Обзор американских кардиологических журналов за неделю (ссылки)

[Chevychelov]

Official Title: The Impact of Remote Monitoring with Automatic Clinician Notifications on the Clinical Care of ICD and CRT-D Patients (CONNECT)
Event: ACC Annual Scientific Session 2010
Topic(s): Arrhythmias
Presenter: George H. Crossley, III
Writer(s): Xiushui Ren
Date Posted: 3/15/2010
Related Resources
Presentation Slides: CONNECT

Summary
Remote monitoring in patients with implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy defibrillators (CRT-Ds) appears to improve patient care and reduce healthcare utilization.

Background
Because expanded indications for ICDs and CRT-D have resulted in a substantially increased number of device implants, clinicians have adjusted their practices to enable proper follow-up. Newer ICD and CRT-D devices provide remote monitoring capabilities that are designed to allow for more efficient follow-up and reduce healthcare utilization.

The Clinical evaluation Of remote NotificatioN to rEduCe Time to clinical decision (CONNECT) study is a randomized controlled trial to examine the clinical and health care utilization impact of wireless remote monitoring versus routine in-office care.

Study Design
The CONNECT study randomized 1997 patients implanted with a Medtronic wireless ICD or CRT-D to remote monitoring (n=1014) versus routine in-office care (n=983). Patients monitored remotely were given a wireless home monitor for transmitting device diagnostics to the clinician's office. Examples of key diagnostics include atrial tachycardia (AT) and atrial fibrillation (AF) daily burden, rapid ventricular response during AT/AF, and shocks delivered. Both groups had lead and device integrity (including lead impedance out of range, VF detection, low battery voltage, and excessive charge time) alerts on.

All patients were followed for 15 months post-implant. Patients in the remote monitoring arm had office visits at only one month and 15 months post-implant. Patients in the routine care arm had office visits at one, three, six, nine, 12, and 15 months post-implant.

The primary objective was to compare time to clinical decision between patients managed remotely and patients managed with routine in-office care. The key secondary objective was to assess the impact of remote monitoring and early notification on healthcare utilization.

Results and Conclusions
Baseline characteristics were similar between the two groups. The mean age was 65 years, and 71% were men. CRT-D comprised 35% of the total devices. The mean LV ejection fraction was 29%, and approximately 88% of the patients were NYHA class II and III.

At follow-up, there were a total of 317 events (172 in remote monitoring arm and 145 in routine in-office care) triggering clinical decisions. The majority of events were high AT/AF burden, fast V rate, and ICD shocks. The median time from event to clinical decision was significantly shorter for the remote monitoring arm (4.6 vs 22 days, p<0.001). The total yearly clinic visits per patient were 3.9 and 6.3 for remote monitoring and routine care groups, respectively. The length of stay per hospitalization for remote monitoring and routine care groups was 3.3 and 4.0 days, p=0.002, respectively.

Thus remote monitoring in patients with ICD and CRT-D resulted in a significant reduction in time from onset of events to clinical decisions in response to arrhythmias and device issues. In addition, remote monitoring seemed to reduce overall healthcare utilization including reduced number of clinic visits and short hospital stay. These data support the use of remote monitoring ICD and CRT-D.

Perspective
It is important to note that, the effect of remote monitoring on battery life and device cost is unclear.