COMMENTARY

Remote Monitoring of Cardiac Devices: An Optimistic View of the Digital Future of Medicine

John Mandrola

Disclosures

May 19, 2015

By itself, it does nothing. No atria burned, no appendage plugged, and no drugs prescribed. Remote monitoring of cardiac devices provides only data. Yet it leads to fewer doctor visits, lower mortality, and less healthcare utilization.

No. That's neither a marketing slogan nor a fairy tale. It's real—and it's why I find the remote monitoring of patients with cardiac devices such a joyous story.

In a late-breaking clinical trial at the Heart Rhythm Society (HRS) 2015 Scientific Sessions, Dr Jonathan Piccini (Duke Clinical Research) presented results of a retrospective observational study of more than 90,000 patients with cardiac devices[1]. In the Impact of Remote Monitoring on Clinical Events and Healthcare Utilization study, Piccini and colleagues used a real-world claims database to compare remote monitoring with in-person follow-up in patients with pacemakers, implantable cardioverter defibrillators (ICDs), cardiac and resynchronization therapy devices (CRT-Ds and CRT-Ps). Steve Stiles from heartwire on Medscape has complete coverage of the study.

In brief, remote monitoring was associated with fewer all-cause hospitalizations, heart-failure admissions (and readmissions), and stroke admissions. For every 100,000 patient-years of follow-up, remote monitoring was associated with 119,000 fewer days in the hospital and $370 million less in hospital payments. Stroke incidence with remote monitoring was 1.1 (per 100-patient-years) vs 1.6 without remote monitoring. The study included devices from all major vendors.

Three Notable Remote-Monitoring Abstracts from HRS 2015

Start remote monitoring as soon as possible after implant, say Dr Niraj Varma (Cleveland Clinic, OH) and colleagues. For this abstract, they looked at data from the multicenter TRUST trial and found remote monitoring in the immediate postprocedure often led to actionable findings at the first in-person visit[2]. These actions included device reprogramming, lead revision, and treatment of silent arrhythmia.

My favorite study on device monitoring looked at the predictive value of physical-activity data[3]. In the Altitude Activity study, Dr Daniel Kramer (Beth Israel Deaconess, MA) and colleagues collected physical-activity data from the Latitude (Boston Scientific) remote monitoring system. They found, not surprisingly, a strong correlation between daily physical activity and survival. This strengthens my main message to cardiac patients: to keep living you must keep moving.

The Achilles' heel of remote monitoring is adherence. If you don't use it, you don't benefit. In humans, one way to improve adherence (to anything) is to make it automatic. Most cardiac devices transmit data automatically and wirelessly. Others require the patient to swipe a wand over the device each night. Dr Najmul Siddiqi (Cleveland Clinic OH) and colleagues compared the frequency of missed transmissions in more than 400 patients with either wireless (automatic) or inductive devices[4]. In pacemaker patients, wireless devices were associated with fewer missed transmissions. I like wireless devices that allow automatic (rather than inductive) remote monitoring.

These findings align well with two studies published this week in the Journal of the American College of Cardiology.

In the first study, Dr Varma and colleagues reported results of an observational cohort of more than 269K patients with cardiac devices[5]. They used the Merlin database (St Jude Medical) and compared outcomes in patients who had remote monitoring with those who had in-person visits only. They found remote monitoring strongly associated with improved survival; the degree of adherence to remote monitoring correlated with the magnitude of benefit, and these associations remained for all types of devices, including pacemakers.

In the second study, Dr Nirmalatiban Parthiban (University of Adelaide and Royal Adelaide Hospital, Australia) and his colleagues performed a meta-analysis of nine randomized controlled clinical trials, including 6900 patients, that compared remote monitoring with in-person follow-up[6]. In measures of overall mortality, cardiovascular mortality, appropriate shocks, and hospitalizations, the authors found no significant differences between remote monitoring and in-person follow-up. Remote monitoring was associated with a lower rate of inappropriate shocks. Interestingly, a significant mortality benefit was noted in the subset of trials that used the wireless automatic BioTronik remote-monitoring system (OR 0.65, 95% CI 0.45–0.94; P=0.021).

Comments

Remote monitoring is as close to a win-win as modern medicine gets. The process engages patients in their health. That alone may be the main driver of its benefit.

I see it work in real life. Remote monitoring discovers problems we can and should treat—new atrial fibrillation, lead issues, and drops in percent BiV pacing, for instance. Unlike the worried well, patients sick enough to warrant an implantable cardiac device stand a greater chance of benefiting from wireless monitoring.

There are barriers to realizing the benefits of remote monitoring. Adherence remains low, and not all countries reimburse for it. Remote monitoring requires buy-in from the patient. It requires a team of advanced care practitioners; doctors cannot do it alone. And data overload could become a problem.

That said, remote monitoring deserves our attention. The observational data are overwhelmingly positive. Although the clinical-trial evidence (overall) yields less robust benefits, the subset of patients on automatic wireless monitoring enjoyed a mortality benefit. If we are going to expose patients to the risks of cardiac devices, it is right and just to do everything we can to maximize benefit and minimize harm.

The remote-monitoring paradigm portends the digital future of medicine. I was drawn to what HRS vice president-elect Dr Michael Gold (Medical University of South Carolina, Charleston) said during the late-breaking-trials' press conference. "I used to see device patients four times per year; now I see them only once per year."

My heart skipped a beat when I heard an established medical leader suggest that big data can deliver better health at lower costs—with less doctoring!

That is joyous indeed.

JMM

PS. See also the well-written 2015 HRS Expert Consensus Statement on Remote Interrogation and Monitoring for Cardiovascular Electronic Implantable Devices[7].

Comments

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