Guardian System
Device Facts
| Record ID | P150009 |
|---|---|
| Device Name | Guardian System |
| Applicant | Avertix Medical, Inc. |
| Product Code | QBI · Cardiovascular |
| Decision Date | Apr 9, 2018 |
| Decision | APPR |
| Device Class | Class 3 |
Indications for Use
The AngelMed Guardian System is an implantable cardiac monitor with patient alerting capability and an additional external alarm device. The Guardian System is indicated for use in patients who have had prior acute coronary syndrome (ACS) events and who remain at high risk for recurrent ACS events. The Guardian System is indicated as an adjunct to patient recognized symptoms. The Guardian System detects potential ongoing ACS events, characterized by sustained ST segment changes, and alerts the patient to seek medical attention for those potential ACS events. A Guardian System alert is a more accurate predictor of ACS events when compared to patient recognized symptoms alone and demonstrates a reduced rate over time of patient presentations without ACS events (false positives) when compared to patient recognized symptoms alone. In the absence of symptoms, the Guardian System may identify asymptomatic ACS events and prompt the patient to seek medical attention.
Device Story
System comprises an implantable medical device (IMD), external device (EXD), and programmer. IMD is implanted in a left pectoral subcutaneous pocket with a transvenous endocardial lead in the right ventricular apex. IMD monitors intracardiac electrograms in real-time, assessing ST segment changes (elevation/depression) against a 24-hour running baseline. If ST shifts exceed a programmable threshold, IMD vibrates and signals EXD to provide audible/visual alerts. EXD provides redundant patient notification. Programmer is used by clinicians to configure the device and retrieve stored electrograms. Device alerts patients to seek medical attention for potential ACS events, including asymptomatic cases. Output assists healthcare providers in diagnosing ACS, potentially reducing time-to-treatment and improving diagnostic accuracy compared to symptom-based monitoring alone.
Clinical Evidence
PMA supported by the ALERTS clinical study (IDE G060259), a Bayesian adaptive randomized trial (n=907) followed by an extended retrospective analysis of ED visits. Primary safety endpoint (complication rate <10%) met. Effectiveness analysis showed ALARMS ON group had higher PPV (25.80% vs 18.23%) and lower FPR (0.164 vs 0.678 FP/pt-year) compared to ALARMS OFF. Study included 3,450 implant years; overall complication rate 6.92%.
Technological Characteristics
System includes IMD, EXD, and Programmer. IMD uses transvenous active-fixation endocardial bipolar pacing lead. Sensing via can-tip vector. Connectivity via RF telemetry. Biocompatibility per ISO 10993. Electrical safety per IEC 60601-1. Sterilization via ethylene oxide. Software life cycle per IEC 62304.
Indications for Use
Indicated for patients >21 years old with prior ACS events (MI, unstable angina, or CABG within 6 months) at high risk for recurrence. Contraindicated in patients with cognitive impairment, inability to feel IMD vibration, existing pacemaker/ICD/CRT, or inability to safely place a pacemaker lead.
Regulatory Classification
Identification
Detect Acute Coronary Syndrome events and prompt the patient to seek medical attention.
Submission Summary (Full Text)
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SUMMARY OF SAFETY AND EFFECTIVENESS DATA (SSED)
I. GENERAL INFORMATION
Device Generic Name: Acute Coronary Syndrome Event Detector
Device Trade Name: AngelMed Guardian System
Device Procode: QBI
Applicant's Name and Address: Angel Medical Systems, Inc.
788 Shrewsbury Avenue, Suite 2200
Tinton Falls, New Jersey 07724
Date(s) of Panel Recommendation: March 16, 2016
Premarket Approval Application (PMA) Number: P150009
Date of FDA Notice of Approval: April 9, 2018
II. INDICATIONS FOR USE
The AngelMed Guardian System is an implantable cardiac monitor with patient alerting capability and an additional external alarm device. The Guardian System is indicated for use in patients who have had prior acute coronary syndrome (ACS) events and who remain at high risk for recurrent ACS events.
The Guardian System is indicated as an adjunct to patient recognized symptoms. The Guardian System detects potential ongoing ACS events, characterized by sustained ST segment changes, and alerts the patient to seek medical attention for those potential ACS events.
A Guardian System alert is a more accurate predictor of ACS events when compared to patient recognized symptoms alone and demonstrates a reduced rate over time of patient presentations without ACS events (false positives) when compared to patient recognized symptoms alone.
In the absence of symptoms, the Guardian System may identify asymptomatic ACS events and prompt the patient to seek medical attention.
III. CONTRAINDICATIONS
The AngelMed Guardian System should not be implanted in:
1. Patients with cognitive impairment that would prevent recognition of alarms
2. Patients who cannot feel the vibration from the IMD
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3. Patients with implanted pacemaker, implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT) devices
4. Patients where a pacemaker lead cannot be placed safely
## IV. WARNINGS AND PRECAUTIONS
The warnings and precautions can be found in the AngelMed Guardian System labeling.
## V. DEVICE DESCRIPTION
The AngelMed Guardian System consists of three (3) main components which are shown in Figure 1 below and described in further detail below:
1. Implantable Medical Device (IMD)
2. External Device (EXD)
3. A Programmer
Figure 1 - Guardian System Component Diagram
## Implantable Medical Device (IMD)
The IMD is implanted in a left pectoral subcutaneous pocket, similar to a permanent pacemaker, and connects to a market approved, IS-1, transvenous active-fixation endocardial bipolar pacing lead which is placed in the right ventricular apex. Using a can-tip vector, the IMD monitors the intracardiac electrograms gathered in real time to assess for ST segment changes including ST depression and elevation. If the device detects an excessive ST shift relative to the baseline ST segment, and if the ST shift exceeds a pre-programmed threshold, the IMD vibrates to warn the patient and simultaneously signals the patient's external device (EXD) to provide redundant audible
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and visual external warning. The IMD also stores electrograms for subsequent retrieval by the Programmer via wireless telemetry.
# Patient External Device (EXD)
The Patient EXD is a telemetry device given to each patient, which provides the redundant auditory and visual alerts via beeps and flashing LEDs when the IMD detects a cardiac event. The front of the EXD contains the Emergency and See Doctor indicator lights, and the Silence Alarm/Check Battery button. The back of the EXD contains a metal ring for attaching the neck cord if desired.
# Programmer
The Programmer is a specially configured portable computer used to configure the IMD and retrieve and store IMD patient data, including electrograms collected by the IMD. The Programmer uses an RF telemetry interface through a Wand EXD to communicate with the IMD.
# Device Functionality
The Guardian System's detection algorithm collects 10 second electrograms every 90 seconds (or 30 seconds if the previous segment was characterized as abnormal) and compares each against a running baseline that it develops from far-field electrograms, measured between the tip of the lead and the IMD can, it acquired over the previous 24 hour period. Specifically, it compares the ST deviation of each sampled beat to that of the baseline, and then compares that difference to the height of the baseline's R wave. (The ST deviation is the average voltage difference between a beat's ST and PQ segments.) These elements of the electrogram are shown in the figure below.
Figure 2 - Detection Algorithm Visualization
If the difference exceeds the ischemia threshold established for the patient, which is a programmable and adjustable value, the beat is considered shifted. Within an electrogram, it takes six (6) shifted beats to declare the electrogram shifted. If three (3) consecutive shifted electrograms occur, the device records this as a detection of a possible ischemic event. The algorithm also tracks the heart rate by measuring the R-to-R interval and classifies the average heart rate of each electrogram as low, irregular, normal, elevated, or high. If the heart rate is low, normal, elevated or irregular, the
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electrogram will be assessed for ST segment shifts. If the calculated ST shift meets criteria, then the algorithm initiates an emergency vibratory and auditory alarm. If the heart rate is "high", then the electrogram will not be assessed for ST shifts. A "high" heart rate is defined by a programmable value and the default value is 160 bpm. In addition to the emergency alarm, there is also a "See Doctor" alert which has a different vibratory and auditory pattern and this alert can be triggered by high heart rates, low battery, or ST shifts specifically detected when the heart rate is abruptly decreasing, which the device presumes is exercise-induced ischemia due to increased demand and workload.
## VI. ALTERNATIVE PRACTICES AND PROCEDURES
There are no alternatives to the proposed device for near real-time, outpatient monitoring for ACS events. Current patients at risk for ACS must rely only on patient recognized symptoms to prompt them to seek medical attention.
## VII. MARKETING HISTORY
The AngelMed Guardian System has received market approval in the following entities:
| Approving Entity | Date of Market Approval |
| --- | --- |
| European Union (CE Mark) | February 24, 2010 |
| Brazil | November 11, 2013 |
## VIII. PROBABLE ADVERSE EFFECTS OF THE DEVICE ON HEALTH
Below is a list of the probable adverse effects (e.g., complications) associated with the use of the system.
- Air embolism
- Allergic reaction
- Bleeding
- Body rejection phenomena including local tissue reaction
- Cardiac dissection
- Cardiac perforation
- Cardiac tamponade
- Chronic nerve damage
- Damage to the vessel at the catheter insertion site
- Death
- Device failure resulting in removal or replacement
- Endocarditis
- Erosion
- Excessive fibrotic tissue growth
- Extrusion
- False negative (FN) device alarms
- False positive (FP) device alarms
- Fluid accumulation
- Formation of fibrotic tissue, local tissue reaction
- Formation of hematoma or cysts
- Induced ventricular ectopy
- Infection
- Ischemia
- Keloid formation
- Lead abrasion and discontinuity
- Lead migration/dislodgment
- Loss of sensing due to dislodgement or mechanical malfunction of the lead
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- Myocardial damage
- Myocardial irritability
- Nausea and vomiting
- Pain in shoulder or arm
- Palpitations
- Pericardial effusion
- Pericardial rub
- Pneumothorax
- Procedure related, random component failure
- Shunting current or insulating myocardium during defibrillation
- Stroke from a clot being disloged by the catheter
- Thromboemboli
- Thrombosis
- Valve damage
- Vascular complications, which may require vessel repair
- Vein wall rupture
- Venous occlusion
- Venous perforation
- Ventricular fibrillation
- Visible bump at implant site that may cause discomfort under clothing
For the specific adverse events that occurred in the clinical study, please see Section X below.
## IX. SUMMARY OF NONCLINICAL STUDIES
### A. Laboratory Studies
Table 1 below details the non-clinical testing performed on the device. As described in Section V above there are three (3) major components: Implantable Medical Device (IMD), External Device (EXD), and Programmer (PROG) and testing denoted with IMD, EXD, or PROG refers to testing that was only performed on that specific component.
Table 1. Summary of Non-Clinical Testing
| Electromechanical Environmental Effects | | | |
| --- | --- | --- | --- |
| Test | Purpose | Acceptance Criteria | Results |
| EAS (Electromagnetic Article Surveillance) | | | |
| Tag Deactivator | To assess the Electromagnetic Environmental Effects on the Guardian system | ASTM F1608 | Pass |
| Metal Detector | | | |
| RFID | | | |
| Microbial Challenge | | | |
| Tensile | | | |
| Burst | | | |
| Dye | | | |
| FCC Certification | | | |
| Test | Purpose | Acceptance Criteria | Results |
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| IMD: | To assess the compliance of the IMD with FCC requirements | ETSI EN 300 220-1: 2010
ETSI EN 300 220-2: 2010
ETSI EN 301 489-1: 2008
ETSI EN 301 489-27: 2004
ETSI EN 301 839-1: 2009
ETSI EN 301 839-2: 2009
IEC 60601-1-2:2007
FCC (47 CFR Part 95) EN45502 | Pass |
| --- | --- | --- | --- |
| EXD: | To assess the compliance of the EXD with FCC requirements | 47 CFR (FCC) Part 95.628
47 CFR (FCC) Part 95.631
47 CFR (FCC) Part 95.633
47 CFR (FCC) Part 95.635
47 CFR (FCC) Part 15.209
CISPR 16-1 (2003)
ETSI EN 300 220, 2000
ETSI EN 301 839-1
ETSI EN 301 489-1, 2002
ETSI EN 301 489-27
IEC 60601-1-2: 2001
IEC 61000-4-2, 2002
IEC 61000-4-3, 2002
IEC 61000-4-6, 2003 | Pass |
| PROG: | To assess the compliance of the PROG with FCC requirements | IEC 60601-1-2:2007/IEC
CISPR:2006
IEC 60601-1-2:2007 clause 17
IEC 60601-1-2:2007 clause 6.2 | Pass |
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| Cellular Phone Interference | | | | |
| --- | --- | --- | --- | --- |
| Test | Purpose | Acceptance Criteria | Results | |
| Analog (AMPS) method
CDMA (Cellular)
CDMA (PCS)
TDMA - 50Hz (Cellular)
TDMA - 50Hz (PCS)
TDMA - 217Hz (GSM-850)
TDMA - 217Hz (GSM-900)
TDMA - 217Hz (DCS-1800)
TDMA - 217Hz (DCS-1900) | To assess the effects of various cellular phone types on the Guardian system | 11 possible interference levels/ categorizations were pre-defined and measured | Pass: Only the following interference levels were observed:
- ‘No interaction’
- ‘Minor Interference; does not impair normal IMD operation | |
| Mechanical & Environmental | | | | |
| Test | Purpose | Acceptance Criteria | Results | |
| IMD:
Weight
Dimensions
AMSG3 Vibration
Characterization Testing
Hermeticity
Radiopaque identification
Operating/storage
temperature/humidity
Temperature shock
Operating/storage atmospheric pressure
Drop (free fall)
Transportation vibration
Operational vibration
Header torque testing
Header push-off testing
AMSG3 Header Insulation Testing
AMSG3 Amplifier/Filter Characterizations | To assess the compliance of the IMD with various Mechanical and Environmental requirements | EN 45502-1:1998
ISO 5841-3:2007
BS EN 50077:1993 | Pass | |
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| EXD: | To assess the compliance of the EXD with various Mechanical and Environmental requirements | EN 45502-1:1998
IEC 60601-1: 2001 | Pass |
| --- | --- | --- | --- |
| Weight
Dimensions
Operating/storage
temperature/humidity
Temperature shock
Excessive Temperatures
Operating/storage atmospheric pressure
Drop (free fall)
Transportation vibration
Operational vibration | | | |
| PROG:
Transport/Storage
Operating
Excessive Temperature
Strength/ Rough Handling
Sinusoidal Vibration (sweep)
Random Vibration
Bump
Free Fall from 75cm
Usage Temperature
Storage Temperature
Humidity | To assess the compliance of the PROG with various Mechanical and Environmental requirements | IEC 60601-1:2005 clause 7.9.3
IEC 60601-1:2005 clause 11.1.1
IEC 60601-1:2005 clause 11.1
IEC 60601-1:2005 clause 15.3
EN 13718-1 4.7.2 Annex A.1
EN 60068-2-6
EN 60068-2-64
EN 60068-2-29
EN 60068-2-32
EN 13718-1 4.2.2
EN 13718-1 4.7.3
EN 60601-1:1990 clauses 10 and 44 | Pass |
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| Electrical Safety | | | |
| --- | --- | --- | --- |
| Test | Purpose | Acceptance Criteria | Results |
| IMD:
Amplifier Input Protection
Electric Shock
Defibrillation
Ultrasound
Radiated Immunity
Energy Delivered
Energy Extracted | To assess the compliance of the IMD with electrical safety standards | EN 45502-1:1998 | Pass |
| EXD:
Electric Shock
Energy Delivered
Energy Extracted | To assess the compliance of the EXD with electrical safety standards | IEC 60601-1: 2001 | Pass |
| PROG:
Electric Shock
Leak Current | To assess the compliance of the PROG with electrical safety standards | IEC 60601-1:2005 clauses 6.1, 8.1, and 8.5 | Pass |
| Human Factors | | | |
| Test | Purpose | Acceptance Criteria | Results |
| Guardian System Risk Assessment | To identify potential hazards of the Guardian system along with the possible causes, mitigation, and risk assessment. | No issues found | Pass |
| Guardian System Human Factors Risk Identification | To identify the Human Factors use issues associated with the Guardian system components | No issues found | Pass |
| Guardian Task Analysis And Use Error Risk Assessment | To examine the potential use error and mitigation for all anticipated patient-and clinician-related tasks. | No issues found | Pass |
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| Vibratory And Auditory Alarm Characteristics | To finalize the vibration and frequency characteristics alarm and alert patterns | No issues found | Pass |
| --- | --- | --- | --- |
| Learning and Memory of Emergency Alarms and See Doctor Alerts | To evaluate patients’ ability to learn and recall the appropriate responses alarms and alerts | No issues found | Pass |
| IMD AMSG3 Vibratory Alarm Characteristics | To verify that patients can readily sense the vibration generated by the AMSG3 vibratory motor | No issues found | Pass |
| Usability Test of the AngelMed Patient Manual | To evaluate the usability of the Patient Manual | No issues found | Pass |
| Guardian Programmer Usability Audit | to evaluate the usability of Programmer | No issues found | Pass |
*Human factors testing was conducted by moving through typical device use cases and observing any potential safety issues that could result from use by an operator. The acceptance criteria for passing is that no issues have been observed. Note: If issues were observed then that result was typically fed back into the design of the device so that the use issue will not occur when the testing is re-performed.
| Packaging | | | |
| --- | --- | --- | --- |
| Test | Purpose | Acceptance Criteria | Results |
| IMD: Package Test Process Qualification Product Performance Qualification | To assess the suitability of the IMD packaging | AAMI/ANSI/ISO 11607 | Pass |
| EXD: Package Test | To assess the suitability of the EXD packaging | ASTM D-4169 | Pass |
| PROG: Package Test | To assess the suitability of the PROG packaging | EN 13718-1 | Pass |
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The engineering study results demonstrated the following conclusions:
- Performs as expected in the presence of systems commonly found in places like retail stores, libraries, and airports (e.g., RFID, EAS Systems, Tag Deactivator Systems, and security metal detectors)
- Passes FCC Certification tests: radiated emissions, conducted emissions, radiated RF immunity and RF safety levels
- Performs acceptably in the presence of commonly used cellular technologies
- Complies with all applicable mechanical and environmental requirements and international standards
- Complies with all applicable electrical requirements and electrical safety standards
- Complies with all applicable packaging standards
Table 2 below summarizes the biocompatibility testing performed to demonstrate that the system will not have an adverse effect on tissues it comes into contact with while implanted. The results for all tests indicated the device met the acceptance criteria of the referenced standards.
Table 2. Biocompatibility
| Test | Standard | Result | Analysis Type |
| --- | --- | --- | --- |
| Genotoxicity: Ames Test (Solids) | ISO 10993-3:2003 ISO 10993-12:2007 | Non-mutagenic | Attribute -- Third Party Testing |
| Genotoxicity: In Vivo Mouse Micronucleus | ISO 10993-3:2003 ISO 10993-12:2007 | Non-mutagenic | Attribute -- Third Party Testing |
| Genotoxicity: Mouse Lymphoma, per Extract | ISO 10993-3:2003 ISO 10993-12:2007 | Non-mutagenic | Attribute -- Third Party Testing |
| Cytotoxicity: MEM Elution | ISO 10993-1:2009 ISO 10993-5:2009 ISO 10993-12:2007 | Non-cytotoxic | Attribute -- Third Party Testing |
| Sensitization: Magnusson-Kligman Method | ISO 10993-10:2010 ISO 10993-12:2007 | Non-sensitive | Attribute -- Third Party Testing |
| Irritation: Intracutaneous Toxicity (ISO) | ISO 10993-10:2010 ISO 10993-12:2007 | Non-irritant | Attribute -- Third Party Testing |
| Systemic Toxicity: Systemic Injection (ISO) | ISO 10993-11:2006 ISO 10993-12:2007 | Non-toxic | Attribute -- Third Party Testing |
| Systemic Toxicity: Material Mediated Pyrogen | ISO 10993-11:2006 ISO 10993-12:2007 | Non-pyrogenic | Attribute -- Third Party Testing |
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The following US and International standards were used in the development and testing of the Guardian System.
Table 3. US and International Standards
| EN 45502-1:1997 | Active implantable medical devices - Part 1: General requirements for safety, marking and information to be provided by the manufacturer (Clauses 8.1, 10.4, 19.3) |
| --- | --- |
| ISO 14971:2007 | Medical devices -- Application of risk management to medical devices |
| ISO 13485:2003 | Medical devices - Quality management systems - Requirements for regulatory purposes |
| ISO/TR 14969:2004 | Medical devices -- Quality management systems -- Guidance on the application of ISO 13485: 2003 |
| ISO 14155-1:2011 | Clinical investigation of medical devices for human subjects -- Part 1: General requirements |
| ISO 14155-2:2003 | Clinical investigation of medical devices for human subjects -- Part 2: Clinical investigation plans |
| ISO 60601-1:2005 | Medical electrical equipment - Part 1: General requirements for basic safety and essential performance |
| IEC 62304:2006 | Medical device software - Software life cycle processes |
| IEC 60812:2006 | Analysis techniques for system reliability - Procedure for failure mode and effects analysis (FMEA) |
| EN 45502-1:1997 | Active implantable medical devices - Part 1: General requirements for safety, marking and information to be provided by the manufacturer |
| ISO 14971:2007 | Medical devices -- Application of risk management to medical devices |
| IEC 62304:2006 | Medical device software - Software life cycle processes |
| IEC 60812:2006 | Analysis techniques for system reliability - Procedure for failure mode and effects analysis (FMEA) |
| IEC 60601-1-1:2000 | General requirements for safety - Collateral standard: Safety requirements for medical electrical systems |
| ISO 13485:2003 | Medical devices - Quality management systems - Requirements for regulatory purposes |
| ISO/TR 14969:2004 | Medical devices -- Quality management systems -- Guidance on the application of ISO 13485: 2003 |
| EN 45502-1:1997 | Active implantable medical devices - Part 1: General requirements for safety, marking and information to be provided by the manufacturer |
| IEC 60601-1-1:2000 | General requirements for safety - Collateral standard: Safety requirements for medical electrical systems |
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| ISO 14971:2007 | Medical devices -- Application of risk management to medical devices |
| --- | --- |
| ISO 13485:2003 | Medical devices - Quality management systems - Requirements for regulatory purposes |
| ISO/TR 14969:2004 | Medical devices -- Quality management systems -- Guidance on the application of ISO 13485: 2003 |
| ISO 14155-1:2011 | Clinical investigation of medical devices for human subjects -- Part 1: General requirements |
| ISO 11607-1:2006 | Packaging for terminally sterilized medical devices -- Part 1: Requirements for materials, sterile barrier systems and packaging systems |
| ISO 11607-2:2006 | Packaging for terminally sterilized medical devices -- Part 2: Validation requirements for forming, sealing and assembly processes |
| ASTM F1980 – 07 | Standard Guide for Accelerated Aging of Sterile Barrier Systems for Medical Devices |
| EN 45502-1:1997 | Active implantable medical devices - Part 1: General requirements for safety, marking and information to be provided by the manufacturer |
| ISO 14971:2007 | Medical devices -- Application of risk management to medical devices |
| ISO 13485:2003 | Medical devices - Quality management systems - Requirements for regulatory purposes |
| ISO/TR 14969:2004 | Medical devices -- Quality management systems -- Guidance on the application of ISO 13485: 2003 |
| EN 45502-1:1997 | Active implantable medical devices - Part 1: General requirements for safety, marking and information to be provided by the manufacturer |
| ISO 14971:2007 | Medical devices -- Application of risk management to medical devices |
| IEC 62304:2006 | Medical device software – Software life cycle processes |
| IEC 60812:2006 | Analysis techniques for system reliability – Procedure for failure mode and effects analysis (FMEA) |
| IEC 60601-1-1:2000 | General requirements for safety – Collateral standard: Safety requirements for medical electrical systems |
| ISO 13485:2003 | Medical devices - Quality management systems - Requirements for regulatory purposes |
| ISO/TR 14969:2004 | Medical devices -- Quality management systems -- Guidance on the application of ISO 13485: 2003 |
| ISO 14155-1:2011 | Clinical investigation of medical devices for human subjects -- Part 1: General requirements |
| EN 45502-1:1997 | Active implantable medical devices - Part 1: General requirements for safety, marking and information to be provided by the manufacturer |
| IEC 60601-1-1:2000 | General requirements for safety – Collateral standard: Safety requirements for medical electrical systems |
| ISO 14971:2007 | Medical devices -- Application of risk management to medical devices |
| ISO 13485:2003 | Medical devices - Quality management systems - Requirements for regulatory purposes |
| ISO/TR 14969:2004 | Medical devices -- Quality management systems -- Guidance on the application of ISO 13485: 2003 |
| EN 45502-1:1997 | Active implantable medical devices - Part 1: General requirements for safety, marking and information to be provided by the manufacturer |
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| ISO 11135-1:2007 | Sterilization of health care products. Ethylene oxide. Requirements for development, validation and routine control of a sterilization process for medical devices |
| --- | --- |
| EN 550:1994 | Sterilization of medical devices. Validation and routine control of ethylene oxide sterilization |
| EN 556:2001 | Sterilization of medical devices. Requirements for medical devices to be designated "STERILE". Requirements for terminally sterilized medical devices |
| EN 868-1:1997 | Packaging materials and systems for medical devices which are to be sterilized. General requirements and test methods |
| ISO 11607-1:2006 | Packaging for terminally sterilized medical devices -- Part 1: Requirements for materials, sterile barrier systems and packaging systems |
| ISO 11607-2:2006 | Packaging for terminally sterilized medical devices -- Part 2: Validation requirements for forming, sealing and assembly processes |
| ISO 14971:2007 | Medical devices -- Application of risk management to medical devices |
| ISO 13485:2003 | Medical devices - Quality management systems - Requirements for regulatory purposes |
| ISO/TR 14969:2004 | Medical devices -- Quality management systems -- Guidance on the application of ISO 13485: 2003 |
| ISO 11737-1:2006 | Sterilization of medical devices -- Microbiological methods -- Part 1: Determination of a population of microorganisms on products |
| ISO 11737-2:2009 | Sterilization of medical devices -- Microbiological methods -- Part 2: Tests of sterility performed in the validation of a sterilization process |
| ISO 11737-3:2004 | Sterilization of medical devices -- Microbiological methods -- Part 3: Guidance on evaluation and interpretation of bioburden data |
| ISO 14937:2009 | Sterilization of health care products -- General requirements for characterization of a sterilizing agent and the development, validation and routine control of a sterilization process for medical devices |
| ISO 14644-1:1999 | Cleanrooms and associated controlled environments -- Part 1: Classification of air cleanliness |
| ISO 14644-2:2000 | Cleanrooms and associated controlled environments -- Part 2: Specifications for testing and monitoring to prove continued compliance with ISO 14644-1 |
| EN 45502-1:1997 | Active implantable medical devices - Part 1: General requirements for safety, marking and information to be provided by the manufacturer |
| EN 1041:2008 | Information supplied by the manufacturer with medical devices |
| EN 980:2008 | Graphical symbols for use in the labeling of medical devices |
| ISO 14971:2007 | Medical devices -- Application of risk management to medical devices |
| ISO 13485:2003 | Medical devices - Quality management systems - Requirements for regulatory purposes |
| ISO/TR 14969:2004 | Medical devices -- Quality management systems -- Guidance on the application of ISO 13485: 2003 |
| ISO 7000:2004 | Graphical symbols for use on equipment -- Index and synopsis |
| TIR 60878 | Graphical symbols for electrical equipment in medical practice |
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| ISO 15223:2000/Amd 1:2001 | Medical devices -- Symbols to be used with medical device labels, labeling and information to be supplied |
| --- | --- |
| ISO 15223-1:2012 | Medical devices – Symbols to be used with medical device labels, labeling, and information to be supplied – Part1: General requirements |
## B. Animal Studies
A formal Good Laboratory Practice (GLP) animal study was conducted in 11 pigs implanted with an RV apical pacemaker lead and the AngelMed Guardian IMD implant. Five (5) pigs were implanted for long-term safety evaluation. Each of the remaining six (6) pigs then received two (2) copper stents in one of the three (3) major coronary arteries. Copper is extremely inflammatory and within 24-48 hours of implant produces a blood clot in the coronary artery mimicking a human acute myocardial infarction. The study demonstrated the ability to sense, detect, and record dramatic, detected ST segment shifts during coronary thrombotic occlusion. The anatomical post-mortem pathology evaluation demonstrated that the Guardian had successfully detected significant ST shifts for all of animals who demonstrated occlusions in Left Anterior Descending, Left Circumflex, and Right Coronary Artery coronary arteries resulting from a coronary blood clot.
## X. SUMMARY OF PRIMARY CLINICAL STUDIES
The applicant conducted the ALERTS Clinical Study to establish a reasonable assurance of safety and effectiveness of the AngelMed Guardian System to monitor a patients' intracardiac electrogram for ST segment shifts indicating coronary ischemia in the US under IDE # G060259. The following two (2) major analyses of data collected from ALERTS study patients were presented to FDA and are summarized below.
a. A pre-specified, randomized analysis; and
b. An Additional Analysis of ALERTS ED Visits
The approval of this PMA is based on the clinical data presented below.
## A. Study Design
### Randomized Analysis/Original Follow-Up
The ALERTS Clinical Study was a Bayesian adaptive, randomized (1:1) controlled trial in which patients in the Alarm ON group had the device's alerts enabled while patients in the Alarm OFF group had those alerts disabled initially.
A total of 1020 subjects were enrolled in the ALERTS Clinical Study with 910 subjects actually implanted and 907 subjects both implanted and randomized (1:1) into ALARMS ON (Treatment) and ALARMS OFF (Control) groups. Patients in both groups were implanted with a Guardian System device and those in the
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ALARMS ON group had the Guardian alarms activated at the time of randomization (7-14 days post implantation) while those in the ALARMS OFF group had their alarms deactivated and devices placed in a monitoring mode for the first 6 months for randomized comparison between the two (2) groups. After the 6 month randomized period the alarms in all trial devices were activated and patients were followed per the IDE protocol.
1. Clinical Inclusion and Exclusion Criteria
Enrollment in the ALERTS study was limited to patients who met the following inclusion criteria:
a. Advanced multi-vessel Cardiac Disease
b. An index ACS event (e.g., Myocardial Infarction (MI), Unstable Angina, or Coronary Artery Bypass Graft (CABG) within 6 months of enrollment)
c. Additional risk factors/co-morbidities (diabetes, TIMI risk score≥3, or renal insufficiency)
d. Lives in a geographic area in close proximity (within 60 minutes by Emergency Medical Services) to any hospital that can treat Acute Myocardial Infarction
e. Greater than 21 years of age
f. Women of childbearing age must have a negative pregnancy test or confirmation of one of the following:
i. Post-menopausal or amenorrheic during the past year
ii. Surgical sterilization
iii. Use of effective contraceptive method
Patients were not permitted to enroll in the ALERTS study if they met any of the following exclusion criteria:
a. In the investigator's opinion, subject lacks ability to respond appropriately to alarms (e.g., illiteracy, poor memory or cognitive function, dementia or other condition affecting memory function, etc.).
b. There is known compromised tissue at the site of lead implantation in the apex of the right ventricle (e.g., prior infarct affecting the RV apex location).
c. A permanent pacemaker or ICD is already in place or the patient is indicated for ICD or pacemaker implantation based on the guidelines published by the American College of Cardiology as Class I and IIa recommendations. Class IIb recommendations are at the investigator's discretion.
d. Subject cannot feel the IMD vibration when placed on top of the skin on the left pectoral side of the chest.
e. Subject has recurrent or persistent atrial fibrillation.
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f. Subject has recurrent or persistent non-sinus cardiac rhythm, second or third degree atrioventricular blocks, QRS duration greater than 120 msec, Benign Early Repolarization (BER), or Brugada Syndrome.
g. Subject has left ventricular hypertrophy evidenced by ECG criteria.
h. Subject has any condition preventing the subcutaneous implantation of the Guardian System in a left pectoral pouch, such as: superior vena cava thrombosis, subcutaneous tissue deemed inappropriate for the procedure, or prior central venous access via portacath, Hickman, Groshong, or similar device placed in a left pectoral location or left side PICC line.
i. Subject has extremely heavy alcohol consumption (participates in binge drinking that leads to alcohol intoxication) or has history of alcohol or illicit drug abuse within past 5 years.
j. There is evidence of unresolved infection (fever > 38°C and/or leukocytosis > 15,000).
k. Subject has history of bleeding disorders or severe coagulopathy (platelets < 100,000 plts/ml; APTT or PT > 1.3 x reference range).
l. Subject has had a hemorrhagic stroke or transient ischemic attack (TIA) in the past 6 months.
m. Subject has other severe diseases, such as cancer or refractory congestive heart failure, associated with limitation of life expectancy (less than 1 year), which may lead to inadequate compliance to the protocol or confusing data interpretation.
n. Subject has clinical conditions such as heart diseases, difficult-to-control blood pressure, difficult-to-control insulin-dependent diabetes or serious prior infections attributed to the diabetes, or others that, at the investigator's discretion, could seriously affect the subject's current clinical condition during study procedures.
o. Subject has previous participation in the DETECT Study, current participation or previous participation in another drug or device study in the past 30 days that conflicts with this study as determined by the study sponsor.
p. Subject has experienced gastro-intestinal hemorrhage in the past 6 months.
q. Subject has any situation in which the use of aspirin is contraindicated for at least 6 months.
r. Subject has epilepsy.
s. Subject has known severe allergies (e.g., peanut, bee sting, etc.).
2. Follow-up Schedule
All patients were scheduled to return for follow-up examinations at 7-14 days and 1, 3, and 6 months and every 6 months after that postoperatively. It should be noted that the effectiveness evaluation for the new clinical analysis plan does not rely on data from scheduled visits but only on adjudication of emergent visits in the Emergency Department (ED).
Preoperatively, all patients were seen in clinic and a baseline 12-lead ECG was
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taken. Postoperatively, the objective parameters measured during the study included any ACS standard of care testing that was performed during an emergent ED visit. Adverse events and complications were recorded at all pre-specified follow-up examinations noted above.
The key time points are shown below in the tables summarizing safety and effectiveness.
## 3. Clinical Endpoints
The following were the primary endpoints for the ALERTS Clinical Study:
a. Primary Safety Endpoint
i. Proportion of subjects free from system-related complications is greater than 90%.
b. Composite Primary Effectiveness Endpoint (ALARM ON < ALARM OFF)
i. Cardiac/Unexplained Death
ii. New Q-Wave MI (QWMI)
iii. Late Arrival – Time-to-door (time between device alarm and medical presentation) > 2 Hours for an ACS Event (confirmed by ECG, Stress test, Angiogram, or Enzymes)
## Additional Analysis of ALERTS ED Visits/Original and Extended Follow-Up
After presentation of the ALERTS Clinical Study/Original Follow-Up to an Advisory Panel, FDA engaged the applicant to create a new clinical analysis plan that would include events in ALERTS patients from both the randomized and non-randomized period of the trial. This additional clinical analysis of ALERTS patient follow-up was a retrospective study of all ED visits for study patients that met specific criteria from the entirety of the follow up from the ALERTS IDE study; therefore, the additional analysis included data that were collected outside the prespecified randomization period and thus were not reviewed under the original PMA or presented to the Advisory Panel. The new clinical analysis compares device functionality related to ED visits for patients whose device alarm initiated (with or without symptoms) the visit (ALARMS ON,) shown in the green in Figure 3 below, and patients whose device alarms were inactive and whom presented due to symptoms (ALARMS OFF,) shown in blue in Figure 3 below.
Figure 3 - Guardian System Component Diagram
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For a study subject’s ED visit to be included in the analysis at least one of the following standard of care tests for ACS had to have been performed on the study subject:
a. 12-Lead ECG;
b. Cardiac Enzymes;
c. Stress Test;
d. Angiography
**Note:** It was not necessary for an ED visit in the ALARMS OFF group to have been initiated by symptoms typically associated with cardiac events to be included in the analysis.
Figure 3 shows how the assignment of the Control and Treatment groups during the 6-month randomization period relates to the ALARMS OFF and ALARMS ON groups used by the new clinical analysis protocol. In the post-randomization period the Control group patients were re-categorized into the ALARMS ON group.”
Each ED visit was evaluated by an independent Clinical Events Committee (CEC) based on pre-specified criteria and adjudicated as an ACS event based on predetermined criteria or a false positive presentation to the ED. The ALARMS ON patients represent the treatment group for this new clinical analysis and were compared to the ALARMS OFF patients which represent the control group for both Positive Predictive Value (PPV) and False Positive Rate (FPR) using frequentist statistics.
The database for the Additional Analysis of ALERTS ED Visits was collected from ALERTS study initiation through May 2016 and included the 907 implanted and randomized patients.
1. **Clinical Inclusion and Exclusion Criteria**
The Inclusion and Exclusion Criteria did not change from the randomized analysis. See above.
2. **Follow-up Schedule**
All patients that were included in the Additional Analysis of ED Visits/Extended Follow-Up followed the follow-up schedule noted above for the pre-specified ALERTS/Original Follow-Up study. It should be noted that this new clinical analysis focused on data collected during emergent visits to the ED and not on data collected during regularly scheduled follow-up visits that occurred every 6 months.
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# 3. Clinical Endpoints
With regards to safety, the following data was collected in the Additional Analysis of ALERTS ED Visits for the entire ALERTS study follow up period independent of randomized group:
a. System-Related Complication Rate
b. Replacement Implant System-Related Complication Rate
c. Explant Procedure System-Related Complication Rate
d. All Cause Death
e. Cardiac Death
No formal statistical tests were performed on the collected safety data for the Additional Analysis of ALERTS ED Visits.
With regards to effectiveness, the co-primary endpoints were analyzed as follows:
a. PPV – Superiority
i. $\mathrm{H_O:PPV_{Alarm\ ON}\leq PPV_{Alarm\ OFF}}$
ii. $\mathrm{H_A:PPV_{Alarm\ ON}\geq PPV_{Alarm\ OFF}}$
b. FPR – Non-Inferiority
i. $\mathrm{H_O:}\beta \geq 1.50$
ii. $\mathrm{H_A:}\beta < 1.50$
iii. Where $\beta$ is a regression coefficient used to approximate $\frac{\text{FPR}(\text{Alarm ON})}{\text{FPR}(\text{Alarm OFF})}$
# B. Accountability of PMA Cohort
At the time of database lock, of 1020 patients enrolled in the PMA study, $88.9\%$ (907) patients were available for analysis. Figures 4 and 5 below depicts the accountability of patients throughout the follow up of the entire ALERTS study.
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Figure 4 - Patient Accountability during Randomized Period of the ALERTS Study/Original Follow-up
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Figure 5 - Patient Accountability after the Randomized Period of the ALERTS Study/Extended Follow-up
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Note: This patient accountability represents the number of patients who had reached each time point at the time of database lock. All patients were followed through the IDE until study exit.
# C. Study Population Demographics and Baseline Parameters
The demographics of the study population are typical for a cardiac device study performed in the US. A summary of those characteristics is provided with respect to their original randomized groups in Table 4 below. Note that all ALARMS OFF patients crossed over to the ALARMS ON group at the 6-month follow-up visit.
Table 4: ALERTS Study Subject Demographics
| Characteristic | ALARMS OFF (Control) Group (N=456) | | ALARMS ON (Treatment) Group (N=451) | | Difference (ON - OFF) |
| --- | --- | --- | --- | --- | --- |
| | N | Mean ± S.D. or N (%) | N | Mean ± S.D. or N (%) | 95% BCI |
| Age at Randomization | 456 | 59.5 ± 10.2 | 451 | 59.4 ± 10.5 | (-1.4, 1.3) |
| Sex (Female) | 456 | 154 (33.8%) | 451 | 137 (30.4%) | (-9.4%, 2.7%) |
| Race/Ethnicity | 456 | | 451 | | |
| - American Indian | | 1 (0.2%) | | 0 (0.0%) | (-1.0%, 0.5%) |
| - Asian/Pacific Islander | | 2 (0.4%) | | 5 (1.1%) | (-0.6%, 2.0%) |
| - Black – Not of Hispanic Origin | | 32 (7.0%) | | 30 (6.7%) | (-3.7%, 2.9%) |
| - Caucasian – Not of Hispanic Origin | | 391 (85.7%) | | 391 (86.7%) | (-3.7%, 5.5%) |
| - Hispanic – any race | | 30 (6.6%) | | 22 (4.9%) | (-4.7%, 1.3%) |
| - Other | | 0 (0.0%) | | 3 (0.7%) | (-0.2%, 1.7%) |
| Presentation of ACS (Qualifying Event) | 456 | | 451 | | |
| - STEMI | | 113 (24.8%) | | 109 (24.2%) | (-6.2%, 5.0%) |
| - NSTEMI | | 127 (27.9%) | | 126 (27.9%) | (-5.7%, 5.9%) |
| - Unstable Angina | | 199 (43.6%) | | 199 (44.1%) | (-6.0%, 6.9%) |
| - Other | | 15 (3.3%) | | 15 (3.3%) | (-2.4%, 2.4%) |
| - Unknown | | 2 (0.4%) | | 2 (0.4%) | (-1.1%, 1.1%) |
| History of Silent MI | 455 | 28 (6.2%) | 451 | 25 (5.5%) | (-3.7%, 2.5%) |
| Diabetes | 456 | 224 (49.1%) | 451 | 206 (45.7%) | (-9.9%, 3.0%) |
| Dyslipidemia Requiring Medication | 456 | 421 (92.3%) | 451 | 416 (92.2%) | (-3.6%, 3.4%) |
| Hypertension Requiring Medication | 456 | 426 (93.4%) | 451 | 414 (91.8%) | (-5.1%, 1.8%) |
| History of Smoking | 456 | 315 (69.1%) | 451 | 322 (71.4%) | (-3.6%, 8.2%) |
| Currently Smoking | 456 | 121 (26.5%) | 451 | 117 (25.9%) | (-6.3%, 5.1%) |
| History of Heart Failure | 452 | 60 (13.3%) | 451 | 79 (17.5%) | (-0.5%, 8.9%) |
| NYHA | 452 | | 451 | | |
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| Characteristic | ALARMS OFF (Control) Group (N=456) | | ALARMS ON (Treatment) Group (N=451) | | Difference (ON - OFF) |
| --- | --- | --- | --- | --- | --- |
| | N | Mean ± S.D. or N (%) | N | Mean ± S.D. or N (%) | 95% BCI |
| - I | | 18 (4.0%) | | 34 (7.5%) | (0.5%, 6.6%) |
| - II | | 32 (7.1%) | | 36 (8.0%) | (-2.6%, 4.4%) |
| - III | | 10 (2.2%) | | 9 (2.0%) | (-2.2%, 1.8%) |
| - None | | 392 (86.7%) | | 372 (82.5%) | (-9.0%, 0.5%) |
| Killip Class | 448 | | 446 | | |
| - I | | 425 (94.9%) | | 410 (91.9%) | (-6.3%, 0.4%) |
| - II | | 20 (4.5%) | | 34 (7.6%) | (0.0%, 6.3%) |
| - III | | 3 (0.7%) | | 2 (0.4%) | (-1.4%, 0.9%) |
| Ejection Fraction (LVEF, %) | 418 | 53.9 ± 8.8 | 411 | 54.1 ± 9.4 | (-1.1, 1.4) |
| History of Renal Insufficiency | 456 | 75 (16.4%) | 451 | 83 (18.4%) | (-3.0%, 6.9%) |
| History of Reperfusion/ Revascularization | 456 | 444 (97.4%) | 451 | 442 (98.0%) | (-1.4%, 2.7%) |
| Angina in previous six months | 456 | 400 (87.7%) | 451 | 395 (87.6%) | (-4.4%, 4.1%) |
| Average Frequency of Angina | 399 | | 394 | | |
| - > 10 times/month | | 63 (15.8%) | | 58 (14.7%) | (-6.0%, 3.9%) |
| - 6-10 times/month | | 44 (11.0%) | | 37 (9.4%) | (-5.9%, 2.6%) |
| - 3-6 times/month | | 87 (21.8%) | | 101 (25.6%) | (-2.1%, 9.7%) |
| - < 3 times/month | | 205 (51.4%) | | 198 (50.3%) | (-8.0%, 5.8%) |
| Angina Status (most recent episode as of pre-procedure exam) | 398 | | 389 | | |
| - Stable | | 233 (58.5%) | | 228 (58.6%) | (-6.8%, 6.9%) |
| - Unstable | | 165 (41.5%) | | 161 (41.4%) | (-6.9%, 6.8%) |
| History of Silent Ischemic Changes | 456 | | 451 | | |
| - Yes | | 34 (7.5%) | | 28 (6.2%) | (-4.6%, 2.1%) |
| - No | | 309 (67.8%) | | 338 (74.9%) | (1.3%, 13.0%) |
| - Unknown | | 133 (24.8%) | | 85 (18.8%) | (-11.2%, -0.5%) |
| TIMI Risk Score (mean) | 454 | 3.623 ± 0.968 | 449 | 3.706 ± 1.023 | (-0.048, 0.213) |
| History of Atrial Arrhythmia | 456 | 25 (5.5%) | 450 | 18 (4.0%) | (-4.3%, 1.3%) |
| History of Ventricular Arrhythmia | 456 | 26 (5.7%) | 450 | 25 (5.6%) | (-3.2%, 2.9%) |
| History of Ectopic Arrhythmia | 456 | 6 (1.3%) | 450 | 5 (1.1%) | (-1.8%, 1.4%) |
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## D. Safety and Effectiveness Results
### Randomized Analysis/Original Follow-up
The key results of the randomized analyses for the ALERTS Clinical Study are presented below. For additional information on these results please refer to the Executive Summary for the relevant Advisory Panel meeting (https://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/CirculatorySystemDevicesPanel/UCM490460.pdf).
### 1. Safety Results
Thirty-one (31) system-related complication events as defined for the primary safety endpoint were observed during the randomized period of the study and are presented in Table 5 below. The primary safety endpoint for the randomized period of the trial was met with a posterior probability of >0.9999 which was above the significance threshold of 0.954.
Table 5: System-Related Complications – Original Follow-Up
| Complication | # of Events (%) |
| --- | --- |
| Cardiac Perforation | 2 (0.22%) |
| Erosion | 3 (0.33%) |
| Infection | 11 (1.21%) |
| Lead migration/dislodgement | 4 (0.44%) |
| Device Malfunction | 2 (0.22%) |
| Lead Malfunction | 1 (0.11%) |
| Loss of sensing due to dislodgement or malfunction of the lead | 2 (0.22%) |
| Pain at or near the pocket site | 5 (0.55%) |
| Visible bump where implanted in the chest | 1 (0.11%) |
These 31 events were observed in 30 patients resulting in an overall complication rate of 3.30% from the randomized period of the study.
### 2. Effectiveness Results
Table 6 below presents the results from the primary effectiveness endpoint for the randomized analysis of the ALERTS clinical study.
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Table 6: ALERTS Randomized Effectiveness Analysis – Original Follow-Up
| | ALARMS OFF (N=456) | | ALARMS ON (N=451) | | Posterior Probability* | |
| --- | --- | --- | --- | --- | --- | --- |
| | | N | Pts (%) | N | | Pts (%) |
| Component – Cardiac or Unexplained Death | | | | | | |
| | | 447 | 1 (0.2%) | 441 | | 3 (0.7%) |
| Component – New QWMI (dual baseline analysis) | | | | | | |
| | | 427 | 13 (3.0%) | 420 | | 7 (1.7%) |
| Component – Time-to-door > 2 hours | | | | | | |
| Look-back Window | 7-Day | 446 | 8 (1.8%) | 439 | | 4 (0.9%) |
| | 90-Day | 446 | 17 (3.8%) | 439 | | 4 (0.9%) |
| Composite Primary Endpoint Events (with dual baseline analysis**) | | | | | | |
| Look-back Window | 7-Day | 428 | 20 (4.7%) | 423 | 13 (3.1%) | 0.8833 |
| | 90-Day | 428 | 28 (6.5%) | 423 | 13 (3.1%) | 0.9908 |
*The significance threshold for the posterior probabilities of event reduction is 0.983 for the primary effectiveness endpoint.
**The dual baseline analysis incorporated both pre-implant and randomization ECGs as baseline to more accurately identify new, persistent Q-waves observed during the study
Additional Analysis of ALERTS ED Visits/Original and Extended Follow-Up
1. Safety Results
The following analysis of long-term device safety was based on events from the implanted cohort of 910 patients that occurred after the randomization period and thus were not included in the safety results from the Original Follow-Up summarized above. This long term device safety and adverse event data are presented in Tables 7 to 9 below.
Thirty-four (34) system-complication events were observed during the post-randomization period of the study and are presented in Table 7 below. Twelve (12) of the device malfunctions listed below were due to IMD replacement due to battery depletion.
Table 7: System-Related Complication Rate – Extended Follow-Up
| Complication | # of Events (%) |
| --- | --- |
| Infection | 4 (0.44%) |
| Erosion | 1 (0.11%) |
| Device Malfunctions | 16 (1.76%) |
| Hematoma (requiring drainage) | 3 (0.33%) |
| Lead Malfunction | 2 (0.22%) |
| Pain | 4 (0.44%) |
| Signal Capture Problem | 4 (0.44%) |
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These 34 events were observed in 33 patients resulting in an overall complication rate of 3.63% from the post-randomization period of the study.
A total of 463 IMD replacement procedures were performed for patients in the Extended Follow-up of the ALERTS Clinical Study. Twelve (12) adverse events in 12 patients were observed during those procedures and are summarized in Table 8 below.
Table 8: Replacement Implant System-Related Complication Rate – Extended Follow-Up
| Complication | # of Events (%) |
| --- | --- |
| Infection | 1 (0.22%) |
| Erosion | 1 (0.22%) |
| Device Malfunctions | 6 (1.30%) |
| Pain | 2 (0.43%) |
| Signal Capture Problem | 2 (0.43%) |
| Total | 2.59% (12/463) |
A total of 703 explant procedures were performed for patients in the Extended Follow-up of the ALERTS Clinical Study. Four (4) adverse events were observed during those procedures and are summarized in Table 9 below.
Table 9: Explant Procedure System-Related Complication Rate – Extended Follow-Up
| Complication | # of Events (%) |
| --- | --- |
| Hematoma (requiring drainage) | 3 (0.43%) |
| Lead Malfunction | 1 (0.14%) |
| Total | 0.57% (4/703) |
**Adverse effects that occurred in the PMA clinical study (Original Follow-Up and Extended Follow-Up):**
Sixty-five (65) system-related complication events were observed for the entire follow-up period of the ALERTS study are summarized in Table 10 below. Overall the acute procedural and long-term implantation risks of the device are comparable to a single chamber pacemaker.
Table 10: System-Related Complication Rate – Original and Extended Follow-Up
| Complication | # of Events (%) |
| --- | --- |
| Cardiac perforation | 2 (0.22%) |
| Device Malfunction | 18 (1.98%) |
| Erosion | 4 (0.44%) |
| Hematoma (requiring drainage) | 3 (0.33%) |
| Infection | 15 (1.65%) |
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| Complication | # of Events (%) |
| --- | --- |
| Lead malfunction | 3 (0.33%) |
| Lead migration/dislodgment | 4 (0.44%) |
| Loss of sensing due to dislodgement or malfunction of lead | 2 (0.22%) |
| Pain at or near the pocket site | 9 (0.99%) |
| Signal capture problem | 4 (0.44%) |
| Visible bump where implanted in the chest | 1 (0.11%) |
These 65 events were observed in 63 patients (out of 910 patient) resulting in an overall complication rate of 6.92% for the complete study follow-up.
## 2. Effectiveness Results
The analysis of effectiveness was based on ED visits from the 907 patients from the entire follow up period for the ALERTS Trial. Key effectiveness outcomes are presented in Tables 11 and 12 below.
Table 11 below shows the results from both components of the primary effectiveness endpoint of the Additional Analysis of ALERTS ED Visits. Based on study results, the null hypothesis was not rejected for PPV and was rejected for FPR. As a secondary endpoint the FPR for the ALARMS ON group was also tested for superiority with respect to ALARMS OFF group and test also demonstrated statistical significance with a p-value of <0.001.
Table 11: Primary Effectiveness Endpoint Results – Additional Analysis of ALERTS ED Visits
| | ALARMS OFF – Symptoms Only | ALARMS ON – Alarm w/ or w/o Symptoms | P-Value |
| --- | --- | --- | --- |
| ED Visits | 181 | 345 | |
| True Positive | 33 | 89 | |
| False Positive | 148 | 256 | |
| PPV | 18.23% | 25.80% | 0.0313* |
| FPR (FP/pt. year) | 0.678 FP/pt. year | 0.164 FP/pt. year | <0.001** |
*One-sided Fisher's exact test for superiority (Significance level = 0.025)
**Generalized linear model based on a Poisson distribution and the canonical log link function.
These data can further be broken down into whether a patient with an alarm also experienced symptoms as shown in Table 12 below.
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Table 12: Additional PPV Results – Additional Analysis of ALERTS ED Visits
| | ALARMS OFF – Symptoms Only | ALARMS ON – Alarm and Symptoms | ALARMS ON – Alarm Only | ALARMS ON – Symptoms Only |
| --- | --- | --- | --- | --- |
| ED Visits | 181 | 135 | 210 | 625 |
| True Positive | 33 | 47 | 42 | 104 |
| False Positive | 148 | 88 | 168 | 521 |
| PPV | 18.23% | 34.81% | 20.00% | 16.64% |
Further analysis of the FP alarms revealed that a relatively small group of patients drove the FPR as shown in Table 13 below. Based on the data collected it was not possible to determine an adequate predictor for patients likely to experience multiple FP alarms.
Table 13: False Positive Frequency – Additional Analysis of ALERTS ED Visits
| # of FP Alarms/Patient | # of Patients |
| --- | --- |
| 0 | 744 |
| 1 | 106 |
| 2 | 37 |
| 3 | 9 |
| 4 | 8 |
| 5 | 2 |
| 6 | 0 |
| 7 | 1 |
Table 14 below presents the False Negatives (FNs) or missed ACS events that were recorded during the study period for the ALARMS ON group. A FN for either symptoms only or a Guardian System alarm could only be observed if the patient presented to the ED. If an ACS event or MI occurred and neither symptoms nor the guardian device prompted the patient to seek medical care it would not be captured in the following data.
Table 14: False Negatives – Additional Analysis of ALERTS ED Visits
| | Alarm | Symptoms |
| --- | --- | --- |
| FN - All ACS Events | 104 | 42 |
| FN - MIs | 59 (3 STEMIs) | 13 (1 STEMI) |
The diagnostic performance of the device should be considered in clinical context and in comparison to the available alternatives.
For all ALERTS study patients, the presence of the device with ALARM ON increased the diagnostic accuracy (the PPV) compared to symptomatic patients without monitoring (ALARM OFF), (25.80% vs. 18.23%). Further, symptomatic patients with a positive alarm had a PPV that was higher than symptomatic patients with a negative alarm (34.81% vs. 16.64%).
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Among patients without symptoms, those who presented to the ED had a 20.00% PPV. Without an alarm, these patients very likely would have gone undiagnosed.
The FPR (FP/patient year) was lower in the ALARMS ON group than in the ALARMS OFF group (0.164 vs. 0.678 FP/pt. year, P<0.001 for non-inferiority).
3. Subgroup Analyses
Analysis of subgroups for the Additional Analysis of ALERTS ED Visits did not reveal any significant conclusions.
4. Pediatric Extrapolation
In this premarket application, existing clinical data was not leveraged to support approval of a pediatric patient population.
E. Financial Disclosure
The Financial Disclosure by Clinical Investigators regulation (21 CFR 54) requires applicants who submit a marketing application to include certain information concerning the compensation to, and financial interests and arrangement of, any clinical investigator conducting clinical studies covered by the regulation. The pivotal clinical study included 96 investigators of which none were full-time or part-time employees of the sponsor and one (1) had disclosable financial interests/arrangements as defined in 21 CFR 54.2(a), (b), (c) and (f) and described below:
- Compensation to the investigator for conducting the study where the value could be influenced by the outcome of the study: 0
- Significant payment of other sorts: 0
- Proprietary interest in the product tested held by the investigator: 0
- Significant equity interest held by investigator in sponsor of covered study: 1
The applicant has adequately disclosed the financial interest/arrangements with clinical investigators. Statistical analyses were conducted by FDA to determine whether the financial interests/arrangements had any impact on the clinical study outcome. The information provided does not raise any questions about the reliability of the data.
XI. PANEL MEETING RECOMMENDATION AND FDA'S POST-PANEL ACTION
A. Panel Meeting Recommendation
At an advisory meeting held on March 16, 2016, the Circulatory System Devices Panel voted 8-4 that there is not reasonable assurance the device is safe, 12-0 that there is not reasonable assurance that the device is effective, and 12-0 that the
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benefits of the device do not outweigh the risks in patients who meet the criteria specified in the proposed indication. The “Brief Summary of the Circulatory System Devices Panel Meeting – March 16, 2016” document can be accessed here: https://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/CirculatorySystemDevicesPanel/UCM491425.pdf
## B. FDA’s Post-Panel Action
After the Advisory Panel’s review of the randomized portion/original follow-up data to support the Guardian System, FDA engaged with the applicant to develop the clinical analysis paradigm to include events from the Additional Analysis of ALERTS ED Visits that is described in Section X above. FDA has determined that the results of that analysis demonstrate a positive benefit-risk profile for the device.
## XII. CONCLUSIONS DRAWN FROM PRECLINICAL AND CLINICAL STUDIES
### A. Effectiveness Conclusions
The diagnostic performance of the device should be considered in clinical context and in comparison to the available alternatives. While the Advisory Panel voted that there was not a reasonable assurance of effectiveness, this re-analysis includes data that were collected outside the prespecified randomization period and thus were not reviewed under the original PMA or presented to the Advisory Committee.
For all ALERTS study patients, the presence of the device with ALARM ON increased the diagnostic accuracy (the PPV) compared to symptomatic patients without monitoring (ALARM OFF), (25.80% vs. 18.23%). Furthermore, symptomatic patients with a positive alarm had a PPV that was higher than symptomatic patients with a negative alarm (34.81% vs. 16.64%).
Among patients without symptoms, those who presented to the ED had a 20.00% PPV. Without an alarm, these patients very likely would have gone undiagnosed.
The FPR (FP/patient year) was lower in the ALARMS ON group than in the ALARMS OFF group (0.164 vs. 0.678 FP/pt. year, P<0.001 for non-inferiority).
The device improved the diagnostic accuracy (PPV) both for patients with and without symptoms, and the device did not increase the false positive rate (FPR) and may reduce it.
### B. Safety Conclusions
The risks of the device are based on nonclinical laboratory and animal studies as well as data collected in a clinical study conducted to support PMA approval as described above.
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In the randomized portion of the study, there were 31 system-related complication events in 30 subjects (3.30%) as defined for the primary safety endpoint. The primary safety endpoint of the trial was met with a posterior probability of >0.9999 which was above the significance threshold of 0.954. The primary safety endpoint was met.
In the Extended Follow-Up portion of the study, there were an additional 34 system-related complications in 33 subjects (3.63%).
These safety data represent data collected from 3450 implant years from the Original and Extended Follow-up.
The risks of the device have been well characterized and relate both to the procedural and device-related aspects as described above. Risks may also result from false positive or false negative results from the device.
## C. Benefit-Risk Determination
The probable benefits of the device are also based on data collected in the Additional Analysis of the ALERTS ED Visits conducted to support PMA approval as described above.
The data submitted in support of the PMA for the Angel Medical Guardian System demonstrates the following notable benefits:
a. Improved positive predictive value for ACS events in subjects presenting with symptoms
b. Improved positive predictive value for ACS events in subjects without symptoms
c. No increase, and a possible reduction in the false positive rate in subjects with device alarms ON compared to subjects with device alarms OFF.
While there is some uncertainty in assessing and quantifying these benefits, including the lack of statistical significance, the overall uncertainty regarding the benefits is acceptable.
Similarly, the risks of the device have been well characterized and relate both to the procedural and device-related aspects as described above. The risks also relate to the false positive and false negative device results. Overall, the uncertainty pertaining to the magnitude of these risks is low.
When considering the overall benefits and risks of the device, FDA concludes that the benefits outweigh the risks for the intended population. An important consideration is that the device fills an unmet medical need by providing more effective diagnosis of a life-threatening condition compared to relying on patient symptoms alone.
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1. Patient Perspectives
This submission contained some specific information on patient perspectives for this device; however, FDA did not find it useful in reaching its final decision.
In conclusion, given the available information above, the data support that for patients who have had prior acute coronary syndrome (ACS) events and who remain at high risk for recurrent ACS events. The probable benefits outweigh the probable risks. This is based on information from both the Original Follow-Up and the Extended Follow-up data sets from the ALERTS Clinical Study. The device fills an unmet medical need by providing more effective diagnosis of a life-threatening condition compared to relying on patient symptoms alone.
D. Overall Conclusions
The data in this application support the reasonable assurance of safety and effectiveness of this device when used in accordance with the indications for use.
The AngelMed device improves diagnostic accuracy of ACS in a clinically meaningful portion of the intended use population, and the risks associated with use of the device are acceptable. The risks of the device were further mitigated with appropriate labeling.
XIII. CDRH DECISION
CDRH issued an approval order on April 9, 2018. The final conditions of approval cited in the approval order are described below.
OSB Lead PMA Post-Approval Study – AngelMed Guardian PAS. The Office of Surveillance and Biometrics will have the lead for studies initiated after device approval. Per protocol synopsis dated 03/29/18 the applicant agreed to conduct a post-approval study to assess diagnostic accuracy of the AngelMed Guardian System, and to evaluate the training programs for both physicians and patients.
The applicant will conduct a prospective, non-randomized, single arm, event-based, multicenter trial. The purpose of the study is to assess: (1) the diagnostic accuracy of the device, (2.1) the compliance of the prescribing physician, (2.2) the experience of the implanting physician, (2.3) the experience of the emergency department physician and (2.4) the patient compliance for "Emergency" and "See Doctor" alerts.
A total of 500 subjects who have had prior acute coronary syndrome (ACS) events and who remain at high risk for recurrent ACS events will be enrolled in the AngelMed Guardian PAS, for the purpose of accruing 314 True Positive or False Positive acute coronary syndrome (ACS) events.
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The diagnostic accuracy primary endpoint is composed of the positive predictive value (PPV) and False Positive Rate (FPR) of the AngelMed Guardian System associated with acute coronary syndrome events. The PPV for Alarms (with or without symptoms) will be compared to a performance goal of 20%. The FPR (with or without symptoms) will be compared to a performance goal of 0.328 false positive events per patient year.
Secondary endpoints include: (1) the frequency of ALARM-Only ACS events (i.e., Silent ACS events), which is defined as the device alarm only presented to the emergency room (ER) physicians and not showing any other symptoms or discomfort/pain, and (2) the symptom-to-door times, defined as time between device alarm and medical presentation. Both secondary endpoints will be analyzed descriptively (frequency, mean, median and percentage of pre-hospital arrivals as a function of time).
Study subject visits will occur at implant, 7-14 days post-implant, 6 and 12 months post-implant and every 6 months thereafter until study exit or study completion. The PAS will be completed once 314 PPV events are collected.
In addition, the adequacy of the training program for the prescribing physician, implanting physician, emergency department physician, and patients will be assessed. Descriptive statistics (the raw count, percentage of all subjects, rate and number of sites) for the following assessments will be provided:
1. instances where the device was prescribed and implanted for patients that do not meet the proper labeling criteria to qualify for a Guardian implantable medical device (IMD)
2. instances of system revisions, e.g. any system problem that requires an invasive corrective procedure to resolve, required within 6 months of implant
3. instances of "Emergency" alarm non-compliance, failure to report to the ER within 72 hours of the alarm
4. instances of "See Doctor" noncompliance, defined as both failure to present to the doctor within 2 weeks of the alarm or reporting to the ER instead of to the doctor in response to the alarm
5. instances of patient non-success to reconfirm ability to recognize and distinguish between "Emergency" and "See Doctor", defined by being able to report the proper actions to take for each and what to do when only symptoms occur in the absence of an alarm.
6. instances of percutaneous intervention (PCI) without at least one positive standard of care (SOC) test reported on a site-based and visit-based basis.
The applicant's manufacturing facilities have been inspected and found to be in compliance with the device Quality System (QS) regulation (21 CFR 820).
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# XIV. APPROVAL SPECIFICATIONS
Directions for use: See device labeling.
Hazards to Health from Use of the Device: See Indications, Contraindications, Warnings, Precautions, and Adverse Events in the device labeling.
Post-approval Requirements and Restrictions: See approval order.
