Remote Monitoring of Implantable Cardioverter-defibrillators and Resynchronization Devices to Improve Patient Outcomes: Dead End or Way Ahead?

Frieder Braunschweig; Stefan D. Anker; Jochen Proff; Niraj Varma

Disclosures

Europace. 2019;21(6):846-855. 

In This Article

Abstract and Introduction

Abstract

Remote monitoring (RM) has become a new standard of care in the follow-up of patients with implantable pacemakers and defibrillators. While it has been consistently shown that RM enables earlier detection of clinically actionable events compared with traditional in-patient evaluation, this advantage did not translate into improved patient outcomes in clinical trials of RM except one study using daily multiparameter telemonitoring in heart failure (HF) patients. Therefore, this review, focusing on RM studies of implantable cardioverter-defibrillators and cardiac resynchronization therapy defibrillators in patients with HF, discusses possible explanations for the differences in trial outcomes. Patient selection may play an important role as more severe HF and concomitant atrial fibrillation have been associated with improved outcomes by RM. Furthermore, the technical set-up of RM may have an important impact as a higher level of connectivity with more frequent data transmission can be linked to better outcomes. Finally, there is growing evidence as to the need of effective algorithms ensuring a fast and well-structured clinical response to the events detected by RM. These factors re-emphasize the potential of remote management of device patients with HF and call for continued clinical research and technical development in the field.

Introduction

Remote monitoring (RM) of cardiovascular implantable electronic devices (CIEDs) was initially introduced to supplement compulsory calendar-based in-person evaluations (IPE), to provide convenience to patients and clinics, and to monitor device function.[1,2] Subsequent clinical trials consistently showed comparative advantages of RM-based follow-up over IPE alone, including a reduction of IPE frequency with maintained patient safety and early detection of clinically actionable events.[3–10] Furthermore, RM+IPE was associated with improved patient satisfaction, quality of life, and adherence to follow-up schedule compared with IPE alone.[10–14] In 2015, a transatlantic expert board recommended implant-based RM as a new standard of care in which individualized and alert-driven IPE should replace most routine follow-ups.[15]

The natural extension of RM applications is to improve patient outcomes. However, results so far have been neutral on this count,[6,7,15–22] with the exception of one randomized trial (IN-TIME) showing advantage of daily multiparameter telemonitoring over IPE in heart failure (HF) patients.[23] This observation arouses curiosity. Since patients enrolled among the trials have been similar, potential reasons for the unique result of IN-TIME may include differences in the remote technology utilized (i.e. transmission frequency and prioritization) and/or interventions undertaken in response to received data.

The present review discusses the possible impact of these differences on patient outcomes in recent studies.[15,24] As the vast majority of randomized controlled trials (RCTs) have enrolled HF patients with implantable cardioverter-defibrillators (ICDs) or cardiac resynchronization therapy defibrillators (CRT-Ds), we focused on clinical endpoints relevant to these groups: all-cause mortality, cardiovascular (CV) mortality, and CV hospitalization.

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