Geographic differences in implantable cardioverter defibrillator usage

Leadless and Wireless Cardiac Devices: The Next Frontier in Remote Patient Monitoring

In the last decade, advances in wireless and sensor technologies, and the implementation of telemedicine, have led to innovative digital health care for cardiac patients. Continuous monitoring of patients' biomedical signals, and acute changes in these signals, may result in timely, accurate diagnoses and implementation of early interventions. In this review, we discuss commonly used wireless and leadless cardiac devices including pulmonary artery pressure sensors, implantable loop recorders, leadless pacemakers and subcutaneous implantable cardioverter-defibrillators. We discuss the concept and function of each device, indications, methods of delivery, potential complications, consideration for implantation, and cost-effectiveness.

Remote monitoring of implantable cardioverter defibrillator patients: a safe, time-saving, and cost-effective means for follow-up

Aims

The purpose of this prospective study was to investigate whether internet-based remote monitoring offers a safe, practical, and cost-effective alternative to the in-office follow-up visits of patients with an implantable cardioverter defibrillator (ICD).

Methods and results

Forty-one patients (62 ± 10 years, range 41–76, 83% male) with previously implanted ICD were followed for 9 months. One-hundred and nineteen scheduled and 18 unscheduled data transmissions were performed. There were no device-related adverse events. Over 90% of the patients found the system easy to use. Physicians reported the system as being ‘very easy’ or ‘easy’ to use and found the data comparable to traditional device interrogation in 99% of the cases. They were able to address all unscheduled data transmissions remotely. Compared with the in-office visits, remote monitoring required less time from patients (6.9 ± 5.0 vs. 182 ± 148 min, P < 0.001) and physicians (8.4 ± 4.5 vs. 25.8 ± 17.0 min, P < 0.001) to complete the follow-up. Substitution of two routine in-office visits during the study by remote monitoring reduced the overall cost of routine ICD follow-up by 524€ per patient (41%).

Conclusion

Remote monitoring offers a safe, feasible, time-saving, and cost-effective solution to ICD follow-up.

ICD Therapy: What Have We Learned From the Clinical Trials?

Development of implantable cardioverter defibrillators (ICD) has been a dramatic advancement in the management of patients with life-threatening ventricular arrhythmias. We hereby reviewed the landmark clinical trials on ICD with special emphasis on late-breaking clinical trials and assessed their impact on every-day decision making and patient selection for ICD implantation.

Regional variation in ICD implantation rates: the shocking truth?

There is considerable disparity in the implantation of ICDs across the UK, with a fourfold difference between regions with the highest and lowest implantation rates.

Utilization of implantable cardioverter-defibrillators in survivors of cardiac arrest in the United States from 1996 to 2001

OBJECTIVES

We analyzed the incidence of implantable cardioverter-defibrillator (ICD) therapy in survivors of cardiac arrest (CA) in the U.S. from 1996 through 2001.

BACKGROUND

Cardiac arrest is a class I indication for ICD therapy. The current patterns of ICD utilization in survivors of CA have not been fully examined.

METHODS

We searched a representative sample of all hospital discharges for patients admitted with the primary diagnosis of CA who survived to hospital discharge. Patients with a concomitant diagnosis of acute myocardial infarction or previous ICD in situ were excluded.

RESULTS

From 1996 to 2001, 113,262 patients were admitted for CA. Of those, 63,745 (56.3%) did not survive to hospital discharge. Of the remaining 49,517 patients, 30.7% received an ICD before discharge, with a gradual increase in implantation rates from 1996 (23.6%) to 2001 (46.3%). Using logistic regression for the years 2000 and 2001, patients who were discharged without an ICD were older (odds ratio [OR] 0.93 for every 10-year increase in age, p < 0.001), more likely to be African American (OR 0.19, p < 0.001), and more likely to be admitted to a smaller hospital (OR 2.24 for each additional 100 beds, p < 0.001). These predictors were independent of other co-morbid illnesses.

CONCLUSIONS

Although they are increasing, the rates of ICD therapy after CA remain very low. There are gross discrepancies by race. At a time when newer indications for ICD implantation are emerging, efforts should be focused on identifying the causes of this underutilization and discrepancies in survivors of CA.

The patient with an implantable cardioverter defibrillator

Electrophysiologic technology developed over the past 20 years has improved the life expectancy of patients who have survived sudden cardiac death events. Use of an implantable cardioverter defibrillator (ICD) continues to increase as more indications for the device are researched. Patients with ICDs will be cared for in the postanesthesia care unit following cardiac and noncardiac surgery and require PACU nurses to be knowledgeable about this advanced and changing technology as well as provide for emotional and psychological needs.

Cardioverter-defibrillators after MADIT-II: the balance between weight of evidence and treatment costs

The possibility of using implantable cardioverter-defibrillators (ICDs) for primary prevention of sudden death in selected high-risk patients has prompted a series of prospective controlled studies. Recently, the MADIT II study highlighted the possibility of effective primary prevention of sudden death in patients with coronary artery disease selected by straightforward clinical data and without expensive screening (electrophysiological study). For patients with previous myocardial infarction and low left ventricular ejection fraction (</=30%), ICD implantation may reduce mortality risk by approximately 31% in the following 2 years. Implementation of this therapeutic strategy threatens to impact on public health-care spending. Possible cost-limiting mechanisms include price cuts because of increasing usage (market forces); identification of subgroups at higher risk of sudden death and use of cheaper devices with limited diagnostic and therapeutic options. Further long-term evaluation of the cost-effectiveness and cost-utility of ICDs should identify subgroups of patients for whom implantation is affordable despite current economic constraints. For heart failure patients, randomized controlled trials are currently evaluating the effects on overall survival of both conventional ICDs and devices with biventricular pacing capabilities. In this perspective, data from the COMPANION trial are expected to stimulate the use of devices with defibrillation back-up in candidates for biventricular pacing.

[The impact of the Multicenter Automatic Defibrillator Implantation Trial II in a university hospital--do all patients with myocardial infarction and reduced left ventricular function need an implantable cardioverter-defibrillator?]

BACKGROUND AND OBJECTIVES

Patients with coronary artery disease (CAD) and severely compromised left ventricular ejection fraction are at high risk to die from sudden cardiac death. The Multicenter Automatic Defibrillator implantation Trial II (MADIT II) shows a significant benefit of a cardioverter-defibrillator (ICD) therapy compared to standard treatment alone in this selected group of patients. The objective of the present study was to investigate the number of patients who will fulfil the MADIT II criteria and are candidates for prophylactic ICD implantation.

METHODS AND MATERIAL

From January to December 2001 a total of 2653 patients underwent coronary angiography at our institution due to angina pectoris, positive exercise stress testing, pathological SPECT myocardial perfusion images, suspected dilated cardiomyopathy or ventricular arrhythmias. According to the MADIT II inclusion criteria patients with significant coronary artery disease (diameter stenosis > 50%), ejection fraction < 0.31% and previous myocardial infarction were included. Exclusion criteria were acute coronary syndromes, patients with ventricular tachyarrhythmias or an existing indication for ICD therapy, and patients with coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty within the past or following three months.

RESULTS

Out of 2653 patients 185 (7%) had an ejection fraction less than 0.31, 149 (5.6%) showed significant coronary artery stenosis and 70 (2.6%) patients fulfilled the MADIT II criteria. The mean age of these patients was 68 +/- 9 years, the left ventricular ejection fraction 24 +/- 6. In 37 patients an ICD system was implanted according to the existing guidelines. 70 patients met the MADIT II inclusion criteria, resulting in an increase of 189% of ICD implantations per year.

CONCLUSION

2.6% out of 2653 patients who were referred to coronary angiography fulfilled the criteria of MADIT II. The expanding indication for ICD therapy will result in an annual increase of 70 (189%) prophylactic ICD implantations in our study population.