"The NHS is traditionally like an oil tanker – it moves slowly, for 39 separate units to ask this, this is something that is no longer in the beginning, it is now mainstream".
Dr. Derek Connolly, a consultant cardiologist at the Sandwell and West Birmingham NHS Trust hospitals, has been using HeartFlow technology for about a year. Over the past 12 months, he has seen the interest in using technology, which helps doctors see coronary arteries growing in the UK.
HeartFlow, a California-based medical consulting firm, recently received $ 500 million in funding to help it market its technology. Its algorithms analyze medical scans to produce 3D reconstructions of coronary arteries and use machine learning and artificial intelligence to improve accuracy.
Coronary arteries are the vessels that supply blood to the heart. If these vessels shrink – for example due to smoking or high cholesterol – the heart does not have the blood it needs to continue working effectively and this can lead to a heart attack. Heart disease is the largest killer of men in the UK and the second leading cause of mortality in general, with over 1 in 10 deaths.
To reduce the number of people dying from heart disease, doctors would like to be able to catch patients before they arrive in A&E – an ounce of prevention is really worth a pound of cure. "When they came to me, they already had a heart attack: in many ways, it would be better if we could catch them before they had a heart attack and change the future," Connolly said.
And this is where HeartFlow comes into play. The technology, which was born from Stanford University research on fluid dynamics, takes data from the patient's CT scans and constructs a 3D representation of their hearts. This allows doctors to see exactly where and to what extent the coronary arteries shrink.
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Although it may seem simple, it marks a significant departure from previous practice – and one that could save patients a lot of stress, wait around and unnecessary invasive tests.
For every patient presenting to the chest with chest pain that is thought to be due to heart disease and then referring to the quick access chest pain clinic, the first-line test is cardiac CT. Patients with evidence of severely restricted arteries may be offered an invasive angiogram – a procedure that sees them inserted into the catheter's laboratory and a wire inserted into a coronary artery and the pressure measured at the top and bottom of the vessels. If the difference, known as functional flow reserve (FFR), is less than 80 percent, the patient will need stents: tubes inside the arteries to keep them open.
"Cardiac CT is very good, it is the most sensitive and specific test we have, but it tends to exaggerate the disease – shrinkage seems worse in cardiac CT than in invasive angiograms. The question is: can we take the technology we use in the Catheter lab and use it downstream? "said Connolly.
By studying the flow of a material called contrast through the patient's arteries during the CT scan of their heart, HeartFlow can calculate a patient's FFR without the need for invasive angiography.
This is good news for the patient, Connolly says, which is spared from the risks associated with invasive tests. For example, the radiation that a patient absorbs in a cardiac CT is a quarter of the amount he absorbs in an invasive angiogram. "The more radiation one gets, the more likely a cancer is to be induced, particularly in younger patients, the lower the radiation consumption, the better. [cardiac CT] save the danger. For every diagnostic angiogram we do, one in 3,000 of the patients could have a serious illness or die. Because we are touching the coronary arteries, we can tear them off and this is not unheard of. It is much safer to have a CT scan than to have an invasive angiogram. "
Using HeartFlow to calculate the FFR, fewer patients end up having an invasive angiogram and the risks that come with it – and those who continue to have an angiogram are the people who really need it.
"For every five patients [that have a CT and HeartFlow], four patients go home knowing they don't need anything else. Half of these will be cholesterol tablets, because they have an early disease, half of the normal coronary arteries. One in five historically we send a catheter angiogram, now seven out of 10 don't need to go to the lab for an invasive procedure, an operation, because HeartFlow rules out that they have a significant stenosis, "said Connolly. .
Not only does it make life easier for patients, but it makes life easier and cheaper for hospitals: fewer invasive angiograms are performed on those who do not need them, saving the money that would be spent on unnecessary procedures and freeing up laboratories for investigate only those who are really at risk of having serious cardiovascular diseases. "If we bring someone to the catheterization lab and have normal coronary arteries, it takes an hour and this is a wasted crack, if we take someone we think they will need a stent, it's a useful time."
Currently, CT scans performed in Birmingham are performed and uploaded to the HeartFlow cloud. Once the algorithms of the company have worked on the scans, the results report – for Birmingham patients, they are about three hours later. Connolly expects the delay to drop, perhaps to the point where a patient can do a scan, go for a coffee and get the results when he has finished his drink.
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While currently scans are performed only on patients with chest pain, if costs and time lag go down, tests could be done on larger populations of people to diagnose the onset of heart disease and work to prevent progresses.
"The next question is: what happens if you take a high-risk population, for example, patients who have diabetes, high blood pressure, high cholesterol, or are heavy smokers, or all of the above – what percentage of those will have a disease "The CT scanner could tell us, so the question is whether they shrink [of their coronary arteries], would they only benefit from tablets or surgical bypass or stents? I think the future will be incredibly bright. "
While CT and HeartFlow can currently only show if patients have significant shrinkage in their arteries and should have stents inserted, in the future the system could give doctors even more guidance on what to do next. Connolly predicts that, before it is too long, HeartFlow will be able to suggest not only whether stents are needed, but also what dimensions should be used, where it should be positioned and what results it might expect, since its machine learning works on greater number of scans.
"At the moment, HeartFlow is able to predict who doesn't need stents. Going forward, we should be able to predict what would happen if we inserted a stent and this will help us formulate a clinical judgment on whether or not a stent is right for the patient, or not. "
The cardiologist rejects concerns that the growing use of artificial intelligence in medicine may see technology doctors disqualifying, and instead regards it as a way to provide doctors with an additional evidence base on which to draw.
"Am I afraid of a machine that tells me the probability of 17 decimal points that the patient would be better with the xoy treatment? Not a small part. We are not there yet, but clearly the technology has its uses and the era of doctor just saying "I think", with not much evidence, is going to disappear and we will be able to connect people to the experience of hundreds of thousands or millions of patients ".
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