title: Predicting heart failure decompensation using cardiac implantable electronic devices: a review of practices and challenges.
abstract: Cardiac implantable electronic devices include remote monitoring tools intended to guide heart failure management. The monitoring focus has been on averting hospitalizations by predicting worsening heart failure. However, although device measurements including intrathoracic impedance correlate with risk of decompensation, they individually predict hospitalizations with limited accuracy. Current 'crisis detection' methods involve repeatedly screening for impending decompensation, and do not adhere to the principles of diagnostic testing. Complex substrate, limited test performance, low outcome incidence, and long test to outcome times inevitably generate low positive and high negative predictive values. When combined with spectrum bias, the generalizability, incremental value, and cost-effectiveness of device algorithms are questionable. To avoid these pitfalls, remote monitoring may need to shift from crisis detection to health maintenance, keeping the patient within an ideal physiological range through continuous 'closed loop' interaction and dynamic therapy adjustment. Test performance must also improve, possibly through combination with physiological sensors in different dimensions, static baseline characteristics, and biomarkers. Complex modelling may tailor monitoring to individual phenotypes, and thus realize a personalized medicine approach. Future randomized controlled trials should carefully consider these issues, and ensure that the interventions tested are generalizable to clinical practice.
authors.affiliation: Division of Cardiology, University of British Columbia, Vancouver, Canada.
authors.forename: Nathaniel M
authors.initials: NM
authors.lastname: Hawkins
authors.affiliation: Division of Cardiology, University of British Columbia, Vancouver, Canada.
authors.forename: Sean A
authors.initials: SA
authors.lastname: Virani
authors.affiliation: Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK.
authors.forename: Matthew
authors.initials: M
authors.lastname: Sperrin
authors.affiliation: Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK.
authors.forename: Iain E
authors.initials: IE
authors.lastname: Buchan
authors.affiliation: Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
authors.forename: John J V
authors.initials: JJ
authors.lastname: McMurray
authors.affiliation: Division of Cardiology, University of British Columbia, Vancouver, Canada.
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Krahn
mesh_terms: D058409:Cardiac Resynchronization Therapy Devices; D002307:Cardiography, Impedance; D017147:Defibrillators, Implantable; D018450:Disease Progression; D006333:Heart Failure / Q000175:diagnosis* / Q000503:physiopathology; D006801:Humans; D018670:Monitoring, Ambulatory
keywords: Cardiac resynchronization therapy; Heart failure; Remote monitoring