Proactive monitoring: implications of implantable devices for future heart failure management

Device diagnostics and early identification of acute decompensated heart failure: a systematic review

BACKGROUND

Traditional methods of heart failure (HF) management are based on reactive strategies to treat late indicators of decompensated HF. Advances in monitoring methods have become available with the evolution of implantable cardioverter-defibrillators and cardiac-resynchronization therapy devices. These devices provide new diagnostic data and remote monitoring capabilities that allow clinicians to proactively monitor patients for earlier signs of worsening HF. The integration of data obtained from implantable cardioverter-defibrillator and cardiac-resynchronization therapy technology could improve outpatient HF care, potentially leading to decreased readmission rates and improved patient outcomes.

OBJECTIVE

This review will synthesize the literature regarding the efficacy of device diagnostic data and the usability of the data in the clinical setting.

METHODS

Articles for review were obtained using Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PubMed, and ClinicalTrials.gov.

RESULTS

Device diagnostics showed strong correlation with established HF biomarkers and hemodynamic measures. The findings from this review indicate that device diagnostic parameters predict impending HF much earlier than traditional methods of monitoring do. Device diagnostics are also more accurate in the early prediction of HF when compared with noninvasive objective measures, particularly when multiple parameters are combined and monitored for trends. Device diagnostics possess a distinct advantage over traditional methods of monitoring for HF because they allow clinicians to remotely monitor the status of their HF patients without relying on patient compliance for data entry and reporting.

CONCLUSIONS

Studies regarding the efficacy of device diagnostic parameters suggest that their integration into clinical practice will provide a more accurate and reliable mechanism for assisting clinicians in risk stratifying and predicting potential episodes of decompensated HF.

ACCF/AHA/HFSA 2011 survey results: current staffing profile of heart failure programs, including programs that perform heart transplant and mechanical circulatory support device implantation: a report of the ACCF Heart Failure and Transplant Committee, AHA Heart Failure and Transplantation Committee, and Heart Failure Society of America

OBJECTIVES

There have been no published recommendations about staffing needs for a heart failure (HF) clinic or an office setting focused on heart transplant. The goal of this survey was to understand the current staffing environment of HF, transplant, and mechanical circulatory support device (MCSD) programs in the United States and abroad. This report identifies current staffing patterns but does not endorse a particular staffing model.

METHODS

An online survey, jointly sponsored by the American College of Cardiology Foundation (ACCF), American Heart Association (AHA), and the Heart Failure Society of America (HFSA), was sent to the members of all 3 organizations who had identified themselves as interested in HF, heart transplant, or both, between March 12, 2009, and May 12, 2009.

RESULTS

The overall response rate to the 1823 e-mail surveys was 23%. There were 257 unique practices in the United States (81% of total sites) and 58 international sites (19%); approximately 30% of centers were in a cardiovascular group practice and 30% in a medical school hospital setting. The large majority of practices delivered HF care in both an inpatient and outpatient environment, and slightly more centers were implanting MCSDs (47%) than performing cardiac transplantation (39%). Most practices (43%) were small, with <4 staff members, or small- to medium-sized (34%), with 4 to 10 staff members, with only 23% being medium (11-20 staff) or large programs (>20 staff). On average, a US HF practice cared for 1641 outpatients annually. An average HF program with transplant performed 10 transplants. Although larger programs were able to perform more transplants and see more outpatient HF visits, their clinician staffing volume tended to double for approximately every 500 to 700 additional HF visits annually. The average staffing utilization was 2.65 physician full-time equivalents (FTEs), 2.21 nonphysician practitioner (nurse practitioner or physician assistant) FTEs, and 2.61 nurse coordinator FTEs annually.

CONCLUSIONS

The HF patient population is growing in number in the United States and internationally, and the clinicians who provide the highly skilled and time-consuming care to this population are under intense scrutiny as a result of focused quality improvement initiatives and reduced financial resources. Staffing guidelines should be developed to ensure that an adequate number of qualified professionals are hired for a given practice volume. These survey results are an initial step in developing such standards.

Therapeutic implications of implantable device-based monitoring of patients with heart failure

Heart failure is one of the most common medical problems faced by patients and clinicians. It has the potential for high morbidity and mortality, and its overall financial cost to society is enormous. Management of heart failure is often difficult and time consuming, and is sometimes frustrating. The usual signs and symptoms of heart failure may not be obvious early in an exacerbation, which has prompted the development of other methods to identify early and subtle clinical changes to initiate early intervention. Current implantable devices, such as defibrillators and pacemakers, can monitor changes in heart rate and heart rate variability, patient activity, arrhythmia frequency, and thoracic impedance, all of which may be markers of clinical decline. Newer implantable devices can also measure right ventricular pressures, oxygen saturation, and pulmonary artery pressures. Many of these technologies have been shown to be feasible and potentially helpful, but outcomes data showing reductions in morbidity and mortality are currently limited. Importantly, none of these newer technologies should be used in isolation; all must be used in combination with clinical findings to provide effective disease management.