Role Of Remote Monitoring Research Articles

Prognostic role of data transmitted by implanted cardiac electric devices in patients with advanced heart failure referred for heart transplantation

Abstract Background Patients (pts) with advanced heart failure (HF) are poorly tolerant to GDMT, frequently hospitalized and are often carriers of implantable cardioverter-defibrillators (ICD) or of cardiac resynchronization therapy (CRT-D). These devices allow HF centers to remotely monitor the occurrence of arrhythmic events and of ICD interventions, such as anti-tachycardia pacing (ATP) bursts or DC-shocks. While HF hospitalizations are an established prognostic marker, the role of remote monitoring in a context of pts referred for heart transplantation (HT) is poorly explored. Purpose In this retrospective monocentric study we aim to evaluate the prognostic value of remotely-transmitted information from ICD/CRT in pts with advanced HF followed in a tertiary Center dedicated to HF and HT. Methods We included all adult pts with a remotely transmitting device followed by both Electrophysiology and Heart Failure Teams in our Center between September 2016 and January 2023. We collected data about heart disease, medical therapy, echocardiography, device-delivered therapies, and hospital admissions for any cause. The outcome was the combined incidence of death from any cause or urgent heart transplantation. Results 123 pts were enrolled ( 57±10 yrs, 75% males, LVEF 34%±10%). 68 had an ICD, 55 CRT-D. 50 pts (41%) received at least one device-delivered therapy (34 pts had at least one ATP; 29 pts had at least one DC-shock, of whom 26 were appropriate). During a mean follow-up of 29 months, we recorded 121 hospitalizations (53% for arrhythmias, 47% for acute HF) in 44 pts. The endpoint occurred in 14 pts : 12 (9.8%) died, 2 (1.6%) underwent to urgent HT; overall, 12 pts (9.8%) were transplanted. Pts with arrhythmic events had more frequently a spontaneous QRS >120ms (60% vs. 40%, p=0.04) and a trend towards more hospitalizations for heart failure (64% vs. 35%, p=0.059). The predictor of the combined endpoint of death or urgent transplant was hospitalization for HF (RR: 4.2, p<0.01); ATP and/or DC-shocks (RR 7.3) and intolerance to vasodilators (ACE-I, ARB, ARNI), (RR (1.5) showed a borderline statistical significance (p=0.06 for both). However, in the subgroup of patients without any HF hospitalization, device-delivered therapies from ICDs and CRT-D carried an higher risk of death and urgent HT (p=0.03), see Figure . Conclusion In a population of patients with advanced HF, while confirming the known prognostic role of HF hospitalization, we found that remote monitoring of ICD shocks/ATP in patients not hospitalized for HF identifies a subgroup of patients at high risk of death or urgent HT. These results underscore the importance of considering these patients for advanced HF therapies and of an integrated approach between electrophysiologists and HF specialists.

The role of remote monitoring in detecting of the defibrillation lead dislocation: case report

The role of remote monitoring in detecting of the defibrillation lead dislocation: case report

The Role of Remote Monitoring in Evaluating Fatigue in Multiple Sclerosis: A Review.

Fatigue is one of the most common multiple sclerosis (MS) symptoms. Despite this, monitoring and measuring fatigue (subjective lack of energy)– and fatigability (objectively measurable and quantifiable performance decline)– in people with MS have remained challenging. Traditionally, administration of self-report questionnaires during in-person visits has been used to measure fatigue. However, remote measurement and monitoring of fatigue and fatigability have become feasible in the past decade. Traditional questionnaires can be administered through the web in any setting. The ubiquitous availability of smartphones allows for momentary and frequent measurement of MS fatigue in the ecological home-setting. This approach reduces the recall bias inherent in many traditional questionnaires and demonstrates the fluctuation of fatigue that cannot be captured by standard measures. Wearable devices can assess patients' fatigability and activity levels, often influenced by the severity of subjective fatigue. Remote monitoring of fatigue, fatigability, and activity in real-world situations can facilitate quantifying symptom-severity in clinical and research settings. Combining remote measures of fatigue as well as objective fatigability in a single construct, composite score, may provide a more comprehensive outcome. The more granular data obtained through remote monitoring techniques may also help with the development of interventions aimed at improving fatigue and lowering the burden of this disabling symptom.

Impact of COVID-19 Pandemic on Cardiac Electronic Device Management and Role of Remote Monitoring.

During the coronavirus disease 2019 (COVID-19) worldwide pandemic, patients with cardiac implantable electronic device (CIED) refused scheduled follow-up visits because of the risk of infection. In this scenario, different telemedicine strategies have been implemented to ensure continuity of care to CIED patients. Patients can be monitored through dedicated applications, telephone calls, or virtual visits providing easy access to valuable information, such as arrhythmic events, acute decompensation manifestations, and device-related issues, without the need for in-person visits. This review provides a comprehensive description of the many possible applications of telemedicine for CIED patients during the COVID-19 period.

PRS63 NON-Adherence in Severe Asthma: Exploration of How to Measure the Extent of IT

Suboptimal adherence to inhaled corticosteroids is the most common reason for treatment failure in asthma. In clinical practice, patient self-reporting offers a simple, inexpensive method of assessing adherence, but typically over-estimates it. The Centre for Evidence-Based Medicine published a risks and considerations document relating to asthma and COVID-19, describing how smartinhalers may allow remote monitoring of compliance. This is particularly relevant given the NICE rapid guidance on severe asthma during COVID-19, where one of the recommendations was to give consideration to remote monitoring. This poster aims to explore the scale of the problem posed by non-adherence in asthma, and the key role of improving adherence measurement. A targeted literature review was conducted in standard, recommended search engines – including Medline, Embase, Cochrane and the Health Technology Assessment (HTA) database. This was combined with a range of case studies and other articles. The review included both the scale of the problem non-adherence poses in asthma, and the current techniques used to measure adherence. Studies reviewed identified a clear disparity between existing measures of adherence, and the objective underlying adherence. For example, Jochmann et al (2017) found there is no correlation between electronic monitoring and records for uptake of prescription. Understanding the extent of non-adherence is critical to interventions and improvement. Analysis of four adult studies concluded that a 25% increase in adherence was associated with an approximately 10% reduction in severe exacerbations. It is clear that non-adherence and measuring it is a significant issue in asthma. With the shift towards expensive biological treatments, it is important that the ability to measure and manage adherence is at the core of asthma management in order for therapies to be optimised. Furthermore, given the pressure on health systems posed by COVID-19, the role of remote monitoring in asthma is increasingly important.

Abstract 14884: Invasive Hemodynamic Remote Monitoring for Heart Failure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: In heart failure (HF) patients, remote monitoring of hemodynamics using implantable devices may be used to predict and reduce HF exacerbations. Methods: A meta-analysis of randomized controlled trials (RCTs) testing remote monitoring versus standard of care for management of HF patients was performed. Endpoints included all-cause mortality and Cardiovascular (CV)/HF hospitalizations. Risk Ratios (RR) and 95% confidence intervals (CI) were calculated for each endpoint. A secondary analysis tested for heterogeneity of treatment effect (HTE) using Chi 2 and I 2 tests comparing implanted right ventricular/pulmonary pressure monitoring versus impedance-based monitoring on HF hospitalization. Results: 10 RCTs (n=6,020) were identified with a mean follow-up of 1.74 years. The mean age and reported ejection fraction were 64.1 and 27.1%, respectively. Remote monitoring did not reduce mortality (RR 0.88, [95% CI 0.76, 1.03]) or CV/HF hospitalizations (RR 0.99, [0.81, 1.20]) (Figure 1). When performing the test of subgroup differences, there was significant HTE for HF hospitalization between those studies that used implanted right ventricular/pulmonary pressure monitoring versus impedance-based monitoring (Chi 2 = 7.92, p = 0.005, I 2 = 87.4%). Conclusions: Compared to standard of care, remote monitoring of physiologic markers of HF did not reduce mortality and CV or HF hospitalization. However, right ventricular/pulmonary pressure monitoring may reduce HF hospitalization compared to impendence-based monitoring. Further studies are necessary to evaluate the role of remote monitoring in patients with heart failure.

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

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

HFA Committee on Comorbidities-report of a meeting on physiological monitoring in the complex multi-morbid heart failure patient.

One of the largest and most active committees of the Heart Failure Association (HFA) is the Committee on Comorbidities, which I have the honour to chair. It is in fact multiple committees, because its remit is so broad, covering study groups looking at Cardio-Oncology (Alex Lyon), Diabetes & Hypertension (Giuseppe Rosano), Cardiorenal Dysfunction (Wilfried Mullens), Heart & Brain (Andrew Coats), Cachexia, Sarcopenia and Frailty (Ewa Jankowska), and Lung Disease and Sleep Disorders (Mitja Lainscak). Co-morbidities are increasingly recognized as crucial components of the heart failure (HF) syndrome, especially in typical older patients (unlike the very highly selected patients who make in into randomized controlled trials). There has been much work published about these issues in the European Journal of Heart Failure recently.1-7 February 28, 2019 saw many of the members of the Committee on Comorbidities come together to tackle a very clinically relevant topic, that of producing an official position paper on how to monitor all these co-morbidities (using simple physiological measurements) in the typical HF patient, if such a person exists. Getting together in the wonderful setting of the eternal city of Rome, we saw the following members work on this topic, along with many more who could not attend in person: Andrew Coats, Maurizio Volterrani, Loreena Hill, Massimo Piepoli, Ovidiu Chioncel, Ewa Jankowska, Mitja Lainscak, Stefan Anker, Marco Metra, Piotr Ponikowski and Petar Seferovic. ECG – patterns, rhythms and conduction - Should we simply do opportunistic ECGs or should we recommend routine ECGs on regular follow-up and should we recommend wearable devices for ECG recordings, looking for example for things such as We then turned our attention to ventricular function, the most important of course being left ventricular function, discussing the role of echocardiography and other imaging techniques, when they should be used and how frequently, and important clinical questions such as what are the recommendations for routine echo follow-up in HFrEF or HFpEF, for valve lesions complicating HF, and whether other circumstances justify routine echo during follow-up, e.g. looking for forms of amyloid, myocarditis etc., and whether we should re-check echo after cardiac resynchronization therapy or drug therapy changes. Another important and frequently clinically relevant topic in transplant and ventricular assist device assessment clinics is that of monitoring of functional capacity, covering topics such as the prognostic value of exercise tolerance, and especially of peak oxyen uptake and other measurements derived from formal cardiopulmonary exercise testing (CPET), such as VE/VCO2 slope, exercise oscillatory ventilation, along with a discussion of the potential for wearable devices and the possibility of daily activity monitoring. Under the heading of advanced forms of monitoring, we considered plasma biomarkers, including their diagnostic role, prognostic value, value as inclusion criteria for certain therapies (e.g. sacubitril/valsartan) and the choice of the optimal biomarkers for HFrEF or HFpEF. Another large topic was the role of remote monitoring and telemedicine—both non-invasive and using implanted technologies (pulmonary artery pressure monitoring and loop recorders). What should we say about recommending remote non-invasive telemonitoring, given the recent TIM-HF2 trial?8, 9 A very important question that will be addressed on the final paper is the issue of what clinical trials and with what endpoints will be needed to get the proof we need to routinely recommend monitoring by implantable devices, and who will pay for this on-going monitoring effort. We finished by reviewing the specific challenges of monitoring the advanced HF patient—given that we all agreed sicker patients need more intense monitoring. This covered emerging topics such as lung congestion or total body water monitoring, along with prevalent co-morbidities, renal impairment, haemoglobin and serum iron, transferrin and transferrin saturation, sodium, potassium (with the advent of potassium binders into our treatment options), sleep disordered breathing, where differentiating central from obstructive sleep apnoea is essential to choose the right therapy for a HF patient with sleep disordered breathing, and of course monitoring diabetic control. We then finished with a discussion about the growing incidence of co-existing cancer and heart disease and need to develop evidence-based strategies for monitoring and protecting cardiac function during many modern anti-cancer regimes. The one thing that became increasingly obvious was that this area is enormously complex and the need for future reach is growing ever more urgent. Andrew J.S. Coats University of Warwick, Coventry, UK ajscoats@aol.com

The role of remote monitoring for cardiac implantable electronic devices

At present, remote monitoring (RM) is available for almost all cardiac implantable electronic devices. RM systems allow for enhanced surveillance and earlier detection of clinically significant events. In recent guidelines, RM is a Class I indication for device follow-up, and the Expert Consensus Statement endorses the use of RM to improve patient compliance. Many clinical studies including randomized clinical trials showed favorable outcomes with RM. This technology reduces costs, allows for early detection of arrhythmias, as well as lead to malfunctions. RM also lowers hospitalization rates, decreases inappropriate implantable cardioverter defibrillator shocks, and detects asymptomatic atrial fibrillation earlier than routine office visits. However, whether RM reduces mortality remains unclear. Prevention of heart failure exacerbation with early detection of surrogate markers of heart failure with RM has not been demonstrated using a single measure such as intrathoracic impedance. However, the use of multiple parameters has encouraging early results, showing improved detection of impending heart failure exacerbation.

Remote Monitoring of Atrial High Rate Episodes in Pacemaker Patients. The Rapid Study Design.

Remote Monitoring (RM) has been introduced for several years and nowadays most pacemakers are equipped with such a technology. RM can provide early detection of high atrial rate episodes (AHREs) onset and enable prompt medical intervention. However, there are still little data on the clinical reactions triggered by the AHRE detected by RM of pacemaker recipients and on their possible benefit on patients' outcome. The RAPID study is a multicenter, prospective, non-interventional study designed to compare the time from onset to first physician's evaluation of AHRE episode with arrhythmic burden ≥5% (72 minutes) for pacemaker recipients without atrial fibrillation history, between patients followed with RM or conventionally with annual in-hospital visits. A total of 98 patients with implanted dual-chamber pacemaker, assigned to RM-OFF or RM-ON according to ordinary clinical site practice, will be followed for a total of 18 months. After the implant, patients will perform their first in-hospital follow-up visit at 1 month and then, in the RM-OFF group, patients will perform an in-hospital FU every 6 months, while in the active group, patients will be continuously monitored via RM until study termination. All AHREs and consequent medical interventions will be collected over the entire study period. The ongoing RAPID study will provide additional information on the role of RM in the management of AHRE detected in pacemaker patients without documented atrial fibrillation history in ordinary clinical practice.

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 asignificantly 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 aprognostic 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 acomprehensive 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.

E4. Remote prenatal follow-up of patients at risk for gestational hypertensive disorders: maternal and neonatal outcomes

Background: Gestational hypertensive disorders (GHD) are major contributors to maternal mortality worldwide. In Ziekenhuis Oost- Limburg (Genk, Belgium), a remote monitoring (RM) program for pregnant women at risk for developing GHD was initiated in January 2015 to evaluate the relevance of a RM program. RM is a relatively new approach that broadly can be defined as the application of telecommunication technologies in interchanging medical data, information and services between healthcare providers and patients.Aim: Evaluation of the role of RM in the obstetrical care for pregnant women at risk for GHD.Methods: A retrospective study was conducted in 44 pregnant women who developed GHD and had a RM prenatal follow-up. They sent twice daily blood pressure measurements and once daily weight measurements to our Clinical Call Center. Those patients were compared with 98 patients with confirmed GHD in routine care (RC). The inclusion period started at the first of January 2015 and ended 31 December 2015. All the interchanged data were analyzed in detail. Primary endpoints were: number of prenatal consultations and Maternal Intensive Care (MIC) admissions. Secondary endpoints were: maternal and neonatal outcomes. SPSS was used for statistical analysis.Results: There is no difference between the two groups in maternal demographics, gestational age at the first prenatal visit, the total number of prenatal visits, CTG’s and echo’s during pregnancy, or amount of days admitted to the MIC. In RM versus RC, the total number of MIC admissions (29% versus 74%; p < 0.01) and the number of long-stay birthing admissions to the MIC (18% versus 64%; p < 0.01) were lower. Maternal and neonatal outcomes were not different for gestational age at delivery, birthweight, birthweight percentile, length, Apgar at 1 min or at 5 min and pH arterial or venous. In RM versus RC, the number of spontaneous deliveries is higher (47% versus 27%; p = 0.01) and the number of admissions to the NIC was lower (11.3% versus 29.2%; p = 0.02).Discussion: A lower number of NIC and MIC admissions in RM versus RC were observed in this retrospective study. When confirmed in a prospective setup, cost effectiveness of prenatal RM can be evaluated.

Cardiac Resynchronization Therapy Follow-up: Role of Remote Monitoring.

Cardiac resynchronization therapy (CRT) is increasingly used in heart failure treatment and management of these patients imposes significant challenges. Remote monitoring is becoming essential for CRT follow-up and allows close surveillance of device function and patient condition. It is helpful to reduce clinic visits, increase device longevity and provide early detection of device failure. Clinical effects include prevention of appropriate and inappropriate shocks and early detection of arrhythmias, such as atrial fibrillation. For modification of heart failure the addition of monitoring to CRT by means of device-based multiparameters may help to modify disease progression and improve survival.

The role of remote monitoring in the reduction of inappropriate implantable cardioverter defibrillator therapies

Implantable cardioverter defibrillators (ICDs) with the integrated Home Monitoring feature use dedicated mobile phone and internet links to provide the physicians and technicians in the ICD clinic with the essential device- and arrhythmia-related data stored in the ICD diagnostic memory. Various counters, graphs and intracardiac electrograms are automatically transmitted via Home Monitoring each day to allow prompt, remote presentation of arrhythmias or detection of technical problems. One of the most inconvenient side-effects of the ICD therapy is inappropriate intervention of the device. Home Monitoring data can help the physician to identify and subsequently reduce the incidence of inappropriate ICD therapy.