Decongestive treatment adjustments in heart failure patients remotely monitored with a multiparametric implantable defibrillators algorithm

Abstract

Aims: HeartLogic algorithm combines data from multiple implantable defibrillators (ICD)-based sensors to predict impending heart failure (HF) decompensation. A treatment protocol to manage algorithm alerts is not yet known, although decongestive treatment adjustments are the most frequent alert-triggered actions reported in clinical practice. We describe the implementation of HeartLogic for remote monitoring of HF patients, and we evaluate the approach to diuretic dosing and timing of the intervention in patients with device alerts. Methods:The algorithm was activated in 229 ICD patients at eight centers. The median follow-up was 17 months (25th-75th percentile: 11-24). Remote data reviews and patient phone contacts were undertaken at the time of HeartLogic alerts, to assess the patient's status and to prevent HF worsening. We analyzed alert-triggered augmented HF treatments, consisting of isolated increases in diuretics dosage.Results: We reported 242 alerts (0.8 alerts/patient-year) in 123 patients, 137 (56%) alerts triggered clinical actions to treat HF. The HeartLogic index decreased after the 56 actions consisting of diuretics increase. Specifically, alerts resolved more quickly when the increases in dosing of diuretics were early rather than late: 28 days versus 62 days, p < .001. The need of hospitalization for further treatments to resolve the alert condition was associated with higher HeartLogic index values on the day of the diuretics increase (odds ratio: 1.11, 95% CI: 1.02-1.20, p = .013) and with late interventions (odds ratio: 5.11, 95% CI: 1.09-24.48, p = .041). No complications were reported after drug adjustments.

The patient perspective on remote monitoring of implantable cardiac devices

“…Nevertheless, studies have shown that with one parameter alone there may be no significant improvement in outcomes (38, 39). Algorithms including multiple parameters may be more appropriate but have to be evaluated (40)(41)(42).…”

Reply to: Clinical utility of remote monitoring using multiparametric implantable defibrillators algorithm

“…We would like to thank Dr Imamura for his interest in our paper and we have greatly appreciated his insights on the current perspective related to heart failure (HF) monitoring. In this reply, we would reply to his thoughts and clarify some aspects of our work 1 . First, it is not entirely true that 44% “were not associated with heart failure‐related events” as this number more correctly represents the number of alerts not followed‐up by the physicians.…”

“…In this reply, we would reply to his thoughts and clarify some aspects of our work. 1 First, it is not entirely true that 44% “were not associated with heart failure‐related events” as this number more correctly represents the number of alerts not followed‐up by the physicians. These could have been false positives, as Dr Imamura correctly implies, nonactionable alerts (therapy changes or interventions already undertaken), or more simply true positives not properly followed by clinical response.…”

Clinical utility of remote monitoring using multiparametric implantable defibrillators algorithm

“…Methodology to monitor impending heart failure decompensation is receiving great concern to improve clinical outcomes in patients with chronic heart failure. Guerra et al 1 demonstrated that decongestive treatment adjustments triggered by the alerts of HeartLogic algorithm, which combines clinical data from multiple implantable defibrillator‐based sensors, was safe and effective. Of note, the early decongestive treatment and the use of high dose of diuretics were associated with more favorable outcomes.…”

“…Of 242 alerts, 105 (44%) were not associated with heart failure‐related events. 1 Could the authors explain the reasons for such a high false alarm? Some heart failure events might not be detected appropriately by this technology.…”