Predicting heart failure decompensation using cardiac implantable electronic devices: a review of practices and challenges

Abstract

Cardiac implantable electronic devices include remote monitoring tools intended to guide heart failure management. The monitoring focus has been on averting hospitalizations by predicting worsening heart failure. However, although device measurements including intrathoracic impedance correlate with risk of decompensation, they individually predict hospitalizations with limited accuracy. Current ‘crisis detection’ methods involve repeatedly screening for impending decompensation, and do not adhere to the principles of diagnostic testing. Complex substrate, limited test performance, low outcome incidence, and long test to outcome times inevitably generate low positive and high negative predictive values. When combined with spectrum bias, the generalizability, incremental value, and cost‐effectiveness of device algorithms are questionable. To avoid these pitfalls, remote monitoring may need to shift from crisis detection to health maintenance, keeping the patient within an ideal physiological range through continuous ‘closed loop’ interaction and dynamic therapy adjustment. Test performance must also improve, possibly through combination with physiological sensors in different dimensions, static baseline characteristics, and biomarkers. Complex modelling may tailor monitoring to individual phenotypes, and thus realize a personalized medicine approach. Future randomized controlled trials should carefully consider these issues, and ensure that the interventions tested are generalizable to clinical practice.

Cases of two patients undergoing remote CRT device monitoring with fluid retention and algorithm assessment

“…A clinical trial conducted by Domenichini et al showed that alert-guided care does not prevent hospitalisation but can help In supporting the patient's well-being and self-assessed quality of life (7) . Moreover, the cost-effectiveness impact on the healthcare system may be beneficial due to implementation of such a solution, where the physician's decisions will be supported by algorithmic remotely gathered findings, but this view will soon be verified according to the rules of evidence-based medicine (8) .…”

“…It is important to take into account that today modern algorithms and systems allow physicians to predict with high accuracy that an owner of a CRT device will soon become (in 30 days) a patient in their (or another) department (5,8) . To understand the gravity of this fact, one need only consider how many preventive actions can be undertaken during those 30 days to avoid such an event.…”

Cost‐Effectiveness of Remote Cardiac Monitoring With theCardioMEMSHeart Failure System

“…However, recent published studies have started to explore the literature on remote monitoring to understand variation in success rates and the inconsistent definition of remote monitoring . The effectiveness of remote monitoring may also depend on the particular monitoring device/system or patient characteristics …”

The Clinical Utility of Circulating Microparticles’ Measurement in Heart Failure Patients

“…cardiac resynchronization therapy devices and implantable defibrillator/cardioverters [8,10]. Furthermore, the clinical outcomes of both phenotypes of HF have been occurred similar or at least not sufficiently distinguished [11] that is important challenge for contemporary medical care service.…”