Cardiology Studies Research Articles

P1430 Analysis of echocardiographic study findings prior to an allogeneic hematopoietic stem cell transplantation

Abstract Allogenic hematopoietic stem cell transplant (Alo-HSTP)has been a therapeutic revolution for patients with hematologic malignancies. Even though this therapy is associated with a high risk of cardiovascular (CV) events during follow-up, a baseline cardiology study is currently not standardised in most centers. Our aim was to analyse transthoracic echocardiogram (TTE) findings in patients candidates to Alo-HSTP. We undertook a retrospective and descriptive analysis that included all patients treated with Alo-HSTP in our center between 2016-2019. Baseline characteristics and TTE findings including global longitudinal strain (GLS) were analysed. We analyzed 144 patients (mean age 50 years, 60% males). Acute myeloblastic leucemia (38%) and non-Hodgkins lymphoma (18%) were the most frequent diseases. Figure. 18 patients (13%) had hypertension, 13% had dyslipidemia and 6% diabetes mellitus. Almost 10% had previous CV history. TTE found left ventricle systolic dysfunction (LVEF< 53%) in 10% of patients, diastolic dysfunction in 12%, valvular heart disease in 4 patients (5,5%) and GLS was abnormal (>-19%) in 35 patients (24%). Up to 47 (33%) patients studied has an abnormal TTE finding. Table. More than one third of patients candidates to Alo-HSTP had an abnormal TTE finding, increasing the risk for CV events during follow-up. A cardiologic study by the Cardio-Onco-Hematology team in these patients before Alo-HSTP could improve their prognosis. Age (years) 50 ± 18 Male (n,%) 86 (60%) Hypertension (n,%) 18 (13%) Diabetes mellitus (n,%) 8 (5,6%) Dyslipidemia (n, %) 18 (13%) Past or current smoking (n, %) 25 (18%) Previous cardiovascular history (n, %) 13 (9,3%) Abnormal TTE (n, %) 47 (33%) LVEDV(ml) 99 ± 29 LVESV (ml) 37 ± 16 LVEF (%) LV dysfunction (n, %) 63 ± 8 15 (10,4%) e/e´ Elevated filling pressures (n, %) 8,2 ± 7,3 4 (3%) Valvular heart disease (≥moderate) (n, %) Mitral Aortic Tricuspid 3 (2%) 4 (3%) 1 (1%) GLS (%) abnormal GLS , >-19% (n, %) -20,4 ± 2,8 35 (24%) LVEDV: Left ventricle end-systolic volume, LVESV: Left ventricle end-systolic volume, LVEF: Left ventricle ejection fraction, GLS: global longitudinal strain Abstract P1430 Figure. Haematologic malignancies

Clinical Aspects of Physiology Teaching for Ergotherapists

Ergotherapist – is the youngest specialty in medical practice of Ukraine. The aim of higher medical educational institutions is to formulate logical, clinical thinking and effective assimilation of medical knowledge to be used by ergotherapists-practitioners. One of the main tasks of an ergotherapist is to restore the body’s functions that have been lost as a result of illness or injury, and to restore a person to a full social life (self-care, work, etc.). These specialists are working to restore the sensory and motor functions of the body, to develop new skills and abilities for the person to adapt to living in society. Achievement of the goal and performance of these tasks is impossible without knowledge of physiology, which provides the basis for the study of pathophysiology, pharmacology, cardiology, physiotherapy and other clinical disciplines. It improves the quality of study and helps to better acquire theoretical material, to master the skills of clinical physiology a competent approach in the organization of Physiology teaching.

Diagnostic tools for early detection of cardiac dysfunction in childhood cancer survivors: Methodological aspects of the Dutch late effects after childhood cancer (LATER) cardiology study

Cancer therapy-related cardiac dysfunction and heart failure are major problems in long-term childhood cancer survivors (CCS). We hypothesize that assessment of more sensitive echo- and electrocardiographic measurements, and/or biomarkers will allow for improved recognition of patients with cardiac dysfunction before heart failure develops, and may also identify patients at lower risk for heart failure. To describe the methodology of the Dutch LATER cardiology study (LATER CARD). The LATER CARD study is a cross-sectional study in long-term CCS treated with (potentially) cardiotoxic cancer therapies and sibling controls. We will evaluate 1) the prevalence and associated (treatment related) risk factors of subclinical cardiac dysfunction in CCS compared to sibling controls and 2) the diagnostic value of echocardiography including myocardial strain and diastolic function parameters, blood biomarkers for cardiomyocyte apoptosis, oxidative stress, cardiac remodeling and inflammation and ECG or combinations of them in the surveillance for cancer therapy-related cardiac dysfunction. From 2017 to 2020 we expect to include 1900 CCS and 500 siblings. The LATER CARD study will provide knowledge on different surveillance modalities for detection of cardiac dysfunction in long-term CCS at risk for heart failure. The results of the study will enable us to improve long-term follow-up surveillance guidelines for CCS at risk for heart failure.

Review of the top 5 cardiology studies of 2017-18

Review of the top 5 cardiology studies of 2017-18

Neonatologist performed echocardiography (NPE) in Italian neonatal intensive care units: a national survey

BackgroundNeonatologist performed echocardiography (NPE) has increasingly been used to assess the hemodynamic status in neonates. Aim of this survey was to investigate the utilization of NPE in Italian neonatal intensive care units (NICUs).MethodsWe conducted an on-line survey from June to September 2017. A questionnaire was developed by the Italian neonatal cardiology study group and was sent to each Italian NICU.ResultsThe response rate was 77%. In 94% of Italian NICUs functional echocardiography was used by neonatologists, cardiologists or both (57, 15 and 28% respectively). All the respondents used NPE in neonates with patent ductus arteriosus and persistent pulmonary hypertension, 93% in neonates with hypotension or shock, 85% in neonates with perinatal asphyxia, 78% in suspicion of cardiac tamponade, and 73% for line positioning.In 30% of center, there was no NPE protocol. Structural echocardiography in stable and critically ill neonates was performed exclusively by neonatologists in 46 and 36% of center respectively.ConclusionsNPE is widely used in Italian NICUs by neonatologists. Structural echocardiography is frequently performed by neonatologists. Institutional protocols for NPE are lacking. There is an urgent need of a formal training process and accreditation to standardize the use of NPE.

The Use of Lung Ultrasound in Acute Medicine

POCUS (Point of Care Ultrasound) refers to ultrasound performed by clinicians as part of their initial patient evaluation, often with the aim of answering a specific question as opposed to being a comprehensive assessment. Such ultrasound is noninvasive, involves no radiation and can be rapidly performed at the bedside. It is also widely practiced in emergency and intensive care medicine leading to earlier and more accurate diagnoses for a wide range of presentations such as shock, renal failure and dyspnoea. POCUS has evolved from cardiological or radiological studies, reduced in complexity and scoped for clinician use. Lung ultrasound (LUS) has been largely developed by acute care clinicians and is a more recent addition to POCUS. Procedural LUS is widely recommended to improve the safety profile of pleural catheter placement (referring to BTS guidelines) but in the UK diagnostic LUS is not widely practiced despite good evidence and guideline support for its use. In this article we briefly review and describe the role of diagnostic LUS as applied to acute medicine. Potential advantages of LUS include a decreased time to diagnosis, improved diagnostic accuracy, a reduction in radiation exposure and unnecessary expensive tests. Studies have shown that at least one diagnosis was missed in around a fifth of patients with acute respiratory symptoms, resulting in increased length of stay and mortality in a third of patients.

P3353Safety and performance of stress testing: results from 78220 nuclear cardiology studies performed over 15 years in Brazil

Abstract Background Stress testing for nuclear cardiology (NC) is safe for evaluating suspected or known coronary heart disease (CHD). Rates of serious adverse events (SAE) are low, roughly 1 death/myocardial infarction: 10,000 studies. However, this may vary depending on patient characteristics using different stress modalities. Purpose To describe the rates of SAE using different stress modalities in patients referred to NC. Methods We included all patients undergoing NC at Quanta in Curitiba, Brazil from 2003 to 2018. Stress modalities were categorized as: exercise (Ex), dipyridamole (Dip), a hybrid protocol of dypiridamole and low workload exercise (DipEx), and dobutamine (Dob). SAE during/after stress were recorded: cardiac arrest or ST segment elevation myocardial acute infarction (STEMI). Development of second or third degree atrial ventricular block (AVB) during stress and recovery were also recorded. Results From 78220 studies in 61984 patients (47% women, mean age 63 years-old), Ex was the most frequent stress modality (67%), followed by Dip (24%), DipEx (7%) and Dob (1,7%). Patients undergoing Ex were the youngest (mean age 60 vs 70 vs 65 vs 71 years old), the least likely of having hypertension (62 vs 78 vs 76 vs 75%) and diabetes (22 vs 35 vs 32 vs 32%) and had the lowest prevalence of known CHD (26 vs 35 vs 41 vs 30%, for Ex vs Dip vs DipEx vs Dob respectively, p<0.001 for all comparisons). Six patients had cardiac arrest and one STEMI, results in SAE rate of 1:11.144 studies. There was important differences among stress modalities, being higher for pharmacological stress, particularly DipEx (Table). This group had the highest prevalence of known CHD and higher baseline risk. AVB rates were higher when dipyridamole was used. All patients who arrested in the laboratory recovered with treatment. Serious adverse events and stress in NC Adverse event Ex Dip DipEx Dob N=52,237 N=18,848 N=5,824 N=1,311 Cardiac Arrest or MI 1 : 17,412 1 : 9,424 1 : 2,912 None 2nd or 3rd Degree AVb 1 : 4,353 1 : 1,885 1 : 1,941 None Observe how adverse event rates different importantly in patients undergoing different stress modalities in NC. Conclusion In this large 15-year registry, rates of SAE related to stress testing in NC were low, albeit the SAE were much higher with pharmacological stress modalities, particularly with DipEx, which had the highest rate of patients with known CHD. Our findings suggest that the well-known 1:10,000 event rate does not necessarily apply to all stress modalities in NC. Physicians should take patient's baseline risk into account, particularly those requiring pharmacologic stress.

The Method of Assessment of the Population Risk of Cardiovascular Diseases: Rationale and Examples of Application

Epidemiological studies in cardiology often are confronted with the need of modeling the population dependence of the development of cardiovascular diseases (CVD) on a complex of influencing risk factors (RF). A method for assessment the CVD population risk is proposed, the calculation of which assumes the population group as the unit of analysis, and the prevalence of risk factors in this group as the input data. Calculation of the population risk is build taking into account predictive value of risk factors basing on their contribution to CVD prevalence. The method of calculation of population risk, examples of its application (arterial hypertension in working population, ethnic groups, ischemic heart disease in open and working population), as well as discussion of its strong and weak sides are presented in this review.

Morphometric description of canine and human heart anatomy: proximities and distances

Article developed as a result of research Project of Studies in Cardiology at the University Center Montes Belos - UniMB, Veterinary Medicine course - Comparative Study of the Cardiological Profile between Dogs and Men: parameters of the main cardiopathies and anatomical similarities. The specific objective of this analysis is to reassess the proximities between the classes’ hominidae and canidae regarding the anatomical aspect of the heart. The proximities, similarities and distances, differences between the cardiac morphometric of the dog and the human. The theoretical referencing was based on an argumentative basis by Ghoshal (1986), Carvalho et al. (2002) and Queiroz et al. (2018) for argumentative support in cardiac and human cardiac morphometric discussion, Cunningham (2011) for cardiac physiology and other authors with equal importance for the support of the argumentative archetype of this work.

Pathophysiology, diagnosis and management of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is a potentially life-threatening condition typically presenting as heart failure with reduced ejection fraction (HFrEF) in the last month of pregnancy or in the months following delivery in women without another known cause of heart failure. This updated position statement summarizes the knowledge about pathophysiological mechanisms, risk factors, clinical presentation, diagnosis and management of PPCM. As shortness of breath, fatigue and leg oedema are common in the peripartum period, a high index of suspicion is required to not miss the diagnosis. Measurement of natriuretic peptides, electrocardiography and echocardiography are recommended to promptly diagnose or exclude heart failure/PPCM. Important differential diagnoses include pulmonary embolism, myocardial infarction, hypertensive heart disease during pregnancy, and pre-existing heart disease. A genetic contribution is present in up to 20% of PPCM, in particular titin truncating variant. PPCM is associated with high morbidity and mortality, but also with a high probability of partial and often full recovery. Use of guideline-directed pharmacological therapy for HFrEF is recommended in all patients respecting contraindications during pregnancy/lactation. The oxidative stress-mediated cleavage of the hormone prolactin into a cardiotoxic fragment has been identified as a driver of PPCM pathophysiology. Pharmacological blockade of prolactin release using bromocriptine as a disease-specific therapy in addition to standard therapy for heart failure treatment has shown promising results in two clinical trials. Thresholds for devices (implantable cardioverter-defibrillators, cardiac resynchronization therapy and implanted long-term ventricular assist devices) are higher in PPCM than in other conditions because of the high rate of recovery. The important role of education and counselling around contraception and future pregnancies is emphasised.

P87-F Severe congenital myopathy related to a novel mutation in the titin gene. A case report

Mutations in the titin gene (TTN) are related to a wide spectrum of disease. In recent years, congenital titinopathy has emerged as a cause of severe early onset myopathy. A case of two female sisters born at 32 weeks of gestation by cesarean section, from a non-consanguineous, healthy couple. They had normal prenatal ultrasounds except from equinovarus foot in one twin. Apgar score was low at birth (6–10 at 1 and 5 min in both). Both girls needed ventilator support because of respiratory insufficiency, severe axial hypotonia, multiple joint contractures distal and proximal and multiple long bone fractures. Chromosomopathy and osteogenesis imperfect were ruled out in the Genetic unit of our institution. Cardiological studies were normal. The neurographic study performed at two months of life showed extremely low amplitudes of the CMAPs with normal conduction velocities and relative preservation of the SNAPs, without clear myopathic features or spontaneous activity in the needle EMG. The whole exome sequencing (GenExComplete) revealed two extremely rare mutations in the titin gene, only expressed in the fetal skeletal transcript of TTN. One of the twins died at 8 months of age from pneumonia and the other baby needs mechanical ventilation for life support to date. In a case of severe congenital myopathy without cardiac involvement, it is essential to consider the global clinical context. Although very rare, mutations in the fetal skeletal transcript of TTN should be excluded.

A Light Wand to Untangle the Myocardial Cell Network.

The discovery of optogenetics has revolutionized research in neuroscience by providing the tools for noninvasive, cell-type selective modulation of membrane potential and cellular function in vitro and in vivo. Rhodopsin-based optogenetics has later been introduced in experimental cardiology studies and used as a tool to photoactivate cardiac contractions or to identify the sites, timing, and location most effective for defibrillating impulses to interrupt cardiac arrhythmias. The exploitation of cell-selectivity of optogenetics, and the generation of model organisms with myocardial cell type targeted expression of opsins has started to yield novel and sometimes unexpected notions on myocardial biology. This review summarizes the main results, the different uses, and the prospective developments of cardiac optogenetics.

Association between Chagas disease and changes in the optic nerve and retinal nerve fiber layer.

To test the hypothesis that Chagas disease predisposes to optic nerve and retinal nerve fiber layer alterations. We conducted a cross-sectional study including 41 patients diagnosed with Chagas disease and 41 controls, paired by sex and age. The patients underwent ophthalmologic examinations, including intraocular pressure measurements, optic nerve and retinal nerve fiber layer screening with retinography, optical coherence tomography, and standard automated perimetry. All of the patients with Chagas disease had a recent cardiologic study; 15 (36.6%) had heart failure, 14 (34.1%) had cardiac form without left ventricular dysfunction, and 12 (29.3%) had indeterminate form. Optic nerve/retinal nerve fiber layer alterations were observed in 24 patients (58.5%) in the Chagas disease group and 7 controls (17.1%) (p£0.01). Among these, optic nerve pallor, optic nerve alterations suggestive of glaucoma, notch, peripapillary hemorrhage, and localized retinal nerve fiber layer defect were detected. Alterations were more prominent in patients with Chagas disease and heart failure (11 patients), although they also occurred in those with Chagas disease without left ventricular dysfunction (7 patients) and those with indeterminate form (6 patients). Optical coherence tomography showed that themean of the average retinal nerve fiber layer thickness measured 89 ± 9.7 mm, and the mean of retinal nerve fiber layer superior and inferior thickness measured 109 ± 17.5 and 113 ± 16.8 mm, respectively were lower in patients with Chagas disease. In controls, these values were 94 ± 10.6 (p=0.02); 117 ± 18.1 (p=0.04), and 122 ± 18.4 mm (p=0.03). Changes in optic nerve/ retinal nerve fiber layer were more prevalent in patients with Chagas disease.

Rationale and Design of the FREQUENCY Study: The Fetal Cardiac Registry of Québec to Improve Resource Utilization in Fetal Cardiology.

Prenatal detection of congenital heart diseases (CHD) decreases morbidity and cost. To improve detections rates, most physicians refer pregnant women with high-risk pregnancies to fetal cardiologists even when there is no suspicion of CHD at the second trimester screening. This paper presents the rationale and detailed method of the Fetal Cardiac Registry of Québec to Improve Resource Utilization in Fetal Cardiology (FREQUENCY) study. The overall objective is to assess the impact of second trimester ultrasound screening (U/S) and referral pattern in fetal cardiology on detection rates, health care costs, and resource utilization, as well as perinatal morbidity and mortality. This multicentre retrospective population-based cohort study will link fetal echocardiography data from all centres performing fetal echocardiography in Québec with administrative health care data. This data linking will allow the determination of a true denominator (all women in Québec who underwent second trimester U/S) with complete follow-up of up to 2 years for offspring. This protocol meets Canadian Task Force Classification II-2. The study investigators have collected and cleaned fetal echocardiography data for 24259 eligible pregnancies referred to fetal cardiology. These data will be matched to approximately 860000 pregnancies between 2007 and 2015. The results of the FREQUENCY study will shed light on the impact of the current prenatal CHD screening strategy in Canada.

Current Status of Patient Radiation Exposure of Cardiac Positron Emission Tomography and Single-Photon Emission Computed Tomographic Myocardial Perfusion Imaging.

Radiation exposure during nuclear cardiology procedures has received much attention and has prompted citations for radiation reduction. In 2010, the American Society of Nuclear Cardiology recommended reducing the average patient study radiation exposure to <9 mSv in 50% of studies by 2014. Cardiac positron emission tomography (PET) for myocardial perfusion imaging (MPI) has emerged within recent years, but current radiation exposure in cardiac nuclear PET laboratories is unknown. This study evaluated current reported patient radiation exposure from nuclear laboratories in the United States applying for Intersocietal Accreditation Commission accreditation for MPI using single photon emission computed tomography (SPECT) or PET. This was an analysis of nuclear cardiology studies submitted to the Intersocietal Accreditation Commission for either or both cardiac PET and SPECT accreditation. Cardiac SPECT data represented year 2015 while PET data combined years 2013 to 2015. Data was analyzed with χ2 and Mann-Whitney U tests (reported as median, 25th percentile, and 75th percentile). Reported PET MPI radiation exposure for 111 laboratories (532 patient cases) was 3.7 (3.2-4.1) mSv per study with no geographic variation. Reported SPECT MPI radiation exposure for 665 laboratories (3067 patient studies) was 12.8 (12.2-14.3) mSv. Highest radiation exposure was found in the South region. Technetium-only studies resulted in a median of 12.2 mSv per study. Radiation exposure from cardiac PET MPI in US laboratories applying for Intersocietal Accreditation Commission accreditation is low (111 laboratories, 3.7 mSv) and substantially lower than cardiac SPECT (665 laboratories, 12.8 mSv).

Current Clinical Practice Patterns of Self-Identified Nuclear Medicine Specialists.

The objective of our study was to study patterns of services rendered by U.S. physicians who self-identify as nuclear medicine (NM) specialists. Recent Medicare physician claims and demographic files were obtained and linked. NM specialists were defined as physicians self-identifying NM as their primary specialty on claims or as any of their specialties during enrollment. Using other self-identified specialties, we classified physicians as nuclear radiologists, nuclear cardiologists, exclusively NM physicians, or Others. Our primary outcome measure was the percentage of NM effort (in work relative value units [WRVUs]) per physician per specialty group. Secondary outcome measures included physician sociodemographic parameters and most common uniquely rendered services. Nationally, 1583 physicians self-identified as NM specialists during the calendar years 2012 through 2015. The distribution of WRVUs attributed to NM varied widely by specialty group; most nuclear radiologists and nuclear cardiologists devoted 10% or less of their effort to NM services whereas most NM physicians devoted 90% or more of their effort to NM services. NM specialists were most commonly nuclear radiologists (52.2%) and men (80.3%) and practiced in urban (98.4%) and nonacademic settings (62.9%). NM physicians interpreted more general NM studies, nuclear radiologists interpreted more cross-sectional imaging studies, and nuclear cardiologists interpreted mostly nuclear cardiology studies, with a majority of their overall work attributed to clinical evaluation and management (E/M). E/M services accounted for less than 2% of WRVUs for both nuclear radiologists and NM physicians. The work patterns of U.S. NM specialists is highly variable. Most NM physicians practice 90% or more NM, whereas most nuclear radiologists and nuclear cardiologists practice 10% or less NM. Commonly performed services vary considerably by specialty group.

P3170Innovative approach for risk stratification of LMNA-related cardiomyopathy: results from an integrated cardiological and neurological 10-year follow-up multicentre study

P3170Innovative approach for risk stratification of LMNA-related cardiomyopathy: results from an integrated cardiological and neurological 10-year follow-up multicentre study

Long-term prognosis, subsequent pregnancy, contraception and overall management of peripartum cardiomyopathy: practical guidance paper from the Heart Failure Association of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy.

Peripartum cardiomyopathy is an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause for heart failure is identified. Outcome varies from full recovery to residual left ventricular systolic dysfunction and even death. Many women return to their physician to acquire information on their long-term prognosis, to seek medical advice regarding contraception, or when planning a subsequent pregnancy. This position paper summarizes current evidence for long-term outcome, risk stratification of further pregnancies and overall management. Based on the best available evidence, as well as the clinical experience of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy members, a consensus on pre- and postpartum management algorithms for women undergoing a subsequent pregnancy is presented.

Genetic Evidence That Carbohydrate-Stimulated Insulin Secretion Leads to Obesity.

A fundamental precept of the carbohydrate-insulin model of obesity is that insulin secretion drives weight gain. However, fasting hyperinsulinemia can also be driven by obesity-induced insulin resistance. We used genetic variation to isolate and estimate the potentially causal effect of insulin secretion on body weight. Genetic instruments of variation of insulin secretion [assessed as insulin concentration 30 min after oral glucose (insulin-30)] were used to estimate the causal relationship between increased insulin secretion and body mass index (BMI), using bidirectional Mendelian randomization analysis of genome-wide association studies. Data sources included summary results from the largest published metaanalyses of predominantly European ancestry for insulin secretion (n = 26037) and BMI (n = 322154), as well as individual-level data from the UK Biobank (n = 138541). Data from the Cardiology and Metabolic Patient Cohort study at Massachusetts General Hospital (n = 1675) were used to validate genetic associations with insulin secretion and to test the observational association of insulin secretion and BMI. Higher genetically determined insulin-30 was strongly associated with higher BMI (β = 0.098, P = 2.2 × 10-21), consistent with a causal role in obesity. Similar positive associations were noted in sensitivity analyses using other genetic variants as instrumental variables. By contrast, higher genetically determined BMI was not associated with insulin-30. Mendelian randomization analyses provide evidence for a causal relationship of glucose-stimulated insulin secretion on body weight, consistent with the carbohydrate-insulin model of obesity.

Data Mining Techniques to Construct a Model: Cardiac Diseases

Using echocardiography flexible Transthoracic Echocardiography reported data set detecting heart disease by using mining techniques designed prediction model the data set can develop the reliability of analysis of cardiac diseases by echocardiography, using eight iterative and interactive steps consisting Knowledge Discovery in Database (KDD) methodology including from 209 patients with echocardiography to extracting the data important mode of action Transthoracic Echocardiography inspection report. This study used data from Faisalabad Institute of Cardiology study from 2012 to 2015. All models exposed the results of J48 decision tree, naive bayes classifier and neural network that has extraordinary classification precision and predictive of heart disease cases are generally comparable. However, J48 model predictive classification accuracy shows of 80% based on the true positive rate ratio and performance slightly better. This study shows to predict heart disease cases and People can be used the results of our study to make more consistent diagnosis of cardiac disease and to help them as a support tool for cardiac disease specialists.