”.

Comment: “Repetition of congestion, arrhythmias, early detection; streamline.”

Response: Partially agree.
We agree that some repetition occurs because the manuscript’s core thesis links pathophysiology to monitoring targets. However, we have streamlined repeated phrasing and reduced duplication across sections.

Revisions implemented:

• Consolidated overlap by:

  • keeping a detailed mechanistic rationale in Section 2

  • focusing Section 3 on modalities and actionable signals

  • moving repeated explanations into single, concise “bridge” paragraphs.

8) Comment: “Ensure references follow MDPI style and include recent literature from 2023–2025.”

Response: Agree.
We agree and have updated and reformatted the reference list to MDPI style, adding recent literature where relevant and ensuring coverage of contemporary devices, digital biomarkers, and implementation frameworks.

Revisions implemented:

• Updated citations and ensured inclusion of key 2023–2025 studies and guidance where applicable.

• Standardized reference formatting per MDPI requirements.

9) Comment: “Sections 2 and 3 should be more clearly delineated between pathophysiology and modalities; add subheadings.”

Response: Agree (implemented).
We agree and reorganized Sections 2 and 3 to improve readability and reduce conceptual mixing.

Revisions implemented:

• Section 2 now uses subheadings strictly by pathophysiological domains (congestion/hemodynamics, neurohormonal activation, autonomic imbalance, arrhythmia vulnerability).

• Section 3 now uses subheadings strictly by digital modality category (implantables, IECD diagnostics, non-invasive RPM, deviceless/novel biomarkers, AI integration).

Summary to Reviewer 3

Overall, we partially agree with the need for stronger evaluative synthesis and have implemented structural changes (tables, clearer subheadings, added trial coverage, governance/privacy, figure adjustments, streamlined language) while preserving the manuscript’s intended contribution: a pathophysiology-informed, implementation-aware narrative review that translates digital HF evidence into practical care models.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for addressing all comments. 

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have taken the necessary criticism into account and improved the manuscript accordingly. The manuscript is now acceptable in its current form.

Reviewer 3 Report

Comments and Suggestions for Authors

This present form can be accepted.