1. Using Monitoring Devices Systems to Optimize Patient Care Giuseppe Stabile CLINICA MEDITERRANEA MEDITERRANEA

2. www.nhlbi.nih.gov/health/public/heart/other/CHF

4. 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 face- to-face visits.”

5. 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 non- scheduled 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.

6. 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 Potential advantages of RM 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

17. ATR  30 507090110130150170190210230  250 0 100 (%) Atrial Paced Sensed  30 Rate (min-1) 507090110130150170190210230  250 0 100 (%) Ventricular Paced Sensed RVLV VT-1VTVF Histogram for “proper” BV therapy Remember – CRT Requires Ventricular Pacing ! Device Diagnostics Histograms

18. ATR  30 507090110130150170190210230  250 0 100 (%) Atrial Paced Sensed  30 Rate (min-1) 507090110130150170190210230  250 0 100 (%) Ventricular Paced Sensed RVLV VT-1VTVF Compromised CRT Due to LV Oversensing Remember – CRT Requires Ventricular Pacing ! Device Diagnostics Histograms

19. ATR  30 507090110130150170190210230  250 0 100 (%) Atrial Paced Sensed  30 Rate (min-1) 507090110130150170190210230  250 0 100 (%) Ventricular Paced Sensed RVLV VT-1VTVF Compromised of CRT due to PR < AV Delay at High Rates Remember – CRT Requires Ventricular Pacing ! Device Diagnostics Histograms

24. Cost effectiveness

25. 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

27. 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.

31. LATITUDE ® Web Server LATITUDE® Patient Management - Overview Health Following Physician & RN Objectives Device Battery Management Patient’s Weight Management Compliance with Guidelines Device Managing Physician & RN Objectives Device management Arrhythmia management BSC CRM Device Patient’s Home LATITUDE ® Weight Scale LATITUDE ® BP Monitor LATITUDE ® Communicator Patient data (Optional)

48. 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

50. Diagnostic Features Trends

59. N=9, R = 0.77 -80 -60 -40 -20 0 20 40 60 -20-15-10-50510 Heart Rate Change (bpm) Change in Mortality (%) SOLVD Vesnarinone Carvedilol FIRST VHeFT-I (PRZSN) PROFILE CONSENSUS VHeFT-I (ISDN/HZN) PROMISE Bristow, 1998 The lower is the HR the better is the prognosis

62. Respiratory Rate Trend Maximum 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 Median Rate  Corresponds most closely to resting respiration rate  Normal median respiratory rate is approximately 14 - 18 breaths per minute Minimum Rate  Most specific measure of respiratory distress  Minimum > / = 20 breaths per minute is indicator of rapid, shallow breathing

63. Respiratory Rate – Clinical Practice 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 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 Symptoms Suggesting HF Diagnosis RR is significantly higher for CHF patients, even at rest 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.)  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  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 Acute CHF Care Chronic HF = Solid bars Normal subjects = Open bars

64. 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

66. JAMA 1993;270:1702

67. Connecting Multiple Physicians Implanting Physician Heart Failure Specialist Monitoring devices systems allows and required multiple physicians to participate in the care of the patient

70. Thank you