Protecting the most vulnerable during COVID-19 and beyond: a case report on the remote management of heart failure patients with cardiac implantable electronic devices

Remotely Monitored Cardiac Implantable Electronic Device Data Predict All-Cause and Cardiovascular Unplanned Hospitalization

Background Unplanned hospitalizations are common in patients with cardiovascular disease. The "Triage Heart Failure Risk Status" (Triage-HFRS) algorithm in patients with cardiac implantable electronic devices uses data from up to 9 device-derived physiological parameters to stratify patients as low/medium/high risk of 30-day heart failure (HF) hospitalization, but its use to predict all-cause hospitalization has not been explored. We examined the association between Triage-HFRS and risk of all-cause, cardiovascular, or HF hospitalization. Methods and Results A prospective observational study of 435 adults (including patients with and without HF) with a Medtronic Triage-HFRS-enabled cardiac implantable electronic device (cardiac resynchronization therapy device, implantable cardioverter-defibrillator, or pacemaker). Cox proportional hazards models explored association between Triage-HFRS and time to hospitalization; a frailty term at the patient level accounted for repeated measures. A total of 274 of 435 patients (63.0%) transmitted ≥1 high HFRS transmission before or during the study period. The remaining 161 patients never transmitted a high HFRS. A total of 153 (32.9%) patients had ≥1 unplanned hospitalization during the study period, totaling 356 nonelective hospitalizations. A high HFRS conferred a 37.3% sensitivity and an 86.2% specificity for 30-day all-cause hospitalization; and for HF hospitalizations, these numbers were 62.5% and 85.6%, respectively. Compared with a low Triage-HFRS, a high HFRS conferred a 4.2 relative risk of 30-day all-cause hospitalization (8.5% versus 2.0%), a 5.0 relative risk of 30-day cardiovascular hospitalization (3.6% versus 0.7%), and a 7.7 relative risk of 30-day HF hospitalization (2.0% versus 0.3%). Conclusions In patients with cardiac implantable electronic devices, remotely monitored Triage-HFRS data discriminated between patients at high and low risk of all-cause hospitalization (cardiovascular or noncardiovascular) in real time.

Patients hospitalised with heart failure across different waves of the COVID-19 pandemic show consistent clinical characteristics and outcomes

BACKGROUND

During the first wave of the COVID-19 pandemic, admissions for cardiovascular disease, including Heart Failure (HF), were reduced. Patients hospitalised for HF were sicker and with increased in-hospital mortality. So far, whether following waves had a different impact on HF patients is unknown.

METHODS

All consecutive patients hospitalised for acute heart failure during three different COVID-19 related national lockdowns were analysed. The lockdown periods were defined according to Government guidelines as 23/3/2020 to 4/7/2020 (First Lockdown), 4/11/2020 to 2/12/2020 (Second Lockdown) and 5/1/2021 to 28/2/2021 (Third Lockdown).

RESULTS

Overall, 184 patients hospitalised for HF were included in the study, 95 during the 1st lockdown, 30 during the 2nd lockdown and 59 during the 3rd lockdown. Across the three groups had comparable clinical characteristics, comorbidities and cardiovascular risk factors. Specialist in-hospital care was uninterrupted during the pandemic showing comparable mortality rates (p = 0.10). Although medical therapy for HF was comparable between the three lockdowns, a significantly higher proportion of patients received Angiotensin Receptor-Neprilysin Inhibitors (ARNI) in the second and third lockdowns (p < 0.001).

CONCLUSIONS

Although public health approaches changed throughout the pandemic, the clinical characteristics and outcomes of HF patients were consistent across different waves. For patients hospitalised in the subsequent waves, a more rapid optimization of medical therapy was observed during hospitalization. Particular attention should be devoted to prevent collateral cardiovascular damage during public health emergencies.

Remote Monitoring of CIEDs-For Both Safety, Economy and Convenience?

Cardiac implantable electronic devices such as pacemakers and defibrillators are increasingly monitored by systems transmitting information directly from the patient to the hospital. This may increase safety and patient satisfaction and also under certain circumstances represent an economic advantage. The review summarizes some of the recent research in the field of remote monitoring of cardiac devices.

Lockdown, slow down: impact of the COVID-19 pandemic on physical activity-an observational study

Aims

In response to the COVID-19 pandemic, the UK was placed under strict lockdown measures on 23 March 2020. The aim of this study was to quantify the effects on physical activity (PA) levels using data from the prospective Triage-HF Plus Evaluation study.

Methods

This study represents a cohort of adult patients with implanted cardiac devices capable of measuring activity by embedded accelerometery via a remote monitoring platform. Activity data were available for the 4 weeks pre-implementation and post implementation of ‘stay at home’ lockdown measures in the form of ‘minutes active per day’ (min/day).

Results

Data were analysed for 311 patients (77.2% men, mean age 68.8, frailty 55.9%. 92.2% established heart failure (HF) diagnosis, of these 51.2% New York Heart Association II), with comorbidities representative of a real-world cohort.

Post-lockdown, a significant reduction in median PA equating to 20.8 active min/day was seen. The reduction was uniform with a slightly more pronounced drop in PA for women, but no statistically significant difference with respect to age, body mass index, frailty or device type. Activity dropped in the immediate 2-week period post-lockdown, but steadily returned thereafter. Median activity week 4 weeks post-lockdown remained significantly lower than 4 weeks pre-lockdown (p≤0.001).

Conclusions

In a population of predominantly HF patients with cardiac devices, activity reduced by approximately 20 min active per day in the immediate aftermath of strict COVID-19 lockdown measures.

Trial registration number

NCT04177199.

Impact of COVID-19 Pandemic on the Implantation of Intra-Cardiac Devices in Diabetic and Non-Diabetic Patients in the Western of Romania

Background and Objectives: COVID-19 pandemic severely impacted public health services worldwide, determining a significant decrease of elective cardiovascular (CV) procedures, especially in patients with associated chronic diseases such as diabetes mellitus (DM). Materials and Methods: This study was first started in 2019 in the western of Romania, to analyze the differences regarding the implantations of intra-cardiac devices such as permanent pacemakers (PPM), cardiac resynchronization therapy (CRT), or implantable cardioverter-defibrillators (ICD) in 351 patients with and without DM and the situation was reanalyzed at the end of 2020. Results: of the first 351 patients with and without DM. 28.20% of these patients had type 2 DM (p = 0.022), exceeding more than twice the prevalence of DM in the general population (11%). Patients with DM were younger (p = 0.022) and required twice as often CRT (p = 0.002) as non-diabetic patients. The state of these procedures was reanalyzed at the end of 2020, a dramatic decrease of all new device implantations being observed, both in non-diabetic and in patients with type 2 DM (79.37%, respectively 81.82%). Conclusions: COVID-19 pandemic determined a drastic decrease, with around 75% reduction of all procedures of new intra-cardiac devices implantation, both in non-diabetics, this activity being reserved mostly for emergencies.