Plan of care has been established, the transmission and note are scanned into the EMR. A physician or physician assistant will contact the patient by phone to review the information and plan of care. We are a team of secretaries, technicians, nurses, physician assistants, and physicians all working together to optimize patient care for our remote monitoring program.

We also use remote monitoring in the hospital setting. Instead of waiting for a device representative or physician to check a patient’s device, the nurse is able to send a remote transmission, which we can instantly access for evaluation. Remote transmission for all post-op device patients are done by the night shift nurse, and the report is available in the chart by 7am. The ER also performs remote transmissions for all their device checks. We are able to immediately access and review these transmissions, allowing for timely and efficient patient care.

Describe remote monitoring for heart failure.

Implantable defibrillators can monitor intrathoracic impedance. The lungs are located between the RV lead and defibrillator, and by measuring the resistance between them, the defibrillator can assess pulmonary fluid status. Conduction is faster through water; therefore, lower intrathoracic impedance (lower resistance) suggests pulmonary fluid accumulation. Low intrathoracic impedance values precede clinical signs and symptoms of congestive heart failure.4-5 Studies show that patients with low intrathoracic impedance measurements are at increased near-term risk of CHF hospitalization.4-6 By remotely monitoring changes in intrathoracic impedance, we can potentially prevent heart failure exacerbations and hospitalizations.

Have studies demonstrated a clinical benefit for heart failure monitoring?

Studies have consistently demonstrated the predictive nature of low intrathoracic impedance and the increased risk of CHF exacerbation and hospitalization.6-7 However, the utilization of this data to improve clinical outcomes is not well established.8 The DOT-HF study evaluated whether intrathoracic impedance values could be utilized to decrease hospitalizations.9 Patients received an audible alert to a decrease in intrathoracic impedance. Results showed an increase in hospitalizations in the treatment group compared with the control group. However, the presence of an audible alert and the lack of remote monitoring may have impacted these results.

Educational approach to remote heart failure monitoring is unique, effective, and can reduce heart failure exacerbations and hospitalizations.

References

1. Mittal S, Piccini JP, Snell J, et al. Improved survival in patients enrolled promptly into remote monitoring following cardiac implantable electronic device implantation. J Interv Card Electrophysiol.
2. Landolina M, Perego GB, Lunati M, et al. Remote monitoring reduces healthcare use and improves quality of care in heart failure patients with implantable defibrillators: the evolution of management strategies of heart failure patients with implantable defibrillators (EVOLVO) study.
3. Slotwiner D, Varma N, Akar JG, et al. HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular electronic implantable devices. Heart Rhythm.
4. Cowie MR, Sarkar S, Koehler J, et al. Development and validation of an integrated diagnostic algorithm derived from parameters monitored in implantable devices for identifying patients at risk for heart failure hospitalization in an ambulatory setting.
5. Yu CM, Wang L, Chau E, et al. Intrathoracic impedance monitoring in patients with heart failure correlation with fluid status and feasibility of early warning preceding hospitalization.
6. Small RS, Wickemeyer W, Germany R, et al. Changes in intrathoracic impedance are associated with subsequent risk of hospitalizations for acute decompensated heart failure: clinical utility of implanted device monitoring without a patient alert.
7. Whellan DJ, Ousdigian KT, Al-Khatib SM, et al. Combined heart failure device diagnostics identify patients at higher risk of subsequent heart failure hospitalizations: results from PARTNERS HF (Program to Access and Review Trending Information and Evaluate Correlation to Symptoms in Patients With Heart Failure) study.
8. Van Veldhuisen DJ, Maass AH. Telemonitoring of outpatients with heart failure: a search for the holy grail? Circulation.
9. Van Veldhuisen DJ, Braunschweig F, Conraads V, et al. Intrathoracic impedance monitoring, audible patient alerts, and outcome in patients with heart failure.
10. Domenichini G, Rahneva T, Diab IG, et al. The lung impedance monitoring in treatment of chronic heart failure (the LIMITCHF study).
11. Rosman J, Rosenbaum M, Kloosterman EM. A Patient-centered Educational Approach To Intrathoracic Impedance Remote Monitoring Can Reduce Hospitalizations.

Remote monitoring is associated with a morbidity and mortality benefit for patients with pacemakers and defibrillators.1-3 By monitoring patients on a daily basis, we are able to immediately diagnose and treat arrhythmias and device/lead-related problems. If we discover atrial fibrillation, we start the patient on anticoagulation right away, then have them follow up in our office or with their cardiologist. If we find a ventricular arrhythmia, we start antiarrhythmic medications over the phone or admit the patient to the hospital to prevent recurrent VT and ICD shocks. If we see lead- or device-related issues, we immediately arrange appropriate care to prevent inappropriate ICD shocks or loss of pacemaker function. Remote monitoring has revolutionized the practice of cardiac electrophysiology and has markedly improved patient outcomes.

How have you incorporated remote monitoring into your practice?

Remote monitoring maximizes our group’s efficiency. We can manage and treat more patients by reducing the number of in-office visits needed for patients followed remotely. We currently remotely monitor 850 patients with implantable defibrillators, 750 patients with implantable loop recorders, and 400 patients with pacemakers. We also have 300 patients in our remote heart failure monitoring program.