A multistate model of clinical trajectories of heart failure patients with implantable electronic devices followed with remote monitoring: what outcome implications of alerts and their timing

Abstract Background Understanding how baseline health conditions influence device alerts and adverse events in heart failure (HF) patients with cardiac implantable electronic devices (CIEDs) and remote monitoring (RM) is crucial for patient management. Purpose We aimed to investigate predictors of alerts from RM and their impact on adverse outcomes using a multistate model analysis. Methods We analysed data from a observational study including HF patients implanted with a CIED and monitored remotely. Eligible alerts for this analysis included those generated from multiparametric HF scores and shock therapies. Using multistate models, we examined transitions from baseline to alert events and, ultimately, to a composite outcome of all-cause death and HF hospitalization (HFH). Cox regression evaluated covariate effects on transition rates and the impact of alert and their timing on outcome. Results A total of 406 HF patients (mean age 68.9 years, SD 11.3; 20.9% female) were included in the analysis. Over a median follow-up of 658 days (IQR 245–1434), 71 patients (17.5%; incidence rate IR 8.0 per 100 person-years pys) experienced alert events, of whom 19 (26.8%; IR 6.3 per 100 pys) subsequently developed the composite outcome. Additionally, 56 patients (13.8%; IR 16.4 per 100 pys) transitioned directly from baseline to the composite outcome. A history of ischemic cardiomyopathy (i-CMP) and atrial fibrillation (AF) was significantly associated with the occurrence of alerts (Figure 1). At three years, patients without i-CMP and AF had a 4.4% probability of experiencing an alert and a 4.2% probability of reaching the composite outcome. Conversely, patients with both i-CMP and AF had a 21.3% probability of experiencing an alert and a 20.0% probability of developing the composite outcome (Figure 2). The occurrence of an alert event did not significantly increase the risk of the composite outcome compared to patients who did not experience alerts (HR 1.32, 95% CI 0.09–17.97, P = 0.836). However, the timing of alerts played a significant role, with earlier alerts being associated with a higher risk of adverse events (HR 0.96, 95% CI 0.92–0.99, P = 0.045 per month earlier occurrence). Conclusions In HF patients with CIEDs, AF and i-CMP significantly influence disease management through RM. While the occurrence of alerts alone was not associated with an increased risk of adverse outcomes, the timing of alerts was critical, with earlier alerts indicating a higher risk.Forest plots of the association of covar Stacked predicted state occupancy probab