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  • Remote monitoring offers ongoing opportunities for managemen

    2019-04-15

    Remote monitoring offers ongoing opportunities for management from three perspectives:
    Concept of remote monitoring for glucocorticoid receptor failure Most HF-related hospitalizations are due to fluid accumulation, and careful surveillance of a patient\'s fluid status and symptoms is important [20]. To effectively prevent HF-related hospitalizations, one needs to detect early clinical deterioration and initiate earlier intervention to avert acute decompensated HF. However, the clinical difficulty lies in the fact that early signs and symptoms of HF, such as dyspnea and decreased exercise tolerance, are nonspecific, whereas more specific signs, such as lower limb edema and pulmonary congestion, occur late. The traditional telemonitoring parameters, such as body weight and natriuretic peptides, have poor sensitivities in predicting impending decompensated HF; they did not confer any survival advantage, nor a reduction in the number of hospitalizations when compared to usual care [21,22]. Implantable sensors offer a new means for the early detection of deteriorating HF in a way that has not been possible before. The concept of remote/home monitoring of patients is not a new one; it was first established in patients with implanted pacemakers in the 1970s. Historically, these sensors were developed to allow rate-adaptive pacing during exercise and hemodynamic optimization (AV interval, LV–RV timing). A newly emerging and arguably more important role for such sensors is in continuous HF monitoring. Nowadays, various companies are establishing novel interface-linking systems that allow remote monitoring by transmitting data from continuous home monitoring to a service center via a cellular network or web application. From these centers, the physician and nursing team can access and review the monitored parameters, and can initiate interventions accordingly [23]. Acute deviations from established trends—e.g., heart rate, atrial and ventricular high-rate episodes, and the percentage of pacing and arrhythmias—can be detected early, in contrast to the traditional in-office routine device interrogations. This allows a physician to reprogram device settings (e.g., AV timing changes) in case of suboptimal device efficiency, treat arrhythmias (e.g., in the event of detection of new-onset atrial fibrillation, or frequent ventricular ectopy that causes <100% biventricular pacing) [24], and start medical treatments to prevent hospitalization for acute decompensated HF.
    Evidence of effectiveness of remote monitoring of heart failure using CRT Two large-scale studies have shown a beneficial impact of remote monitoring systems. The Lumos-T Safely RedUceS Routine Office Device Follow-up (TRUST) multicenter study [25] was a prospective study that compared automatic remote home monitoring with conventional in-office interrogation and follow ups. Varma et al. showed that a remote monitoring system allowed earlier detection of clinically important events (both silent and symptomatic), as well as device or lead malfunction and lead fractures, thereby allowing timely interventions. Home monitoring reduced the median time between detection of an arrhythmic event and physician evaluation from 35.5 days in the conventional group to <2 days in the home-monitoring group. Furthermore, 85.8% of all 3-monthly follow-ups were done remotely, without compromising morbidity. The Evolution of Management Strategies of Heart Failure Patients with Implantable Defibrillators (EVOLVO) study [26] showed that remote monitoring was able to reduce emergency department and urgent in-office visits from 52% to 34%, while decreasing in-person office follow ups by half. This translated to a reduction in total healthcare utilization in patients with implantable cardioverter defibrillators (ICDs). Again, the lapsed time between an ICD alert status and data review was reduced from 24.8 days in the standard arm to 1.4 days in the remote arm. Furthermore, patients\' quality of life scores were found to be more favorable amongst patients in the remote arm.