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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