The End of the Waiting Room? Virtual Monitoring of Pacemakers and Defibrillators Proves as Safe as Clinic Visits — and Cheaper
Every year, roughly 1.25 million people worldwide have a pacemaker or an implantable cardioverter defibrillator (ICD) fitted in their chest — and every one of those devices must be checked, over and over, for the rest of the patient’s life. For decades, that has meant a familiar ritual: a trip to a specialist clinic, a waiting room, and a technician waving a wand over the chest to interrogate the implanted hardware through the skin. Two randomized trials presented at ESC Congress 2026 in Munich suggest that ritual may no longer be strictly necessary. A virtual e-health system known as VIRTUES, which replaces routine clinic visits with remote device transmissions and direct digital communication between physicians and patients, proved as safe and as effective as standard in-clinic care over 18 months of follow-up. It also cut costs for both health systems and patients, and earned what the investigators describe as overwhelmingly positive reviews from the people who actually used it.
The stakes are easy to underestimate. A pacemaker is a small, hermetically sealed generator implanted beneath the skin near the collarbone and connected to the heart by thin insulated wires called leads. It continuously surveys the heart’s electrical activity and delivers precisely timed electrical pulses whenever the natural rhythm slows to a dangerous degree, a condition known as bradycardia. An ICD performs the same round-the-clock surveillance but adds a life-saving escalation: when it detects a lethal rapid rhythm such as ventricular tachycardia or ventricular fibrillation, it can fire a burst of antitachycardia pacing or deliver an internal electric shock that resets the heart within seconds. Both devices run on batteries that deplete over years, both depend on leads that can fracture or degrade, and both quietly log every arrhythmia the patient experiences along the way. Implantation, in other words, is not the end of treatment but the start of a surveillance obligation that can span decades — one covering battery longevity, lead integrity, sensing and pacing thresholds, and any emerging rhythm disturbances.
At present, that obligation is discharged largely in person. Patients travel to device clinics, sometimes across considerable distances, taking time away from work and family, while health systems must staff those clinics and process thousands of appointments. Remote monitoring technology already exists — most modern implants can radio their data to a bedside transmitter that forwards it over telephone or cellular networks — and it has proven useful for catching problems between appointments. But in most health systems it supplements the clinic-based model rather than replacing it. “Globally, around 1.25 million people are implanted with devices like pacemakers every year,” said principal investigator Professor Ratika Parkash of Dalhousie University in Halifax, Canada, who led the VIRTUES research programme. “It is important to follow these patients over their lifetimes to check their devices are working well; however, this entails regular visits to specialist clinics, which can be burdensome for the patient and healthcare system.”
VIRTUES was designed to test whether that burden could be lifted almost entirely. The platform routes transmission reports generated by a patient’s implanted device directly to the responsible physician, who reviews the incoming data — battery status, lead performance, arrhythmia episodes and device alerts — and then sends messages to the patient describing how well the device is working. Care becomes a continuous digital conversation rather than a calendar of appointments, with the clinic held in reserve for genuine need. Importantly, the trials did not strand patients in a purely virtual world: unscheduled in-clinic visits remained available in both the experimental and control groups whenever device-related concerns arose. In effect, VIRTUES represents a wholesale redesign of device follow-up, in which the virtual channel becomes the primary pathway of care and the clinic visit becomes the exception rather than the rule.
The evidence comes from two companion randomized trials — VIRTUES PM, enrolling patients with pacemakers, and VIRTUES ICD, enrolling those with defibrillators — conducted at 13 centres across Canada. In total, 1,115 patients carrying a compatible device were randomly assigned, one to one, to one of two care pathways for 18 months: the VIRTUES platform, consisting of remote monitoring with virtual care communications only, or standard care, consisting of routine in-clinic visits with or without conventional remote monitoring. The participants had a mean age of 67 years, and 27% were women. Randomization is the most powerful safeguard in clinical research against bias, ensuring that any differences in outcomes reflect the model of care rather than differences between patients. And because patients and clinicians inevitably knew which pathway they were on, the trials anchored their conclusions in hard, objectively measured events — death, stroke and hospitalization — rather than subjective impressions. Because the goal was to show that virtual follow-up is not worse than the traditional kind, the studies were framed as noninferiority trials, a statistical design in which a new approach must demonstrate that it does not fall beyond a predefined threshold of acceptable risk relative to the existing standard.
The primary safety outcome was a composite endpoint — a single measure combining several clinically serious events — defined as death, stroke, cardiovascular hospitalization or device-related hospitalization during the 18-month follow-up. Composite endpoints of this kind are standard in cardiology research because the individual components are relatively uncommon, yet together they capture a patient’s overall clinical trajectory. In the ICD trial, 11.0% of patients managed through VIRTUES reached the composite endpoint, compared with 11.2% under standard care, satisfying the noninferiority criterion with p=0.007. In the pacemaker trial, the corresponding figures were 6.1% versus 7.4%, again noninferior, with p=0.0213. In plain terms, patients whose follow-up moved almost entirely into the virtual realm fared no worse than those who kept travelling to the clinic — the fundamental question that any challenger to a decades-old standard of care must answer first.
Effectiveness told a similar story — and, in one arm of the research, arguably a better one. The primary efficacy endpoint measured the time from a clinically important event, such as an arrhythmia or a device issue, to a clinic decision in response. In the ICD trial, the median difference was just one day, with noninferiority met at p<0.0001: virtual care did not meaningfully delay the medical response to serious events. In the pacemaker trial, the direction actually favoured VIRTUES, with a median difference of −3.25 days — a signal pointing toward superiority, alongside p<0.0001 for noninferiority. For patients whose pacemakers flagged an arrhythmia or a technical problem, the clinical decision arrived sooner rather than later when care ran through the virtual system, plausibly because data flowed continuously to physicians instead of accumulating until the next scheduled appointment. The finding punctures one of the most persistent anxieties about digital medicine: that removing the physical encounter also removes the urgency.
Then there is the money. The trials recorded an adjusted total difference of 77 Canadian dollars per patient in favour of the VIRTUES platform, driven primarily by lower costs to the healthcare system and to patients as a result of fewer in-clinic visits — less staffing of device clinics on one side of the ledger, less travel, parking and lost time on the other. The figure looks modest at the level of the individual patient, but the arithmetic of scale transforms it. “We estimate this system could save around $10 million annually in Canada alone,” Professor Parkash noted. With roughly 1.25 million new implants worldwide every year, expanding indications for both pacemakers and ICDs, and ageing populations that guarantee future demand, the potential savings in larger health systems grow correspondingly larger.
What may prove most consequential of all, however, is how patients felt about it. Participants in the virtual arm were strongly supportive of the digital approach, the investigators reported — a notable result in a field where digital health projects often stumble on patient engagement. The system gave people a sense of control over their own care: rather than waiting for the next appointment to learn whether their heart device was behaving, they received direct messages telling them how well it was working. Most said they would keep using the platform if given the opportunity. “In addition to similar safety and efficacy and the cost savings, patients were strongly supportive of this digital approach,” said Professor Parkash, who described the results as overwhelmingly positive for patients. “We have shown that the VIRTUES system is both patient centric and reduces the clinic burden, which can be challenging to demonstrate in digital health studies.”
The caveats are real but clearly bounded. Both trials were conducted entirely in Canada, a country with a single-payer health system and vast geographic distances that make virtual care especially attractive; the results have not yet been tested in other regions, or under other models of healthcare financing and delivery. Professor Parkash is explicit about that limitation. “The VIRTUES system could be scalable for use globally although it has only been tested in Canada so far and further studies would be needed in other regions,” she concluded. Even so, the VIRTUES findings stand among the clearest demonstrations yet that a fully virtual model of chronic device care can match the safety and speed of in-person medicine while costing less and satisfying patients more. For the more than a million people who will receive a pacemaker or a defibrillator next year, the message from Munich is quietly radical: the most important appointment in their cardiac follow-up may soon be the one they never have to attend.
Subject of Research: Randomized evaluation of the VIRTUES virtual e-health remote monitoring platform versus standard in-clinic care for follow-up of patients with pacemakers and implantable cardioverter defibrillators
Subject of Research: Medicine
Article Title: “Overwhelmingly positive” results reported with a virtual e-health system (VIRTUES) to monitor cardiac implantable electronic devices
Article References: European Society of Cardiology. (2026, August 29). “Overwhelmingly positive” results reported with a virtual e-health system (VIRTUES) to monitor cardiac implantable electronic devices [Press release]. EurekAlert! Original publication
Image Credits: AI Generated
DOI: Not provided
Keywords: VIRTUES, remote monitoring, pacemaker, implantable cardioverter defibrillator, cardiac implantable electronic devices, digital health, e-health, noninferiority trial, telemedicine, ESC Congress 2026, patient-centred care, cost-effectiveness
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Ophelia Keating. (August 29, 2026). Virtual e-health system VIRTUES shows overwhelmingly positive results for monitoring cardiac devices. Scienmag. https://scienmag.com/virtual-e-health-system-virtues-shows-overwhelmingly-positive-results-for-monitoring-cardiac-devices/
Ophelia Keating. “Virtual e-health system VIRTUES shows overwhelmingly positive results for monitoring cardiac devices.” Scienmag, 29 August 2026, https://scienmag.com/virtual-e-health-system-virtues-shows-overwhelmingly-positive-results-for-monitoring-cardiac-devices/. Accessed 29 August 2026.
Ophelia Keating. “Virtual e-health system VIRTUES shows overwhelmingly positive results for monitoring cardiac devices.” Scienmag. August 29, 2026. https://scienmag.com/virtual-e-health-system-virtues-shows-overwhelmingly-positive-results-for-monitoring-cardiac-devices/
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