Influence of remote monitoring on long-term cardiovascular outcomes after cardioverter-defibrillator implantation
Introduction
Technological developments and expanded indications have translated into a large population of recipients of implantable electronic cardiac devices. There has been a significant increase in the number of patients submitted to implantation of cardioverter-defibrillators (ICD). This growing population represents a unique challenge regarding their follow-up, requiring an experienced team with in-depth knowledge of device programming and potential complications [1]. To this date, optimal clinical resource allocation regarding adequate follow-up to these patients is not yet established.
In this setting, remote monitoring (RM) is poised as an optimal tool in the intensive and continuous follow-up of ICD patients. Published data supports the safety and efficacy of this intervention [1]. However, data regarding potential clinical benefits has been scarce, with a short duration of follow-up and mainly limited to specific ICD brands.
In this study we aimed to assess the long-term clinical benefits of RM in a population of patients with ICD for primary prevention of sudden cardiac death. As such, we sought to investigate the effect of RM on hospital admissions for heart failure (HF), cardiovascular death and all-cause death.
Section snippets
Methods
We performed a retrospective cohort study in patients who underwent ICD implantation for primary prevention and compared a group followed with use of RM (RM +) versus a group on conventional outpatient clinic follow-up (RM −). Consecutive patients referred to a tertiary center for implantation of an ICD between December 2002 and October 2014 were included. The study population was divided in two groups, according to the modality of follow-up: RM + versus RM −. The protocol was approved by the
Statistical analysis
Continuous variables were displayed as mean and standard deviation where they followed a normal distribution, and in terms of their median and interquartile range where they did not. Qualitative variables were expressed in terms of frequency and percentage. Baseline comparisons were performed using the chi-square test for qualitative data and the t-student test for continuous variables.
The analysis of main outcome of time to admission for HF and mortality was performed by Kaplan–Meier curves,
Study population
A total of 923 patients received an ICD during this period. Of these, 611 patients were excluded on the basis of concomitant CRT (473 patients) or implantation in the setting of secondary prevention (138 patients). After exclusion, a total of 312 patients underwent further analysis.
Patient characteristics at implantation are described in Table 1. Most patients had an indication for ICD in primary prevention in the setting of left ventricular systolic dysfunction (85.6%). The etiology was
Discussion
The main finding of our study was a significantly lower incidence of unplanned hospital admissions for HF and overall mortality at very-long follow-up in patients under RM. This reduction in mortality was mainly driven by a reduction in cardiovascular mortality.
To further validate our findings and adjust for the potential confounding effect of other baseline characteristics, we used a stepwise approach to calculate a multivariate Cox regression model performed a multivariate regression
Limitations
This was a single center non-randomized study, thus the generalizability of our results is limited. As this is a retrospective cohort trial, we cannot exclude the effect of unmeasured confounders or some degree of bias; in particular, despite there being no significant differences between both groups at baseline, we cannot exclude the effect of potential selection bias. In addition, since patients had to agree to the use of RM, we could hypothesize that some of those who refused RM had also
Conclusions
In this very long-term retrospective cohort study, the use of RM in patients submitted to implantation of an ICD for primary prevention was independently associated with increased survival. RM was also associated with a lower incidence of a composite endpoint of hospitalization for HF or cardiovascular mortality. Larger, adequately powered randomized clinical trials are warranted to definitely establish whether device-based remote monitoring can lead to improved outcomes in this high-risk
Conflict of interest
The authors report no relationships that could be construed as a conflict of interest.
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Cited by (9)
Importance of monitoring zones in the detection of arrhythmias in patients with implantable cardioverter-defibrillators under remote monitoring
2019, Revista Portuguesa de CardiologiaCitation Excerpt :Programming an MZ for primary prevention in ICD patients leads to the detection of symptomatic or asymptomatic arrhythmias, indicating that it may be a useful tool in the optimization of medical and interventional treatment in this population. The benefits of RM in preventing hospital admission for heart failure or cardiovascular death are well documented.5–7 However, its usefulness in optimization of antiarrhythmic treatment has not been so extensively studied.
Ventricular Arrhythmia Occurrence and Compliance in Patients Treated With the Wearable Cardioverter Defibrillator Following Percutaneous Coronary Intervention
2018, Heart Lung and CirculationCitation Excerpt :An additional training session, a few days to weeks after discharge, might be useful to improve the patient’s knowledge and handling of the device. Finally, remote monitoring is a valuable tool to detect patients with poor compliance, which improves long-term outcome in ICD recipients [18,19]. Daily remote monitoring is available with the WCD and does not require active patient participation.
Remote Monitoring for Chronic Disease Management: Atrial Fibrillation and Heart Failure
2018, Cardiac Electrophysiology ClinicsCitation Excerpt :Nonrandomized studies show benefit of RM. Smaller studies inclusive of differing RM technologies (eg, the prospective clinical efficacy in the management of heart failure [EFFECT] trial49 and the retrospective analysis by Portugal and colleagues50) suggested that RM improved clinical outcomes of death and cardiovascular hospitalizations. Also, a matched cohort study based on Contemporary Modalities In Treatment of Heart Failure Registry (COMMIT-HF; an ongoing prospective observational registry) showed that RM of ICD/cardiac resynchronization therapy defibrillator significantly reduced long-term mortality in a real-world clinical condition.51
The patient perspective on remote monitoring of implantable cardiac devices
2023, Frontiers in Cardiovascular MedicineA systematic review and meta-analysis of the prevalence of left ventricular non-compaction in adults
2020, European Heart JournalRemote monitoring for heart failure
2019, Remote Monitoring: Implantable Devices and Ambulatory ECG
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This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation