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Artificial Intelligence in Cardiology: Opportunities for Cardio-Oncology

History was made recently with the inaugural and first ever continuing medical education conference on artificial intelligence (#AI) in Cardiology. While most of the presentations were on artificial intelligence or cardiology or both, several sessions also made reference to other fields in which AI has been or is being used, such as Oncology. There was even one study presented on Cardio-Oncology. As study after study was presented, it became clear to me that perhaps several of these techniques and methodologies could potentially be useful to our patients in Cardio-Oncology.

Every single piece of technology started with one single prototype. Every single new piece of software started with one single algorithm. Every single patent started with one single idea. Every single idea started with the impact that disruptive technology could have for at least one single patient – one single case.

As I view various case reports in Cardio-Oncology, I think about how #AI could influence care delivery to potentially improve outcomes and the experience for each patient and their health professionals.

One example that was reiterated in multiple presentations was that of the ECG. Applying #AI to the ECG has been shown in the studies presented to determine the age, sex, and heart condition of the individual. Details were shown for a case of hypertrophic cardiomyopathy (yes, HCM, not just left ventricular hypertrophy) diagnosed via #AI analysis of an ECG that appeared relatively unremarkable to physicians’ eyes. After the septal surgery/procedure, although the ECG then looked remarkably abnormal to physicians’ eyes, the #AI algorithm could identify resolution of the hypertrophic cardiomyopathy.

Another example reiterated throughout the conference was identifying undiagnosed left ventricular systolic dysfunction, in a general community population and also in patients referred to a cardio-oncology practice at a large referral center.

Recently, #AI in Cardiology has been used most frequently for monitoring and detection of arrhythmias, such as atrial fibrillation. Everyone can purchase their own wearable to determine this. Physicians are also now prescribing these wearables for ease-of-use, given their pervasive presence and coupling with smartphones owned by much of the population or provided temporarily by the physician group. Such wearables are transitioning from standalone electrodes, to watches, skin patches, and clothing (e.g., shirts, shorts).

Many direct-to-consumer #AI applications in daily life actually are not wearable, such as Alexa and Siri. One study described the ability of #AI to help diagnose mood disorders and cardiac conditions and risk factors by simply “listening to” and analyzing voice patterns. The timing of a young man’s “voice breaking” can potentially predict his risk for heart disease!

A popular use for #AI in medicine overall is to assist with interpretation of various imaging, such as chest X-rays, MRIs, or CT scans. This applies in Cardiology as well. Further, in Cardiology, #AI is being used to help guide the procurement of echocardiograms. The algorithms provide visual instructions (such as curved arrows) to indicate directions in which the ultrasound probe should be moved to obtain the standard view, to which the algorithm is comparing the image being procured moment-by-moment. The idea is for #AI to help less experienced sonographers or echocardiographers learn and perform echocardiography even more expediently.

The theme of the conference was current advances and future applications of #AI in Cardiology. Accordingly, a historical perspective was given, describing some of the earliest attempts at #AI in various fields. A video of a possible precursor to current automated vacuum cleaners was shown, from archives dating back to the 1960s. In addition to ways in which #AI is now being studied or applied, future opportunities for using #AI were also postulated, for example for coronary artery disease, since stress tests are not 100% sensitive and the gold standard coronary angiography is invasive. #AI could help stratify patients who needed versus did not need the invasive procedure for recurrent convincing symptoms in the absence of a positive stress test. Of course, coronary CT angiography could help fill this gap, but #AI might assist with decision-making sooner.

There have been studies on #AI in Cardiology, and studies on #AI in Oncology, and at least one study in #AI in Cardio-Oncology – a study I predicted; one that is quite intuitive and mentioned above. I propose that we continue to apply #AI in Cardio-Oncology, so that the field can catch up with the rest of Cardiology and Oncology, and help us continue to develop this emergent and burgeoning multidisciplinary subspecialty.

This is an exciting time for me to be alive. I am an early adopter of artificial intelligence. I look forward to seeing more and more the availability of #AI to enhance our use of electrocardiography, echocardiography, wearables, biosensors, voice analysis, and more in Cardiology, and particularly in Cardio-Oncology, with an emphasis on primary and primordial prevention even before secondary and tertiary prevention in the area of Preventive Cardio-Oncology, and especially in women.

 

 

 

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Preventive Cardio-Oncology: The Role Of High Intensity Interval Training

Heart disease is the number one killer of survivors of cancer1, 2, 3. It is our responsibility to help our patients with cancer understand and mitigate this risk. Prevention of heart disease in these patients should occur at three stages: in Cardio-Oncology prehabilitation2, 4, habilitation2, 4, and rehabilitation2, 4, 5. At all three stages, exercise is a key component and can be optimized with consideration of high intensity interval training (HIIT).

HIIT has emerged as an exercise structure that adds more efficiency and power to typical continuous exercise regimens. Studies in the general population suggest that HIIT is safe and non-inferior or superior to continuous exercise regimens in its effect on fitness6, 7, lipids7, 8, blood pressure9, blood glucose levels9, waist circumference8, body fat percentage7, 8, insulin resistance7, and more. Beneficial findings and safety have also been reported for individuals with cardiovascular disease (including coronary artery disease and heart failure)10, as well as cancer11.

The format of HIIT is just as it sounds – incorporating high intensity intervals into exercise training. This is not necessarily training for marathons, sprints, or triathlons. This is training for life. Life that individuals with cancer fight so hard for. We owe it to these individuals to help them live their best life when their cancer is in remission. Part of that is their best heart health, and incorporating heart-healthy behaviors most seamlessly into their daily lives. One safe, effective, and efficient way to do that is with HIIT. In HIIT, following warmup individuals work out at high intensity for 30-120 seconds, then either rest or work out at low/moderate intensity for 30-120, alternating between the two for the duration of their set-aside exercise time or program. For example, an individual on a bicycle would cycle at 10 mph for 30-120 seconds, then at 0 or 5-9 mph for 30-120 seconds, alternating between the two for the duration of their set-aside exercise time or program. The new physical activity and prevention of cardiovascular disease guidelines provide great additional examples of moderate versus high intensity aerobic exercises12, 13.

A recent article suggested that HIIT may be the answer to meeting the needs of women in cardiac rehabilitation14. Indeed, HIIT may also be part of the solution to meeting the needs of women in Cardio-Oncology prehabilitation, habilitation, and rehabilitation. Yet for several years, clinicians and researchers have noted a myriad of barriers faced by women in cardiac rehabilitation14, 15, and that a plethora of women are not referred to cardiac rehab at all15. Besides time and accessibility limitations, other reported barriers include lower education level, multiple comorbid conditions, non-English native language, lack of social support, and high burden of family responsibilities. It should therefore be noted that while HIIT may serve as part of the answer to meeting the needs of women in cardiac rehabilitation or in Cardio-Oncology prehabilitation, habilitation, and rehabilitation, other solutions will be needed to address the variety of barriers unrelated to time and accessibility. The use of automatic referral and assisted enrollment can improve the participation of women in cardiac rehabilitation15, while incentive-based strategies and home-based programs may enhance program completion15. Additional solutions will be needed to address remaining barriers, such as health literacy related to lower education level, multiple comorbidities, non-English native language, high burden of family responsibilities, and of course adverse effects of cancer therapies.

As we step out into and carry on in our Early Careers, it is important for us to be aware of high intensity interval training and its incredible potential to elevate our care of women and men in cardiac rehabilitation in Preventive Cardiology, as well as in Cardio-Oncology prehabilitation, habilitation, and rehabilitation.

References
1. Mehta LS, Watson KE, Barac A, Beckie TM, Bittner V, Cruz-Flores S, Dent S, Kondapalli L, Ky B, Okwuosa T, Piña IL, Volgman AS; American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Council on Quality of Care and Outcomes Research. Cardiovascular Disease and Breast Cancer: Where These Entities Intersect: A Scientific Statement From the American Heart Association. 2018 Feb 20;137(8):e30-e66. doi: 10.1161/CIR.0000000000000556. Epub 2018 Feb 1.

2. Squires RW, Shultz AM, Herrmann J. Exercise Training and Cardiovascular Health in Cancer Patients. Curr Oncol Rep. 2018 Mar 10;20(3):27. doi: 10.1007/s11912-018-0681-2.

3. Patnaik JL, Byers T, DiGuiseppi C, Dabelea D, Denberg TD. Cardiovascular disease competes with breast cancer as the leading cause of death for older females diagnosed with breast cancer: a retrospective cohort study. Breast Cancer Res. 2011 Jun 20;13(3):R64. doi: 10.1186/bcr2901.

4. https://earlycareervoice.professional.heart.org/preventive-cardio-oncology-the-rise-of-prehabilitation/. Accessed April 20, 2019.

5. Gilchrist SC, Barac A, Ades PA, Alfano CM, Franklin BA, Jones LW, La Gerche A, Ligibel JA, Lopez G, Madan K, Oeffinger KC, Salamone J, Scott JM, Squires RW, Thomas RJ, Treat-Jacobson DJ, Wright JS; American Heart Association Exercise, Cardiac Rehabilitation, and Secondary Prevention Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Council on Peripheral Vascular Disease. Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and Survivors: A Scientific Statement from the American Heart Association. Circulation. 2019 Apr 8:CIR0000000000000679. doi: 10.1161/CIR.0000000000000679. [Epub ahead of print].

6. Su L, Fu J, Sun S, Zhao G, Cheng W, Dou C, Quan M. Effects of HIIT and MICT on cardiovascular risk factors in adults with overweight and/or obesity: A meta-analysis. PLoS One 2019 Jan 28;14(1):e0210644. doi: 10.1371/journal.pone.0210644. eCollection 2019.

7. Fisher G, Brown AW, Bohan Brown MM, Alcorn A, Noles C, Winwood L, Resuehr H, George B, Jeansonne MM, Allison DB. High Intensity Interval- vs Moderate Intensity- Training for Improving Cardiometabolic Health in Overweight or Obese Males: A Randomized Controlled Trial. PLoS One 2015 Oct 21;10(10):e0138853. doi: 10.1371/journal.pone.0138853. eCollection 2015.

8. Stavrinou PS, Bogdanis GC, Giannaki CD, Terzis G, Hadjicharalambous M. High-intensity Interval Training Frequency: Cardiometabolic Effects and Quality of Life. Int J Sports Med. 2018 Feb;39(3):210-217. doi: 10.1055/s-0043-125074. Epub 2018 Feb 2.

9. Batacan RB Jr, Duncan MJ, Dalbo VJ, Tucker PS, Fenning AS. Effects of high-intensity interval training on cardiometabolic health: a systematic review and meta-analysis of intervention studies. Br J Sports Med. 2017 Mar;51(6):494-503. doi: 10.1136/bjsports-2015-095841. Epub 2016 Oct 20. Review.

10. Wewege MA, Ahn D, Yu J, Liou K, Keech A. High Intensity Interval Training for Patients With Cardiovascular Disease—Is It Safe? A Systematic Review. J Am Heart Assoc. 2018 Nov 6;7(21):e009305. doi: 10.1161/JAHA.118.009305.

11. Mugele H, Freitag N, Wilhelmi J, Yang Y, Cheng S, Bloch W, Schumann M. High-intensity interval training in the therapy and aftercare of cancer patients: a systematic review with meta-analysis.
Mugele H, Freitag N, Wilhelmi J, Yang Y, Cheng S, Bloch W, Schumann M.
J Cancer Surviv. 2019 Apr;13(2):205-223. doi: 10.1007/s11764-019-00743-3. Epub 2019 Feb 26. Review.

12. Piercy KL, Troiano RP, Ballard RM, Carlson SA, Fulton JE, Galuska DA, George SM, Olson RD. The Physical Activity Guidelines for Americans. JAMA. 2018 Nov 20;320(19):2020-2028. doi: 10.1001/jama.2018.14854.

13. Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC Jr, Virani SS, Williams KA Sr, Yeboah J, Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
J Am Coll Cardiol. 2019 Mar 17. pii: S0735-1097(19)33876-8. doi: 10.1016/j.jacc.2019.03.009.

14. Way KL, Reed JL. Meeting the Needs of Women in Cardiac Rehabilitation. Circulation. 2019; 139(10):1247–1248.

15. Supervía M, Medina-Inojosa JR, Yeung C, Lopez-Jimenez F, Squires RW, Pérez-Terzic CM, Brewer LC, Leth SE, Thomas RJ. Cardiac Rehabilitation for Women: A Systematic Review of Barriers and Solutions. Mayo Clin Proc. 2017 Mar 13. pii: S0025-6196(17)30026-5. doi: 10.1016/j.mayocp.2017.01.002. [Epub ahead of print] Review.

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Preventive Cardio-Oncology: A Role For Cardiopulmonary Stress Testing

Cardiopulmonary exercise stress testing can be useful in a variety of ways, particularly for Preventive Cardiology and Preventive Cardio-oncology. The test helps to assess for levels of fitness, causes of functional limitation, and evidence of ischemia. Test results can be used to counsel individuals, guide exercise prescriptions, and reassure, encourage, and motivate individuals for lifestyle modification and behavior change.

The exercise ECG portion of the test gives information regarding evidence of ischemia, exercise capacity, and adequacy of heart rate response, and response of blood pressure to exercise. The information of this portion of the test can help to determine whether there are any high-risk cardiac features that need to be addressed, such as evidence of ischemia or hypotensive response to exercise. Limited heart rate response is also useful to help determine whether rate-limiting medications or pacemaker settings need to be adjusted. Often, when medications like metoprolol or pacemaker heart rate response are adjusted, this can improve the function and experience of patients who are previously limited by their heart rate during activity. The exercise capacity information given by the exercise ECG, such as excellent, good, average, below average, fair, or poor can give an indication of individuals’ ability to meaningfully, safely, and successfully pursue exercise. Oftentimes, some patients who have had prior cardiovascular events may shy away from moderate or intense exercise for fear of cardiovascular injury as a result of exertion. Pursuing an exercise ECG portion of the cardiopulmonary stress test can help individuals in such cases recognize that they can perform moderate or intense exercise safely without injuring their heart. The exercise capacity reported on the test can help these individuals see that their exercise or aerobic capacity is poor because of their hesitation to pursue moderate or intense exercise. This can be motivating for individuals to recognize that they can benefit from doing more and that they can do more safely. This is particularly the case for individuals who have experienced a cardiovascular event from spontaneous coronary artery dissection, which does not have many modifiable risk factors, and understandably leads to apprehension in young women diagnosed with this condition. However, the exercise ECG portion alone lacks several informative parameters important for patient care in Preventive Cardiology and Cardio-Oncology.

The specific addition to the test provided by the ‘cardiopulmonary’ portion involves oxygen consumption. If oxygen consumption (or VO2) is below average, limited, or poor, there can be several reasons for this. The most common reasons include cardiac impairment, pulmonary impairment, deconditioning, excess weight, and limited heart rate reserve. There are various parameters in the cardiopulmonary stress test results that will indicate whether deconditioning plays a role, whether BMI plays a role, whether cardiac impairment plays a role (in which case this could be due to low flow from systolic dysfunction or due to diastolic dysfunction or even heart rate), or whether pulmonary impairment plays a role (which could be of varied etiology). This addition to the test also helps patients to objectively see data supporting the suspicion that they have become deconditioned after a cardiovascular event or after cancer therapies. They get to see that the cancer therapies or their subsequent levels of activity following their cardiovascular event could currently or potentially affect their function, and may explain any current functional limitation or in fact set them up for functional limitation going forward. The test can also help patients see the effect of any excess weight on their compromised oxygen consumption. Given that cancer therapies for breast cancer, for example, will often include radiation, surgery, and chemotherapy that can injure the heart and/or the lungs, it is helpful to determine the suggested underlying causes of functional limitation as assessed by oxygen consumption in these patients who have had treatment involving the chest. Performing the cardiopulmonary stress test at baseline before treatment helps individuals see their level of fitness, deconditioning, weight effect, cardiac impairment, or pulmonary impairment, even before ever undergoing cancer therapy. Given that fitness levels and injuries to the heart or the lungs can be affected by cancer therapies, then repeating the test after therapies can show patients the change that has occurred as a response to therapies. This can be helpful for patient to have a sense of their original baseline and goals that they can work towards to supersede even that baseline. For individuals who are not going to undergo cancer therapies, obtaining a baseline also helps individuals with a sense of how much they could potentially achieve. Then, once they have achieved a particular goal, the test can be repeated to show the improvement and continue to inspire motivation. This objective collection of evidence and data that can be used for motivation, reassurance, counseling, and exercise prescription is all key for lifestyle modification and behavior change in Preventive Cardiology and Preventive Cardio-Oncology. Thus, for all these reasons and more cardiopulmonary stress testing will evolve to play a large role in Cardio-Oncology prehabilitation, habilitation, and rehabilitation1,2,3, as we help individuals prepare for, experience well, and long outlive their cancer therapies.

 

References

  1. https://earlycareervoice.professional.heart.org/preventive-cardio-oncology-the-rise-of-prehabilitation/. Accessed April 20, 2019.
  2. Squires RW, Shultz AM, Herrmann J. Exercise Training and Cardiovascular Health in Cancer Patients. Curr Oncol Rep. 2018 Mar 10;20(3):27. doi: 10.1007/s11912-018-0681-2.
  3. Gilchrist SC, Barac A, Ades PA, Alfano CM, Franklin BA, Jones LW, La Gerche A, Ligibel JA, Lopez G, Madan K, Oeffinger KC, Salamone J, Scott JM, Squires RW, Thomas RJ, Treat-Jacobson DJ, Wright JS; American Heart Association Exercise, Cardiac Rehabilitation, and Secondary Prevention Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Council on Peripheral Vascular Disease. Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and Survivors: A Scientific Statement from the American Heart Association. Circulation. 2019 Apr 8:CIR0000000000000679. doi: 10.1161/CIR.0000000000000679. [Epub ahead of print].
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The Emergence of The Field of Cardio-Oncology

By 2026, it is anticipated that there will be more than 20 million cancer survivors in the US1. The increase in prevalence of cancer survivors is largely due to discovery and implementation of effective chemotherapeutics and radiation therapy.  This success has come with a price, however, as the same chemotherapeutics and radiation therapy that cure cancer also damage vital organs, such as the heart. A wide range of chemotherapeutics have been associated with coronary artery disease, pericardial disease, and thromboembolic disease. Radiation therapy may accelerate premature atherosclerosis through acute inflammation leading to early vasculopathy in irradiated regions. With the introduction of each effective novel agent in treatment that prolongs survival,  side effects may  affect patient health and quality of life.

These factors have prompted the newly published AHA Scientific Statement on the field of Cardio-oncology, focused on the vascular and metabolic ramification of cancer treatment2. Cardio-oncology is a rapidly growing field of study given the prevalence of cancer and the need for physicians to address the unique challenges of treatment of cardiovascular disease in the cancer population.

Similar to general cardiology, prevention is a vital aspect of the field of cardio-oncology. This is due to the fact that both detection and treatment of cardiotoxicity is difficult. Symptomatically, cardiotoxicity can take years to manifest with the use of certain chemotherapeutics  and detection of subclinical cardiotoxicity is challenging. Thus, monitoring and screening become the most effective ways to minimize risk of development of cardiotoxicity and vascular complications.

Care in the cancer population should be multi-disciplinary from the moment the decision is made on the chemotherapeutics/radiation cycle to be used in treatment. Oncologist, cardiologists, and primary care physician are a vital part of care and must work together to make sure patients are medically optimized before start of treatment regimens. This includes thorough risk stratification and analysis of the benefits of treatment modalities, which needs to be individualized. Demographic factors such as the patient’s family history, prior cardiac history, current exercise tolerance are important factors to consider. Identification of patients at high risk would allow for consideration of alternative therapy, closer monitoring, screening, and possibly prophylactic treatment with cardioprotective medications. These patients can be monitored closely and undergo regular screening for signs of ventricular dysfunction.

Cardio-oncology is an exciting field of study with many unanswered questions. As literature continues to grow, I hope that we can meet the many challenges of cancer treatment.

 

References:

  1. Miller KD, Siegel RL, Lin CC, Mariotto AB, Kramer JL, Rowland JH, Stein KD, Alteri R, Jemal A. 2016. Cancer treatment and survivorship statistics. CA: A Cancer Journal for Clinicians 66 271–289.
  2. Campia U, Moslehi JJ, Amiri-kordestani L, et al. Cardio-Oncology: Vascular and Metabolic Perspectives: A Scientific Statement From the American Heart Association. Circulation. 2019;139(13):e579-e602.