Remote Monitoring of Patients With CIEDs: What Do the Guidelines Say?
Niraj Varma
KEY POINTS
A strategy of remote cardiac implantable electronic device (CIED) monitoring and interrogation, combined with at least annual in-person evaluation (IPE), is recommended over a calendar-based schedule of in-person CIED evaluation alone (when technically feasible). It might be beneficial to start remote monitoring (RM) within 2 weeks following CIED implantation.
RM should be performed for surveillance of lead function and battery conservation.
Patients with a CIED component that has been recalled or is on advisory should be enrolled in RM to enable early detection of actionable events.
RM reduces the incidence of inappropriate implantable cardioverter defibrillator shocks.
RM has potential application for disease management.
INTRODUCTION
Contemporary postimplant follow-up of patients receiving cardiac implantable electronic devices (CIEDs) is erratic because many patients do not maintain recommended follow-up.1 In the United States, only a minority of patients adhere to regular postimplant follow-up, if at all.2 Even under trial conditions, relying on strictly in-person methods demonstrates operational inefficiency and patient attrition.3 These observations suggest that conventional follow-up methods are not only onerous but also modestly effective. Nevertheless, the onus of responsibility to maintain postimplant surveillance rests with the physician. Automatic remote monitoring (RM) facilitates this.4 The 2015 Consensus Statement advocated RM as the standard of care and that it should be offered to all patients.5
RECOMMENDATION CLASS 1 LOE A: A strategy of remote CIED monitoring and interrogation, combined with at least annual IPE, is recommended over a calendar-based schedule of in-person CIED evaluation alone (when technically feasible).
This marks a significant change from the prior 2008 statement in which RM played an adjunctive role for the occasional replacement of routine scheduled in-person evaluations (IPEs) during periods of stability.6 Now implementation of a system of nearly continuous monitoring, with most IPEs initiated in response to alert notifications communicated by the RM, is recommended at or soon after implant, with scheduled IPEs only on an annual basis.5 This is in response to a wealth of evidence accumulated in the last 5 years, together with the evolution of remote technology itself from patient-activated “inductive” systems used for remote interrogation to automatic wireless systems capable of near continuous “monitoring.”7 This is possible because of the availability of embedded technologies permitting devices to relay data regarding their own function, occurrence of arrhythmias, and physiologic parameters (See Chapter 1).
Clinic Workflow
Several randomized trials beginning with TRUST in 2010 have shown that RM more effectively and durably attained the follow-up goals of timely scheduled follow-up and patient retention, compared to conventional methods.3,8,9,10,11 Moreover, replacement of many IPEs with remote interrogation follow-up evaluations was safe and created efficiencies for both patients and clinics. Thus, in-clinic encounters were almost halved, while still maintaining monitoring and reducing patient attrition (Figure 9.1). This requires an organized infrastructure based on a cooperative interaction between a
nurse and physician with an agreed list of respective tasks and responsibilities. Only problematic remote assessments (that occur infrequently) need to be directed to physicians. The process should be initiated early.
nurse and physician with an agreed list of respective tasks and responsibilities. Only problematic remote assessments (that occur infrequently) need to be directed to physicians. The process should be initiated early.
 FIGURE 9.1 Remote home monitoring compared versus conventional care during postimplant follow-up (from the TRUST trial). Remote monitoring (A) reduced cardiac resource utilization (scheduled and unscheduled clinic and hospital visits [including responses to alert notifications]) by 45% in 1 year safely and (B) improved detection time of significant clinical problems (eg, lead fracture and arrhythmia onset) to a median of 24 hours, even if asymptomatic. These results have since been consistently reproduced with trials using a variety of proprietary technologies in different healthcare models, with all cardiac implantable electronic device types. Data from Varma N, Epstein A, Irimpen A, et al. Efficacy and safety of automatic remote monitoring for ICD follow-up: the TRUST trial. Circulation. 2010;122:325-332. |
RECOMMENDATION CLASS II LOE A-C: It might be beneficial to start RM within the 2 weeks following CIED implantation.
Options are at the patient’s postimplant office visit, or even prior to hospital discharge, so that the patient is enrolled and sent home with a RM transmitter. Once home, the patient connects the hardware and initiates the “check” transmission; receipt of the transmission is confirmed at the first in-office visit. Earlier activation was shown to be beneficial.12
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
