Potential value of automated daily screening of cardiac resynchronization therapy defibrillator diagnostics for prediction of major cardiovascular events: results from Home-CARE (Home Monitoring in Cardiac Resynchronization Therapy) study

Automatic daily remote monitoring in heart failure patients implanted with a cardiac resynchronisation therapy-defibrillator: a single-centre observational pilot study

INTRODUCTION

The impact of remote monitoring (RM) on clinical outcomes in heart failure (HF) patients with cardiac resynchronisation therapy-defibrillator (CRT-D) implantation is controversial. This study sought to evaluate the performance of an RM follow-up protocol using modified criteria of the PARTNERS HF trial in comparison with a conventional follow-up scheme.

MATERIAL AND METHODS

We compared cardiovascular (CV) mortality (primary endpoint) and hospitalisation events for decompensated HF, and the number of ambulatory in-office visits (secondary endpoint) in CRT-D implanted patients with automatic RM utilising daily transmissions (RM group, n = 45) and conventional follow-up (CFU group, n = 43) in a single-centre observational study.

RESULTS

After a median follow-up of 25 months, a significant advantage was seen in the RM group in terms of CV mortality (1 vs. 6 death event, p = 0.04), although RM follow-up was not an independent predictor for CV mortality (HR = 0.882; 95% CI: 0.25-3.09; p = 0.845). Patient CV mortality was independently influenced by hospitalisation events for decompensated HF (HR = 3.24; 95% CI: 8-84; p = 0.022) during follow-up. We observed significantly fewer hospitalisation events for decompensated HF (8 vs. 29 events, p = 0.046) in the RM group. Furthermore, a decreased number of total (161 vs. 263, p < 0.01) and unnecessary ambulatory in-office visits (6 vs. 19, p = 0.012) were seen in the RM group as compared to the CFU group.

CONCLUSIONS

Follow-up of CRT-D patients using automatic RM with daily transmissions based on modified PARTNERS HF criteria enabled more effective ambulatory interventions leading indirectly to improved CV survival. Moreover, RM directly decreased the number of HF hospitalizations and ambulatory follow-up burden compared to CRT-D patients with conventional follow-up.

Accelerometer-assessed physical behavior and the association with clinical outcomes in implantable cardioverter-defibrillator recipients: A systematic review

Background

Current implantable cardioverter-defibrillator (ICD) devices are equipped with a device-embedded accelerometer capable of capturing physical activity (PA). In contrast, wearable accelerometer-based methods enable the measurement of physical behavior (PB) that encompasses not only PA but also sleep behavior, sedentary time, and rest-activity patterns.

Objective

This systematic review evaluates accelerometer-based methods used in patients carrying an ICD or at high risk of sudden cardiac death.

Methods

Papers were identified via the OVID MEDLINE and OVID EMBASE databases. PB could be assessed using a wearable accelerometer or an embedded accelerometer in the ICD.

Results

A total of 52 papers were deemed appropriate for this review. Out of these studies, 30 examined device-embedded accelerometry (189,811 patients), 19 examined wearable accelerometry (1601 patients), and 3 validated wearable accelerometry against device-embedded accelerometry (106 patients). The main findings were that a low level of PA after implantation of the ICD and a decline in PA were both associated with an increased risk of mortality, heart failure hospitalization, and appropriate ICD shock. Second, PA was affected by cardiac factors (eg, onset of atrial fibrillation, ICD shocks) and noncardiac factors (eg, seasonal differences, societal factors).

Conclusion

This review demonstrated the potential of accelerometer-measured PA as a marker of clinical deterioration and ventricular arrhythmias. Notwithstanding that the evidence of PB assessed using wearable accelerometry was limited, there seems to be potential for accelerometers to improve early warning systems and facilitate preventative and proactive strategies.

Emerging Implantable Device Technology for Patients at the Intersection of Electrophysiology and Heart Failure Interdisciplinary Care

Cardiac implantable electronic devices (CIEDs), including implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT), are part of guideline- indicated treatment for a subset of patients with heart failure with reduced ejection fraction (HFrEF). Current technological advancements in CIEDs have allowed the detection of specific patient physiologic parameters used for forecasting clinical decompensation through algorithmic, multiparameter remote monitoring. Other recent emerging technologies, including cardiac contractility modulation (CCM) and baroreflex activation therapy (BAT), may provide symptomatic or physiologic benefit in patients without an indication for CRT. Our goal in this state-of-the-art review is to describe the commercially available new technologies, purported mechanisms of action, evidence surrounding their clinical role, limitations, and future directions. Finally, we underline the need for standardized workflow and close interdisciplinary management of this population to ensure the delivery of high-quality care.

Remote monitoring of implantable defibrillators is associated with fewer inappropriate shocks and reduced time to medical assessment in a remote and rural area

BACKGROUND

Implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation therapy with defibrillators (CRT-D) reduce mortality in certain cardiac patient populations. However, inappropriate shocks pose a problem, having both adverse physical and psychological effects on the patient. The advances in device technology now allow remote monitoring (RM) of devices to replace clinic follow up appointments. This allows real time data to be analysed and actioned and this may improve patient care.

AIM

To determine if RM in patients with an ICD is associated with fewer inappropriate shocks and reduced time to medical assessment.

METHODS

This was a single centre, retrospective observational study, involving 156 patients implanted with an ICD or CRT-D, followed up for 2 years post implant. Both appropriate and inappropriate shocks were recorded along with cause for inappropriate shocks and time to medical assessment.

RESULTS

RM was associated with fewer inappropriate shocks (13.6% clinic vs 3.9% RM; P = 0.030) and a reduced time to medical assessment (15.1 ± 6.8 vs 1.0 ± 0.0 d; P < 0.001).

CONCLUSION

RM in patients with an ICD is associated with improved patient outcomes.

Hybrid comprehensive telerehabilitation in heart failure patients (TELEREH-HF): A randomized, multicenter, prospective, open-label, parallel group controlled trial-Study design and description of the intervention

Guidelines recommend exercise training as a component of heart failure (HF) management. There are large disparities in access to rehabilitation and introducing hybrid comprehensive telerehabilitation (TR) consisting of remote monitoring of training in patients' homes might be an optimal solution in Poland.

PURPOSE

The primary objective of the TELEREH-HF trial is to determine whether introducing TR will significantly increase days alive and out of hospital compared with usual care. The secondary objectives including assessment the effects of TR compared to usual care on all-cause and cardiovascular mortality and all-cause, cardiovascular and HF hospitalization. The tertiary analyses include: evaluation of the safety, effectiveness, quality of life, depression, anxiety, patients' acceptance of and adherence to TR.

METHODS

The TELEREH-HF study is a randomized, multicenter, prospective, open-label, parallel group controlled trial in 850 HF patients after a hospitalization incident in NYHA I-III and LVEF≤40%. Patients were randomized to TR + usual care (TR group) or to usual care only (control group) and are followed for a maximum of 24 months. The TR group patients underwent a 9-week TR program consisting of an initial stage (1 week) conducted at hospital and a basic stage (8-week) home-based TR five times weekly.

RESULTS

All patients were randomized and completed initial intervention in the TR group. The follow up of both groups is in progress.

CONCLUSION

The TELEREH-HF trial will provide novel data on the effects of telerhabilitation on hospitalization and mortality in HF patients, and on safety, quality of life, depression, anxiety and acceptance of and adherence to this intervention.

Incremental Value of Implantable Cardiac Device Diagnostic Variables Over Clinical Parameters to Predict Mortality in Patients With Mild to Moderate Heart Failure

Background

Heart failure remains a leading cause of morbidity and mortality. Clinical prediction models provide suboptimal estimates of mortality in this population. We sought to determine the incremental value of implantable device diagnostics over clinical prediction models for mortality.

Methods and Results

RAFT (Resynchronization/Defibrillation for Ambulatory Heart Failure Trial) patients with implanted devices capable of device diagnostic monitoring were included, and demographic and clinical parameters were used to compute Meta‐Analysis Global Group in Chronic Heart Failure (MAGGIC) heart failure risk scores. Patients were classified according to MAGGIC score into low (0–16), intermediate (17–24), or high (>24) risk groups. Mortality was evaluated from 6 months postimplant in accordance with the RAFT protocol. In a subset of 1036 patients, multivariable analysis revealed that intermediate and high MAGGIC scores, fluid index, atrial fibrillation, and low activity flags were independent predictors of mortality. A device‐integrated diagnostic parameter that included a fluid index flag and either a positive atrial fibrillation flag or a positive activity flag was able to significantly differentiate higher from lower risk for mortality in the intermediate MAGGIC cohort. The effect was more pronounced in the high‐risk MAGGIC cohort, in which device‐integrated diagnostic–positive patients had a shorter time to death than those who were device‐integrated diagnostic negative.

Conclusions

Device diagnostics using a combination of fluid index trends, atrial fibrillation burden, and patient activity provide significant incremental prognostic value over clinical heart failure prediction scores in higher‐risk patients. This suggests that combining clinical and device diagnostic parameters may lead to models with better predictive power. Whether this risk is modifiable with early medical intervention would warrant further studies.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00251251.

Transtelephonic ECG Monitoring to Guide Outpatient Antiarrhythmic Drug Therapy in Patients With Non-Permanent Atrial Fibrillation: Efficacy and Safety From a Single-Center Experience

Initiation of antiarrhythmic drug therapy (AADx) for atrial fibrillation (AF) on an outpatient basis requires intensive ECG monitoring in order to assess antiarrhythmic efficacy as well as ECG signals of potential proarrhythmia. Dronedarone (DRO) reduces cardiovascular endpoints in AF patients fulfilling criteria of the ATHENA trial [1]. In the present study transtelephonic ECG monitoring was used to guide initiation of AADx in AF patients fulfilling the ATHENA criteria. In 19 consecutive patients (37% female; age 65+10 years; LVEF 62+7%; mean CHA2DS2-VASc score 2.9 + 1.6 (median=2), with symptomatic non-permanent AF and additional cardiovascular risk factors, DRO was prescribed as AADx of first choice. Initiation of therapy and follow-up were monitored by transtelephonic ECG recordings (VITAPHONE™100 IR; Vitaphone GmbH; Germany). In patients with persistent AF, electrical cardioversion was performed on an outpatient basis when DRO was started. Patients were followed for changes in QT intervals as well as AF recurrency. ECGs were transmitted according to a scheduled FU form as well as any time in case of pts symptoms. Patients in whom DRO did not prevent AF recurrence were switched to alternative AADx, or to pulmonary vein isolation (PVI), respectively. At the end of long-term follow-up, DRO alone was successful in preventing AF recurrence in 5 of 19 patients (26%). When pts who responded to AADx of second or third choice or who underwent PVI were included, SR could be maintained in 17/19 pts (89%). No patient required discontinuation of AADx due to ventricular depolarization abnormalities, symptomatic bradycardia or pathologic QT prolongation. In conclusion, transtelephonic ECG transmission is useful for close rhythm monitoring during initiation and follow-up of AADx, also during change from DRO to other AADx. DRO was effective to prevent AF recurrence in 26% of patients during a mean long-term follow-up of more than 30 months - which is well in line with data from the literature.

Evaluation of thoracic impedance trends for implant-based remote monitoring in heart failure patients - Results from the (J-)HomeCARE-II Study

AIMS

Remote monitoring by implantable devices substantially improves management of heart failure (HF) patients by providing diagnostic day-to-day data. The use of thoracic impedance (TI) as a surrogate measure of fluid accumulation is still strongly debated. The multicenter HomeCARE-II study evaluated clinically apparent HF events in the context of remote device diagnostics, focusing on the controversial role of TI.

METHODS AND RESULTS

We followed 497 patients (66.6 ± 10.1 years, 77% male, QRS 139.8 ± 36.0 ms, ejection fraction 26.8 ± 7.0%) implanted with a CRT-D (67%) or an ICD (33%) for 21.4 ± 8.1 months. An independent event committee confirmed 171 HF events of which 82 were used to develop a TI-based algorithm for the prediction of imminent cardiac decompensation. Highly inter-individual variations in patterns of TI trends were observed. The algorithm resulted in a sensitivity of 41.5% (50.0%) with 0.95 (1.34) false alerts per patient year, and a positive predictive value of 7.9% overall and 27.9% in the HF event group of patients. Averaged ratio statistics showed a significant pre-hospital decrease and a highly significant in-hospital increase in TI after intensified diuresis. Recurrent decompensations turned out to be preceded by a significantly stronger decrease of TI compared to first events with a higher chance for detection (63.6% sensitivity, p < 0.05).

CONCLUSIONS

Overall performance in predicting imminent decompensation by monitoring TI alone is limited due to its high inter-patient variability. TI stand-alone applications should be redirected towards a target population with more advanced symptoms where post-hospital observation aimed to maintain the patient's discharge status might be the most valuable approach.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT00711360 (HomeCARE-II) and NCT01221649 (J-HomeCARE-II).

[Basic structural features of a cardiac telemedicine center for patients with heart failure and implanted devices, cardiac arrhythmias, and increased risk of sudden cardiac death : Recommendations of the working group 33 Telemonitoring of the German Cardiac Society]

Heart failure is one of the most common diseases. It is associated with high morbidity and mortality. Since heart failure is age-associated, the number of patients with heart failure is constantly increasing. At the same time, the imbalance between the need for treatment and the provision of care is growing. Telemonitoring/telemedicine offers patients in rural or remote areas access to high-quality health care and enables fast access to specialists. The working group 33 Telemonitoring of the German Cardiac Society describes the characteristics and possible applications of telemonitoring/telemedicine in the treatment of patients with heart failure. Furthermore, quality criteria for cardiological telemedicine centres are defined. In addition to the personnel structure of a telemedicine centre and the competencies of employees, requirements for the technical infrastructure and the management of incoming data and alarms are described.

Diagnostic power and healthcare resource consumption of a dedicated workflow algorithm designed to manage thoracic impedance alerts in heart failure patients by remote monitoring

PURPOSE

Modern cardiac implantable devices provide diagnostic information on several physiological variables which are associated with worsening heart failure, creating an opportunity for early intervention to prevent heart failure symptoms and hospitalizations. We evaluated diagnostic accuracy and workload of a remote monitoring (RM) workflow algorithm which leverages intrathoracic impedance and other device diagnostics.

METHODS

In our RM workflow a team of expert nurses was responsible for continuity of care, direct relationship with patients and implementation of a specific protocol to evaluate RM alerts and to limit unnecessary resource consumption. Each patient was univocally assigned to a reference nurse. End points were diagnostic accuracy, healthcare utilization, defined as any hospital admission, and actionability of alerts, defined as medication change or other clinical action.

RESULTS

One-hundred twenty-six consecutive patients with implantable cardioverter defibrillator/cardiac resynchronization therapy defibrillator were followed for a median time of 23 months. Out of 2176 remote transmissions, 893 (41%) in 111 patients (88.1%) showed clinically relevant events triggered by 574 alerts [2.2 (95% confidence interval = 2.0-2.4) per patient per year]. Among 309 alerts with intrathoracic impedance crossing, heart failure deterioration was confirmed in 116 (37.5%). Clinical actions followed 76/116 (65.5%) true heart failure alerts and 17/193 (8.8%) false-positive alerts (P < 0.001). In particular, drug therapy change followed 72/116 (62.1%) true heart failure alerts and 15/193 (7.8%) false-positive alerts (P < 0.001). Healthcare utilization occurred in 65.5% true heart failure alerts and in 24.9% false-positive alerts (P < 0.001).

CONCLUSION

A dedicated workflow algorithm results in more focused clinical surveillance leading to prompt detection and treatment of acute heart failure events without wasting healthcare resource.

The management of patients with chronic heart failure: the growing role of e-Health

INTRODUCTION

The increasing pandemic of heart failure is becoming a serious challenge for the health care system. The medical world is searching for solutions which could decrease its scale and improve patients' quality of life and prognosis. Telemanagement of heart failure patients is a new promising option. Technical and technological platforms to perform e-Health management in heart failure patients' homes have become available. This paper's aims are to present different forms of e-Health including telecare, home monitoring of cardiovascular implantable electronic devices, remote monitoring of hemodynamic implantable devices and telerehabilitation in providing optimal long term management for heart failure patients. Areas covered: E-education and self-monitoring, structured telephone support and telemonitoring, remote monitoring of cardiovascular implantable electronics devices and hemodynamic implantable electronic devices and telerehabilitation. Expert commentary: The data analyzed in the paper suggests that remote monitoring is capable of identifying life-threatening deterioration and helps heart failure patients avoid seeking medical assistance in hospitals and that home-based telerehabilitation is well accepted, safe, effective and has high adherence among HF patients.

Telerehabilitation in heart failure patients: The evidence and the pitfalls

Accessibility to the available traditional forms of cardiac rehabilitation programs in heart failure patients is not adequate and adherence to the programs remains unsatisfactory. The home-based telerehabilitation model has been proposed as a promising new option to improve this situation. This paper's aims are to discuss the tools available for telemonitoring, and describing their characteristics, applicability, and effectiveness in providing optimal long term management for heart failure patients who are unable to attend traditional cardiac rehabilitation programs. The critical issues of psychological support and adherence to the telerehabilitation programs are outlined. The advantages and limitations of this long term management modality are presented and compared with alternatives. Finally, the importance of further research, multicenter studies of telerehabilitation for heart failure patients and the technological development needs are outlined, in particular interactive remotely controlled intelligent telemedicine systems with increased inter-device compatibility.

Early Indication of Decompensated Heart Failure in Patients on Home-Telemonitoring: A Comparison of Prediction Algorithms Based on Daily Weight and Noninvasive Transthoracic Bio-impedance

Background

Heart Failure (HF) is a common reason for hospitalization. Admissions might be prevented by early detection of and intervention for decompensation. Conventionally, changes in weight, a possible measure of fluid accumulation, have been used to detect deterioration. Transthoracic impedance may be a more sensitive and accurate measure of fluid accumulation.

Objective

In this study, we review previously proposed predictive algorithms using body weight and noninvasive transthoracic bio-impedance (NITTI) to predict HF decompensations.

Methods

We monitored 91 patients with chronic HF for an average of 10 months using a weight scale and a wearable bio-impedance vest. Three algorithms were tested using either simple rule-of-thumb differences (RoT), moving averages (MACD), or cumulative sums (CUSUM).

Results

Algorithms using NITTI in the 2 weeks preceding decompensation predicted events (P<.001); however, using weight alone did not. Cross-validation showed that NITTI improved sensitivity of all algorithms tested and that trend algorithms provided the best performance for either measurement (Weight-MACD: 33%, NITTI-CUSUM: 60%) in contrast to the simpler rules-of-thumb (Weight-RoT: 20%, NITTI-RoT: 33%) as proposed in HF guidelines.

Conclusions

NITTI measurements decrease before decompensations, and combined with trend algorithms, improve the detection of HF decompensation over current guideline rules; however, many alerts are not associated with clinically overt decompensation.

Comparison of partners-heart failure algorithm vs care alert in remote heart failure management

AIM: To compare the utility of the partners-heart failure (HF) algorithm with the care alert strategy for remote monitoring, in guiding clinical actions oriented to treat impending HF.

METHODS: Consecutive cardiac resynchronization-defibrillator recipients were followed with biweekly automatic transmissions. After every transmission, patients received a phone contact in order to check their health status, eventually followed by clinical actions, classified as “no-action”, “non-active” and “active”. Active clinical actions were oriented to treat impending HF. The sensitivity, specificity, positive and negative predictive values and diagnostic accuracy of the partners-HF algorithm vs care alert in determining active clinical actions oriented to treat pre-HF status and to prevent an acute decompensation, were also calculated.

RESULTS: The study population included 70 patients with moderate to advanced systolic HF and QRS duration longer than 120 ms. During a mean follow-up of 8 ± 2 mo, 665 transmissions were collected. No deaths or HF hospitalizations occurred. The sensitivity and specificity of the partners-HF algorithm for active clinical actions oriented to treat impending HF were 96.9% (95%CI: 0.96-0.98) and 92.5% (95%CI: 0.90-0.94) respectively. The positive and negative predictive values were 84.6% (95%CI: 0.82-0.87) and 98.6% (95%CI: 0.98-0.99) respectively. The partners-HF algorithm had an accuracy of 93.8% (95%CI: 0.92-0.96) in determining active clinical actions. With regard to active clinical actions, care alert had a sensitivity and specificity of 11.05% (95%CI: 0.09-0.13) and 93.6% respectively (95%CI: 0.92-0.95). The positive predictive value was 42.3% (95%CI: 0.38-0.46); the negative predictive value was 71.1% (95%CI: 0.68-0.74). Care alert had an accuracy of 68.9% (95%CI: 0.65-0.72) in determining active clinical actions.

CONCLUSION: The partners-HF algorithm proved higher accuracy and sensitivity than care alert in determining active clinical actions oriented to treat impending HF. Future studies in larger populations should evaluate partners-HF ability to improve HF-related clinical outcomes.

[Implantable hemodynamic monitoring devices]

Heart failure is one of the most frequent diagnoses in hospital admissions in Germany. In the majority of these admissions acute decompensation of an already existing chronic heart failure is responsible. New mostly wireless and remote strategies for monitoring, titration, adaptation and optimization are the focus for improvement of the treatment of heart failure patients and the poor prognosis. The implantation of hemodynamic monitoring devices follows the hypothesis that significant changes in hemodynamic parameters occur before the occurrence of acute decompensation requiring readmission. Three different hemodynamic monitoring devices have so far been investigated in clinical trials employing right ventricular pressure, left atrial pressure and pulmonary artery pressure monitoring. Only one of these systems, the CardioMENS™ HF monitoring system, demonstrated a significant reduction of hospitalization due to heart failure over 6 months in the CHAMPION trial. The systematic adaptation of medication in the CHAMPION trial significantly differed from the usual care of the control arm over 6 months. This direct day to day management of diuretics is currently under intensive investigation; however, further studies demonstrating a positive effect on mortality are needed before translation of this approach into guidelines. Without this evidence a further implementation of pressure monitoring into currently used devices and justification of the substantial technical and personnel demands are not warranted.

Implantable device diagnostics on day of discharge identify heart failure patients at increased risk for early readmission for heart failure

Aims

We hypothesized that diagnostic data in implantable devices evaluated on the day of discharge from a heart failure hospitalization (HFH) can identify patients at risk for HF readmission (HFR) within 30 days.

Methods and results

In this retrospective analysis of four studies enrolling patients with CRT devices, we identified patients with a HFH, device data on the day of discharge, and 30-day post-discharge clinical follow-up. Four diagnostic criteria were evaluated on the discharge day: (i) intrathoracic impedance >8 Ω below reference impedance; (ii) AF burden >6 h; (iii) CRT pacing <90%; and (iv) night heart rate >80 b.p.m. Patients were considered to have higher risk for HFR if ≥2 criteria were met, average risk if 1 criterion was met, and lower risk if no criteria were met. A Cox proportional hazards model was used to compare the groups. The data cohort consisted of a total of 265 HFHs in 175 patients, of which 36 (14%) were followed by HFR. On the discharge day, ≥2 criteria were met in 43 (16% of 265 HFHs), only 1 criterion was met in 92 (35%), and none of the four criteria were met in 130 HFHs (49%); HFR rates were 28, 16, and 7%, respectively. HFH with ≥2 criteria met was five times more likely to have HFR compared with HFH with no criteria met (adjusted hazard ratio 5.0; 95% confidence interval 1.9–13.5, P = 0.001).

Conclusion

Device-derived diagnostic criteria evaluated on the day of discharge identified patients at significantly higher risk of HFR.

Remote monitoring of cardiac implantable electronic devices in Europe: results of the European Heart Rhythm Association survey

The aim of this European Heart Rhythm Association survey was to provide an insight into the current use of remote monitoring for cardiac implantable electronic devices in Europe. The following topics were explored: use of remote monitoring, infrastructure and organization, patient selection and benefits. Centres using remote monitoring reported performing face-to-face visits less frequently. In many centres (56.9%), a nurse reviews all the data and forwards them to the responsible physician. The majority of the centres (91.4%) stated that remote monitoring is best used in patients with implantable cardioverter-defibrillators and those live far from the hospital (76.6% top benefit). Supraventricular and ventricular arrhythmias were reported to be the major events detected earlier by remote monitoring. Remote monitoring will have a significant impact on device management.

Implant-based multiparameter telemonitoring of patients with heart failure (IN-TIME): a randomised controlled trial

BACKGROUND

An increasing number of patients with heart failure receive implantable cardioverter-defibrillators (ICDs) or cardiac resynchronisation defibrillators (CRT-Ds) with telemonitoring function. Early detection of worsening heart failure, or upstream factors predisposing to worsening heart failure, by implant-based telemonitoring might enable pre-emptive intervention and improve outcomes, but the evidence is weak. We investigated this possibility in IN-TIME, a clinical trial.

METHODS

We did this randomised, controlled trial at 36 tertiary clinical centres and hospitals in Australia, Europe, and Israel. We enrolled patients with chronic heart failure, NYHA class II-III symptoms, ejection fraction of no more than 35%, optimal drug treatment, no permanent atrial fibrillation, and a recent dual-chamber ICD or CRT-D implantation. After a 1 month run-in phase, patients were randomly assigned (1:1) to either automatic, daily, implant-based, multiparameter telemonitoring in addition to standard care or standard care without telemonitoring. Investigators were not masked to treatment allocation. Patients were masked to allocation unless they were contacted because of telemonitoring findings. Follow-up was 1 year. The primary outcome measure was a composite clinical score combining all-cause death, overnight hospital admission for heart failure, change in NYHA class, and change in patient global self-assessment, for the intention-to-treat population. The trial is registered with ClinicalTrials.gov, number NCT00538356.

FINDINGS

We enrolled 716 patients, of whom 664 were randomly assigned (333 to telemonitoring, 331 to control). Mean age was 65·5 years and mean ejection fraction was 26%. 285 (43%) of patients had NYHA functional class II and 378 (57%) had NYHA class III. Most patients received CRT-Ds (390; 58·7%). At 1 year, 63 (18·9%) of 333 patients in the telemonitoring group versus 90 (27·2%) of 331 in the control group (p=0·013) had worsened composite score (odds ratio 0·63, 95% CI 0·43-0·90). Ten versus 27 patients died during follow-up.

INTERPRETATION

Automatic, daily, implant-based, multiparameter telemonitoring can significantly improve clinical outcomes for patients with heart failure. Such telemonitoring is feasible and should be used in clinical practice.

FUNDING

Biotronik SE & Co. KG.

Noninvasive monitoring of stroke volume with resynchronization devices in patients with ischemic cardiomyopathy

BACKGROUND

A novel method to estimate cardiac volumes based on impedance measurements using the leads of a resynchronization device has been developed. This study investigated the method in patients with ischemic cardiomyopathy and documented wall motion abnormalities.

METHOD AND RESULTS

Fifteen postinfarction patients (age 68 ± 8 years, ejection fraction 27 ± 5%) with symptomatic heart failure and ≥ 1 akinetic or dyskinetic segment were included. During the implantation of a cardiac resynchronization therapy (CRT) device, acute impedance curves were recorded along with stroke volume determined by the arterial pulse contour method. In an overdrive protocol, the impedance parameter "stroke impedance" decreased in significant correlation with stroke volume in all patients. The median correlation coefficient between stroke volume and stroke impedance was 0.83 (interquartile range 0.70-0.89). Furthermore, the atrioventricular delay was optimized based on impedance and reference stroke volume. After optimization by the impedance method, it differed by 18 ± 15 ms from the figure after optimization by the invasive reference. Compared with a standard atrioventricular delay of 120 ms, stroke volume was improved by 8.6 ± 9.8% with the use of invasive optimization and by 6.4 ± 10.8% with the use of impedance-based optimization.

CONCLUSIONS

In CRT patients with chronic infarction and wall motion abnormalities, impedance is a valid parameter to estimate stroke volume and to guide optimization of CRT timing.

Long-term effectiveness of the combined minute ventilation and patient activity sensors as predictor of heart failure events in patients treated with cardiac resynchronization therapy: Results of the Clinical Evaluation of the Physiological Diagnosis Function in the PARADYM CRT device Trial (CLEPSYDRA) study

AIMS

Monitoring early signs of clinical deterioration could allow physicians to adjust medical treatment for patients at risk of acute heart failure decompensation. To date, several strategies using different surrogate measures of clinical status emerged, but none has yet been proven to predict clinical events. We hypothesized that the Physiological Diagnostic feature, which combines data from minute ventilation and physical activity sensors, predicts heart failure events in patients implanted with cardiac resynchronization therapy with defibrillation (CRT-D) devices.

METHODS AND RESULTS

The Clinical Evaluation of the Physiological Diagnostic feature in the PARADYM CRT device (CLEPSYDRA) trial is a multicentre, prospective, non-randomized, double-blind study comprising 521 CRT-D patients with heart failure [67.4 ± 10.1 years (mean ± SD), 82% male, New York Heart Association class III/IV 85.0%/6.7%, QRS 155.3 ± 26.6 ms, left ventricular ejection fraction 25.7 ± 7.7%]. The objective of the study was the sensitivity and false positive rate of the Physiological Diagnostic algorithm to predict heart failure events within the following month. After a mean follow-up of 17.0 ± 8.7 months, 130 (25.6%) patients experienced a heart failure event. The sensitivity of the algorithm to predict an event was 34% and the false positive rate was 2.4 per patient-year.

CONCLUSION

Thirty-four per cent of heart failure events occurring within a month were predicted by the Physiological Diagnostic algorithm, and 2.4 alerts per patient per year were not followed by an heart failure event within the subsequent month.

Quarterly vs. yearly clinical follow-up of remotely monitored recipients of prophylactic implantable cardioverter-defibrillators: results of the REFORM trial

Aims

The rapidly increasing number of patients with implantable cardioverter-defibrillators (ICD) places a large burden on follow-up providers. This study investigated the possibility of longer in-office follow-up intervals in primary prevention ICD patients under remote monitoring with automatic daily data transmissions from the implant memory.

Methods and results

Conducted in 155 ICD recipients with MADIT II indications, the study compared the burden of scheduled and unscheduled ICD follow-up visits, quality of life (SF-36), and clinical outcomes in patients randomized to either 3- or 12-month follow-up intervals in the period between 3 and 27 months after implantation. Remote monitoring (Biotronik Home Monitoring) was used equally in all patients. In contrast to previous clinical studies, no calendar-based remote data checks were performed between scheduled in-office visits. Compared with the 3-month follow-up interval, the 12-month interval resulted in a minor increase in the number of unscheduled follow-ups (0.64 vs. 0.27 per patient-year; P = 0.03) and in a major reduction in the total number of in-office ICD follow-ups (1.60 vs. 3.85 per patient-year; P < 0.001). No significant difference was found in mortality, hospitalization rate, or hospitalization length during the 2-year observation period, but more patients were lost to follow-up in the 12-month group (10 vs. 3; P = 0.04). The SF-36 scores favoured the 12-month intervals in the domains ‘social functioning’ and ‘mental health’.

Conclusion

In prophylactic ICD recipients under automatic daily remote monitoring, the extension of the 3-month in-office follow-up interval to 12 months appeared to safely reduce the ICD follow-up burden during 27 months after implantation.

ClinicalTrials.gov Identifier

NCT00401466 (http://www.clinicaltrials.gov/ct2/show/NCT00401466).

Economic impact of remote monitoring on ordinary follow-up of implantable cardioverter defibrillators as compared with conventional in-hospital visits. A single-center prospective and randomized study

INTRODUCTION

Few data are available on actual follow-up costs of remote monitoring (RM) of implantable defibrillators (ICD). Our study aimed at assessing current direct costs of 1-year ICD follow-up based on RM compared with conventional quarterly in-hospital follow-ups.

METHODS AND RESULTS

Patients (N = 233) with indications for ICD were consecutively recruited and randomized at implant to be followed up for 1 year with standard quarterly in-hospital visits or by RM with one in-hospital visit at 12 months, unless additional in-hospital visits were required due to specific patient conditions or RM alarms. Costs were calculated distinguishing between provider and patient costs, excluding RM device and service cost. The frequency of scheduled in-hospital visits was lower in the RM group than in the control arm. Follow-up required 47 min per patient/year in the RM arm versus 86 min in the control arm (p = 0.03) for involved physicians, generating cost estimates for the provider of USD 45 and USD 83 per patient/year, respectively. Costs for nurses were comparable. Overall, the costs associated with RM and standard follow-up were USD 103 ± 27 and 154 ± 21 per patient/year, respectively (p = 0.01). RM was cost-saving for the patients: USD 97 ± 121 per patient/year in the RM group versus 287 ± 160 per patient/year (p = 0.0001).

CONCLUSION

The time spent by the hospital staff was significantly reduced in the RM group. If the costs for the device and service are not charged to patients or the provider, patients could save about USD 190 per patient/year while the hospital could save USD 51 per patient/year.

Effectiveness of remote monitoring of CIEDs in detection and treatment of clinical and device-related cardiovascular events in daily practice: the HomeGuide Registry

Aims

The HomeGuide Registry was a prospective study (NCT01459874), implementing a model for remote monitoring of cardiac implantable electronic devices (CIEDs) in daily clinical practice, to estimate effectiveness in major cardiovascular event detection and management.

Methods and results

The workflow for remote monitoring [Biotronik Home Monitoring (HM)] was based on primary nursing: each patient was assigned to an expert nurse for management and to a responsible physician for medical decisions. In-person visits were scheduled once a year. Seventy-five Italian sites enrolled 1650 patients [27% pacemakers, 27% single-chamber implantable cardioverter defibrillators (ICDs), 22% dual-chamber ICDs, 24% ICDs with cardiac resynchronization therapy]. Population resembled the expected characteristics of CIED patients. During a 20 ± 13 month follow-up, 2471 independently adjudicated events were collected in 838 patients (51%): 2033 (82%) were detected during HM sessions; 438 (18%) during in-person visits. Sixty were classified as false-positive, with generalized estimating equation-adjusted sensitivity and positive predictive value of 84.3% [confidence interval (CI), 82.5–86.0%] and 97.4% (CI, 96.5–98.2%), respectively. Overall, 95% of asymptomatic and 73% of actionable events were detected during HM sessions. Median reaction time was 3 days [interquartile range (IQR), 1–14 days]. Generalized estimating equation-adjusted incremental utility, calculated according to four properties of major clinical interest, was in favour of the HM sessions: +0.56 (CI, 0.53–0.58%), P < 0.0001. Resource consumption: 3364 HM sessions performed (76% by nurses), median committed monthly manpower of 55.5 (IQR, 22.0–107.0) min × health personnel/100 patients.

Conclusion

Home Monitoring was highly effective in detecting and managing clinical events in CIED patients in daily practice with remarkably low manpower and resource consumption.

Workload and usefulness of daily, centralized home monitoring for patients treated with CIEDs: results of the MoniC (Model Project Monitor Centre) prospective multicentre study

AIM

Automated, daily Home Monitoring (HM) of pacemaker and implantable cardioverter-defibrillator (ICD) patients can improve patient care. Yet, HM introduction to routine clinical practice is challenged by resource allocation for regular HM data review. We tested the feasibility, safety, workload, and clinical usefulness of a centralized HM model consisting of one monitor centre and nine satellite clinics.

METHODS AND RESULTS

Having no knowledge about patients' clinical data, a telemonitoring nurse (TN) and a supporting physician at the monitor centre screened and filtered HM data in 62 pacemaker and 59 ICD patients from nine satellite clinics for over 1 year. Basic screening of arrhythmic and technical events required 25.7 min (TN) and 0.7 min (physician) per working day, normalized for 100 patients monitored. Communication of relevant events to satellite clinics per email or phone required additional 4.3 min (TN) and 0.4 min (physician). Telemonitoring nurse also screened for abnormal developments in longitudinal data trends weekly for 3 months after implantation, and then monthly; one patient session lasted 4.0 ± 2.9 min. To handle transmission-gap notifications, TN needed additional 2.8 min daily. Satellite clinics received 231.3 observations from the monitor centre per 100 patients/year, which prompted 86.3 patient contacts or intensive HM screening periods by the satellite clinic itself (37.3% response rate), 51.7 extra follow-up controls (22.3%), and 30.1 clinical interventions (13.0%).

CONCLUSION

Centralized HM was feasible, reliable, safe, and clinically useful. Basic screening and communication of relevant arrhythmic and technical events required a total of 30 min (TN) and 1.1 min (physician) daily per 100 patients monitored.

Heart failure highlights in 2011

Heart failure (HF) remains a major medical problem, and the European Journal of Heart Failure is dedicated to publishing research further investigating its pathophysiology and diagnosis in order to help clinicians alleviate symptoms and improve patient outcomes.( 1) This review reports on important studies in the field of HF published in 2011. All research areas are addressed, including experimental studies, biomarkers, clinical trials, arrhythmias, and new insights into the role of device therapy.

[Advances in cardiac pacing]

This article contains a review of the current status of remote monitoring and follow-up involving cardiac pacing devices and of the latest developments in cardiac resynchronization therapy. In addition, the most important articles published in the last year are discussed.