2023 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Practical Management of the Remote Device Clinic

Abstract

Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.

Keywords: Alerts; CIED; Cardiovascular implantable electronic device; Connectivity; Device clinic; Programming; Remote monitoring.

Figure 1

Staffing challenges with remote monitoring. AI = artificial intelligence; EHR = electronic health record; RM = remote monitoring.

Figure 2

2015 HRS Expert Consensus Statement on RM vs 2023 HRS Expert Consensus Statement. APP = advanced practice provider; CIED = cardiovascular implantable electronic device; EHR = electronic health record; HRS = Heart Rhythm Society; NP = nurse practitioner; PA = physician assistant; RN = registered nurse; Tech = technician.

Figure 3

Example of a timeline for patients with cardiovascular implantable electronic devices on remote monitoring. CIED = cardiovascular implantable electronic device; ERI = elective replacement indicator.

Figure 4

Traditional personal 1:1 vs site‐based remote monitoring. With traditional personal 1:1 remote monitoring (RM), each patient is individually enrolled into the RM program and the RM data is routed to both the facility and the patient's device clinic. With site‐based RM, multiple patients can use the system, even if they are not individually enrolled into the RM program, and the RM data is shared with that facility's clinic in addition to the patient's home clinic.

Figure 5

Illustrative example of unscheduled cardiovascular implantable electronic device interrogation using a site‐based remote monitoring transmitter. CIED = cardiovascular implantable electronic device.

Figure 6

Alert recommendations by device type. Color corresponds to the class of recommendation (COR) in Table 1. ATP = anti‐tachycardia pacing; CRT = cardiac resynchronization therapy; HF = heart failure; ICD = implantable cardioverter defibrillator; PM = pacemaker; RV = right ventricular.

Figure 7

Red and yellow alerts for pacemakers and implantable cardioverter‐defibrillators. Red alerts are defined as critical alerts requiring urgent review. Yellow alerts are those that, with early review, may lead to an action that impacts patient outcomes. ^aMultiple shocks could demonstrate clinical deterioration or be ineffective. ATP = anti‐tachycardia pacing; bpm = beats per minute; CRT = cardiac resynchronization therapy; LV = left ventricular; ICD = implantable cardioverter‐defibrillator; ILR = implantable loop recorder; MRI = magnetic resonance imaging; NSVT = nonsustained ventricular tachycardia; PM = pacemaker; RA = right atrial; RV = right ventricular; VF = ventricular fibrillation.

Figure 8

Remote monitoring alerts that should be considered “high‐priority.” Red corresponds to red alerts, and yellow corresponds to yellow alerts. High/low impedance can be considered a red or yellow alert. ICD = implantable cardioverter‐defibrillator.

Figure 9

Minimizing alerts for nonactionable events. Each cardiovascular implantable electrical device transmission alert is critically reviewed by a credentialed clinician. If the event is a known clinical event that has been previously addressed, the specific alert may be programmed OFF and it is no longer considered an actionable event. If this is not a known clinical event, more information is needed about the patient's status. Based on the review of additional information, the alert may be adjusted or programmed OFF. CIED = cardiovascular implantable electronic device.

Figure 10

Suggested components of remote monitoring report. *Additional manufacturer‐specific features can be added if these data will influence patient care/management and be used by the local device clinic (eg, activity monitor, heart rate variability, heart failure algorithms). Listed data elements (✓) would be considered the mandatory minimal data set for a remote monitoring report, unless otherwise denoted. †Availability of alerts are manufacturer specific. These may include but are not limited to RV lead integrity alert, RV lead noise, lead impedance out of range, AT/AF daily burden (as per user set threshold), excessive charge time, and low battery voltage. Alert programming should balance patient safety and actionable clinical information with the burden of nonactionable alerts that device clinics may encounter with undiscerning programming. AF = atrial fibrillation; AT = atrial tachycardia; CIED = cardiovascular implantable electronic device; CRT = cardiac resynchronization therapy; EGM = electrogram; ICD = implantable cardioverter‐defibrillator; ILR = implantable loop recorder; LV = left ventricular; PM = pacemaker; RV = right ventricular; VT = ventricular tachycardia; VF = ventricular fibrillation.

Figure 11

Patient as a team member in remote monitoring.

Figure 12

Remote monitoring outsourcing to third‐party resources. CIED = cardiovascular implantable electrical device.