Clinical impact of remote heart failure management using the multiparameter ICD HeartLogic alert.

INTRODUCTION AND OBJECTIVES: The multiparametric implantable cardioverter-defibrillator HeartLogic index has proven to be a sensitive and timely predictor of impending heart failure (HF) decompensation. We evaluated the impact of a standardized follow-up protocol implemented by nursing staff and based on remote management of alerts. METHODS: The algorithm was activated in HF patients at 19 Spanish centers. Transmitted data were analyzed remotely, and patients were contacted by telephone if alerts were issued. Clinical actions were implemented remotely or through outpatient visits. The primary endpoint consisted of HF hospitalizations or death. Secondary endpoints were HF outpatient visits. We compared the 12-month periods before and after the adoption of the protocol. RESULTS: We analyzed 392 patients (aged 69±10 years, 76% male, 50% ischemic cardiomyopathy) with implantable cardioverter-defibrillators (20%) or cardiac resynchronization therapy defibrillators (80%). The primary endpoint occurred 151 times in 86 (22%) patients during the 12 months before the adoption of the protocol, and 69 times in 45 (11%) patients (P<.001) during the 12 months after its adoption. The mean number of hospitalizations per patient was 0.39±0.89 pre- and 0.18±0.57 postadoption (P<.001). There were 185 outpatient visits for HF in 96 (24%) patients before adoption and 64 in 48 (12%) patients after adoption (P<.001). The mean number of visits per patient was 0.47±1.11 pre- and 0.16±0.51 postadoption (P<.001). CONCLUSIONS: A standardized follow-up protocol based on remote management of HeartLogic alerts enabled effective remote management of HF patients. After its adoption, we observed a significant reduction in HF hospitalizations and outpatient visits.

Implantable loop recorder allows an etiologic diagnosis in one-third of patients. Results of the Spanish reveal registry.

BACKGROUND: The implantable loop recorder (ILR) is a useful tool for diagnosing paroxysmal conditions potentially related to arrhythmias. Most investigations have focused on selected clinical studies or high-volume centers. The aim of this study was to evaluate the indications and outcomes of the ILR in real clinical practice. METHODS AND RESULTS: This was a prospective, multicenter registry of patients undergoing ILR implantation for clinical indications (April 2006-December 2008). Clinical characteristics (symptoms, arrhythmias, treatments) were recorded in a database. Follow-up data at 1 year or after the occurrence of the first episode were also recorded. Total enrollment: 743 patients (male, 413, 55.6%; 64.9 ± 16 years); 228 (30.7%) had structural heart disease (SHD), and 183 (24.6%), bundle branch block (BBB). Recurrent syncope (76.4%) was the most common indication for implantation. Complete follow-up was obtained for 680 patients (91.5%). Three hundred and twenty-five patients (48%) presented 414 events, with a final diagnosis in 230 patients (70.8% of patients with events; 33.1% of patients with follow-up). Syncope secondary to bradyarrhythmia was the most frequent diagnosis. Similar rates of final diagnoses were noted in subgroups of SHD, BBB and normal heart. Regarding the cause of implantation, higher event rates were registered among patients with recurrent syncope. CONCLUSIONS: One-third of patients obtained a final diagnosis with the ILR, independent of the baseline characteristics. Only the cause of implantation provided different rates of final diagnosis.

Remote heart failure management using the HeartLogic algorithm. RE-HEART registry.

INTRODUCTION AND OBJECTIVES: HeartLogic is a multiparametric algorithm incorporated into implantable cardioverter-defibrillators (ICD). The associated alerts predict impending heart failure (HF) decompensations. Our objective was to analyze the association between alerts and clinical events and to describe the implementation of a protocol for remote management in a multicenter registry. METHODS: We evaluated study phase 1 (the investigators were blinded to the alert state) and phases 2 and 3 (after HeartLogic activation, managed as per local practice and with a standardized protocol, respectively). RESULTS: We included 288 patients from 15 centers. In phase 1, the median observation period was 10 months and there were 73 alerts (0.72 alerts/patient-y), with 8 hospitalizations and 2 emergency room admissions for HF (0.10 events/patient-y). There were no HF hospitalizations outside the alert period. In the active phases, the median follow-up was 16 (95%CI, 15-22) months and there were 277 alerts (0.89 alerts/patient-y); 33 were associated with HF hospitalizations or HF death (n=6), 46 with minor decompensations, and 78 with other events. The unexplained alert rate was 0.39 alerts/patient-y. Outside the alert state, there was only 1 HF hospitalization and 1 minor HF decompensation. Most alerts (82% in phase 2 and 81% in phase 3; P=.861) were remotely managed. The median NT-proBNP value was higher within than outside the alert state (7378 vs 1210 pg/mL; P <.001). CONCLUSIONS: The HeartLogic index was frequently associated with HF-related events and other clinically relevant situations, with a low rate of unexplained events. A standardized protocol allowed alerts to be safely and remotely detected and appropriate action to be taken on them.

Programación del desfibrilador automático implantable / Programming implantable cardioverter–defibrillators

Los desfibriladores automáticos modernos incluyen entre sus funciones la estimulación antibradicardia, la cardioversión de baja energía y la desfibrilación de alta energía. Tienen, además, criterios adicionales de detección para discriminar en lo posible las arritmias ventriculares de las de origen supraventricular. Son multiprogramables y pueden ser programados para actuar en diferentes zonas de frecuencia de taquicardia, lo que permite tratar de forma diferente cada taquicardia ventricular (TV) que pueda tener un paciente. Esto es particularmente útil en pacientes que presentan TV con ciclos diferentes. La estimulación antitaquicardia disminuye la necesidad de cardioversión o desfibrilación en pacientes con TV. Se han comparado diferentes algoritmos de estimulación con resultados similares. En este capítulo de la monografía se analizan dichos algoritmos y su mejor programación, la necesidad de estimulación antibradicardia y la selección del modo de estimulación, y cómo evitar en lo posible las terapias inapropiadas debidas a arritmias supraventriculares (AU)

Among other functions, modern implantable cardioverter-defibrillators (ICDs) are able to perform antibradycardia pacing, low-energy cardioversion, and highenergy defibrillation. In addition, they can implement a range of different arrhythmia detection criteria that enable them to discriminate, when possible, between ventricular and supraventricular tachycardias. The devices can be programmed in a range of different ways. They can be set to respond differently according to specific tachycardia frequency ranges, thereby enabling each form of tachycardia experienced by the patient to be treated differently. This capability is particularly useful in patients who present with ventricular tachycardias with a number of different cycle lengths. Antitachycardia pacing reduces the need for cardioversion or defibrillation in patients with ventricular tachycardias. Comparison of different pacing algorithms has shown that they give similar results. This part of the monograph contains reviews of the efficacy of these algorithms and how they can be better programmed, of the need for antibradycardia pacing and selection of the most appropriate pacing mode, and of how the administration of inappropriate shocks in response to supraventricular arrhythmias can be avoided (AU)