Nobody ever said it would be easy. But for the medical community in pursuit of solutions that help solve Cardiovascular Disease (CVD) and improving outcomes, and the technology companies that produce these offerings, the challenge is getting harder and harder by the day.

On 2020 World Heart Day, despite progress in the overall decline of CVD mortality, CVD remains the leading cause of death globally¹ and certain demographics fare worse than others. With an increasingly disproportionate number of CVD patients presenting with multifactorial complexities such as aging, obesity, comorbidity, environmental influence, and lack of access to quality care, how these patients are being cared for is changing and evolving to become a more personalized and holistic approach whereby technology providers are working to help doctors treat the patient, not just the disease.

Dr. Casey Culbertson performing rounds in the ICU at Nhi Dong (Children’s Hospital) #3’s in Ho Chi Minh City (Saigon). Since 2005, Culbertson and team have performed heart surgeries on over 20,000 children in Vietnam.

With the knowledge that Cardiologists are focused on delivering optimum clinical outcomes, it’s vital that technology developers create solutions that integrate seamlessly and are equipped with AI to help heart care teams make sound diagnostic decisions and operate at peak efficiency while delivering high-quality patient care.

Every second of every day, an average of four hearts are diagnosed or treated by clinicians using GE Healthcare equipment worldwide. There’s no single tool, technology, or solution to combat and solve CVD, but there is one goal: improve clinical outcomes.

That is why the role of Chief Scientist and Chief Medical Officer (CMO) are becoming more important. Chief Scientists look for trends and predict the future, while CMOs manage teams of doctors and researchers to help with product development and contribute thought leadership to inform and educate the industry.

Dr. Jeff Hersh pictured in Haiti during a visit to provide emergency care and medical evaluation
of patients who were impacted by the earthquake that hit on January 12, 2010.

In observance of 2020 World Heart Day, Insights interviewed GE Healthcare Chief Scientist for Diagnostic Electrocardiography, Ian Rowlandson, and three Chief Medical Officers, each with a different clinical background and expertise: Dr. Jeff Hersh, Chief Medical Officer (Internal Medicine, Pediatrics and Emergency Medicine); Prof. Dr.med Mathias Goyen, Chief Medical Officer for GE Healthcare’s EMEA region (Radiology); and Dr. Casey Culbertson (Pediatric Cardiology).

Q: From your experience, what does the future of cardiology look like? What concerns you most?

Ian Rowlandson: COVID is going to have a huge impact on cardiology. It’s sad. Even when a person is asymptomatic, the virus can still get into the heart and create havoc. A recent study on athletes showed 15 percent of players have myocarditis--inflammation of the heart muscle, which in and of itself is not bad, but how the heart heals from it is bad because it can grow scars and those scars can create arrhythmia or lack of proper relaxation in the heart. A large population of people are going to be impacted by this, including the elderly, young, and people without pre-existing conditions. This is a silent catastrophe and we are involved with trying to fix it.

Dr. Jeff Hersh: The continued increase in CVD and access to physiological data like wearable ECG devices is already resulting in an increasing influx of data. Reliable triage is key; how can we find which patients really need diagnostic testing and imaging, and which ones are false positives. Once appropriately triaged, then we can start to look and see what is happening anatomically and physiologically. I see four separate areas where I think cardiac imaging will grow: acquire, interact, interpret and report.

We will continue to see improvements in the acquisition of images, ranging from simultaneous acquisition (e.g. Synthetic MRI) to automated acquisition, such as an imaging AI that recommends optimum settings for, MRI, CT, x-ray, etc. or AI that automates image acquisition on point-of-care ultrasound.

Imaging devices will further interact with the clinician and patient. Some examples are mammography systems that allow patients to adjusted their own pressure, ultrasound dynamic needle guidance interacting with the clinician, and technology that fuses images from different modalities to interact with each other.

This is a key role of artificial intelligence (AI), which acts as an aid to support clinicians. Some examples include handheld ultrasound equipped with an AI tool that automates ejection fraction assessment, or a mobile x-ray system equipped with algorithms that flag an image with a suspected pneumothorax.

And what really excites me is AI for structured reporting, as creating imaging reports today may be tedious, time consuming and yet still have inconsistent formats and presentation.

The COVID-19 pandemic has posed new challenges to cardiologists around the world. Ian Rowlandson, Chief Scientist of Diagnostic Cardiology at GE Healthcare is seen here with Dr. Nicola Cosentino of the Monzino Cardiology Center in Milan, Italy discussing diagnosing ST-elevation acute myocardial infarction (STEMI) in COVID-19 patients.

Q: What solutions are critical in helping clinicians combat CVD, the number one killer globally?

Ian Rowlandson: ECG is not perfect, but it can be widely used to pick up problems in patients who are experiencing cardiac-related issues, such as those who are harboring myocarditis. In the case of myocarditis, beginning with an ECG, then following up with an echo study (Ultrasound) or Cardiovascular MR is probably the most important technology for evaluating what I see in front of us.

Dr. Mathias Goyen: CVD is diagnosed using an array of laboratory tests and imaging studies. The primary part of diagnosis is medical and family histories of the patient, risk factors, physical examination, and coordination of these findings with the results from tests and procedures.

Non-invasive cardiovascular imaging has traditionally been stratified into two distinct types: anatomic imaging and functional imaging.

The main aim of anatomic imaging is the identification of atherosclerosis, while functional imaging provides information relating to the hemodynamic significance of that atherosclerosis. Anatomic imaging modalities include multi-detector computed tomography (MDCT), electron beam computed tomography (EBCT) and magnetic resonance angiography (MRA), while functional imaging modalities include single photon emission computed tomography (SPECT), myocardial perfusion imaging (MPI), stress echocardiography (SE), cardiac magnetic resonance imaging (CMR), and positron emission tomography (PET) perfusion imaging. Currently, the assessment of functionally significant coronary heart disease (CHD) has relied primarily upon nuclear MPI or SE. Both MPI and SE have demonstrated robust ability to diagnose significant CHD, as well as the capability to prognosticate future outcomes.

Particularly with current generation CT scanners with built-in AI capabilities, MDCT has evolved into a non-invasive modality with extremely high sensitivity and specificity for the detection of obstructive coronary artery stenosis. In comparison with MPI and SE, MDCT demonstrates superior ability to detect significant stenosis.

Q: What is the biggest game changer when it comes to helping cardiologists improve outcomes?

Ian Rowlandson: There are not enough cardiologists to take this crisis on and assess the number of patients who need care. Getting tools like ECG and echocardiography in the primary care setting, in the hands of physicians who are not experts in cardiology but can do basic assessments and then know when to turn to a cardiologist who can provide more advanced care, is key.

A good example of this is the management of high blood pressure (BP). In some patients, even slightly elevated BP can result in abnormal growth of the heart which can ultimately lead to heart failure. Hence, it is critical to detect this abnormal growth early before the heart becomes big and ineffective. It should be appreciated that echo and ECG measure different aspects of this abnormality. Although an echo provides a macroscopic / anatomical view of the enlarged heart, it does not provide a view of the microscopic changes in the cellular substrate, which can impact how the heart propagates the electrical impulse generated with each heartbeat. By a combination of measures from echo and ECG, primary care physicians could determine whether drug treatments they provide are not only controlling BP but arresting the abnormal growth of the heart which can lead to heart failure.

Dr. Casey Culbertson: The future of both Pediatric Cardiology and Cardiology in general will be about the precision diagnosis and treatment of patients upon presentation. The largest concern about this future is for the healthcare providers (both physicians, nurses and ancillary healthcare workers) to manage and implement the immense amount of medical data (which is doubling every 73 days) for the benefit of each patient.

Dr. Jeff Hersh: Knowledge is power. What intervention is best and when it is needed are always the key questions. We have gone from CABG to stents placed based on anatomy to stents based on physiology (e.g. FFR); we continue to see the need to not just understand anatomy but also to understand the underlying pathophysiology. Being able to identify ‘vulnerable plaques’ is one game changer I think will be coming (hopefully soon).

Dr. Mathias Goyen: Truly connected health systems are key where digital transformation allows patients to experience a seamless cardiac care journey that is connected across care settings. This is the direction we are going in GE Healthcare. If we take the patient longitudinal view of all cardiology images and reports and manage to provide a decision support and predicted outcome, we could change the way cardiology is practiced today.

Prof. Dr. med Mathias Goyen, Chief Medical Officer for GE Healthcare’s EMEA region (Radiology) speaking on
The Future of Radiology at the Korean Congress of Radiology in 2019.

Q: What worries you most about CVD during COVID-19 and what advice do you have for doctors trying to improve outcomes?

Dr. Jeff Hersh: We are still focused on the acute situation from COVID, yet we know there are long term issues created by this disease. The more chronic issues that will manifest in patients having recovered from the acute effects of COVID are still a poorly understood issue.

Dr. Casey Culbertson: The biggest concern is getting to the patient guideline based information – not only nationally for the prevention/diagnosis of COVID, but also Cardiac society (ACC, AHA, ASNC, etc.) driven guidelines for the diagnosis and treatment of their cardiac disease in the COVID era.

Q: What does it mean to treat the whole patient and not just the disease? Why is this approach important to improve outcomes for patients with CVD?

Dr. Casey Culbertson: In most patients, lifestyle is a huge part of CVD. If we only treat the disease, we do not address these aspects. Treating the whole patient means also addressing these other issues including stress, exercise, BMI, smoking, diet and many other modifiable factors.

Q: How has data deluge impacted the cardiology community and what do you suggest is the solution to better manage it?

Ian Rowlandson: We generate a lot of data and we are proud of that. But we also have to recognize that there are other pieces of data that we don’t have that are important, and ask ourselves: what problem are we trying to solve? We have to be razor sharp as engineers and scientists to make sure we are providing cardiologists with data they need.

Today in Cardiology, there are multiple workflows. It is very important to collect all of this data and compare it to multiple sources to put together a story that makes sense, otherwise, you can end up with poor data and no answers.

Dr. Jeff Hersh: Here is another place where Interactive Augmented Intelligence (IAI) will come into play in the future. There is a huge amount of work to be done to get there. There are several industry partnerships GE has that will be a great step in this direction.

Dr. Mathias Goyen: The explosive increase in the amount and flow of information and data represents an important professional challenge for healthcare. I predict that the availability of big data analytical tools for use in cardiovascular practice and research will grow rapidly as big data analytical applications, such as predictive models for patient risk and resource use, have a great potential to improve cardiovascular quality of care and patient outcomes. The best analytical or AI application is the one that is invisible, that is seamlessly integrated into the cardiologist’s workflow unfolding its magic in the background. Ideally, cardiologists don’t even know that AI is working.

For nearly six decades, GE Healthcare has provided transformational cardiology technology with enhanced patient outcomes through advanced imaging and therapeutic decision support across multiple modalities. Today, this technology enables clinicians in the diagnosis and treatment of more than 145 million hearts each year. Click here to learn more about GE Healthcare cardiology solutions.

¹ World Health Organization, https://www.who.int/health-topics/cardiovascular-diseases#tab=tab_1

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