Remote patient monitoring systems reduced all-cause mortality by 11% (relative risk 0.890) among heart failure patients across 57 randomized trials involving approximately 22,000 participants. The analysis encompassed telephone support, non-invasive telemonitoring, and invasive hemodynamic monitoring, with trial sequential analysis confirming the evidence threshold has been definitively reached—meaning additional studies are unlikely to overturn this mortality benefit. Heart failure hospitalizations dropped by 20%, though this effect showed greater variability across different healthcare settings. The finding represents a significant milestone in cardiovascular care, establishing remote monitoring as an evidence-based intervention for one of medicine's costliest conditions affecting over 6 million Americans. However, this preprint analysis awaiting peer review reveals a critical blind spot: only 2 of 57 trials examined rural versus urban populations, creating an evidence gap precisely where remote monitoring could theoretically provide the greatest benefit. This limitation is particularly concerning given that rural populations face higher heart failure mortality rates and reduced access to specialized care. The moderate-quality evidence suggests remote monitoring's mortality benefit is robust, but questions remain about equitable access and effectiveness across diverse geographic and socioeconomic populations.