Nearly two million people worldwide have pacemakers, defibrillators or other machines to help their hearts beat faster, slower or more regularly.

For years, attention focused on who should get these gadgets and whether insurance should pay. Now doctors are facing the daunting task of making sure that the devices are working and that patients hear about safety issues like the recalls that have shaken the industry in recent years.

The guidelines spell out who should do what to ensure good care. They tackle ethical dilemmas, such as when to turn off a device and let a patient die. This is aimed at preventing horror stories such as those of dying cancer patients whose defibrillators continue to shock their failing hearts back to life.

The guidelines also endorse new wireless technology that lets doctors check devices remotely while a patient is at home - an emerging standard of care.

"To some people technology is scary and they would rather talk face to face," said the Cleveland Clinic's Bruce Wilkoff. But to others, home monitoring saves time and money, gives peace of mind, and avoids trips to the hospital, he said.

He led the panel that wrote the guidelines, which were announced in San Francisco at a meeting of the Heart Rhythm Society, doctors who treat heartbeat problems.

At the meeting, Cleveland Clinic researchers reported results of a five-year experiment with home monitoring. Remote checkups rose dramatically - from 94 people at the start of the study to more than 5,000 by its end - without a big burden to the clinic's staff.

"It's a whole new way of being able to treat patients," said Kenneth Ellenbogen, a heart-device expert at Virginia Commonwealth University and a spokesman for the American Heart Association. "It is becoming standard with all new defibrillators and in the next couple years will become standard with all new pacemakers. It is going to provide us with data that we've never, ever had before."

Devices have not just grown more common, doctors say, but also have increased in complexity and do not just run on "autopilot" without regular maintenance.

The new guidelines, to be published in the June issues of the HeartRhythm Journal, include recommendations that a single doctor both implant the device and coordinate all follow-up care; that checkups be scheduled every three to 12 months, and at least once a year in person; and that the role of device manufacturer representatives be limited at all levels of medical care.