Background: Regular physiologist led cardiac device follow up appointments are useful in highlighting and troubleshooting device-detected issues in both the acute and late phase. While most programming concerns are generally dealt with by device physiologists, it is necessary at times to escalate issues which warrant a doctors input or adjudication for external referrals, medication prescriptions and or correspondence to GP surgeries. Implanted cardiac devices have the ability to store details of arrhythmias and it is well understood, for example, that device-detected atrial high rates are associated with an increased risk of stroke (Glotzer et al., 2003). Therefore, by ensuring a dedicated SpR is on hand to cover the device clinic offers an opportunity to integrate the routine device check and address issues surrounding medical management, arrhythmias and reasons for poor biventricular pacing in the most efficient manner.
Purpose: To assess the proportion and indication of SpR reviews from the device clinic of a large tertiary centre, which follows-up PPM, CRT, ICD and ILRs, in a series of patients with device detected events or device site issues.
Methods: A retrospective review of a database containing clinical and follow-up data of all consecutive patients who were referred to a SpR for a review or medical assessment for the month of January 2019. The following data were recorded for analysis: Assessment of beta-blockers, consideration for anticoagulation, wound reviews, liaising with cardiac admissions, non-device related issues, device reprogramming, general medication reviews and patient reassurance.
Results: One-hundred-and-forty-five patients out of a total 1,156 (12.5%) who were referred to the device SpR were included in the study. In 43 (27.9%) there was an indication to commence beta blocker or an alternative form of rate modulating medication. Twenty-eight (18.2%) patients needed input for referring to cardiac admissions for routine or urgent generator change due to recommended replacement time (71.4%), lead integrity issues (18%), infection (7.1%) or pauses discovered on an implantable loop recorder requiring a PPM implant (3.5%). Non-device related issues were highlighted in 23 (14.9%), which included external referrals to other specialities, chest x-ray and a discussion surrounding palliative care. Nineteen (12.3%) required either a wound review or stitch removal for new devices at first clinic follow-up. The decision to continue monitoring and offer reassurance occurred in 14 (9.1%). Thirteen (8.4%) of patients were considered for anticoagulation following evidence of atrial fibrillation. The remaining patients either required a general medication review (n=10, 6.5%) or device reprogramming (n=4, 2.6%).
Conclusion: The preponderant issue presented to the SpR covering the device clinic was for commencement or adjustment of rate modulating drugs. This is followed by communication with cardiac admissions for box changes and lead integrity issues. The presence of an SpR at each device clinic is useful to be able to deal with device detected issues as efficiently as possible and utilise the diagnostic capability of cardiac devices to ensure the best possible patient care.