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Can the good be the enemy of the best? Monitoring of patients with implanted cardiac devices
Pode o bom ser inimigo do ótimo? Como fazer o seguimento em doentes com sistemas cardíacos implantados?
Pedro Adragão
Serviço de Cardiologia, CHLO, Hospital de Santa Cruz, Carnaxide, Portugal
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"http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2017;36:189-95" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2082 "formatos" => array:3 [ "EPUB" => 177 "HTML" => 1551 "PDF" => 354 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "A link to better care: The effect of remote monitoring on long-term adverse cardiac events in a propensity score-matched cohort" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "189" "paginaFinal" => "195" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "O efeito da monitorização remota em eventos cardíacos adversos numa amostra emparelhada por <span class="elsevierStyleItalic">propensity-score matching</span>" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1213 "Ancho" => 1620 "Tamanyo" => 123910 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Kaplan-Meier plot of incidence of the primary endpoint (composite outcome of hospital admission for heart failure or cardiovascular death). 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"apellidos" => "Ferreira" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255117300136" "doi" => "10.1016/j.repc.2016.08.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117300136?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917300594?idApp=UINPBA00004E" "url" => "/21742049/0000003600000003/v1_201703240113/S2174204917300594/v1_201703240113/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Can the good be the enemy of the best? Monitoring of patients with implanted cardiac devices" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "197" "paginaFinal" => "199" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Pedro Adragão" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Pedro" "apellidos" => "Adragão" "email" => array:1 [ 0 => "padragao@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, CHLO, Hospital de Santa Cruz, Carnaxide, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Pode o bom ser inimigo do ótimo? Como fazer o seguimento em doentes com sistemas cardíacos implantados?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Remote monitoring (RM) of pacemakers was introduced in 2001<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> and was subsequently extended to implantable cardioverter-defibrillators (ICDs), cardiac resynchronization therapy defibrillators (CRT-Ds) and, most recently, implantable loop recorders.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The introduction of RM was a response to the need to monitor the equipment for failures of implanted devices that could impact patient survival.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">RM provides daily data on the functioning of such devices and access to electrograms and clinical parameters. However, it cannot be used for remote reprogramming to resolve malfunctions.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The value of the information RM provides has been demonstrated in various observational studies involving hundreds of thousands of patients, and the ability to assess clinical parameters, particularly in patients with heart failure, has led an increasing number of centers to take advantage of the technology.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However, the costs of RM can be high, with significantly increased demands on technical and human resources that may not be readily available. It is thus important to perform cost-benefit analyses.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The value of RM lies in the immediate transmission of data and hence the ability to perform more timely therapeutic interventions. The less efficiently these data are used, the less benefit is derived from the technique. The efficiency of centers using RM is difficult to assess based on published reports, but it could have a considerable effect on their clinical results. It is therefore no surprise that while some results of RM programs are highly favorable, others reveal major disadvantages and limitations.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Among the more positive studies is the ALTITUDE registry, which included 69 556 patients with ICDs and CRT-Ds, and showed a 50% reduction in mortality.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> The large study population means that this registry gives a close approximation to real-life clinical practice.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Randomized prospective trials on RM have been small and are therefore of less clinical significance. A study by Hindricks et al. of 664 patients with ICDs and CRT-Ds confirmed the benefits of RM, with a significant reduction in the composite endpoint of mortality and hospitalization and in one-year mortality (10 vs. 27 patients).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">By contrast, a meta-analysis of nine randomized trials involving over 6000 patients showed no significant difference in mortality or hospitalization or reduction in appropriate therapies. There were, however, fewer inappropriate shocks.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The article by Portugal et al. in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> is a retrospective study of patients with ICDs for primary prevention of sudden death (SD). It excluded patients with pacemakers, ICDs for secondary prevention and ventricular resynchronization systems. This exclusion is of no little importance, since the clinical benefits expected from RM include detection of supraventricular arrhythmias, particularly atrial fibrillation (an indication for anticoagulant therapy) and assessment of signs of heart failure decompensation, especially useful in patients with ventricular resynchronization systems. The decision to include only patients with ICDs for primary prevention of SD limits their evaluation of the benefits of RM.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Even so, the study confirms the beneficial effects of RM, since it showed a reduction in the composite outcome of first hospital admission for heart failure or cardiovascular death, as well as a non-significant trend towards lower overall mortality.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Since this was a single-center study, the size and characteristics of the study population (propensity score-matched paired sample of 168 patients selected from 312 with ICDs for primary prevention) should be borne in mind.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The proportion of patients hospitalized for heart failure would probably have been greater if patients without left ventricular dysfunction had been excluded.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The rate of appropriate therapies in this cohort was similar in the RM and conventional follow-up groups, and RM did not reduce the number of inappropriate shocks.</p><p id="par0075" class="elsevierStylePara elsevierViewall">There was no mention of device dysfunction being detected, particularly oversensing due to lead fracture.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Our experience at Hospital de Santa Cruz is in many ways similar. We have over a thousand patients followed remotely with only one routine in-office visit a year, and so RM has enabled the number of consultations to be safely reduced. RM has been effective at detecting events and has led to faster responses to alerts that require rapid intervention. It also detects more events, thus confirming that it provides more complete and reliable data. Most of our patients consider that RM helps improve their quality of life.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Since RM is known to increase, improve and speed up transmission of the information recorded by implanted devices (pacemakers, ICDs and CRT-Ds) and that it reduces the number of routine in-office visits, why is it not more generally implemented?</p><p id="par0090" class="elsevierStylePara elsevierViewall">Could it be that the good is the enemy of the best?</p><p id="par0095" class="elsevierStylePara elsevierViewall">One of the most important laws of human nature is the principle of least effort. This means that RM would have to confer proven, clear and significant advantages to be consistently recommended.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The European guidelines on pacemakers, ICDs and CRT-Ds<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> recommend the use of RM for early detection of clinical problems, such as ventricular tachyarrhythmias or atrial fibrillation, and technical issues like lead fracture or insulation defect.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The study by Portugal et al. highlights the benefits of RM and points out that follow-up by RM was associated with a significant reduction in morbidity and mortality (the composite endpoint) in patients with an ICD for primary prevention of SD.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The study's impact would be enhanced if its results could be confirmed in prospective, randomized and multicenter trials with a wider range of patients. Such a study, adapted to the situation in Portugal, could determine to what extent RM is implemented in this country, and would be particularly valuable if it included patients with severe ventricular dysfunction, particularly those with ventricular resynchronization devices to treat heart failure refractory to optimal medical therapy.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Adragão P. Pode o bom ser inimigo do ótimo? Como fazer o seguimento em doentes com sistemas cardíacos implantados? Rev Port Cardiol. 2017;36:197–199.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The value of permanent follow-up of implantable pacemakers: first results of an European trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "K. Wallbrück" 1 => "C. Stellbrink" 2 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 3 | 10 |
| 2024 October | 32 | 25 | 57 |
| 2024 September | 29 | 23 | 52 |
| 2024 August | 40 | 39 | 79 |
| 2024 July | 34 | 28 | 62 |
| 2024 June | 34 | 17 | 51 |
| 2024 May | 27 | 23 | 50 |
| 2024 April | 22 | 22 | 44 |
| 2024 March | 23 | 23 | 46 |
| 2024 February | 20 | 32 | 52 |
| 2024 January | 23 | 35 | 58 |
| 2023 December | 18 | 28 | 46 |
| 2023 November | 25 | 20 | 45 |
| 2023 October | 15 | 19 | 34 |
| 2023 September | 14 | 21 | 35 |
| 2023 August | 19 | 9 | 28 |
| 2023 July | 12 | 9 | 21 |
| 2023 June | 18 | 9 | 27 |
| 2023 May | 26 | 21 | 47 |
| 2023 April | 20 | 7 | 27 |
| 2023 March | 13 | 20 | 33 |
| 2023 February | 18 | 22 | 40 |
| 2023 January | 17 | 10 | 27 |
| 2022 December | 28 | 21 | 49 |
| 2022 November | 30 | 27 | 57 |
| 2022 October | 27 | 29 | 56 |
| 2022 September | 15 | 34 | 49 |
| 2022 August | 22 | 31 | 53 |
| 2022 July | 23 | 32 | 55 |
| 2022 June | 18 | 24 | 42 |
| 2022 May | 21 | 30 | 51 |
| 2022 April | 15 | 21 | 36 |
| 2022 March | 17 | 35 | 52 |
| 2022 February | 22 | 36 | 58 |
| 2022 January | 21 | 30 | 51 |
| 2021 December | 20 | 39 | 59 |
| 2021 November | 30 | 36 | 66 |
| 2021 October | 32 | 57 | 89 |
| 2021 September | 18 | 32 | 50 |
| 2021 August | 24 | 30 | 54 |
| 2021 July | 23 | 22 | 45 |
| 2021 June | 23 | 17 | 40 |
| 2021 May | 19 | 57 | 76 |
| 2021 April | 34 | 43 | 77 |
| 2021 March | 50 | 15 | 65 |
| 2021 February | 54 | 21 | 75 |
| 2021 January | 25 | 10 | 35 |
| 2020 December | 33 | 12 | 45 |
| 2020 November | 30 | 20 | 50 |
| 2020 October | 14 | 12 | 26 |
| 2020 September | 47 | 12 | 59 |
| 2020 August | 20 | 18 | 38 |
| 2020 July | 37 | 9 | 46 |
| 2020 June | 34 | 12 | 46 |
| 2020 May | 26 | 5 | 31 |
| 2020 April | 35 | 20 | 55 |
| 2020 March | 30 | 13 | 43 |
| 2020 February | 48 | 19 | 67 |
| 2020 January | 21 | 5 | 26 |
| 2019 December | 32 | 3 | 35 |
| 2019 November | 33 | 5 | 38 |
| 2019 October | 23 | 5 | 28 |
| 2019 September | 13 | 8 | 21 |
| 2019 August | 31 | 10 | 41 |
| 2019 July | 37 | 7 | 44 |
| 2019 June | 38 | 10 | 48 |
| 2019 May | 36 | 5 | 41 |
| 2019 April | 33 | 14 | 47 |
| 2019 March | 38 | 16 | 54 |
| 2019 February | 72 | 6 | 78 |
| 2019 January | 38 | 6 | 44 |
| 2018 December | 114 | 10 | 124 |
| 2018 November | 144 | 7 | 151 |
| 2018 October | 246 | 20 | 266 |
| 2018 September | 78 | 16 | 94 |
| 2018 August | 47 | 6 | 53 |
| 2018 July | 51 | 5 | 56 |
| 2018 June | 56 | 3 | 59 |
| 2018 May | 76 | 9 | 85 |
| 2018 April | 70 | 6 | 76 |
| 2018 March | 83 | 17 | 100 |
| 2018 February | 48 | 5 | 53 |
| 2018 January | 30 | 5 | 35 |
| 2017 December | 84 | 9 | 93 |
| 2017 November | 46 | 4 | 50 |
| 2017 October | 39 | 7 | 46 |
| 2017 September | 28 | 11 | 39 |
| 2017 August | 38 | 13 | 51 |
| 2017 July | 41 | 13 | 54 |
| 2017 June | 49 | 12 | 61 |
| 2017 May | 51 | 16 | 67 |
| 2017 April | 56 | 20 | 76 |
| 2017 March | 58 | 13 | 71 |
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