Remote monitoring of cardiac implantable electronic devices: Experience in Hong Kong patients
Cardiac implantable electronic devices (CIEDs) play a crucial role in the detection and management of arrhythmias and heart failure (HF). Remote monitoring has emerged as a safe and effective way to manage patients using these devices, with the added benefit of optimizing the use of healthcare resources. In an interview with MIMS Doctor, Dr Katherine Fan of the Cardiac Medical Unit, Grantham Hospital, Hong Kong, shared her experience running the CIED monitoring service in Hong Kong during the past 10 years.
Introduction of CIEDs in Hong Kong
CIEDs have been developed for either therapeutic or diagnostic use. They include the pacemaker, implantable cardioverter-defibrillator (ICD), cardiac resynchronization therapy (CRT) device, and implantable loop recorder (ILR). The pacemaker corrects a slow or irregular heart rate. The ICD manages ventricular tachycardia or ventricular fibrillation and is used for primary prevention of sudden cardiac death. The CRT devices come with pacing and/or defibrillation capabilities and provide ventricular resynchronization in HF patients. The ILR is a diagnostic tool for identifying arrhythmia-related syncope and detecting silent/asymptomatic atrial fibrillation.
“The first electronic pacemaker was implanted in Hong Kong in 1973, with three implants performed that year. The ICD and CRT were introduced in the early 1980s and late 1990s, respectively. The number of patients receiving CIEDs is growing steadily at about 3 percent a year, and we currently perform approximately 3,000 procedures a year,” said Fan.
The need for remote CIED monitoring
While the growing number of indications eligible for a CIED has made patient follow-up more complex, concurrent advances in technology make remote monitoring an effective and attractive strategy to manage these patients.
“In 2008, the Heart Rhythm Society/European Heart Rhythm Association [HRS/EHRA] expert consensus guidelines first recommended remote monitoring of CIEDs as an adjunct to scheduled in-person clinic visits. In the 2015 update, remote monitoring was actively promoted with a class I recommendation,” highlighted Fan. [Europace 2008;10:707-725; Heart Rhythm 2015;12:e69-e100]
Benefits of remote CIED monitoring
Several clinical studies have demonstrated the value of remote CIED monitoring for patients and healthcare providers.
A retrospective, observational cohort study involving 269,471 consecutive patients receiving new CIEDs with embedded remote monitoring technology showed that survival correlated with the degree of adherence to remote monitoring. (Figure 1) [J Am Coll Cardiol 2015;65:2601-2610]
The long-term, randomized, prospective RM-ALONE trial (n=445) demonstrated that surveillance of CIEDs by remote monitoring alone (remote monitoring plus remote interrogations) was noninferior to remote monitoring plus in-office visits in terms of safety. In addition, remote monitoring alone was associated with a 79.2 percent reduction in the number of face-to-face visits, with no significant increase in unscheduled visits (p=0.15), and a significantly reduced workload for healthcare professionals (p<0.0001). [Eur Heart J 2019;40:1837-1846]
In the randomized, prospective TRUST trial (n=1,339), remote monitoring reduced the number of scheduled and unscheduled in-office visits by 45 percent per year vs conventional follow-up (p<0.001). Remote monitoring was also associated with earlier detection of arrhythmias and silent events; median time to evaluation was <2 days in the remote monitoring group vs 36 days in the conventional group for all arrhythmic events (p<0.001). [Circulation 2010;122:325-332]
Remote CIED monitoring in Hong Kong
“Most of the contemporary CIEDs developed within the last 10 years have embedded technologies for remote monitoring. However, only about 10–12 percent of eligible patients in Hong Kong are currently implanted with such devices,” commented Fan. [Europace 2015;17:1267-1275]
Remote monitoring involves automated transmission of data (downloaded from the cardiac device by a transmitter), based on prespecified alerts, to the device manufacturer’s server, where it is stored. This transmission occurs through either a landline telephone or a mobile telecommunications network. Hospital staff can then access the data when needed, most commonly, in case of an alert.
“The incoming alerts are colour-coded, where red alerts require urgent or immediate action. Although patient data are streamed continuously and alerts are received spontaneously, they will be acted upon only during regular office hours. Patients need to be aware that remote monitoring service is not a substitute for emergency care, and they will need to visit a hospital emergency department if their condition worsens,” explained Fan.
According to Fan, acceptance of remote monitoring technology is generally high among patients, while awareness remains low. “Once patients learn about the possibility of remote monitoring, many are asking to be included in the programme. For those who are enrolled, it gives a sense of reassurance in the care they are receiving,” shared Fan.“Since the implementationof remote monitoring servicesat Grantham Hospital in 2010, the numberof participating patients has increased >30 times, from just 11 in the first year of the programme to >350 in 2020.” (Figure 2)
However, as Hong Kong is compact with medical services within reach for most patients, the uptake of remote monitoring services has been slow. Perceived increase in workload and legal liability concerns of frontline staff represent another challenge in adopting the programme.
“We are currently launching a centralized ‘hub-and-spoke’ model for remote monitoring of patients with CIEDs in Hong Kong, with Grantham Hospital acting as the hub. Changes are being made in the Hospital Authority’s IT infrastructure to allow communication with cardiac teams in other hospitals. With increasing awareness of the programme’s efficiency, we anticipate the monitoring service will rapidly expand to include patients from other hospitals,” said Fan.
Remote monitoring of patients with CIEDs has demonstrated many benefits over conventional care, including earlier detection and correction of clinical events, immediate awareness of device malfunction, improved survival, and reduced use of healthcare resources, which can be diverted to critical patients. Based on these data, treatment guidelines have endorsed remote monitoring in the routine management of patients with CIEDs.
Overall, the shift to telemedicine is well received by physicians and patients alike. “As physicians realize that cost-effective, high-quality care can be delivered remotely, remote interrogations will gradually replace scheduled in-office follow-up visits. At the same time, the healthcare infrastructure will continue to evolve to meet the needs and expectations of patients,” concluded Fan.