Case Study: Timely Intervention for Ventricular Fibrillation Detection and Therapy in the Setting of Antiarrhythmic Medication Nonadherence
Introduction
Continuous remote monitoring (RM) technology has transformed cardiovascular implantable electronic device (CIED) patient care models and offers patients numerous clinical advantages, including benefits in mortality, morbidity, and health care utilization. However, this technology has opened the floodgates for the continuous flow of data to device clinics. Review, triage, and management of this data contributes to increasingly more burden on staffing resources. Increases in device patient volume and indications for implant, coupled with technical connectivity improvements, translate to around-the-clock receipt of alert transmissions.
Remote Monitoring Clinic Burden
Approximately 74% of remote transmissions are received between 5:00 PM and 9:00 AM.1 In a study examining remote monitoring alert burden in a population of >26,000 patients, O’Shea and colleagues found that 40.2% of the analyzed RM transmissions were alerts. Of the 78,862 alerts analyzed, 95.2% were low-acuity alerts (yellow alerts) and 4.8% were high-acuity alerts (red alerts), with most red alerts coming from implantable cardioverter-defibrillators (ICDs).2
Most device clinics lack sufficient staffing resources to monitor multiple vendor websites 24/7/365. Staff availability during traditional clinic hours only provides 25% coverage for alert monitoring of vendor websites in a typical week. Commonly, device clinic mornings are spent scouring vendor websites for alerts, filtering through false-positives and managing issues sequentially as discovered with no mechanism to assist in finding the most clinically relevant data in a timely manner.
Mondays tend to be extremely onerous due to accumulated alerts and patient-initiated transmissions. This burden may be further compounded by backlogged volume from the previous week and from the day’s required work such as in-clinic interrogations, incision assessments, patient triage, documentation, scheduling, and billing tasks.
A Software Solution 
PaceMate™’s proprietary clinical alerts engine, embedded in the PaceMate™LIVE software platform, allows users to customize and prioritize every alert beyond device and vendor settings. This case study report demonstrates the effectiveness of PaceMate™LIVE’s alerts engine and the clinical expertise and partnership between the PaceMate™ and Steward Medical Group clinicians to facilitate timely intervention for a patient experiencing post-ICD implant recurrent ventricular fibrillation (VF).
Case Description
This case was a 60-year-old female with a past medical history of hypertension, tobacco use, migraines, mixed anxiety and depression disorder, and attention-deficit/hyperactivity disorder who experienced sudden cardiac arrest (SCA) on the front lawn of her home. Prompt bystander cardiopulmonary resuscitation was administered by a relative, and the patient was resuscitated and subsequently hospitalized. No deficits were noted post arrest. Interestingly, the episode was captured by video doorbell camera, which enabled the medical team to witness the event.
Post-SCA event cardiac catheterization and EP study were negative. Cardiac MRI and echocardiogram confirmed a preserved ejection fraction (EF) of 55%. There was no known obstructive coronary artery disease.
After shared decision making, the patient and medical team proceeded with implantation of a an ICD on July 28, 2021. The patient was discharged on a titrating dose of amiodarone 200 mg qd, lisinopril 40 mg, and metoprolol succinate ER 25 mg qd. Usual post-implant care was performed with incision assessment, patient education, and initiation of continuous RM. The following clinic uses PaceMate™’s end-to-end software+service solution for remote CIED monitoring.
PaceMate™ Service
On August 23, 2021, the PaceMate™ clinical services team received a critical alert for this patient. VF at 300 bpm, lasting 18 seconds, was detected and terminated successfully with one 40J shock. The clinic’s customized alert settings automatically applied the red flag alert. The device technician was notified immediately and called the patient, but received no answer. Emergency medical services (EMS) were called by the device technician, and thankfully, the patient was found alive.
Upon regaining consciousness, the patient reported to EMS that she had been sitting at her kitchen table and thought she had fallen asleep. She had no recollection of the ICD therapy. At the hospital, the patient informed the hospitalist that she had stopped taking her medications. Medications were resumed and there have been no further ventricular arrhythmia detections. EF remains at 60%. Amiodarone was discontinued, and current medications include sotalol 80 mg bid, lisinopril 40 mg qd, metoprolol succinate ER 25 mg qd, and atorvastatin 20 mg qd. The patient remains adherent to medical therapy.
Discussion
PaceMate™’s proprietary alerts engine prioritized the VF alert condition across all vendor and device types, and immediately flagged the alert to the top of the transmission list for the PaceMate™ clinical team to assess and triage to the clinic. PaceMate™’s display of both the red flag and the reason for the alert—“Episode - VF” and “Shock x1”—enabled the PaceMate™ clinical team to quickly identify the alert, review the transmission, and notify the clinic according to their customized notification protocol.
The phone call to the clinic was an essential factor in this case. PaceMate™’s customer-facing audit log shows that VF was detected and therapy was delivered at 1:59 PM, the transmission was received at 2:01 PM, and the clinic was notified at 2:16 PM, with immediate calls to the patient and EMS placed by the clinic’s device technician. Timely intervention for this patient was critical, as recurrence of VF was likely in the setting of nonadherence to antiarrhythmic therapy.
Conclusions
Clinically relevant alerts require timely notification. In this case, prompt notification of the critical alert reduced detection-to-intervention time. The PaceMate™LIVE software supports reduced detection-to-intervention time for clinically actionable alerts. This quick notification, coupled with the device technician’s persistence to contact the patient, may have prevented a poor outcome.
RM alert management cannot be limited to regular clinic business hours and should not be delayed until business hours resume. PaceMate™’s software+service solution, available 24/7/365 or “On Demand,” promotes patient safety, quality of care, and reduction in liability for the practice.
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This article is published with support from PaceMate™ and Steward Medical Group.
References
1. PaceMate™ internal data.
2. O’Shea CJ, Middeldorp ME, Hendriks JM, et al. Remote monitoring alert burden: an analysis of transmission in >26,000 patients. JACC: Clinical Electrophysiol. 2021;7(2):226-234. https://www.ahajournals.org/doi/10.1161/CIRCEP.121.009635
