Remote Monitoring of Cardiac Implantable Electronic Devices: Alert Burden, Staffing and the Signals Nobody Reads

Abstract

Remote monitoring of cardiac implantable electronic devices (CIEDs) has one of the strongest evidence bases in cardiac
electrophysiology: the CONNECT trial found a nearly fivefold reduction in time from clinical event to clinical decision (4.6
versus 22 days), and a pooled analysis of three randomised trials found a 1.9% absolute reduction in 12-month all-cause
mortality (number needed to treat 52), rising to a 5.6% absolute reduction when heart-failure hospitalisation is included
(number needed to treat 18). The 2023 HRS/EHRA/APHRS/LAHRS expert consensus statement responded by codifying what a
remote device clinic needs to deliver this benefit safely -- a minimum of 3.0 full-time equivalent staff per 1,000 monitored
patients, and alert-based rather than purely time-based follow-up. Two gaps stand between this evidence and its delivery at
scale. First, only around half of eligible CIED patients are actually enrolled in remote monitoring, and facility-level
adherence among those who are enrolled has been reported to range from 46% to 96% across otherwise comparable clinics in
the same health system. Second, even a clinic staffed to the recommended ratio drowns in low-yield signal: one dedicated
heart-failure device clinic required very nearly the recommended 3.0 FTE per 1,000 patients to process its transmission
volume, yet only 2.0% of its unscheduled transmissions resulted in any management change, and a separate multi-site analysis
of over 15,000 unscheduled transmissions found that roughly 85% were not clinically actionable, with yield ranging from 79%
for ventricular tachyarrhythmia alerts down to 0.4% for false loop-recorder alerts. This review sets out the evidence for
remote monitoring's benefit, the staffing response the specialty has built to deliver it, and closes with the complication that
staffing math alone does not resolve: a clinic that meets the guideline can still be reviewing hundreds of transmissions to find
one that matters, and half of eligible patients never enter that system in the first place.