HCM

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Artificial Intelligence in Cardiology: Opportunities for Cardio-Oncology

Sherry-Ann Brown, MD, PhD

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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What Can You Do When 15 Minutes Isn’t Enough?

Nosheen Reza, MD

In the last year of my fellowship continuity clinic, my “new patient” visits were allotted 30 minutes and my “return” patients were scheduled for 15 minutes. Despite having more flexibility than my attendings, it never seemed like I was able to offer all of the critical thinking, counseling, and education to which I aspired. The myriad constraints of electronic documentation, overbooking, and care fragmentation ultimately result in limited face-to-face time between patients and their physicians. I realized that, regardless of their health literacy, patients are forced to seek health information from other sources – whether these sources were friends and family, traditional media, or social media platforms.

When I began my training in our specialized inherited cardiomyopathy clinic, I learned about a number of support resources for patients and by patients with these complex disorders. These resources fulfill many of our patients’ needs, ones that our current system does not give physicians the time and space to acknowledge. Here, I will use the example of hypertrophic cardiomyopathy (HCM) to illustrate a few benefits of understanding this landscape – for us and for our patients.

The Patient Experience

In our specialized clinic embedded in a large academic medical center, many of the individuals we see are referred from outside of our health system. We spend a significant amount of “pajama time” wading through the mass of progress notes, procedure reports, and imaging data to ensure our consultations incorporate all of the available and pertinent information.1 In doing this with such frequency in this setting or in any other specialized clinic, we can become desensitized to the patient’s experience of wading through the masses.

This month, Cynthia Burstein Waldman, the creator/founder of HCMBeat, posted a blog about her 12-year post-myectomy follow-up at Mayo Clinic. Ms. Waldman was diagnosed with HCM almost 20 years ago and has since started a website to assist others living with HCM. In her blog about this visit, she details her pre-visit preparations, skills in navigating patient portals, issues with phlebotomy after being instructed to fast for 12 hours, cardiovascular testing, clinic experience, and post-visit communication. Reading her account and interpretation of this encounter was incredibly enlightening for me, especially because it allowed me to appreciate the aspects of a “follow-up visit” that patients might genuinely value and consider essential to a good experience. Patient-authored blogs like this one and the AHA’s Support Network on Cardiomyopathy can help contextualize the patient experience for us in ways that cannot be accomplished solely through periodic clinic visits.

 

Education

One of the core values of the Hypertrophic Cardiomyopathy Association, the largest U.S. organization serving individuals with HCM, is to provide “education to patients, families, the medical community and the public about HCM.” Within this core value, the HCMA provides education about HCM symptoms and treatment, raises awareness about malignant arrhythmias and sudden cardiac death in HCM, and promotes HCM research. Similar to HCMBeat, HCMA was founded by another woman affected by HCM, Lisa Salberg. The website’s Resources section is very well curated with information on HCM itself, finding an HCM center, links to academic journal articles about HCM, and it also has a multimedia collection with webinars and podcasts related to these topics. While intended to be primarily patient-facing, the website also serves as a valuable educational resource for clinicians. In our current age of medical mistrust and ever-present threats of medical misinformation, resources like this one represent one approach for patients and for clinicians to close the literacy gap.

 

Advocacy

In January, Christa Trexler, PhD wrote a great AHA Early Career blog about the importance of advocacy in cardiovascular medicine and research. Staying abreast of the active legislation and political conversations regarding health care can be daunting for clinicians, especially those without health policy experience, but the above mentioned websites also have dedicated sections on advocacy, state and federal legislation pertaining to HCM, and on navigating the U.S. healthcare system. These toolkits are a great place to start for clinicians interested in taking a more active role in educating our legislators and promoting change in our communities.

 

Do you know of similar patient support resources in your field? If not, I encourage you to start by checking out the AHA’s Support Network and engaging with patients and caregivers of cardiovascular disease and stroke.

 

References

  1. Sinsky C, Colligan L, Li L, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med. 2016;165(11):753-760.

 
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Hypertrophic Cardiomyopathy Comes in Different Shapes and Sizes

John Chen, MD

Scientific Sessions 2018 marks many firsts for me—my first time at Scientific Sessions and my inaugural blog post on the AHA Early Career Voice.  Both are tremendous opportunities.

I specifically sought out the Sunday morning session, “State of the Art in Hypertrophic Cardiomyopathy.”  As an internal medicine resident at Emory, I’ve had several experiences seeing patients with hypertrophic cardiomyopathy (HCM) in the outpatient clinic.  Unlike many other fields of cardiology, HCM is a niche dominated by young, otherwise healthy patients.  The title of this session alludes to how little we know about HCM, and how the practice of managing this complex condition truly is an “Art.”

Much of the session was an exercise in taxonomizing the umbrella term, “HCM,” splitting that pie from a number of interesting angles.  Dr. Sharlene Day divided HCM by obstructive phenotype: obstruction at rest, obstruction with provocation, and no obstruction.  Our approach to therapies has been driven by a focus on relieving obstruction, but strategies for treating symptoms in the absence of obstruction represents an open frontier.  Currently, the MAVERICK-HCM trial is studying the use of a cardiac myosin modulator in this patient population.

Dr. Jodie Ingles compared “familial” versus “non-familial” HCM.  The latter case, she argued, tends to involve men, present later, and portend a lower risk of cardiovascular events.  Discerning which cases of HCM is considered “familial” versus “non-familial,” and whether such a dichotomy truly exists, sparked much debate in the Q&A.

Drs. Elizabeth McNally, Adam Helms, and Jil Tardiff shared similarly thought-provoking insight, highlighting the heterogeneity of genotypes and phenotypes in HCM.  Multiple disparate mechanisms are responsible for producing sarcomere dysfunction, subsequent organic dysfunction, and finally clinical symptoms.  An appreciation for these finer details is necessary to guide a sophisticated approach to management.