Category Archives: Cardiology

Cardiology

Young at Heart – Yated.com – Yated.com

Dr. Benico Barzilai is one of the nations foremost cardiologists. As former head of the Cleveland Clinics cardiology department, he has watched over the past four decades as treating heart disease went from managing pain to treatments which begin as soon as the patient is brought in.

But he is dissatisfied with the way people view heart disease. A heart attack, he says, means that somewhere along the line, the patient was failed by the medical system. You dont want to be taking care of them when the illness is more extreme, he said. You want to be taking care of them much earlier.

Born to two Holocaust survivors from Thessaloniki, Greece, Dr. Barzilai is no stranger to the frum community. Last year, he was a featured panelist at the Boro Park Jewish Community Councils senior health expo.

I had a opportunity to interview Dr. Barzilai recently. Although health is not my usual interview subject, it is Dr. Barzilais sole occupation so thats what we discussed.

What is the most common misconception about heart health that you hear about? What is the one thing you want readers to take away from this interview?

I dont know whether this is the most common misconception, but most people dont think about their heart health until theyre in their 50s, or maybe their 60s. But we know that hardening of the arteries probably starts when people are in their 20s and 30s, so people need to realize that heart health is a lifelong thing. So many people I know get real and jump on the bandwagon only when they are in their late 40s or 50s. They dont realize that it has been going on for a long time.

So kids shouldnt be given candies and nosh from a young age in order to train them for when they get older?

No. With kids the problem is that they start with obesity. Childhood obesity has gone up dramatically, and with childhood obesity comes early diabetes and early high blood pressure.

Its very important for people to know, even in their 30s what is their blood pressure? What is their blood sugar? What is their cholesterol? You should probably start checking your cholesterol every five years sometime in your 30s, and if you have a family history, then maybe in your 20s.

Were talking about making sure people are cognizant of their health early on.

Take a person in his 40s who never paid attention to his heart health, and they are now reading this interview and see that Dr. Barzilai is saying, Youre late to the game. What should they do now?

Its really important to know your numbers. Are you overweight? Do you have high blood pressure? Do you have diabetes or prediabetes? A lot of people at that age have prediabetes. You need a cholesterol check in your 40s for sure. And of course, if they have a family history, they need to be cognizant of all these things. If you have a mother or father who had heart trouble starting in their 50s, you must start thinking about it in your 40s.

What would be an ideal diet for someone who wants to take care of his heart but doesnt want to give up all the comfort foods he is used to?

The Cleveland Clinic and other institutions such as the American Heart Association are now recommending the Mediterranean diet. What is that? Thats a lot of vegetables, fruits, things like beans and fish, maybe one or two servings of meat a week. Stay away from processed foods something like a hot dog or salami is processed food. Eat a lot more grains; salmon and white fish are good for you.

Stay away from concentrated carbohydrates; we have way too many carbohydrates in our diet. You know, everyone says, Oh, lets get rid of the fats. Well, thats fine, but then if you get rid of the fats dont substitute it with sugars or carbohydrates or that type of stuff.

By carbohydrates, I guess you mean bread, crackers, those things.

Oh, yes. Bread, crackers, cookies, cakes. We eat too much of that stuff. The amount of sugar we eat in the United States per capita is way too much. Those are the types of things were talking about.

Could you give me an example of a success story of a patient of yours who listened to the doctor and was able to turn it all around?

The thing that always gets me is when I see someone in the office they know theyre overweight because they quickly get on the scale before I walk in. We talk about what their ideal weight is, and lo and behold, you see them six months later and theyve lost maybe 30 or 40 pounds. Im not saying its just diet, its probably a mix of diet and exercise, sometimes medicines. Those people really pay attention.

I saw one lady last week who was 65 pounds down over a year. It was absolutely shocking how these people actually took the advice very seriously.

When it comes to diet changes, changing the foods people eat, is it common for people to be able to change how they eat from one day to the next?

Yes. There are two things that happened. One, they realize that theyre eating much too often and much too large sizes, maybe having way too many courses, the course sizes are too big, the amount of food that theyre eating is too big, and the calorie density is too great. And two, they are not getting any exercise. You cant lose weight unless you also exercise. You have to be putting on 7,000, 8,000, or 10,000 steps a day, besides cutting out a few thousand calories hopefully a day. That helps a lot.

Its important to realize that exercise is important. Just getting up and moving around is important; dont be very sedentary, be very active.

Aside from that, any other lifestyle changes you would recommend?

Reduce your salt intake. Depending on what type of diet you have it can be very high in salt, which can contribute to high blood pressure. Stay away from store-bought food, which is usually high in salt. You can avoid putting in salt when you make things from scratch.

Those are all important issues.

One oddity in health is, everybody knows someone who is overweight and doesnt seem to care much about his diet, yet he lives to his 90s in perfect health. Is that all genetics? What allows a person to lead a long and healthy life even though he doesnt follow the science books?

Theres been a long argument in the medical literature about this concept of the healthy overweight. Is there a group of people that can be healthy and overweight? Theres been a long argument about that, and I would say that probably not. When people are overweight and theyre still healthy, if you will, theyre probably doing a lot of things correctly. They dont smoke, theyre not heavy alcohol drinkers those are two things that people get into a lot of trouble with. They probably are somewhat active I will guarantee you that if theyre healthy and are overweight, theyre very active. They are walking 7,000 to 8,000 steps a day.

So yes, I think there are some people who are overweight and kind of healthy, but I guarantee you theyd be healthier still if they lost 20 or 30 pounds. And Ive had that experience people you tell that they need to lose weight because theyve had their first heart attack or something like that, and they just cant believe how much better they feel when they lose some of that excess weight.

You were in Boro Park last year for the Boro Park Jewish Community Council seminar. What was your impression of Boro Parks seniors?

I was impressed by the amount of energy in that place. The level of energy and enthusiasm was really high. You have to understand, I grew up in Chicago, I spent a lot of time in St. Louis and Cleveland, and Ive never really experienced that type of incredible energy.

We had a question-and-answer session, and I couldnt get off the stage because there were so many questions. Furthermore, the best questions came from the women. I thought that was kind of interesting. It was fun, but I will tell you, there was this incredible intensity and interest and energy about the whole issue.

Your name is Barzilai. It sounds biblical.

Yes.

Where do you come from?

My parents survived World War II. My father was a prisoner of war, but theyre both from northern Greece, Salonika Thessaloniki now. Barzilai is a pretty common name in Sephardic circles.

What made you decide to go into cardiology?

Growing up in Chicago, I originally wanted to do engineering so I went to engineering school in Cleveland, at Case Western University. About halfway through, I decided I wanted to go to medical school, so I went to the University of Illinois.

I did something that is kind of unusual these days I actually worked through medical school. I had a job once a week working in a blood bank. You cant do that nowadays because the finances arent there. But then I was able to make enough money to pay my tuition, believe it or not. Now tuition is $50,000 or $60,000 a year; theres no way youre going to make that type of money.

I lived at home while I was in medical school, and then I went to St. Louis at Washington University for my training in internal medicine and cardiology. I became a full-time staff member there in 1984, spent 25 years there, and then I was recruited to the Cleveland Clinic in 2009 to head up the section of clinical cardiology. I did that for 10 years, and I stepped down in 2019. Now I remain a staff member.

So Ive been a cardiologist since 1984. This is quite a long time, actually.

Wow. Cleveland Clinic is one of the top medical centers in the country.

Yes. One of the things you always have to feel good about is if your family members are sick or youre sick or your friends are sick, do you feel good about the quality of care that you can offer your friends and family? Particularly in cardiology, we can offer tremendous care to people.

The tremendous experience of the institution, and the number of cases we do, give us a lot of experience. The commitment toward excellence and we measure our outcome, so we know, quarter by quarter, how were doing, whether we are meeting our benchmarks. Theres a real passion to give people the best care in the most efficient and safest way possible.

When Damar Hamlin of the Buffalo Bills collapsed on the field earlier this year, he went into cardiac arrest. I think he was taken to the Cleveland Clinic

No, he was down in Cincinnati.

It was a very interesting case. We all talked about it.

Hes doing fine now. What are the odds of surviving a cardiac arrest without any side effects?

I think people misunderstand the importance of having good resuscitation equipment. That guy had the ideal resuscitation. Someone watched it, someone recognized it, he had a team on the field within minutes, and hes young so even though his brain probably was deprived of oxygen for a few minutes it was a very few minutes they got his heart back in rhythm when he was on the floor of the stadium. This is all ideal. How often does this happen? Not often enough, thats for sure. We wish it would happen more often.

What about a heart attack? Years ago it used to be pretty fatal. What are the odds today of leading a regular life?

Its interesting. When I started in 1984, the treatment for a heart attack was we put you in intensive care, we made sure you didnt have any fatal arrhythmia or funny heart rhythms, and that was about it. We didnt have any medicine. We didnt send people to do heart catheterizations during a heart attack. We didnt have stents. We had open heart surgery, but we would never do open heart surgery in the immediate period.

A large heart attack in the front of the heart probably had a mortality back then of close to 30 percent. And that person would have a large portion of his heart damaged, so his life would be limited.

Now, that same type of person would be admitted quickly, go to the heart catheterization laboratory, they would find the blockage, put a stent in right away, and get the blood flow restored. Things are much better. Someone can have a heart attack and live for 20 or 30 years after that. We have many examples of that.

But I guess the best thing is not to get there by doing what the doctor said.

You say doing what the doctor said. How about seeing the doctor? You cant know your blood pressure, your cholesterol, and all those things if youve never had them checked. Its half the battle just getting people to go to the doctor and get checked out.

Are you talking about a regular doctor or a cardiologist?

You start with a regular doctor. If they find something, then you go see a cardiologist.

How often should a healthy adult see a doctor?

I would say once a year at least.

What is important to tell your doctor when you go there?

Family history is very important. Pay attention to your family history, particularly if you have early cardiac disease in your family. There are other diseases we didnt talk about, but many of those run in families, so you should recognize those diseases and make sure you get checked out for them.

Its important to be checked early in the course of the disease. I do a lot of work on valvular heart disease, which is abnormal heart failure, and I cant tell you how many people say, You know, I never knew I have that problem, and you know theyve had that problem for 30 years. So somewhere along the line, the medical system or someone has failed that person, because you dont want to be taking care of them when the illness is more extreme; you want to be taking care of them much earlier.

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Young at Heart - Yated.com - Yated.com

Cardiology

New Study Reveals Latest Data on Global Burden of Cardiovascular Disease – Diagnostic and Interventional Cardiology

December 11, 2023 A world without cardiovascular disease (CVD) is possible, yet millions of lives are lost prematurely to heart disease each year, according to the new Global Burden of Disease (GBD) special report published today inthe Journal of the American College of Cardiology, JACC. The report provides an update of health estimates for the global, regional and national burden and trends of CVD from 1990-2022 by analyzing the impact of cardiovascular conditions and risk factors across 21 global regions.

Research from this study reflects an urgent need for countries to establish public-health strategies aimed at preventing cardiovascular diseases by underscoring the global action needed to disseminate information and implement health programs, especially in hard-to-reach countries. While cardiovascular disease rates are high globally, regions of Asia, Europe, Africa and the Middle East were estimated to have the highest burden of CVD mortality. High blood pressure, high cholesterol, dietary risks and air pollution remain its leading causes.

Cardiovascular diseases are a persistent challenge that lead to an enormous number of premature and preventable deaths, said Gregory A. Roth, MD, MPH, senior author of the paper and associate professor in the Division of Cardiology and director of the Program in Cardiovascular Health Metrics at the Institute for Health Metrics and Evaluation at the University of Washington. There are many inexpensive, effective treatments. We know what risk factors we need to identify and treat. There are simple healthy choices that people can make to improve their health. This atlas provides detailed information on where countries stand in their efforts to prevent and treat cardiovascular diseases.

The mortality rates are broken down by location, along with age, sex and time categories. The report identifies disability-adjusted life years (DALYs), the years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs). The results presented include several updates to previously published estimates, reflecting new data and new disease modelling methods.

The paper specifically addresses 18 cardiovascular conditions and provides estimates for 15 leading risk factors for cardiovascular disease: environmental (air pollution, household air pollution, lead exposure, low temperature, high temperature), metabolic (systolic blood pressure, LDL-C, body mass index, fasting plasma glucose, kidney dysfunction) and behavioral (dietary, smoking, secondhand smoke, alcohol use, physical activity.

We formed the Global Burden of Cardiovascular Diseases Collaboration three years ago to help bring state-of-the-art research to the forefront of the global cardiovascular community, said Valentin Fuster, MD, PhD, an author of the paper, President of Mount Sinai Fuster Heart Hospital, physician-in-chief of The Mount Sinai Hospital, and editor-in-chief of JACC. Fuster added, We are excited to publish this 2023 Almanac as a dedicated issue of the Journal to inform the realities of CVD risk and inspire strategies for a heart-healthy world.

Key takeaways from the report:

Identifying sustainable ways to work with communities to take action to prevent and control modifiable risk factors for heart disease is essential for reducing the global burden of heart disease, said George A. Mensah, M.D., F.A.C.C., F.A.H.A., director of the Center for Translation Research and Implementation Science at the National Heart, Lung, and Blood Institute (NHLBI). The 2023 Almanac represents an important resource for using locally relevant data to inform local-level actions for heart-healthy and thriving communities.

Launched in 2020, the Global Burden of Cardiovascular Diseases Collaboration is an alliance between theJournals of the American College of Cardiology, the Institute for Health Metrics and Evaluation at the University of Washington, and the National Heart, Lung, and Blood Institute (NHLBI). Serving as an update to 2022s GBD Study, the 2023 publication includes data from 204 countries and territories, highlighting the leading global modifiable cardiovascular risk factors, their contribution to disease burden and recent prevention advancements.

For more information: http://www.acc.org

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New Study Reveals Latest Data on Global Burden of Cardiovascular Disease - Diagnostic and Interventional Cardiology

Cardiology

Deaths from CVD are on the rise, cardiologists warnhigh blood pressure, obesity remain 2 primary culprits – Cardiovascular Business

We formed the Global Burden of Cardiovascular Diseases Collaboration three years ago to help bring state-of-the-art research to the forefront of the global cardiovascular community, Fuster said. We are excited to publish this 2023 Almanac as a dedicated issue of JACC to inform the realities of CVD risk and inspire strategies for a heart-healthy world.

Cardiovascular diseases are a persistent challenge that lead to an enormous number of premature and preventable deaths, added senior author Gregory A. Roth, MD, associate professor in the division of cardiology at the Institute for Health Metrics and Evaluation. There are many inexpensive, effective treatments. We know what risk factors we need to identify and treat. There are simple healthy choices that people can make to improve their health.

These are some of the biggest takeaways from the updated findings:

We know enough to prevent and control most CVD; however, knowing is not enough, the authors wrote in their introduction to the updated report. We must also take action to disseminate promising practices and implement evidence-based interventions that constitute guideline-directed management of CVD and risks.

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Deaths from CVD are on the rise, cardiologists warnhigh blood pressure, obesity remain 2 primary culprits - Cardiovascular Business

Cardiology

American College of Cardiology names renowned cardiologist the next editor-in-chief of its flagship journal – Cardiovascular Business

I will emphasize inclusion, impact and inspiration, positioning the journal to provide evidence and wisdom to guide us through a rapidly evolving landscape of cardiology, as we seek to maximize the possibilities for great advances and mitigate, and even avoid, the potential for harm, Krumholz added in the same statement.

Krumholz is expected to start transitioning into the role in January 2024, and he officially kicks off his five-year term in July 2024. He certainly has big shoes to fill, as the publications current editor-in-chief is Valentin Fuster, MD, PhD, one of the worlds most prominent cardiologists.

Harlans creativity will allow JACC to positively evolve with these rapidly changing times, Fuster said.

JACC is the ACCs premier publication. The JACC family of journals also includes JACC: Cardiovascular Interventions, JACC: Cardiovascular Imaging, JACC: Heart Failure, JACC: Clinical Electrophysiology, JACC: Basic to Translational Science, JACC: Case Reports, JACC: CardioOncology, JACC: Asia and JACC: Advances.

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American College of Cardiology names renowned cardiologist the next editor-in-chief of its flagship journal - Cardiovascular Business

Cardiology

New ‘Atherosclerosis Atlas’ Sheds Light on Heart Attacks, Strokes – Diagnostic and Interventional Cardiology

December 13, 2023 University of Virginia School of Medicine researchers have created an atlas of atherosclerosis that reveals, at the level of individual cells, critical processes responsible for forming the harmful plaque buildup that causes heart attacks, strokes and coronary artery disease.

Atherosclerosis, or hardening of the arteries, affects half of Americans between ages 45 and 84, and many dont even know it, the National Institutes of Health reports. Over time, fatty plaques build up inside the arteries, where they can slow blood flow. When they break loose, they can be deadly, triggering strokes and heart attacks.

Doctors and scientists have been eager to better understand the complex factors that influence the formation and stability of the plaques, and UVAs new work offers unprecedented insights that will facilitate the development of new ways to treat atherosclerosis, battle coronary artery disease (CAD) and help prevent plaque formation.

To begin to develop effective treatments targeting specific disease processes in the vessel wall, we need to characterize gene expression programs at single-cell resolution, said researcher Clint L. Miller, PhD, of the University of Virginia School of Medicines Center for Public Health Genomics, as well as its Departments of Biochemistry and Molecular Genetics and Public Health Sciences. By establishing this map, we can inform strategies to reprogram dysregulated cell states in order to prevent or reverse the disease or identify biomarkers to assess a patients risk of having clinical events.

The formation of atherosclerotic plaques involves multiple types of cells, including immune cells, smooth muscle cells and endothelial cells that line the arteries. Many of these cells transition into other types of cells during plaque formation, making it a huge challenge for scientists to determine the composition and origin of the plaque itself.

Miller and his collaborators, led by graduate student Jose Verdezoto Mosquera, have built a comprehensive single cell map of human atherosclerosis encompassing almost 120,000 cells from atherosclerotic coronary and carotid arteries. In addition to charting broad cell lineages, the researchers leveraged this resource to dissect more granular and rare cell subtypes within atherosclerotic plaques.

The study also reveals new insights on the changes smooth muscle cells go through during disease progression, some of which contribute to the calcification, or hardening, of the coronary arteries. This led to the finding that two genes,LTBP1andCRTAC1, can serve as measures for the progression of atherosclerosis.

Beyond characterizing cell diversity, integrating this newly built atherosclerosis single-cell reference with large-scale human genetic data was critical to start identifying disease-causing cell types and subtypes, Mosquera said. For example, we identified the contribution of smooth muscle cell subtypes, such as fibroblast-like and lipid-rich smooth muscle cells, as well as the genes associated with these phenotypes.

The UVA researchers say their new atlas represents a critical step toward developing better, more targeted interventions to battle atherosclerosis and CAD, as well as identify candidate biomarkers to prevent heart attacks and strokes and improve patient outcomes.

We plan to extend this single-cell atlas with future iterations to include additional datasets from defined disease stages and patients from diverse backgrounds, Miller said. By integrating the corpus of single-cell data generated in the scientific community, we can mitigate sampling bias and establish more robust candidate disease mechanisms and potential interventions.

The researchers havepublished their findings in the scientific journal Cell Reports. The research team consisted of Mosquera,Galle Auguste, Doris Wong, Adam W. Turner, Chani J. Hodonsky, Catalina Alvarez Yela, Yipei Song, Qi Cheng, Christian L. Lino Cardenas, Konstantinos Theofilatos, Maxime Bos, Maryam Kavousi, Patricia A. Peyser, Manuel Mayr, Jason C. Kovacic, Johan L.M. Bjrkegren, Rajeev Malhotra, P. Todd Stukenberg, Aloke V. Finn, Sander W. van der Laan, Chongzhi Zang, Nathan C. Sheffield and Miller. Miller has received funding from biopharmaceutical company AstraZeneca for an unrelated project; a full list of the authors disclosures is included in the paper.

For more information: https://med.virginia.edu/

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Cardiology

What’s new in cardiac imaging? 2 experts discuss the latest trends – Cardiovascular Business

Picking the best cardiac imaging test

"Coronary disease is a growing area for cardiac imaging. The trend we are seeing is that both anatomic and structural imaging play a very important role in certain patient populations. And physiologic imaging is also very relevant for patient populations that are higher risk," DiCarli explained. "So the way the clinical evidence is shaping up, for low and intermediate risk patients, CT seems to be a very effective test to exclude significant coronary disease and help clinicians assess the burden of atherosclerosis. It is very difficult to challenge CT on its negative predictive value as a rule-out test for coronary disease."

For patients who have more coronary disease, or known coronary disease, these patients are better suited for physiological imaging, such as nuclear or MRI, DiCarli said.

Patients with more advanced cardiovascular disease often have higher amounts of calcium in their coronary vessels, making CT more difficult to interpret.

"In these patients, functional imaging for the detection of ischemia and ventricular function starts to become become more relevant and can potentially lead to better decisions," Beanlands said.

The best cardiac centers will have a mix of CT, MR, SPECT and PET to offer the best imaging modality to answer specific questions is specific patients. Over the past decade, there has been a reduction in the number of SPECT exams, but an increase in the number of cardiac CT, MRI and PET exams. The use of echocardiography is still the most widely used cardiac imaging modality and is considered the frontline imaging test for most patients, he said.

CT is considered an anatomical test that can show very detailed images of the anatomy, but until recently, it did not offer functional information. Even if a coronary has a clear blockage, CT cannot offer a physiological assessment of whether the blockage is flow limiting or not. At least, that was the case until multiple studies validated fractional flow reserve CT (FFR-CT), which uses computational fluid dynamics to estimate the coronary blood flow past a lesion or series of narrow vessel segments. FFR-CT was also included in the 2021 chest pain guidelines. However, FFR-CT has the barriers of access and cost. While a growing number of centers are using it, the overall number is still relatively small.

"Cardiac MRI is also a wonderful option for imaging coronary disease. MRI also can quantify perfusion and patients with microvascular disease," DiCarli said.

In addition, he added, MRI has the best soft tissue delineation of any of the cardiac imaging modalities. However, it has certain limitations, including high costs, potentially limited access and the longer exam times.

Beanlands, a former president of the American Society of Nuclear Cardiology (ASNC), said single photo emission computed tomography (SPECT) is the most widely used nuclear imaging technology in both the U.S. and around the world.

"It's been a go-to technology for many, many years, but it has pitfalls that make it more challenging," he explained. "People are developing technologies to offer quantification of flow, which has some advantages."

Beanlands also said that clinical studies to validate SPECT quantification software are still ongoing, but that technology is already in clinical use withpositron emission tomography (PET). PET in many ways is seen as a better technology, with clearer imaging, use of fused CT for attenuation correction, the CT also adds anatomical imaging, and it has the ability to calculate coronary flow reserve. But PET adoption has been limited because of the cost for these systems and the required change in radiotracers and workflow.

"PET is emerging more and more and is becoming widely used, because it has the advantage of this flow quantification, which really can distinguish the patients who are high risk and low risk. It has the potential to risk stratify patients with that important piece of information," Beanlands explained. "And not only for coronary disease, but for what we call microvascular disease."

He said PET may play an increasing role to better quantify the extent of these microvascular diseases, like myocardial ischemia with no obstructive coronary arteries (INOCA), or myocardial infarction with non-obstructive coronary arteries (MINOCA).

For years these patients, particularly women who have a higher prevalence of these conditions, where brushed off and told the chest pain was just in their head, because there was no clearly seen obstruction inside their coronaries, Beanlands said.

Another advantage associated with PET is that the rubidium radiotracer used only has a 75 second half life, so the exams are very faster compared to SPECT.

"I think PET is ahead of SPECT," Beanlands said. "Don't get me wrong, SPECT is useful and you want to be using it in certain patients. But, PET as significant advantages pretty much in all areas."

DiCarli agreed PET is a better imaging modality and more accurate. However, while it may be better, he said access to PET is still limited, so SPECT will likely remain the workhorse nuclear technology for years to come.

He added that PET also has a new imaging agent in trials to improve perfusion imaging that does not require an on-site cyclotron, or the use of an expensive rubidium generator. DiCarli said the agent can be produced by commercial cyclotrons off-site and sent as unit doses to the hospital. This will lower the cost of ownership for PET systems and accelerate wider adoption. He said it is possible the new agent may see FDA clearance in the next two years.

"That will help open access in ways that we have not been able to realize with the currently approved FDA radiopharmaceutical," DiCarli said.

Another trend in cardiac imaging is the area of visualizing inflammation in the heart. This includes amyloidosis, sarcoid, pericarditis, myocarditis and other inflammatory disorders.

"We have seen over the last fives years a tremendous growth in the referrals for those patients," DiCarli explained. He added that imagers also have learned how to use the complimentary advantages of PET and MRI together for a more accurate diagnosis.

Beanlands said inflammation also plays a role in atherosclerosis, so being able to image it may play a future role in how these patients are managed.

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What's new in cardiac imaging? 2 experts discuss the latest trends - Cardiovascular Business

Cardiology

Study reveals a novel method for assessing an important measure of heart function – News-Medical.Net

Coronary heart disease is the leading cause of adult death worldwide. The coronary angiography procedure provides the clinical standard diagnostic assessment for nearly all related clinical decision-making, from medications to coronary bypass surgery. In many cases, quantifying left ventricular ejection fraction (LVEF) at the time of coronary angiography is critical to optimize clinical decision-making and treatment decisions, particularly when angiography is performed for potentially life-threatening acute coronary syndromes (ACS).

Since the left ventricle is the heart's pumping center, measuring the ejection fraction in the chamber provides critical information about the percentage of blood leaving the heart each time it contracts. Presently, measuring LVEF during angiography requires an additional invasive procedure called left ventriculography where a catheter is inserted into the left ventricle and contrast dye is injected which carries additional risks and increases the contrast exposure.

In a study published May 10 in JAMA Cardiology, senior author and UCSF cardiologist Geoff Tison, MD, MPH, and first author Robert Avram, MD, of the Montreal Heart Institute, set out to determine whether deep neural networks (DNNs), a category of AI algorithm, could be used to predict cardiac pump (contractile) function from standard angiogram videos. They developed and tested a DNN called CathEF, to estimate LVEF from coronary angiograms of the left side of the heart.

CathEF offers a novel approach that leverages data that is routinely collected during every angiogram to provide information that is not currently available to clinicians during angiography, effectively expanding the utility of medical data with AI and provides real-time LVEF information that informs clinical decision-making."

Geoff Tison, UCSF Associate Professor of Medicine and Cardiology

The researchers performed a cross-sectional study of 4042 adult angiograms matched with corresponding transthoracic echocardiograms (TTEs) from 3679 UCSF patients and trained a video-based neural network to estimate reduced LVEF (less than or equal to 40%) and to predict (continuous) LVEF percentage from standard angiogram videos of the left coronary artery.

The results showed that CathEF accurately predicted LVEF, with strong correlations to echocardiographic LVEF measurements, the standard noninvasive clinical approach. The model was also externally validated in real-world angiograms from the Ottawa Heart Institute. The algorithm performed well across different patient demographics and clinical conditions, including acute coronary syndromes and varying levels of renal function-;patient populations that may be less well suited to receive the standard left ventriculogram procedure.

"This study presents a novel method for assessing LVEF, an important measure of heart function, during any routine coronary angiography without requiring additional procedures or increasing cost," said Avram, an interventional cardiologist and former UCSF research fellow. "LVEF is essential for making decisions during the procedure and for managing patient care."

Although the algorithm was trained on a large dataset of angiograms from UCSF and then separately validated in a dataset from the Ottawa Heart Institute, the investigators are undertaking further research to test this algorithm at the point-of-care and determine its impact on the clinical workflow in patients suffering heart attacks. To this end, a multi-center prospective validation study in patients with ACS is underway to compare the performance of CathEF and the left ventriculogram with TTEs performed within 7 days of ACS.

"This work demonstrates that AI technology has the potential to reduce the need for invasive testing and improve the diagnostic capabilities of cardiologists, ultimately improving patient outcomes and quality of life," said Tison.

Source:

Journal reference:

Avram, R., et al. (2023) Automated Assessment of Cardiac Systolic Function From Coronary Angiograms With Video-Based Artificial Intelligence Algorithms. JAMA Cardiology. doi.org/10.1001/jamacardio.2023.0968.

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Study reveals a novel method for assessing an important measure of heart function - News-Medical.Net

Cardiology

Cardiology has embraced AI more than most other specialties – Cardiovascular Business

Artificial intelligence (AI) algorithms are being used more and more by cardiologists and other cardiovascular professionals. In fact, of the more than 500 clinical AI algorithmscleared by the U.S. Food and Drug Administration (FDA), cardiology has more than all but one other specialty: radiology has more than 400, and cardiology has more than 60.

Those numbers continue to grow, suggesting that this is just the beginning for cardiology's relationship with this evolving technology.

Beyond the clinical, patient-facing AI algorithms the FDA reviews, there are hundreds more non-clinical algorithms now embedded into back-end health IT systems to speed workflow, improve efficiency, complete time-consuming tasks, analyze data and more.

Here is the breakdown for the number of FDA-cleared algorithms across specialties as of the FDA's last update in January 2023.

Radiology396 Cardiology58 Hematology 14 Neurology 10 Clinical chemistry 7 Ophthalmic 7 Gastroenterology and urology 5 General and plastic surgery 5 Pathology 4 Microbiology 4 Anesthesiology 4 General Hospital 3 Orthopedic 1 Dental 1

See the complete list of FDA-cleared algorithms here

Additionally, the American College of Radiology (ACR) also maintains a frequently updated database of medical imaging AI FDA approvals. According the the ACR database, and additional 35 medical imaging AI algorithms were cleared between January and March 30, 2023. This included 8 new cardiac related algorithms, bringing the total for cardiology to 66. Radiology algorithms overall are now at 431.

The first AI algorithm was cleared by the FDA in 1995, and fewer than 50 algorithms were approved over the next 18 years. However, the numbers have increased rapidly in the past decade, and more than half of algorithms on the U.S. market were cleared between 2019 to 2022more than 300 apps in just four years. Last October, the FDA approved 178 new AI and machine learning (ML) systems. That number is expected to grow rapidly into the future, the FDA has said.

Ami Bhatt, MD, theAmerican College of Cardiology (ACC)chief innovation officer and adult congenital heart disease cardiologist at Mass General Hospital, said artificial intelligence really needs to be renamed "collaborative intelligence," because it is really a collaboration between a human doctor and the machine to leverage the best abilities both have to offer to improve patient care and efficiencies in healthcare. The ACC has been a big advocate for bringing more cardiology AI to the market to help augment physicians amid a growing shortage of cardiologists in the U.S.

"It's simply that the human eye can't necessarily take all of that data and process it the way a computer can. So we are not saying we are replacing humans with computers, we are trying to allow clinicians to work at the top of their license and to given them some guidance as to what may be a good direction to go in. And there are times when our clinical acumen will supersede what a computer may suggest, and that is OK and that needs to happen, because then we reteach that computer how to learn," Bhatt explained.

Bhatt also emphasized that this does not mean every physician has to be an expert when it comes to AI.

"[Physicians just] need to understand there is some AI here with computational aspects, and here is what it is meant to do. Any beyond that, they just need to use their clinical acumen," she said.

Bhatt and others have also noted that AI needs to be seamlessly integrated into workflow, just like medical devices or reporting software to make it usable by clinicians.

"We really need to upscale cardiologists' understanding of this technology. We live in a digital world and medicine tends to be fairly conservative, but I think people are recognizing AI is here to stay and we have to embrace it. In the clinical community, we need to be at the forefront,"explainedEd Nicol, MD, consultant cardiologist and honorary senior clinical lecturer withKings College London,and president-elect of theSociety of Cardiovascular Computed Tomography (SCCT).

The academic discussions on AI and its future applications are largely over. What is now being discussed are actual FDA-cleared products sold on the market and in clinical use.

Making this more real is the fact that the first cardiology AI algorithm is now included in practice guidelines in both Europe and the United States. TheACC/AHA 2021 Chest Pain Guidelinesinclude the recommended use of AI-driven fractional flow reserve hemodynamic flow measurements derived from noninvasive CT imaging (FFR-CT).

"If you had said to me 15 years ago we were going to have some sort of computational fluid dynamics tool in the U.S. chest pain guidelines, you would have been laughed at. Everyone would have said you were crazy. But that is the reality, we see FFR-CT in the international guidelines, based on evidence. That will be the first, I suspect, of many," Nicol said.

He said the biggest thing cardiologists need to understand is how the AI they are evaluating or using works. This way they can understand if there are issues in the AI-generated data and how they should validate it.

"We the clinicians really need to own this," Nicol explained. "And you can really only own this and challenge it if you understand it and the strengths and weaknesses of AI. We are not trying to change the whole radiology/cardiology community into programmers, but they need to understand how those programs work, even if they do not understand all the strings of computer code."

"One of the things I am amazed about is the rapid progression of non-invasive imaging and using artificial intelligence to try and standardize analysis," explainedJuan Granada, MD, president and CEO of theCardiovascular Research Foundation (CRF), when describing key technology trends he sees in cardiology.

AI in cardiac imaging enables faster exam reads by automating quantification and making measurements more consistent, eliminating the usual variability between radiologists or cardiologists. Granada believes AI will soon play a big part in cardiac care in all of its the subspeciality areas, including interventional cardiology.

While there are FDA-cleared AI algorithms to automatically assess ECG data and wearable heart monitor data,most of the cardiac AI has been concentrated in imaging. In addition, many of the radiology-cleared algorithms are actually specifically for cardiovascular, peripheral vascular and neurovascular imaging. These include uses in CT, MRI, nuclear imaging and cardiac ultrasound.

"AI is coming along in many areas of echocardiography. It is just exploding and it is very exciting," explained echocardiography expertPatricia A. Pellikka, MD. She is the editor-in-chief ofJournal of the American Society of Echocardiography, director of theMayo Clinic Ultrasound Research Centerand a consultant for Mayo Clinic department of cardiovascular medicine."One of the areas is the use of AI too help improve ultrasound acquisition of images by teaching inexperienced users how to get the image. Another area is applying AI to the data that is already acquired to remeasure things, or to apply AI to all the measurements that have already been obtained to detect disease."

In her research at Mayo, Pellikka has been involved with the development of AI that looks at the ultrasound images to directly detect disease. The algorithms can pick out radiomic signatures of disease in the image that may not be evident to the human eye.

"I think the potential there is enormous," Pellikka said.

Over the past few years there has been a big increase in the use of point-of-care ultrasound (POCUS) systems in a variety of settings, including clinics, physician offices, emergency departments and ICUs. These echos are being performed by much less experienced sonographers than those in hospital echo labs.A couple AI vendors have developed FDA-cleared algorithms to show POCUS users how to move their probe into the correct position and walk them through how to acquire each of the standard echo views. The AI also tells the operator when they are in the correct position and judges the quality of the images they are acquiring. Many echo experts say this can significantly improve exam diagnostic quality, leading to fewer repeat exams, faster and better diagnosis of patients.

"This will extend the reach of cardiovascular ultrasound to places and times when there isn't an experienced cardiac sonographer available to do the imaging. I think the potential for this is extremely exciting," Pellikka explained.

AI is also being used to speed up patient assessments by automating echo strain, ejection fractions and other measurements. Pellikka said several vendors have now developed FDA-cleared algorithms in these areas. This automation can eliminate the need for a sonographer to perform manual contouring of the ventricles, or manually using calipers to take various measurements. She said the sonographer can still edit these AI-generated contours if they feel they are incorrect. Overall, she said this results in a much faster exam or post-processing of the exam, enabling more patient throughput.

Importantly, Pellikka and other echo experts say this type of AI automation also reduces the variability in measurements between different sonographers. AI automatically picks the same landmark locations to perform measurements, helping deliver more consistency. This is especially important when monitoring patients over time.

"I think this is just the tip of the iceberg and I think we will be automating many other measurements as well, such as automatic assessment of valvular heart disease. All of this is going to increase the standardization of echocardiography and make it so the communication between one center doing an echo and another is more standardized than it is today," Pellikka said.

Excerpt from:

Cardiology has embraced AI more than most other specialties - Cardiovascular Business

Cardiology

Getting to the heart of it: Leading cardiologists share the journey of care – The Salem News

Salem resident Frank Curtin, then 56, was in cardiac arrest when he arrived at Salem Hospital.

I ended up crashing right in the lobby of the emergency room, Curtin explained. The next thing I remember is I was on the table. They were doing chest compressions on me.

The doctors went through resuscitation for the next 15 to 20 minutes to try to get his pulse back.

We were working tirelessly to get him back to his family, said Dr. Lola Ojutalayo, explaining that they immediately contacted Medflight to transport him to Mass General Hospital where he recovered thanks to the treatment at both Salem and Boston.

Franks story is one of thousands where a life was saved because of the quality care from a team of board certified cardiologists at Salem Hospital and their partnership with Mass General Brigham.

This team is being led by two women of color who are determined to change the narrative around women in leadership: Chief of Cardiology Sohah N. Iqbal, MD, and Medical Director Lola Ojutalayo, MD.

Historically, cardiology has been mostly an all boys club, explained Ojutalayo, who lives in North Reading.

Ojutalayo was born in the U.K. while her parents studied in London but identify as Nigerian American. She moved to New Jersey when she was 12 years old and eventually completed her medical training at Drexel University College of Medicine Philadelphia, where she had her two sons.

I love spending time with them and traveling to learn new cultures, Ojutalayo said.

She has also held positions as an Interventional Cardiologist at St. Josephs Health in New York and at Mass. General Hospital.

According to a 2021 article published in the Journal of the American Heart Association, while 50% of medical school graduates in the United States are women, only 21% of cardiology fellowships are awarded to women and only 13% of practicing cardiologists are women. Among operators who perform coronary interventional procedures in the U.S., only 4.5% are women.

Despite efforts from U.S. professional societies to better engage and support women in cardiology, these numbers remain unchanged over the past several years and have been referred to as the leaky pipeline, the article reads.

Iqbal, who has worked at Salem Hospital since 2020, went to college at MIT, completed her medical school at Harvard and then moved to New York for residency at Columbia. Before moving back to Boston, Iqbal completed a cardiology fellowship at New York University where she stayed on as faculty for a decade.

While being the first woman to train in interventional cardiology at a past institution, Iqbal, who now lives in Marblehead, was told by the men who trained her that she wouldnt be able to do it and that she should do things like a man in the cardiac catheterization laboratory.

Words to describe women in the workplace included cupcake and bossy, she explained.

But that didnt stop her from pursuing her passion.

My passion for what I do and the patients I serve has always driven me to want to improve systems. Iqbal said. I needed to find a professional home that would be open to my ideas and not threatened by them.

Salem Hospital is definitely that place, she added.

In 2022, the U.S. News and World Report named Salem Hospital a high-performing hospital, which is the highest award a hospital can receive for U.S. News Best Hospitals Procedures and Conditions ratings.

We are very proud that the exceptional care we offer at Salem Hospital is recognized on a national scale, says Roxanne Ruppel, President and Chief Operating Officer of Salem Hospital. It is a tribute to our extraordinary nurses, physicians and staff who, even during the COVID-19 pandemic, continued to meet the highest standards of care.

The hospital provides fully integrated cardiac evaluation and treatment to North Shore patients including angioplasty, cardiac ablation, cardiac catheterization, cardiac evaluation and testing, cardiac rehabilitation, electrophysiology and percutaneous coronary interventions and stents.

We have such a special community here and I feel lucky to work here, Iqbal said.

Iqbal and Ojutalayo have worked alongside former director Dr. Howard Waldman and Dr. Pat Gordan to develop the Impella and Mobile ECMO programs two devices that make Salem Hospital a leading medical center for critical care.

Iqbal explained that the Impella device is a tiny heart pump that is used to help maintain blood flow during high-risk protected percutaneous coronary interventions (PCI).

The second program is the mobile ECMO program, which stands for extracorporeal membrane oxygenation. The ECMO machine is designed to support critically ill patients by providing cardiopulmonary functions normally performed by the patients hearts and lungs. ECMO can support the heart, lungs, or both.

While Iqbal and Ojutalayo have had to navigate the challenges of working in a male-dominated industry, they have hope for the next generation of female cardiologists.

Unfair as it may be, you push through these biases by working harder, Ojutalayo explained. You go the extra mile to prove yourself. You utilize the resources around you the best that you can. Most of all, you value the people around you who see you, embrace your uniqueness and want to see you succeed.

The hope is that in the future that it might be a little different for those coming behind us, she added.

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Getting to the heart of it: Leading cardiologists share the journey of care - The Salem News