What are the professional and logistic demands to appropriately follow patients with an implantable cardioverter-defibrillator?

Incidence and predictors of pacemaker reprogramming: potential consequences for remote follow-up

AIMS

Remote follow-up (FU) enables to cope with the expanding number of pacemaker (PM) FU. Although remote FU offers comparable monitoring options to in-office FU, reprogramming of device settings is not available, thereby imposing a potentially important restriction to the applicability of remote FU.  The aim of this study was to assess in a large cohort of bradycardia PM recipients, the incidence of PM reprogramming during long-term FU and its predictors, to judge the possibilities for remote FU.

METHODS AND RESULTS

Between 2003 and 2010 all in-office FU of 1517 bradycardia PM recipients included in the FOLLOWPACE study were recorded. Only 24.5% of all 13 258 recorded FU visits >3 months after implantation were visits-with-reprogramming (VWRs), occurring in 1158 patients (79%). Fifty percent of patients were free of reprogramming at 9 months, and 29% at 24 months. Using multivariable binary logistic regression analysis, the following patient characteristics were predictive for frequent PM reprogramming, defined as >3 VWRs during 3 year FU: age, a history of atrial arrhythmias, PM complication <3 months after implantation, congestive heart failure, PM indication, and lead fixation method. This model had a receiver operating characteristic area of 0.66 (95% confidence interval 0.61-0.71).

CONCLUSION

This study observed a low proportion of VWR (∼25%) during a mean FU of 5.3 years; however, those patients at high risk for PM reprogramming cannot easily be predicted. The vast majority of patients (>80%) do not need frequent reprogramming, suggesting a potential benefit of using remote FU to reduce the number of unnecessary in-office visits.

Actions elicited during scheduled and unscheduled in-hospital follow-up of cardiac devices: results of the ATHENS multicentre registry

AIM

The number of cardiac implantable electronic devices (CIEDs) is continuously growing and this translates into a high number of in-hospital follow-ups. This workload justifies the increasing popularity of remote monitoring systems for the follow-up of CIEDs. The ATHENS registry was designed to find out what actions are taken during in-hospital follow-up of CIEDs at 10 different centres in Northern Italy.

METHODS AND RESULTS

Between 1 March 2010 and 30 June 2010, all patients who came to our centres for a follow-up of their CIEDs were enrolled in the registry. We defined as visit with an action (VWA) a follow-up that elicited an action in that patient. The primary endpoint was the prevalence of VWA on the whole population. The secondary endpoints were: prevalence of VWA on the pacemaker (PM) population; prevalence of VWA on the implantable cardioverter defibrillator (ICD) population; prevalence of VWA on the cardiac resynchronization therapy (CRT) population; predictors of VWA in univariate and multivariate analyses. A total of 3362 patients were recruited. The primary endpoint was reached in 762 patients, 22.8% of patients (95% CI 21.4-24.3). The prevalence of action was highest for CRT (29.8%), followed by PM (22.8%) and ICD (18.6%). In a multivariate model, the prevalence of action was higher for CRT, than for PM and was lowest for ICD and it was higher for unscheduled visits and first visits than for scheduled visits.

CONCLUSIONS

Our registry demonstrates that 'some actions' are taken during about 20% of scheduled in-hospital follow-up of CIEDs. These data should encourage the use of remote follow-up systems.

Healthcare personnel resource burden related to in-clinic follow-up of cardiovascular implantable electronic devices: a European Heart Rhythm Association and Eucomed joint survey

AIMS

A pilot European survey was conducted to assess the cumulative time spent by healthcare personnel for in-office follow-up of cardiac implantable electrical devices (CIEDs), including cardiac pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy (CRT) devices.

METHODS AND RESULTS

Resource use data were collected during a session of in-clinic follow-up. Among 407 visits, 93% were scheduled and 7% unscheduled. Visit duration (total cumulative time) lasted a mean of 27 min for scheduled visits, and was ∼30% longer for unscheduled visits. Independent determinants of visit duration were: unscheduled visit (+7.6 min, P = 0.01), the need for device reprogramming (+7.5 min, P < 0.001), and the type of device checked, with CRT devices needing 9.1 and 6.6 more minutes than single- (P < 0.001) and dual-chamber devices (P = 0.002), respectively. Most visits involved two different types of healthcare personnel (239 of 407, 59%), simultaneously. The most frequent combination was the involvement of both a cardiologist and a nurse (216 of 407 visits with both of them only, and 65 additional visits with also an internal technician, an external technician, or both). Overall, an external technician was involved in 18% of visits.

CONCLUSIONS

In 'real-world' practice, the follow-up of CIEDs nowadays requires important resources in terms of time dedicated by specialized personnel, corresponding to cardiologists, nurses, internal technicians, and external, industry-employed technicians. These observations should be the basis for addressing clinical, organizational, financial, and policy initiatives targeted to optimize follow-up procedures in order to face the increase in the number of patients treated with CIEDs expected for the next years.