Utilization of remote reprogramming to manage insertable cardiac monitor arrhythmia alert burden.

INTRODUCTION: The increasing use of insertable cardiac monitors (ICMs) for long-term continuous arrhythmia monitoring creates a high volume of transmissions and a significant workload for clinics. The ability to remotely reprogram device alert settings without in-office patient visits was recently introduced, but its impact on clinic workflow compared to the previous ICM iteration is unknown. METHODS: The aim of this real-world study was to evaluate the impact of device reprogramming capabilities on ICM alert burden and on clinic workflow. Deidentified data was obtained from US patients and a total of 19 525 receiving a LINQ II were propensity score-matched with 19 525 implanted with LINQ TruRhythm (TR) ICM based on age and reason for monitoring. RESULTS: After reprogramming, ICM alerts reduced by 20.5% (p < .001). Compared with patients monitored with LINQ TR, patients with LINQ II had their device reprogrammed sooner after implant and more frequently during follow-up. Adoption of remote programming was projected to lead to an annual total clinic time savings of 211 h per 100 ICM patients managed. CONCLUSION: These data suggest that utilization of ICM alert reprogramming has increased with remote capabilities, which may reduce clinic and patient burden for ICM follow-up and free clinician time for other valuable patient care activities.

Health care utilization in a nurse practitioner-led atrial fibrillation clinic.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is emerging in prevalence with an increasingly aging population. The complex nature of the disease and its association with significant morbidity and mortality has resulted in a call for a new integrative, multidisciplinary approach to AF management. PURPOSE: Determine if the use of a nurse practitioner (NP)-led AF clinic (NPAFC) can improve care for patients. METHODOLOGY: An NPAFC was designed to serve as an independent clinic for standardizing patient care and improving access to care. Baseline patient demographics, care pathway, and interventions were characterized in clinic. Primary outcomes were hospitalizations and emergency department (ER) visits, before and after clinic implementation. RESULTS: Overall, 1,442 patients were enrolled in the AF clinic between January 2016 and June 2018. The mean age at the first AF clinic visit was 68.7 ± 12.6 years, 54% were male, and the mean body mass index was 31 ± 7 kg/m2. Among the patients, 45.2% had paroxysmal AF, 43.6% persistent AF, and 5.5% permanent AF. With an average of 3 ± 3 clinic visits per patient, the number of patients with ≥1 hospitalization decreased by 78% after clinic implementation. Similarly, the number of patients with ≥1 ER visit decreased by 79%, and 22.7% of patients avoided at least one ER visit. CONCLUSIONS: The number of patients with ≥1 hospitalization or ≥1ER visit decreased within two years after the implementation of an NPAFC. IMPLICATIONS: Implementation of an NP-led AF clinic in the United States may reduce hospitalizations and ER visits if implemented in an integrative model.

Heart Rhythm Society Atrial Fibrillation Centers of Excellence Study: A survey analysis of stakeholder practices, needs, and barriers.

BACKGROUND: An integrated, coordinated, and patient-centered approach to atrial fibrillation (AF) care delivery may improve outcomes and reduce cost. OBJECTIVE: The purpose of this study was to gain a better understanding from key stakeholder groups on current practices, needs, and potential barriers to implementing optimal integrated AF care. METHODS: A series of comprehensive questionnaires were designed by the Heart Rhythm Society Atrial Fibrillation Centers of Excellence (CoE) Task Force to conduct surveys with physicians, advanced practice professionals, patients, and hospital administrators. Data collected focused on the following areas: access to care, stroke prevention, education, AF quality improvement, and AF CoE needs and barriers. Survey responses were collated and analyzed by the Task Force. RESULTS: The surveys identified 5 major unmet needs: (1) Standardized protocols, order sets, or care pathways in the emergency department or inpatient setting were uncommon (36%-42%). (2) All stakeholders agreed stroke prevention was a top priority; however, prior bleeding or risk of bleeding was the most frequent barrier for initiation. (3) Patients indicated that education on modifiable causes, AF-related complications, and lowering stroke risk is most important. (4) Less than half (43%) of the health care systems track patients with AF or treatment status. Patients reported that stroke and heart failure prevention and access to procedures were priority areas for an AF CoE. The most common barriers to implementing AF CoE identified by clinicians were administrative support (69%) and cost (52%); administrators reported physical space (43%). CONCLUSION: On the basis of the findings of this study, the Task Force identified high priority areas to develop initiatives to aid the implementation of AF CoE.

Challenges in managing a remote monitoring device clinic.

BACKGROUND: Recent advances in remote cardiac monitoring technology have created new challenges for clinicians and staff working in device clinics who are left processing large volumes of data. Often, this process is fractured and inefficient, with occurrence of unnecessary alerts that strain staff time and resources. OBJECTIVE: The purpose of this survey was to identify challenges allied health professional clinicians and staff encounter when managing a remote monitoring device clinic. METHODS: A 27-item mixed methods survey was developed using a Qualtrics-encrypted, anonymous Web survey tool. Demographic information and questions rating satisfaction level for remote device clinic issues were obtained using a 5-point Likert scale. Three open-ended questions were included that addressed challenges and successes in managing a remote monitoring clinic and served as a method for identifying common themes. RESULTS: Major themes identified were poor connectivity, staffing issues, and large volume of alerts. Approximately 50% of respondents were either satisfied or unsatisfied with issues surrounding managing remote monitoring device clinics. Strategies for success included optimizing alerts, assigning designated staff, and partnering with third-party platforms. CONCLUSION: This survey confirms these issues as an opportunity for industry and digital health leaders to determine best practices for incorporating these technologies into patient care.

Clinic Time Required for Remote and In-Person Management of Patients With Cardiac Devices: Time and Motion Workflow Evaluation.

BACKGROUND: The number of patients with cardiac implantable electronic device (CIED) is increasing, creating a substantial workload for device clinics. OBJECTIVE: This study aims to characterize the workflow and quantify clinic staff time requirements for managing patients with CIEDs. METHODS: A time and motion workflow evaluation was performed in 11 US and European CIEDs clinics. Workflow tasks were repeatedly timed during 1 business week of observation at each clinic; these observations included all device models and manufacturers. The mean cumulative staff time required to review a remote device transmission and an in-person clinic visit were calculated, including all necessary clinical and administrative tasks. The annual staff time to manage a patient with a CIED was modeled using CIED transmission volumes, clinical guidelines, and the published literature. RESULTS: A total of 276 in-person clinic visits and 2173 remote monitoring activities were observed. Mean staff time required per remote transmission ranged from 9.4 to 13.5 minutes for therapeutic devices (pacemaker, implantable cardioverter-defibrillator, and cardiac resynchronization therapy) and from 11.3 to 12.9 minutes for diagnostic devices such as insertable cardiac monitors (ICMs). Mean staff time per in-person visit ranged from 37.8 to 51.0 and from 39.9 to 45.8 minutes for therapeutic devices and ICMs, respectively. Including all remote and in-person follow-ups, the estimated annual time to manage a patient with a CIED ranged from 1.6 to 2.4 hours for therapeutic devices and from 7.7 to 9.3 hours for ICMs. CONCLUSIONS: The CIED patient management workflow is complex and requires significant staff time. Understanding process steps and time requirements informs the implementation of efficiency improvements, including remote solutions. Future research should examine heterogeneity in patient management processes to identify the most efficient workflow.

Guidance for Rebooting Electrophysiology Through the COVID-19 Pandemic From the Heart Rhythm Society and the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology: Endorsed by the American College of Cardiology.

Coronavirus disease 2019 (COVID-19) has presented substantial challenges to patient care and impacted health care delivery, including cardiac electrophysiology practice throughout the globe. Based upon the undetermined course and regional variability of the pandemic, there is uncertainty as to how and when to resume and deliver electrophysiology services for arrhythmia patients. This joint document from representatives of the Heart Rhythm Society, American Heart Association, and American College of Cardiology seeks to provide guidance for clinicians and institutions reestablishing safe electrophysiological care. To achieve this aim, we address regional and local COVID-19 disease status, the role of viral screening and serologic testing, return-to-work considerations for exposed or infected health care workers, risk stratification and management strategies based on COVID-19 disease burden, institutional preparedness for resumption of elective procedures, patient preparation and communication, prioritization of procedures, and development of outpatient and periprocedural care pathways.

Predictors of atrial fibrillation detection and features of recurrent strokes in patients after cryptogenic stroke.

BACKGROUND AND PURPOSE: Use of implantable cardiac monitors (ICMs) has increased diagnosis of atrial fibrillation (AF) in cryptogenic stroke (CS) patients. Identifying AF predictors may enhance the yield of AF detection. Recurrent strokes after CS are not well described. We aimed to assess the predictors for AF detection and the characteristics of recurrent strokes in patients after CS. METHODS: We reviewed electronic medical records of CS patients who were admitted between February 2014 and September 2017 and underwent ICM placement with minimum one-year follow-up. Patient demographics, stroke characteristics, pre-defined risk factors as well as recurrent strokes were compared between patients with and without AF detection. RESULTS: 389 patients with median follow-up of 548 days were studied. AF was detected in 102 patients (26.2%). Age (per decade increase, OR 2.10, CI 1.64-2.68, with vs. without AF) and left atrium diameter (per 5 mm increase, OR 1.91, CI 1.33-2.74) were identified as AF predictors. Intracranial large vessel stenosis >50% irrelevant to the index strokes was associated with AF detection within 30 days (OR 0.24, CI 0.09-0.69, >30 vs. <30 days). Recurrent strokes occurred in 14% patients with median follow-up about 2.5 years. Topography of these strokes resembled embolic pattern and was comparable between patients with and without AF. Among recurrent strokes in patients with AF, the median time to AF detection was much shorter (90 vs. 251 days), and the median time to first stroke recurrence was much longer (422 vs. 76 days) in patients whose strokes recurred after AF detection than those before AF detection. CONCLUSIONS: Older age and enlarged left atrium are predictors for AF detection in CS patients. Intracranial atherosclerosis is more prevalent in patients with early AF detection within 30 days. Recurrent strokes follow the embolic pattern, and early AF detection could delay the stroke recurrence.

Guidance for Rebooting Electrophysiology Through the COVID-19 Pandemic From the Heart Rhythm Society and the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology.

Coronavirus disease 2019 (COVID-19) has presented substantial challenges to patient care and impacted healthcare delivery, including cardiac electrophysiology practice throughout the globe. Based upon the undetermined course and regional variability of the pandemic, there is uncertainty as to how and when to resume and deliver electrophysiology services for patients with arrhythmia. This joint document from representatives of the Heart Rhythm Society, American Heart Association, and American College of Cardiology seeks to provide guidance for clinicians and institutions reestablishing safe electrophysiological care. To achieve this aim, we address regional and local COVID-19 disease status, the role of viral screening and serological testing, return-to-work considerations for exposed or infected health care workers, risk stratification and management strategies based on COVID-19 disease burden, institutional preparedness for resumption of elective procedures, patient preparation and communication, prioritization of procedures, and development of outpatient and periprocedural care pathways.

Guidance for rebooting electrophysiology through the COVID-19 pandemic from the Heart Rhythm Society and the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology: Endorsed by the American College of Cardiology.

Coronavirus disease 2019 (COVID-19) has presented substantial challenges to patient care and impacted health care delivery, including cardiac electrophysiology practice throughout the globe. Based upon the undetermined course and regional variability of the pandemic, there is uncertainty as to how and when to resume and deliver electrophysiology services for arrhythmia patients. This joint document from representatives of the Heart Rhythm Society, American Heart Association, and American College of Cardiology seeks to provide guidance for clinicians and institutions reestablishing safe electrophysiological care. To achieve this aim, we address regional and local COVID-19 disease status, the role of viral screening and serologic testing, return-to-work considerations for exposed or infected health care workers, risk stratification and management strategies based on COVID-19 disease burden, institutional preparedness for resumption of elective procedures, patient preparation and communication, prioritization of procedures, and development of outpatient and periprocedural care pathways.

Detection of atrial fibrillation using an implantable loop recorder following cryptogenic stroke: implications for post-stroke electrocardiographic monitoring.

PURPOSE: Approximately 10-40% of strokes are cryptogenic (CS). Long-term electrocardiographic (ECG) monitoring has been recommended in these patients to search for atrial fibrillation (AF). An unresolved issue is whether ambulatory ECG (AECG) monitoring should be performed first, followed by an implantable loop recorder (ILR) if AECG monitoring is non-diagnostic, or whether long-term ECG monitoring should be initiated using ILRs from the onset. The purpose of this study was to assess, using an ILR, AF incidence in the first month after CS. METHODS: We enrolled consecutive CS patients referred for an ILR. All patients were monitored via in-hospital continuous telemetry from admission until the ILR (Medtronic [Minneapolis, MN] LINQ™) was implanted. The duration and overall burden of all AF episodes ≥ 2 min was determined. RESULTS: The cohort included 343 patients (68 ± 11 years, CHA2DS2-VASc 3.5 ± 1.7). The time between stroke and ILR was 3.7 ± 1.5 days. During the first 30 days, only 18 (5%) patients had AF. All episodes were paroxysmal, lasting from 2 min to 67 h and 24 min. The median AF burden was 0.85% (IQR 0.52, 10.75). During 1 year of follow-up, 67 (21%) patients had AF. CONCLUSION: The likelihood of AF detection by an ILR in the first month post-CS is low. Thus, the diagnostic yield of 30 days of AECG monitoring is likely to be limited. These data suggest a rationale for proceeding directly to ILR implantation prior to hospital discharge in CS patients, as many have AF detected during longer follow-up.