Download Device Diagnostics Histograms

Using Monitoring Devices Systems to
Optimize Patient Care
Giuseppe Stabile
CLINICA
MEDITERRANEA
www.nhlbi.nih.gov/health/public/heart/other/CHF
Telemonitoring, the use of communication technology to
monitor patients’ clinical status, is gaining attention as a
strategy to improve the care of patients with chronic disease.
By allowing clinical data to be collected without the need for
face-to-face contact with patients, telemonitoring can make
care more accessible for patients and has the potential to
improve outcomes. The Institute of Medicine’s endorsement
of this approach is evident, as the first of its 10 rules for
redesigning the health care system outlined in the report,
“Crossing the Quality Chasm” (Committee on Quality of Health
Care in America. 2001) is “Patients should receive care
whenever they need it and in many forms, not just faceto-face visits.”
The rate of implantable cardioverter defibrillator (ICD)
implantation has gone up as primary and secondary
prevention trials have relatively consistently shown
significant improvement in mortality and morbidity. Most
patients with ICDs are followed routinely at intervals ranging
from 3 to 6 months. Many patients require additional nonscheduled visits to investigate symptoms that may or may not
relate to their cardiac disease or device. Appropriate and
inappropriate therapies of implantable cardioverter
defibrillators have a major impact on morbidity and quality
of life in ICD recipients. Remote monitoring systems can
substitute for routine follow-up visits and/ or deliver
continuous diagnostic and device status information.
Remote monitoring of ICDs can decrease the need for
many patient visits and, thereby, probably reduce
expense.
Potential advantages of RM

Early detection of device technical troubles

Early detection and reaction to changes in patient clinical
status

Reduction of unnecessary out-patient visits

Optimization of health-care resource allocation
Success of telemedicine

The easy of use of the system by the patient and the
clinician

Their acceptance and satisfaction with the monitor and with
rewieving device data via the website
Device Diagnostics
Histograms
ATR
100
Atrial
Paced
Sensed
(%)
0
 30
50
70
90
110
130
150
100
190
VT-1
VT
210
230
 250
VF
Remember – CRT Requires Ventricular Pacing !
Ventricular
RV LV
(%)
Paced
Sensed
0
170
 30
50
70
90
110
130
150
Rate (min-1)
170
190
210
Histogram for “proper” BV therapy
230
 250
Device Diagnostics
Histograms
ATR
100
Atrial
Paced
Sensed
(%)
0
 30
50
70
90
110
130
150
100
190
VT-1
VT
210
230
 250
VF
Remember – CRT Requires Ventricular Pacing !
Ventricular
RV LV
(%)
Paced
Sensed
0
170
 30
50
70
90
110
130
150
Rate (min-1)
170
190
210
230
Compromised CRT Due to LV Oversensing
 250
Device Diagnostics
Histograms
ATR
100
Atrial
Paced
Sensed
(%)
0
 30
50
70
90
110
130
150
100
190
VT-1
VT
210
230
 250
VF
Remember – CRT Requires Ventricular Pacing !
Ventricular
RV LV
(%)
Paced
Sensed
0
170
 30
50
70
90
110
130
150
Rate (min-1)
170
190
210
230
 250
Compromised of CRT due to PR < AV Delay at High Rates
Cost effectiveness
Health-care resource utilization
A total of 167 in-hospital visits took place. Of note,
in an equivalent period, 200 in hospital visits would
be expected for a standard follow-up scheduling
Easy of use and patients’ acceptance
Patient satisfaction with the convenience
and reliability of the remote monitoring
system ranged from 93 to 97% in SF-36
surveys.
Dressing TJ, Schott R, McDowell C, et al. Transtelephonic ICD follow-up is
better: more comprehensive, less intrusive and more desirable (abstract). Pacing
Clin electrophysiol 2002; 24:577.
LATITUDE® Patient Management - Overview
Patient’s Home
Health Following
Physician & RN
BSC CRM
Device
Patient data
(Optional)
LATITUDE®
Communicator
LATITUDE®
Weight Scale
LATITUDE®
Web Server
Objectives
• Device Battery Management
• Patient’s Weight Management
• Compliance with Guidelines
Device Managing
Physician & RN
LATITUDE®
BP Monitor
Objectives
• Device management
• Arrhythmia management
•During 240 days of follow-up, 19.5%, 15.9%, and
12.7% of days were lost as the result of death or
hospitalization for UC, NTS, and HTM,
respectively (no significant difference).
•The number of admissions and mortality were
similar among patients randomly assigned to NTS
or HTM, but the mean duration of admissions was
reduced by 6 days (95% confidence interval 1 to 11)
with HTM.
•Patients randomly assigned to receive UC had
higher one-year mortality (45%) than patients
assigned to receive NTS (27%) or HTM (29%) (p
0.032
Diagnostic Features Trends
The lower is the HR the better is the prognosis
60
PROFILE
Change in Mortality (%)
FIRST
40
N=9, R = 0.77
20
PROMISE
VHeFT-I (PRZSN)
0
-20
-15
-10
-5
SOLVD
0
5
-20
VHeFT-I (ISDN/HZN)
-40
CONSENSUS
Carvedilol
-60
Vesnarinone
-80
Heart Rate Change (bpm)
Bristow, 1998
10
Respiratory Rate Trend
Maximum Rate
Median Rate
Minimum Rate

Most specific measure of activity level

Should be significantly higher than minimum (up to 3-4
times that of resting) and vary day by day

Normal respiratory rate is approximately 30-50 breaths
per minute

Corresponds most closely to resting respiration rate

Normal median respiratory rate is approximately 14 - 18
breaths per minute

Most specific measure of respiratory distress

Minimum > / = 20 breaths per minute is indicator of
rapid, shallow breathing
Respiratory Rate – Clinical Practice
Symptoms Suggesting HF Diagnosis
HFSA 2006 Compressive HF Guidelines:
Dyspnea at rest or on exertion
Orthopnea
Shortness of breath increases
when patient lies down or needs
(sleeping with more than 1 pillow helps)
Paroxysmal nocturnal dyspnea
Sudden onset of shortness of
breath after a period of sleep
ACC/AHA Guidelines (1997)
Dyspnea is one of the cardinal symptoms of
heart disease
Circ, Vol 77, No 3, pp 552-559, March 1998
Eorpeanjournal of HF 9 (2007) 702-708
Am Heart J 2006;151:844.e1-10.
Am Heart J 2001;142:714-9.)
RR is significantly higher for CHF patients,
even at rest
Chronic HF
= Solid bars
Normal subjects
= Open bars
Acute CHF Care

Dyspnea is the most frequent symptom in
HF patients presenting in ED

Increasing dyspnea is usually present 8 to 12
days before admission to hospital
Respiratory Rate – Clinical Practice
Cumulative percent of
patients reporting
worsening symptoms vs.
number of days before HF
hospitalization
Decompensated Heart Failure:
Symptoms,
Patterns of Onset, and Contributing
Factors Schiff, Fung, Speroff, McNutt,
2002
JAMA 1993;270:1702
Connecting Multiple Physicians
Monitoring devices systems allows
and required multiple physicians to
participate in the care of the patient

Heart Failure
Specialist

Implanting
Physician
Thank you