Abstract:
The invention relates to an active implantable medical device. The device includes a VNS pulse generator, an activity sensor for detecting a patient&#39;s current activity level, and a processor. The processor is configured to collect the electrical activity of the heart, such as a current intrinsic heart rate of the patient. The processor further calculates values of a reference heart rate based on the patient&#39;s current activity level. A first histogram is constructed from the reference heart rate values, and a second histogram is constructed from the intrinsic heart rate values. An index representative of the patient&#39;s condition is derived by comparing the first and second histograms.

Description:
CROSS-REFERENCE TO RELATED PATENT APPLICATIONS 
       [0001]    This application claims the benefit of and priority to French Patent Application No. 1459919, filed Oct. 16, 2014, which is incorporated herein by reference in its entirety. 
       BACKGROUND 
       [0002]    The invention relates to “active implantable medical devices” as defined by the Directive 90/385/EEC of 20 Jun. 1990 of the Council of the European Communities, namely implants for delivering stimulation therapy to the vagus nerve or to one of its branches, known as VNS (Vagus Nerve Stimulation) therapy. 
         [0003]    It more particularly relates to the use of such therapies in patients at risk of heart failure. 
         [0004]    VNS acts on cardiovascular function by reducing heart rate and myocardial contractility with decreased duration of diastole, which may help reduce the development of cardiac remodeling that may lead to heart failure. 
         [0005]    In general, patients with risk of heart failure have an increased heart rate (HR) compared to healthy patients, which may require taking drugs such as beta blockers to reduce the heart rate and thus improve the patient prognosis. 
         [0006]    A high heart rate is often a predictor of increased mortality in the general population, with a higher risk of stroke, this risk being typically increased by 3% for each increase of one beat per minute (bpm) of the average heart rate. 
         [0007]    It is also known that VNS therapies have a direct effect on heart rate by acting on the parasympathetic balance. This heart rate reduction effect occurs: 
         [0008]    In the short term, by a change in the SympathoVagal Balance (SVB) leading to a restoration of a heart rate well suited to the patient&#39;s current activity, and 
         [0009]    In the long term with beneficial effects after months of VNS therapy even if the instant restoration of SVB balance is not reached. 
         [0010]    One of the difficulties of VNS therapy lies in the adjustment of the stimulation parameters. 
         [0011]    In the short term, when dynamic change of the stimulation, depending on the patient&#39;s instantaneous activity, is required, this change is made from a variety of parameters representative of the patient&#39;s current condition such as heart rate, metabolic needs, etc. 
         [0012]    VNS therapy is then automatically controlled or modulated as a function of the level of detected current activity, for example by selection between a plurality of energy levels of VNS stimulation pulses. 
         [0013]    However, when adjustment of the VNS therapy parameters is desirable for getting a beneficial effect in the long term, this adjustment is generally left to the discretion of the physician, who does it more or less empirically. 
         [0014]    Furthermore, adjustment or readjustment of these parameters by the physician is only performed during monitoring visits, even though the patient&#39;s condition can change over time, due to VNS therapy or independently thereof, and the initial setup does not reflect these changes. 
         [0015]    Thus, techniques such as those described for example by US 2012/0095530 A1 (U.S. Pat. No. 8,433,419 B2) are used to adapt the VNS therapy to the patient&#39;s activity level. The activity level can be evaluated by an appropriate sensor such as an accelerometer integrated into the housing of the implanted VNS pulse generator. The sensor signal is compared to a set of predefined thresholds, and the VNS stimulation parameters, mainly the stimulation energy, are selectively adjusted according to the crossed thresholds, especially to adapt the therapy by allowing the expression of an increased heart rate correlated to the effort. 
         [0016]    However, with this device the modulation of VNS therapy does not take into account the medium and/or long-term evolution (e.g. one day to another and/or over a period of several days or weeks) of the pathology of the patient, in case of worsening as well as in case of improving of his/her condition. 
         [0017]    Other similar techniques have been proposed, but it is always to make a dynamic adaptation of the VNS therapy by rate response over a signal from an activity sensor or other sensor of a physiological parameter of the patient. This dynamically improves the instant effectiveness of the VNS therapy but without taking into account changes in the long term of the patient&#39;s condition. 
         [0018]    WO 2014/074523 A1 discloses a VNS stimulator for storing various physiological and stimulation data, and incorporating adaptation functions in the time of VNS stimulation, controlled for example by monitoring arrhythmias induced by therapy, or implementing a weighting of physiological events stored so as to give greater importance to recent events compared to the oldest ones. 
       SUMMARY 
       [0019]    According to one embodiment of the invention, a technique is provided to automatically adapt the parameters of a VNS therapy based on a patient&#39;s physiological activity monitored over a given period of time. A retrospective analysis over the long term of patient activity, for example over a period of one month, is performed. A comparison between an intrinsic patient heart rate (HR int ), measured by the device, and a reference heart rate (HR ref ), calculated according to the aforementioned retrospective analysis, is performed based on data produced by an activity sensor. 
         [0020]    The intrinsic heart rate HR int  may be determined from the measured inter-beat (RR) intervals, excluding all pathological cycles (especially those containing extrasystoles), those having noise, those with over-detection or under-detection, etc. 
         [0021]    For a normal patient, the values of the reference rate HR ref  calculated from the activity sensor are very close to those of the intrinsic rhythm HR int . 
         [0022]    In contrast, in the case of pathology, particularly for patients at risk of heart failure, the intrinsic rhythm HR int  will exceed the reference rhythm HR ref . 
         [0023]    However, if the patient&#39;s general condition is improving, it is assumed that: 
         [0024]    the reference rhythm HR ref  increases due to better physical activity, and simultaneously 
         [0025]    the intrinsic rhythm HR int  decreases due to the improvement of the patient&#39;s condition relative to its pathology, in part due to the issuance of VNS therapy. 
         [0026]    Therefore, the two values HR int  and HR ref  will tend to converge, leading to a diagnosis of an improved patient condition. 
         [0027]    Conversely, if the gap increases, alerts can be generated so that the physician following the patient can be warned without waiting for the next visit. 
         [0028]    Also, the parameters of the VNS stimulation may be modified according to the diagnosis of improvement or worsening of the patient&#39;s condition. 
         [0029]    Specifically, one exemplary embodiment of the invention provides an active implantable medical device for the treatment of heart failure by VNS stimulation, including in a manner in itself known, notably from the WO 2014/074523 A1 above: a VNS pulse generator and an electrode able to be placed on the vagus nerve or proximity thereof; an activity sensor, capable of delivering successive values of the patient&#39;s current level of activity; methods for collecting the electrical activity of the heart, capable of delivering successive values of the patient&#39;s current intrinsic heart rate HR int ; and methods for calculating a reference heart rate, able to calculate successive values of the reference heart rate according to the respective values of the patient&#39;s current activity level. 
         [0030]    Various embodiments of the invention further include: 
         [0031]    methods for construction of a first histogram from said reference heart rate values HR ref  calculated depending on the respective values of the patient&#39;s current activity level issued by the activity sensor, over a predetermined monitoring period; 
         [0032]    methods for construction of a second histogram, separate from the first histogram, from said intrinsic heart rate values HR int  based on the electrical activity of the heart over said monitoring period; and 
         [0033]    comparison methods adapted to compare the first and second histogram and to derive an index representative of the patient&#39;s condition at the end of the monitoring period. 
         [0034]    According to various advantageous subsidiary characteristics: 
         [0035]    the comparison methods are adapted to calculate, for each of the first and second histograms, at least one parameter of the histogram, and to compare said respective parameter(s) for deriving said index representative of the patient&#39;s condition at the end of the monitoring period; 
         [0036]    the histogram parameter belongs to the group including: maximum value of the histogram, histogram of average value, median of the histogram values, area under the histogram envelope curve, and combinations thereof; 
         [0037]    the methods of calculation of the reference heart rate are methods adapted to apply the following relationship: 
         [0000]    
       
         
           
             Fg 
             = 
             
               Basic_rate 
               + 
               
                 
                   ( 
                   
                     G_sample 
                     + 
                     
                       G_low 
                        
                       _point 
                     
                   
                   ) 
                 
                  
                 
                   
                     Max_rate 
                     - 
                     Basic_rate 
                   
                   
                     
                       G_high 
                        
                       _point 
                     
                     - 
                     
                       G_low 
                        
                       _point 
                     
                   
                 
               
             
           
         
       
     
         [0000]    Fg being the value of the reference heart rate, G_sample being the value of the patient&#39;s current activity level issued by the activity sensor, and Basic_rate, max_rate, G_high_point and G_low_point being predetermined constants; 
         [0038]    the methods of calculation of the reference heart rate are methods adapted to further operate a filtering of the calculated reference heart rate value, by applying a time constant to the heart rate reference values successively calculated; 
         [0039]    the device further comprises control means such as a controller or computer processor programmed to evaluate the changes in said index representative of the patient&#39;s condition over a plurality of successive monitoring periods; 
         [0040]    the control means may be further adapted to modify at least one operating parameter of the VNS generator according to the verification or not of predetermined criteria by said variations in said index representative of the patient&#39;s condition over said plurality of successive monitoring periods; 
         [0041]    the control means may be further adapted to trigger an alert depending on the verification or not of predetermined criteria by said variations in said index representative of the patient&#39;s condition over said plurality of successive monitoring periods. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0042]    Further features, characteristics and advantages of the present invention will become apparent to a person of ordinary skill in the art from the following detailed description of preferred embodiments of the present invention, made with reference to the attached drawings, in which like reference characters refer to like elements and in which: 
           [0043]      FIG. 1  is an overview presentation of the device of the invention, showing the pulse generator, the heart and the cervical vagus nerve as well as the leads used. 
           [0044]      FIG. 2  is a block diagram illustrating the main features of the generator of the device of the invention. 
           [0045]      FIG. 3  is a histogram, established on 24 hours, of the patient activity mean values measured by an accelerometric sensor. 
           [0046]      FIG. 4  shows the transfer function for obtaining a target value of heart rate based on the sample value of the activity signal G. 
           [0047]      FIG. 5  shows the transfer function for, with application of a time constant, getting the reference heart rate from the target heart rate. 
           [0048]      FIG. 6  shows the comparison between two histograms obtained respectively from the measured intrinsic heart rate and the reference heart rate determined by the calculation. 
           [0049]      FIG. 7  shows the evolution in the long term of the intrinsic and reference heart rates in the case of a patient whose condition does not vary significantly. 
           [0050]      FIG. 8  is homologous to  FIG. 7 , for a patient whose condition is improving due to the application of VNS therapy. 
           [0051]      FIG. 9  is a representation, in coordinates independent of time, of the two intrinsic heart rate and reference heart rate parameters whose evolution is shown in  FIG. 8 . 
           [0052]      FIGS. 10 and 11  are homologous to  FIGS. 8 and 9 , in the case wherein the initially applied VNS therapy is changed during the period. 
           [0053]      FIG. 12  is a flowchart showing the sequence of steps of a first monitoring phase of a technique of the invention. 
           [0054]      FIG. 13  is a flowchart showing the sequence of steps of a second phase of VNS therapy adjustment, of a technique of the invention. 
           [0055]      FIG. 14  is a flowchart showing the sequence of steps of a third phase, consisting of alert management, of a technique of the invention. 
       
    
    
     DETAILED DESCRIPTION 
       [0056]    An exemplary embodiment of the technique of the invention will now be described. 
         [0057]    Regarding its software aspects, the invention may be implemented by appropriate programming of the controlling software of a known stimulator of the vagus nerve (VNS stimulator). 
         [0058]    Such a pacemaker includes a programmable microprocessor provided with circuits for shaping and delivering stimulation pulses to implanted electrodes. It is possible to transmit to it by telemetry software that will be stored in memory and executed to implement the functions of the invention which will be described below. The adaptation of these devices to implement the functions of the invention is within the reach of a person skilled in the art and will not be described in detail. 
         [0059]    The method of the invention is implemented primarily by software, through appropriate algorithms performed by a microcontroller or a digital signal processor. For the sake of clarity, the various processing applied will be decomposed and schematized by a number of separate functional blocks in the form of interconnected circuits, but this representation, however, is only illustrative, these circuits including common elements in practice corresponding to a plurality of functions generally performed by the same software. 
         [0060]    In  FIG. 1 , reference  10  designates the housing of a pulse generator. The vagus nerve stimulation is delivered by a lead  12  carrying at its distal end an electrode implanted in the cervical vagus nerve  14  and able to stimulate the latter by applying pulse trains produced by the generator  10 . This technique of stimulation of the parasympathetic system is nevertheless not limiting and other methods may be used for this purpose. 
         [0061]    The generator  10  is also provided with a cardiac lead  16 . The cardiac lead is provided at its distal end  18  an electrode for collecting of the electrical activity of the heart  20 . The lead  16  collects the endocardial electrogram signals (EGM) that will deliver a signal representative of the patient&#39;s cardiac activity, in the present case the heart rate, determined by the duration of RR intervals of successive cardiac depolarizations. This technique of collection of heartbeat is however not exhaustive and other methods can be employed for this purpose. 
         [0062]    The housing  10  is also provided with an activity sensor  22 , including a motion sensor such as an accelerometer or “G sensor”. Again, this particular type of sensor is not limiting, and other collection methods of patient activity parameter can be used, for example a physiological sensor such as a minute ventilation (MV) sensor giving indication of the patient&#39;s activity level according to his/her metabolic requirements measured from the respiratory rate and tidal volume. 
         [0063]      FIG. 2  illustrates the main components of the generator  10 . 
         [0064]    The generator  10  includes a unit  24  for collecting and processing data produced by the cardiac activity sensor (lead  16 ) and the activity sensor (G sensor  22 ) to determine and calculate various parameters that will be described below. These parameters control a VNS generator  26  delivering electrical pulses to the lead  12 . The energy (current or voltage stimulation by pulses of controlled width), the burst configuration, the repetition frequency, the duty cycle, etc., of the pulses are determined by the unit  24 . 
         [0065]    The generator  10  also includes a data memory  28  for recording the data calculated by the unit  24  in order to form histograms and comparative series of data over the long term. 
         [0066]    The generator  10  is also provided with a communication interface  30 , allowing the generator  10  to exchange by telemetry data with external devices such as a programmer  32  and/or a home monitoring device  34 . This allows for remote transmission of information stored in memory  28  to a remote site for daily monitoring of the patient from this remote site. 
         [0067]    The method by which the signals collected by the sensors are processed within the generator  10  according to various teachings of the invention will now be described in detail. 
         [0068]    According to one embodiment, this therapy consists of three phases, namely: 
         [0069]    a patient monitoring phase (the details of which will be given in reference to the flowchart in  FIG. 12 ) for producing series of data of reference heart rate HR ref  and of intrinsic heart rate HR int , memorizing these series in the long term, establishing histograms and extracting these indicators of the patient&#39;s condition over the long term; 
         [0070]    a phase of adjustment of the parameters of the VNS stimulation (the details of which will be given in reference to the flowchart in  FIG. 13 ) according to the status indicators obtained during the previous phase; and 
         [0071]    a possible phase of delivering of alerts (the details of which will be given in reference to the flowchart in  FIG. 14 ), intended to warn the doctor in case of worsening of the patient&#39;s condition. 
       First Phase: Monitoring and Evaluation of the Patient&#39;s Condition 
       [0072]    The period of supervision or monitoring is the period during which the data is collected, processed and analyzed to then estimate the change in the long term of the patient&#39;s condition. This period may be fixed or variable. In this example, the monitoring period is set at 24 hours but may be set for any amount of time (one week, one month, etc.) or vary according to the condition of the patient (e.g., a more critical or less critical condition). 
         [0073]    During this monitoring period, two parameters are measured continuously, namely the heart rate (HR) and the patient&#39;s activity level. 
         [0074]    If the activity level is measured by an acceleration sensor (G sensor), the signal is filtered to keep only a bandwidth of typically between 0.6 and 6 Hz to remove the static component according to the patient position and experienced external vibrations, especially when the patient takes a mode of transport. The filtered signal is then averaged, e.g. over a period of Y=6 s, resulting in a sample G mean  of average activity level, issued every Y seconds. 
         [0075]    The distribution of these G mean  activity values over a period of e.g. 24 hours is illustrated in  FIG. 3 . 
         [0076]    According to one exemplary embodiment, this G mean  activity level value is used to determine a value of the reference heart rate HR ref  corresponding to the expected heart rate of the patient if he/she was healthy, for his/her activity level. 
         [0077]    This reference heart rate HR ref  is calculated every X cardiac cycles, typically X=4 cycles, depending on the last sample delivered by the activity sensor. 
         [0078]    The following linear relationship is applied for this purpose, which defines the transfer function of the G sensor: 
         [0000]    
       
         
           
             Fg 
             = 
             
               Basic_rate 
               + 
               
                 
                   ( 
                   
                     G_sample 
                     + 
                     
                       G_low 
                        
                       _point 
                     
                   
                   ) 
                 
                  
                 
                   
                     Max_rate 
                     - 
                     Basic_rate 
                   
                   
                     
                       G_high 
                        
                       _point 
                     
                     - 
                     
                       G_low 
                        
                       _point 
                     
                   
                 
               
             
           
         
       
     
         [0000]    Fg being a heart rate corresponding to a target value HR target , G_sample being the last signal sample value issued by the G sensor, and Basic_rate, G_low_point, G_high_point and Max_rate being custom constants, parameterized by the physician based on the physical activity of each patient; alternatively, these values can be set to an arbitrary average value, as long as they do not change over time. 
         [0079]      FIG. 4  illustrates the transfer function HR target =f (G_sample) corresponding to the relationship given above. 
         [0080]    HR target , which is calculated every four cardiac cycles, is raw data with rapid changes, for example during rest/activity/recovery cycles, as shown in  FIG. 5 . 
         [0081]    Additional filtering is needed to reproduce the natural smoothing of the changes in heart rate between rest and activity, by application of a time constant according to a technique described for example in EP 0657187 A1 (Sorin CRM S.A.S). The resulting value is the reference heartbeat HR ref  that will be used later in the data processing. 
         [0082]    In  FIG. 5 , the patient is initially in a resting phase, the two HR target  and HR ref  values being at a value corresponding to the patient&#39;s baseline rhythm. During the exercise phase that follows, heart rate HR target  immediately goes to 100 bpm, while reference heart rate HR ref  increases slowly until reaching the HR target  value after about sixty seconds. When the exercise is completed, HR target  immediately falls to 60 bpm during the recovery phase, while the reference heart rate HR ref  slowly decreases to this value after about thirty seconds. 
         [0083]    A histogram of HR ref  values thus calculated is established on the duration of the monitoring period.  FIG. 6  shows the histogram. 
         [0084]    Meanwhile, during the same monitoring period, the patient&#39;s intrinsic heart rate is measured, and a second histogram is constructed from the values HR int  thus obtained. 
         [0085]    The intrinsic heart rate is the “normal-normal” rate determined from the detected RR intervals, excluding abnormal cycles (including extrasystoles) or insignificant cycles (especially noise cycles). Reference may be made for this definition to “Heart Rate Variability. Standards of Measurement, Physiological Interpretation, and Clinical use. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology.” Eur Heart J, 17 (3): 354-381 (1996). 
         [0086]    Note that both HR ref  and HR int  histograms include the same basic statistical parameters, namely bins of the same duration, typically 5 bpm, and sampling at a same frequency, typically every four cardiac cycles. 
         [0087]    At the end of each monitoring period (typically daily), each of the two histograms HR ref  and HR int  thus formed is analyzed on the basis of one or more parameters characterizing the histogram (e.g. maximum value reached, average value, median and/or area included under the curve, or any other statistical relationship between the two histograms). A representative daily index is then stored for HR ref  and for HR int . 
         [0088]      FIG. 12  shows in flowchart form the various successive steps of this monitoring phase. 
         [0089]    When the G sensor provides new data (block  100 ), the reference heart rate HR ref  is calculated as shown above (block  102 ) and the corresponding histogram is updated. 
         [0090]    Meanwhile, when new heart rate data to calculate the intrinsic rhythm is available (block  104 ), the HR int  value is recalculated and the corresponding histogram is updated (block  106 ). 
         [0091]    At the end of the monitoring period (block  108 ) the two histograms are compared (block  110 ), depending on the different parameters that can characterize each histogram (average value, median value, maximum value, area under the curve, statistical test, etc.). If a significant difference is detected (e.g., a difference value above a threshold value) (block  112 ), a STATE flag is set to ‘OK’ or ‘NOK’ and the histograms are reset (blocks  114 ,  116 ). Data for HR ref  and HR int  are then stored (block  118 ) for further evaluation. 
       Second Phase: Analysis of the Evolution of the Patient&#39;s Condition 
       [0092]    The indexes obtained daily for HR ref  and HR int  values, which reflect the condition of the patient at a given day, are compared in order to assess their relative change in the long term. 
         [0093]      FIG. 7  illustrates an example of evolution of these indexes over approximately one month. It is noted that, in this case, the gap AHR between the two curves HR ref  and HR int  remains substantially constant, indicating that the patient&#39;s condition remains stationary. 
         [0094]      FIG. 8  is similar to  FIG. 7 , after insertion of a VNS therapy continued throughout the duration of the study. 
         [0095]    VNS therapy should normally increase HR ref  (under the effect of the patient&#39;s improvement to achieve physical activity) and decrease HR int , which is what is seen on the curves in  FIG. 8 . 
         [0096]    Therefore, a significant improvement in the patient&#39;s condition can be diagnosed as the result of applied VNS therapy. 
         [0097]    In a functional representation as illustrated  FIG. 9  (with HR int  versus HR ref ), it can be seen that the two parameters are associated approximately linearly with a negative slope reflecting the favorable evolution of the patient&#39;s condition under the effect of the applied therapy (“VNS” arrow). 
         [0098]      FIGS. 10 and 11  are homologous to  FIGS. 8 and 9 , in a situation wherein the VNS therapy initially applied (VNS 1 , for example stimulation by bursts of four pulses of 3 mA, 0.24 ms width, with a 1/1 duty cycle and a sequencing of 10″/30″) has been changed after a fortnight (VNS 2 , for example stimulation by bursts of 2 pulses of 2 mA, 0.24 ms width, with a 1/1 duty cycle and a sequencing of 10″/30″), for example with increase/decrease of the stimulation energy, change in frequency and/or content of the pulse bursts, of their duty cycle, etc. Note that 10″/30″ sequencing refers to a repeated pattern of 10 seconds of active VNS stimulation followed by 30 seconds of no stimulation. 
         [0099]    It is then found that, after having converged (improvement of the patient&#39;s condition), the two curves come to deviate, this reflecting degradation of the patient&#39;s condition after the therapy has been modified from VNS 1  and VNS 2 . 
         [0100]    On the functional representation of  FIG. 11 , the squares illustrate the successive values recorded during the first period, while the diamonds illustrate those recorded during the second period. There is a reversal of direction (between the “VNS 1 ” arrow and the “VNS 2 ” arrow), reflecting in the second period a deterioration of the condition of the patient because of the new therapy. 
         [0101]    In response, the parameters of VNS therapy may be adjusted so as to return to a configuration improving the patient&#39;s condition. 
         [0102]    This re-setting may be performed periodically, for example weekly, until the gap between the two HR ref  and HR int  curves decreases below a predefined threshold (HR ref , which is a calculated value based on patient activity, representing the ideal towards which HR int  must converge). 
         [0103]    The periodicity of the adjustment of VNS parameters can be the same as the monitoring period (e.g. daily), or much longer than the monitoring period (for example weekly) to adjust VNS therapy more slowly. 
         [0104]      FIG. 13  shows in flowchart form the steps of this phase of adjustment of VNS parameters. 
         [0105]    At the end of the predetermined duration of the adjustment phase (block  200 ), the indicator STATUS is tested (block  202 ). If this is the value ‘OK’, an ALERT parameter is set to ‘OK’, meaning that the patient is compliant and does not trigger any alert. 
         [0106]    In this case, the VNS therapy should be reassessed at regular intervals (block  214 ). If that time is reached, for example after seven consecutive ‘OK’ days, the level of VNS stimulation is reduced (block  216 ). For example, the number of pulses of each VNS burst is reduced by one, and if a lower limit is reached, for example two pulses per burst, then the current supplied is decreased by a step (typically 0.5 mA). 
         [0107]    If the STATUS indicator is ‘NOK’, then the device examines whether the level of VNS stimulation is at its maximum (block  206 ). If so, the ALERT parameter is set to ‘MAXIMUM REACHED’, to signify that, although the indicator&#39;s status is unsatisfactory, the VNS stimulation has reached the maximum level it was possible to issue (block  208 ). Otherwise, the level of VNS stimulation is increased (block  210 ) and the ALERT parameter is set to ‘INCREMENT’ (block  212 ) to indicate that it was necessary to apply to the patient a higher VNS therapy. For example, the number of VNS pulses of each burst is increased by one unit, and if an upper limit is reached, for example, four pulses per burst, then the delivered current is increased one step (typically 0.5 mA). 
         [0108]    However, to decrease or increase the effect on heart rate, any other parameter can be modulated to achieve the desired effect (pulse frequency, QRS-VNS burst delay, etc.). 
       Third Phase: Management of the Alerts 
       [0109]    If HR ref  and HR int  curves come to diverge (as in the second period illustrated  FIG. 10 ), it may be desirable to warn the physician without waiting for the follow-up visit, for example by generating an alert and by transmitting it to a remote site via a home monitoring system. 
         [0110]      FIG. 14  illustrates, in flowchart form, the different steps of the third phase of alert management. 
         [0111]    At the end of the predetermined time of alert management (block  300 ), for example daily, the ALERT flag is examined (block  302 ). If it is not at the ‘OK’ value, then the values of the STATUS and ALERT indicators are remotely transmitted (block  304 ) for analysis and possible action by the practitioner, typically using a home monitoring system connected to a remote site.