Early Detection and Treatment of Atrial Arrhythmias Alleviates the Arrhythmic Burden in Paced Patients: The SETAM Study

The incidence of atrial fibrillation, new oral anticoagulation, stroke, and significant bleeds in patients receiving a new dual-chamber pacemaker

Background and objectives

Atrial fibrillation and flutter (AF/AFL) can be easily detected in patients who have a dual-chamber pacemaker (PM). This can result in a high detection rate of these arrhythmias especially if patients are monitored remotely and detection limits are sensitive.

Materials and methods

A single-center retrospective registry analysis of 1,285 consecutive AF/AFL and anticoagulation naïve patients from a limited geographical area undergoing implantation of a new dual-chamber PM (between 2013 and 2019). Seven-year follow-up data for incident AF/AFL, initiation of new oral anticoagulation and for incident strokes and bleeds was obtained from an in-depth review of all relevant patient records including written medical records and death certificates detailing causes of death.

Results

During the follow-up, mortality reached 22.2 % and cumulative incidence of AF/AFL, new anticoagulation, strokes, and bleeds were 52.6 %, 40.4 %, 4.7 % and 10.4 %. In 92.6 % of the cases, AF/AFL was discovered by PM. Remote monitoring was initiated in 67 % (n = 856). Risk factor adjusted mortality in this group was significantly lower when compared to patients in regular out-patient clinic controls (HR 0.45, 95 % CI 0.35-0.57). Despite of their better overall prognosis, the AF/AFL was discovered, and oral anticoagulation was initiated more often in remote monitoring group (HR 1.58, 95 % CI 1.23-1.79 for AF/AFL and HR 1.67, 95 % CI 1.33-2.09 for anticoagulation). There was no significant difference in the incidence of strokes or bleeds.

Conclusions

The incidence of new AF/AFL is high in this population. Remote monitoring is associated with higher diagnostic yields of AF/AFL and initiated anticoagulation, but not with stroke and significant bleeds.

Role of atrial high-rate episodes in stratifying thromboembolic risk: a multiple cut-off diagnostic meta-analysis

Aims

Despite the high prevalence rate of atrial high-rate episodes (AHREs) detected using cardiac implantable electronic devices (CIEDs), clinical guidelines and consensus documents have disagreed on a universal AHRE definition and a temporal cut-off related to subsequent thromboembolic events. This diagnostic test accuracy meta-analysis aims to derive the optimal temporal threshold of clinically significant AHREs from the available literature.

Methods

The PubMed/MEDLINE and EMBASE databases were screened for studies on CIED patients reporting the incidence of thromboembolic events related to at least one AHRE temporal cut-off. A total of 23 studies were included: 19 considering the longest single AHRE and four the AHRE burden, respectively. A random-effect diagnostic test accuracy meta-analysis with multiple cut-offs was performed. Two analyses were performed according to the AHRE temporal cut-off subtype (longest episode vs. cumulative burden).

Results

The analysis on the longest single AHRE indicated 0.07 min as the optimal duration to differentiate AHRE associated or not with thromboembolic events [sensitivity 65.4% (95% CI 48.8%-79.0%), specificity 52.7% (95% CI 46.0%-59.4%), and area under the summary receiver operating characteristic curve (AUC-SROC): 0.62]. The analysis on AHRE burden indicated 1.4 min as the optimal cut-off [sensitivity 58.2% (95% CI 25.6%-85.0%), specificity 57.5% (95% CI 42.0%-71.7%), and AUC-SROC 0.60]. A sensitivity analysis excluding patients with a history of atrial fibrillation and including high-quality studies only yielded similar results.

Conclusion

The presence of AHRE, rather than a specific duration, relates to an increased, albeit low, thromboembolic risk in CIED patients. Any AHRE should constitute an additional element in patient-specific thromboembolic risk assessment.

Long-Term Remote vs. Conventional Monitoring of Pacemakers: Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE OF REVIEW

Remote monitoring (RM) is the standard of care for patients with cardiac implantable electronic devices (CIEDs), particularly pacemakers. However, the long-term outcomes of RM versus conventional monitoring (CM) of pacemakers and its effectiveness in reducing in-office (IO) visits for device reprogramming require elucidation. This systematic review and meta-analysis aimed to compare the RM and CM of pacemakers over a long-term follow-up.

RECENT FINDINGS

We systematically searched the PubMed/MEDLINE, Embase, Cochrane, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing RM and CM of pacemakers with at least 12 months of follow-up. Binary endpoints were pooled with risk ratios (RRs), whereas continuous outcomes were computed using mean differences (MDs) or standardized MDs (SMDs). Heterogeneity was assessed using I2 statistics. Among the eight included RCTs, 2159 (48.9%) of 4063 patients underwent RM. Follow-up periods ranged from 12 to 24 months. There were no significant between-group differences in all-cause mortality (RR = 1.19; 95% confidence interval [CI], 0.90-1.57; p = 0.22; I2 = 0%), stroke (RR = 0.90; 95% CI, 0.43-1.91; p = 0.79; I2 = 23%), hospitalizations for cardiovascular and/or device-related adverse events (RR = 0.95; 95% CI, 0.75-1.21; p = 0.70; I2 = 0%), and quality of life (SMD = - 0.06; 95% CI, - 0.22 to 0.10; p = 0.473; I2 = 0%). RM was associated with fewer IO visits/patient/year (MD = 0.98; 95% CI, - 1.64 to - 0.33; p = 0.08; I2 = 98%) and higher rates of atrial tachyarrhythmia (ATA) detection (RR = 1.22; 95% CI, 1.01-1.48; p = 0.04; I2 = 0%) than was CM. This meta-analysis suggests that RM of pacemakers leads to higher rates of ATA detection and fewer IO visits/patient/year, without compromising patient safety.

2023 HRS/EHRA/APHRS/LAHRS expert consensus statement on practical management of the remote device clinic

Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.

2023 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Practical Management of the Remote Device Clinic

Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.

2023 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Practical Management of the Remote Device Clinic

Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.

Remote Monitoring of Cardiac Implantable Electronic Devices: What is the Evidence?

PURPOSE OF REVIEW

This review offers an overview of the evidence in diagnostic and therapeutic applications of remote monitoring implantable devices.

RECENT FINDINGS

Remote monitoring of cardiac implantable devices has become more and more popular in recent years as healthcare is moving towards a more patient centralized system. For heart failure patients with an ICD or pacemaker, there is controversial evidence regarding improvements in the clinical outcome, e.g., reduction of hospitalization rates or overall mortality. New developments as hemodynamic remote monitoring via measurement of the pulmonary artery pressure are promising technical achievements showing encouraging results. In cardiac remote monitoring of syncope and arrhythmias, implantable loop recorder plays an important role in diagnostic algorithms. Although there is controversial evidence according to remote monitoring of implantable devices, its use is rapidly expanding, giving healthcare providers the opportunity to react promptly to worsening of their patients. Adequate evaluation of the data created by remote monitoring systems remains an unsolved challenge of contemporary healthcare services.

Abnormality classification from electrocardiograms with various lead combinations

As cardiovascular diseases have been one of the leading causes of death, early and accurate diagnosis of cardiac abnormalities with less cost becomes particularly important. Given the electrocardiogram (ECG) datasets from multiple sources, there exist many challenges to develop the generalized models that can identify multiple types of cardiac abnormalities from both 12-lead ECG signals and reduced-lead ECG signals. In this study, our objective is to build robust models which can accurately classify 30 types of abnormalities from various lead combinations of ECG signals. Given the challenges of this problem, we proposed a framework for building robust models for ECG signal classification. Firstly, a pre-processing workflow was adopted for each ECG dataset to mitigate the problem of data divergence. Secondly, to capture the lead-wise relations, we used a squeeze-and-excitation deep residual network (SE_ResNet) as our base model. Thirdly, we proposed the cross relabeling strategy and applied the sign-augmented loss function to tackle the corrupted labels in the data. Furthermore, we utilized a pos-if-any-pos ensemble strategy and a dataset-wise cross evaluation strategy to handle the uncertainty of the data distribution in the application. In the Physionet/Computing in Cardiology Challenge 2021, our approach achieved the challenge metric scores of 0.57, 0.59, 0.59, 0.58, 0.57 on 12, 6, 4, 3, 2 lead versions and an averaged challenge metric score of 0.58 over all the lead versions.Using the proposed framework, we developed the models from several large datasets with sufficiently labeled abnormalities. Our models could identify 30 ECG abnormalities accurately based on various lead combinations of ECG signals. The performance on hidden test data demonstrated the effectiveness of the proposed approaches.

Early evaluation of atrial high rate episodes using remote monitoring in pacemaker patients: Results from the RAPID study

Aim

Remote monitoring (RM) of implantable cardiac devices has enabled continuous surveillance of atrial high rate episodes (AHREs) with well‐recognized clinical benefits. We aimed to add evidence on the role of the RM as compared to conventional follow‐up by investigating the interval from AHRE onset to physician’s evaluation and reaction time in actionable episodes.

Methods and Results

A total of 97 dual‐chamber pacemaker recipients were followed with RM (RM‐ON group; N = 64) or conventional in‐office visits (RM‐OFF group; N = 33) for 18 months. In‐office visits were scheduled at 1, 6, 12, and 18 months in the RM‐OFF group and at 1 and 18 months in the RM‐ON group. The overall AHRE rate was 1.98 per patient‐year (95% confidence interval [CI], 1.76–2.20) with no difference between the two groups (RM‐ON vs. RM‐OFF weighted‐HR, 0.88; CI, 0.36–2.13; p = .78). In the RM‐ON group, 100% AHREs evaluated within 11 days from onset, and within 202 days in the RM‐OFF group, with a median evaluation delay 79 days shorter in the RM‐ON group versus the RM‐OFF group (p < .0001). Therapy adjustment in actionable AHREs occurred 77 days earlier in the RM‐ON group versus the control group (p < .001). In the RM‐ON group, there were 50% less in‐office visits as compared to the RM‐OFF group (p < .001).

Conclusions

In our pacemaker population with no history of atrial fibrillation, RM allowed significant reduction of AHRE evaluation delay and prompted treatment of actionable episodes as compared to biannual in‐office visit schedule.

Atrial High-Rate Episode Duration Thresholds and Thromboembolic Risk: A Systematic Review and Meta-Analysis

Background

Available evidence supports an association between atrial high‐rate episode (AHRE) burden and thromboembolic risk, but the necessary extent and duration of AHREs to increase the thromboembolic risk remain to be defined. The aim of this systematic review and meta‐analysis was to identify the thromboembolic risk associated with various AHRE thresholds.

Methods and Results

We searched PubMed and Scopus until January 9, 2020, for literature reporting AHRE duration and thromboembolic risk in patients with implantable electronic devices. The outcome assessed was stroke or systemic embolism. Risk estimates were reported as hazard ratio (HR) or relative risk alongside 95% CIs. We used the Paule‐Mandel estimator, and heterogeneity was calculated with I² index. Among 27 studies including 61 919 patients, 23 studies reported rates according to the duration of the longest AHRE and 4 studies reported rates according to the cumulative day‐level AHRE duration. In patients with cardiac implantable devices, AHREs lasting ≥30 seconds significantly increased the risk of stroke or systemic embolism (HR, 4.41; 95% CI, 2.32–8.39; I², 5.5%), which remained consistent for the thresholds of 5 minutes and 6 and 24 hours. Patients with previous stroke or transient ischemic attack and AHREs lasting ≥2 minutes had a marginally increased risk of recurrent stroke or transient ischemic attack. The risk of stroke or systemic embolism was higher in patients with cumulative AHRE ≥24 hours compared with those of shorter duration or no AHRE (HR, 1.25; 95% CI, 1.04–1.52; I², 0%).

Conclusions

This systematic review and meta‐analysis suggests that single AHRE episodes ≥30 seconds and cumulative AHRE duration ≥24 hours are associated with increased risk of stroke or systemic embolism.

[Home monitoring follow-up of implantable cardiac defibrillators and stimulators : Current situation in France and possible future after ETAPESprogram]

Home monitoring follow-up is part of the routine follow-up of the majority of implantable cardiac defibrillators, and is increasing regarding pacemakers follow-up. This article reviews history, guidelines and legislation for home monitoring follow-up of implantable cardiac devices, and discusses its evolution after ETAPES program.

Remote monitoring of pacemakers

Exactly two decades have elapsed since pacemakers first provided automatic remote monitoring. This innovation has been well received by patients. However, there is still a widely held perception that remote monitoring of pacemakers is non-essential, despite the very similar gains that are achieved compared with remote monitoring of implantable cardioverter defibrillators. Reducing in-office evaluations and overall staff workload is important when these resources are stretched to their limits. The early detection ability provided by remote monitoring facilitates device management (extending battery longevity) and the ability to exercise vigilance over recalled components. Clinical complications, such as arrhythmic events, are also detected earlier. Remote monitoring has been shown to produce similar reductions in the risk of all-cause hospitalization and death for pacemakers and implantable cardioverter defibrillators in a mega-cohort observational study. This review is an evidence-based plea for the recognition and systematic implementation of remote monitoring for pacemakers.

Does remote patient monitoring reduce acute care use? A systematic review

OBJECTIVE

Chronic diseases are associated with increased unplanned acute hospital use. Remote patient monitoring (RPM) can detect disease exacerbations and facilitate proactive management, possibly reducing expensive acute hospital usage. Current evidence examining RPM and acute care use mainly involves heart failure and omits automated invasive monitoring. This study aimed to determine if RPM reduces acute hospital use.

METHODS

A systematic literature review of PubMed, Embase and CINAHL electronic databases was undertaken in July 2019 and updated in October 2020 for studies published from January 2015 to October 2020 reporting RPM and effect on hospitalisations, length of stay or emergency department presentations. All populations and disease conditions were included. Two independent reviewers screened articles. Quality analysis was performed using the Joanna Briggs Institute checklist. Findings were stratified by outcome variable. Subgroup analysis was undertaken on disease condition and RPM technology.

RESULTS

From 2050 identified records, 91 studies were included. Studies were medium-to-high quality. RPM for all disease conditions was reported to reduce admissions, length of stay and emergency department presentations in 49% (n=44/90), 49% (n=23/47) and 41% (n=13/32) of studies reporting each measure, respectively. Remaining studies largely reported no change. Four studies reported RPM increased acute care use. RPM of chronic obstructive pulmonary disease (COPD) was more effective at reducing emergency presentation than RPM of other disease conditions. Similarly, invasive monitoring of cardiovascular disease was more effective at reducing hospital admissions versus other disease conditions and non-invasive monitoring.

CONCLUSION

RPM can reduce acute care use for patients with cardiovascular disease and COPD. However, effectiveness varies within and between populations. RPM's effect on other conditions is inconclusive due to limited studies. Further analysis is required to understand underlying mechanisms causing variation in RPM interventions. These findings should be considered alongside other benefits of RPM, including increased quality of life for patients.

PROSPERO REGISTRATION NUMBER

CRD42020142523.

Role of Remote Monitoring in Detection of Atrial Arrhythmia, Stroke Reduction, and Use of Anticoagulation Therapy - A Systematic Review and Meta-Analysis

BACKGROUND

The effect of remote monitoring (RM) in atrial arrhythmia detection, stroke reduction, and anticoagulation therapy remains unknown, particularly for patients with implantable or wearable cardiac devices.Methods and Results:We performed a systematic review and meta-analysis to evaluate the role of RM in atrial arrhythmia detection, stroke reduction and anticoagulation therapeutic intervention. Online databases were queried to include randomized controlled trials comparing detection of atrial arrhythmia and stroke risk between patients undergoing RM and those receiving in-office (IO) follow-up. Outcomes and complications of RM-guided anticoagulation therapy and conventional therapy in patients with atrial fibrillation were also reviewed. A total of 16 studies were included. Compared with patients receiving IO follow-up, patients undergoing RM had a significantly higher detection rate of atrial arrhythmia (risk ratio [RR], 1.363; 95% confidence interval [CI], 1.147-1.619), and a lower risk of stroke (RR, 0.539; 95% CI, 0.301-0.936). The higher rate of atrial arrhythmia was only noted in patients with wearable devices (RR, 4.070; 95% CI, 2.408-6.877), and the lower risk of stroke was only noted in patients with cardiovascular implantable electronic devices (CIED) (RR, 0.513; 95% CI, 0.265-0.996).

CONCLUSIONS

RM is effective for atrial arrhythmia detection in patients using wearable devices and for reducing the risk of stroke in patients with CIED.

Cardiac Electronic Devices: Future Directions and Challenges

Cardiovascular implantable electronic devices (CIEDs) are essential management options for patients with brady- and tachyarrhythmias or heart failure with concomitant optimal pharmacotherapy. Despite increasing technological advances, there are still gaps in the management of CIED patients, eg, the growing number of lead- and pocket-related long-term complications, including cardiac device–related infective endocarditis, requires the greatest care. Likewise, patients with CIEDs should be monitored remotely as a part of a comprehensive, holistic management approach. In addition, novel technologies used in smartwatches may be a convenient tool for long-term atrial fibrillation (AF) screening, especially in high-risk populations. Early detection of AF may reduce the risk of stroke and other AF-related complications. The objective of this review article was to provide an overview of novel technologies in cardiac rhythm–management devices and future challenges related to CIEDs.

e-Health: A Future Solution for Optimized Management of Elderly Patients. GER-e-TEC™ Project

Background: Elderly residents in nursing homes have multiple comorbidities (including cognitive and psycho-behavioral pathologies, malnutrition, heart failure, diabetes, chronic obstructive pulmonary disease, and renal failure) and use multiple medications. Methods: The GER-e-TEC project aims to provide these fragile and complex patients with telemedicine tools, more specifically telemonitoring, backed by a well-defined and personalized protocol. Results: Medically, this implies the need for regular monitoring and a high level of medical and multidisciplinary expertise for the healthcare team. The tools use non-invasive communicating sensors and artificial intelligence techniques, allowing daily monitoring with the ability to detect any abnormal changes in the patient's condition early. Conclusions: The GER-e-TEC project specifically considers the challenges of aging residents and significant challenges in nursing homes, with the main geriatric syndromes (falls, malnutrition, cognitive-behavioral disorders, and iatrogenic conditions).

A Deep Learning Approach for Featureless Robust Quality Assessment of Intermittent Atrial Fibrillation Recordings from Portable and Wearable Devices

Atrial fibrillation (AF) is the most common heart rhythm disturbance in clinical practice. It often starts with asymptomatic and very short episodes, which are extremely difficult to detect without long-term monitoring of the patient’s electrocardiogram (ECG). Although recent portable and wearable devices may become very useful in this context, they often record ECG signals strongly corrupted with noise and artifacts. This impairs automatized ulterior analyses that could only be conducted reliably through a previous stage of automatic identification of high-quality ECG intervals. So far, a variety of techniques for ECG quality assessment have been proposed, but poor performances have been reported on recordings from patients with AF. This work introduces a novel deep learning-based algorithm to robustly identify high-quality ECG segments within the challenging environment of single-lead recordings alternating sinus rhythm, AF episodes and other rhythms. The method is based on the high learning capability of a convolutional neural network, which has been trained with 2-D images obtained when turning ECG signals into wavelet scalograms. For its validation, almost 100,000 ECG segments from three different databases have been analyzed during 500 learning-testing iterations, thus involving more than 320,000 ECGs analyzed in total. The obtained results have revealed a discriminant ability to detect high-quality and discard low-quality ECG excerpts of about 93%, only misclassifying around 5% of clean AF segments as noisy ones. In addition, the method has also been able to deal with raw ECG recordings, without requiring signal preprocessing or feature extraction as previous stages. Consequently, it is particularly suitable for portable and wearable devices embedding, facilitating early detection of AF as well as other automatized diagnostic facilities by reliably providing high-quality ECG excerpts to further processing stages.

Effectiveness and Safety in Remote Monitoring of Patients with Pacemakers Five Years after an Implant: The Poniente Study

Health-related quality of life (HRQoL) and functional capacity values immediately after pacemaker (PM) implantation have been well established; however, not much has been known about its long-term effects. The present study compared the long-term effectiveness and safety of remote monitoring plus a clinic visit versus clinic visits alone during follow-up of adults implanted with PMs. This study was a single-centre, controlled, non-randomised, non-blinded clinical trial. Data were collected pre-implantation and after 60 months. The patients in the PONIENTE study were assigned to two different groups: remote monitoring (RM) and conventional monitoring (CM). The EuroQol-5D (EQ-5D) questionnaire was used to assess HRQoL and Duke Activity Status Index was used for the functional capacity. After five years, 55 patients completed the study (RM = 21; CM = 34). EuroQol-5D and functional capacity values were improved; however, significant differences were observed only in the EQ5D visual analogue scale (p < 0.001). Remote monitoring was equally feasible, reliable, safe, and clinically useful as CM. The frequencies of rehospitalisations and emergency visits did not differ between the groups. RM was found to be safe and effective in early detection and treatment of medical- and device-related events and in reducing hospital visits. Improved HRQoL was described not only immediately after PM implantation but also extended over a long time.

Telemedicine and Cardiology in the Elderly in France: Inventory of Experiments

Telemedicine is now in vogue, allowing through computer and communication tools to be deployed in the field of health, such as cardiology, area in which it has shown interest, in international studies. As the population ages, older people are increasingly concerned with this innovative practice. We take a look at telemedicine projects in France concerning the elderly, in the field of cardiology.

Active periodic electrograms in remote monitoring of pacemaker recipients: the PREMS study

AIMS

Remote monitoring (RM) is considered as a standard of care for pacemaker recipients. Remote monitoring systems provide calendar-based intracardiac electrogram recordings (IEGM) only with the current pacemaker settings (passive IEGM). PREMS (Pacemaker Remote Electrogram Monitoring Study), an observational, multicentre trial, prospectively evaluated the clinical value of an active IEGM (aIEGM), including three 10-s sections (passive IEGM, encouraged sensing, and encouraged pacing), compared to other RM data and to its passive IEGM section. Secondary objectives included the added value of the aIEGM to fully assess the sensing and pacing functions of each lead.

METHODS AND RESULTS

Patients were enrolled within 3 months after pacemaker implantation and followed until the first transmitted aIEGM, which was analysed together with all other RM data. In total, 567 patients were enrolled (79 ± 9 years, 62% men, 19% single-chamber, and 81% dual-chamber pacemakers). Of 547 aIEGMs transmitted in 547 patients, 161 [29.4%; 95% confidence interval (95% CI) 25.6-33.3%] indicated at least one anomaly non-detectable with certainty-or at all-on other RM data, including atrial arrhythmia, extrasystoles, undersensing, oversensing, and loss of capture. In 21.7% of cases the detected events deserved a corrective action. The sensing and pacing function of each lead could be fully assessed in 77.3% of aIEGM (95% CI 72.6-82.0%) vs. 15.5% (95% CI 11.4-19.6%) when considering only the passive IEGM section (P < 0.001).

CONCLUSION

An active IEGM improves the clinical value of remote pacemaker follow-up. Furthermore, compared to a passive IEGM, the aIEGM increases the capability to fully assess remotely the sensing and pacing functions.

Focus on the Different Projects of Telemedicine Centered on the Elderly In France

Telemedicine is now in vogue, allowing computer and communication tools to be deployed in different fields of health, such as Cardiology, Dermatology, areas in which it has received interest, and in international studies. As the population ages, older people are increasingly concerned about this innovative practice. This is a narrative review of both the literature and Internet pertaining to telemedicine projects within the field of geriatric subjects in France. Since the beginning of the 2000's, several telemedicine projects and trials focused on chronic heart failure have been developed in the elderly, and also in the field of dermatology. The potential contribution of second-generation telemedicine projects in terms of mortality, morbidity, and the number of hospitalizations avoided is currently under study. Their impact in terms of health economics is likewise being investigated, taking into account that the economic and social benefits brought up by telemedicine solutions were previously validated by the original telemedicine projects. We take a look at telemedicine projects in France concerning the elderly.

[Telemonitoring of implanted cardiac devices : Clinical necessity or senseless luxury?]

In addition to the telemedical follow-up at a fixed point in time, there is the possibility of a close-meshed telemetric monitoring in modern devices. By transferring device and patient-specific data, errors in the integrity of the device or electrodes and cardiac arrhythmias can be detected early, in various studies significantly reducing the number of outpatient or inpatient visits and the rate of inadequate implantable cardioverter-defibrillator (ICD) therapies. Measurement of various surrogate parameters allows better clinical assessment of heart failure patients, yet no improvement in outcome with therapy guided by telemetric data has been demonstrated. Retrospective analyzes, a prospective randomized study, and various meta-analyzes identified a reduction in all-cause mortality through the use of remote monitoring. This effect is mainly due to monitoring as closely as possible, timely examination of the findings, accordingly early interventions and specification of clear therapeutic regimens in certain clinical scenarios. Such comprehensive patient care requires the creation of telemonitoring centers with appropriate structural and personal equipment, whereby the creation of such structures has not yet been remunerated in the German healthcare system. In this paper, an overview of remote monitoring and identify possibilities and limitations of device-based telemedical monitoring is provided.

Telemedicine and Geriatrics in France: Inventory of Experiments

Telemedicine is now in vogue, being deployed through computer and communication tools in various health fields, such as diabetology, nephrology, dermatology, neurology, and cardiology. With population ageing, geriatrics is coming into sharp focus. Telemedicine practices differ for home-based or institutionalized patients in long-term care homes. We take a look at telemedicine projects in France concerning the elderly.

Remote Monitoring for Chronic Disease Management: Atrial Fibrillation and Heart Failure

This review aims to cover the latest evidence of remote monitoring of cardiac implantable electronic devices for the management of atrial fibrillation and heart failure. Remote monitoring is useful for early detection for device-detected atrial fibrillation, which increases the risk of thromboembolic events. Early anticoagulation based on remote monitoring potentially reduces the risk of stroke, but optimal alert setting needs to be clarified. Multiparameter monitoring with automatic transmission is useful for heart failure management. Improved adherence to remote monitoring and an optimal algorithm for transmitted alerts and their management are warranted in the management of heart failure.

[Diagnosis of arrhythmias on memories of pacemakers and defibrillators: Practical management]

Pacemakers and defibrillators have holter capabilities that can record episodes of arrhythmias. Different studies evaluated the effect on the risk of strokes of different durations of arrhythmias. The question of the management of patients depending on the duration of the arrhythmia episode is addressed in this article depending on the duration of the episode and the arrhythmia burden.

[Device-based remote monitoring : Current evidence]

Telemedicine is increasingly used in clinical cardiology. It offers early detection of arrhythmias, technical device follow-up and support of heart failure management. Regarding technical device follow-up, remote monitoring significantly reduces usage of the health care system. Furthermore, remote monitoring is associated with a significantly reduced time from device malfunction to physician's perception of the event. Using remote monitoring, inappropriate ICD (implantable cardioverter defibrillator) shocks can be significantly reduced compared to routine in-office follow-up. In retrospective studies and meta-analyses a prognostic benefit with respect to mortality has been shown. Device-based detection of atrial fibrillation and atrial high rate episodes is feasible. However, clinical relevance is currently studied in prospective randomized clinical trials. Heart failure management based on surrogate parameters has not been shown to significantly improve outcome. However, therapeutic management based on pulmonary artery pressure has been shown to significantly reduce morbidity and mortality. This review offers a comprehensive overview on the role of remote monitoring in heart failure management, technical device follow-up and detection of atrial fibrillation and atrial high rate episodes.