Cardiovascular Clinical Practice Research Articles

IMPACTO DA INTELIGÊNCIA ARTIFICIAL NA DETECÇÃO PRECOCE DE DOENÇAS CARDIOVASCULARES: UM ESTUDO DE REVISÃO INTEGRATIVA

Introduction: Artificial intelligence (AI) has emerged as a transformative tool in medicine, with significant applications in the cardiovascular field, especially in the early detection of cardiovascular diseases (CVDs). Its ability to process large volumes of clinical data through technologies such as machine learning (ML) and deep neural networks (DL) has provided faster, more accurate, and personalized diagnoses. Objectives: To analyze how AI contributes to the early detection of CVDs and, as specific objectives, to identify the main algorithms used, describe the benefits for patients and health professionals, and discuss the ethical and technical challenges associated with their implementation. Justification: The research highlights the social importance of reducing mortality associated with CVDs, the academic relevance of consolidating knowledge about AI in cardiology, and the scientific impact of exploring new diagnostic approaches to improve health care. Methodology: An integrative literature review was carried out, covering articles published between 2018 and 2023, in databases such as PubMed, Scopus, and Embase. Inclusion criteria prioritized peer-reviewed studies that discussed the application of AI in the diagnosis and management of CVDs. Results and discussion: The results showed that AI improves diagnostic accuracy, reduces response time, and enables personalized prognoses. However, challenges such as data privacy, algorithmic bias, and acceptance by professionals were identified as barriers to its implementation. Conclusion: AI is a promising tool in cardiovascular clinical practice, but its consolidation depends on strategies that address ethical and technical limitations and promote adequate training of health professionals.

The Western Denmark Heart Registry and Population-Based National Health Registries.

The Western Denmark Heart Registry (WDHR) is a semi-national, multicenter-based clinical registry with unique potential for cardiovascular research. The registry has provided detailed prospectively registered information on patient and procedure characteristics since 1999. WDHR data can be linked to additional data in other healthcare registries in Denmark. Therefore, the WDHR is a valuable data resource for cardiovascular research, providing a foundation for numerous research projects and publications. This review describes three currently available cohorts from the WDHR containing individual-level information on: i) 200,647 first-time coronary angiographies from 2003 to 2021, ii) 88,630 first-time percutaneous coronary interventions from 1999 to 2022, and iii) 85,512 first-time coronary computed tomography angiographies from 2008 to 2021. Furthermore, we describe other frequently cross-linked Danish healthcare registries containing information on various patient characteristics and outcomes, such as vital status, cause of death, hospitalizations, medications, and laboratory test results. The comprehensive overview of these cohorts aims to assist researchers, collaborators, and other interested parties in understanding the scope and potential applications of the available data. All cohorts are regularly updated, thereby supporting continuing research on cardiovascular clinical practice and prognosis in Denmark.

Recommendations for prediction models in clinical practice guidelines for cardiovascular diseases are over-optimistic: a global survey utilizing a systematic literature search.

This study aimed to synthesize the recommendations for prediction models in cardiovascular clinical practice guidelines (CPGs) and assess the methodological quality of the relevant primary modeling studies. We performed a systematic literature search of all available cardiovascular CPGs published between 2018 and 2023 that presented specific recommendations (whether in support or non-support) for at least one multivariable clinical prediction model. For the guideline-recommended models, the assessment of the methodological quality of their primary modeling studies was conducted using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). In total, 46 qualified cardiovascular CPGs were included, with 69 prediction models and 80 specific recommendations. Of the 80 specific recommendations, 74 supported 57 models (53 were fully recommended and 4 were conditionally recommended) in cardiovascular practice with moderate to strong strength. Most of the guideline-recommended models were focused on predicting prognosis outcomes (53/57, 93%) in primary and tertiary prevention, focusing primarily on long-term risk stratification and prognosis management. A total of 10 conditions and 7 types of target population were involved in the 57 models, while heart failure (14/57, 25%) and a general population with or without cardiovascular risk factor(s) (12/57, 21%) received the most attention from the guidelines. The assessment of the methodological quality of 57 primary studies on the development of the guideline-recommended models revealed that only 40% of the modeling studies had a low risk of bias (ROB). The causes of high ROB were mainly in the analysis and participant domains. Global cardiovascular CPGs presented an unduly positive appraisal of the existing prediction models in terms of ROB, leading to stronger recommendations than were warranted. Future cardiovascular practice may benefit from well-established clinical prediction models with better methodological quality and extensive external validation.

Beyond the Heartbeat: Single-Cell Omics Redefining Cardiovascular Research.

This review aims to explore recent advances in single-cell omics techniques as applied to various regions of the human heart, illuminating cellular diversity, regulatory networks, and disease mechanisms. We examine the contributions of single-cell transcriptomics, genomics, proteomics, epigenomics, and spatial transcriptomics in unraveling the complexity of cardiac tissues. Recent strides in single-cell omics technologies have revolutionized our understanding of the heart's cellular composition, cell type heterogeneity, and molecular dynamics. These advancements have elucidated pathological conditions as well as the cellular landscape in heart development. We highlight emerging applications of integrated single-cell omics, particularly for cardiac regeneration, disease modeling, and precision medicine, and emphasize the transformative potential of these technologies to advance cardiovascular research and clinical practice.

In vivo phage display identifies novel peptides for cardiac targeting

Heart failure remains a leading cause of mortality. Therapeutic intervention for heart failure would benefit from targeted delivery to the damaged heart tissue. Here, we applied in vivo peptide phage display coupled with high-throughput Next-Generation Sequencing (NGS) and identified peptides specifically targeting damaged cardiac tissue. We established a bioinformatics pipeline for the identification of cardiac targeting peptides. Hit peptides demonstrated preferential uptake by human induced pluripotent stem cell (iPSC)-derived cardiomyocytes and immortalized mouse HL1 cardiomyocytes, without substantial uptake in human liver HepG2 cells. These novel peptides hold promise for use in targeted drug delivery and regenerative strategies and open new avenues in cardiovascular research and clinical practice.

Cardiovascular surgery and cardiology, current status of two sister specialties in Spain: the CARDIOXCARDIO study

In recent years, there has been a notable shift in cardiovascular clinical practice within cardiology and surgery. The CARDIOXCARDIO study aimed to identify professionals’ opinions on working practices and relations between specialties. A survey was simultaneously sent to the 4442 members of the Spanish Society of Cardiovascular and Endovascular Surgery (SECCE) and the Spanish Society of Cardiology (SEC), yielding 385 valid responses. More than half (59%) of respondents were men, mostly specialists (7.3% residents), and 74.8% worked in the field of cardiology, predominantly in public centers (88.3%). Using a Likert scale ranging from 1 to 5 (worst to best), respondents rated relations between surgery and cardiology with an average of 3.57±0.9 points. Cardiologists rated surgeons with a mean score of 3.83±0.8, while surgeons gave cardiologists a mean score of 3,92±0.72. In addition, respondents provided numerous suggestions for improvement, which are discussed in detail, highlighting certain discrepancies in criteria between specialties. Implementing strategies based on the suggestions of professionals, together with a proactive approach to continuous improvement, could substantially enhance the quality of cardiovascular care in Spain.

First In-Vivo demonstration of 1000fps High Speed Coronary Angiography (HSCA) in a swine animal model.

High-speed-angiography (HSA) 1000 fps imaging was successfully used previously to visualize contrast media/blood flow in neurovascular anatomies. In this work we explore its usage in cardiovascular anatomies in a swine animal model. A 5 French catheter was guided into the right coronary artery of a swine, followed by the injection of iodine contrast through a computer-controlled injector at a controlled rate of 40 (ml/min). The injection process was captured using high-speed angiography at a rate of 1000 fps. The noise in the images was reduced using a custom built machine-learning model consisting of Long Short-term memory networks. From the noise reduced images, velocity profiles of contrast/blood flow through the artery was calculated using Horn-Schunck optical flow (OF) method. From the high-speed coronary angiography (HSCA) images, the bolus of contrast could be visually tracked with ease as it traversed from the catheter tip through the artery. The imaging technique's high temporal resolution effectively minimized motion artifacts resulting from the heart's activity. The OF results of the contrast injection show velocities in the artery ranging from 20 - 40 cm/s. The results demonstrate the potential of 1000 fps HSCA in cardiovascular imaging. The combined high spatial and temporal resolution offered by this technique allows for the derivation of velocity profiles throughout the artery's structure, including regions distal and proximal to stenoses. This information can potentially be used to determine the need for stenoses treatment. Further investigations are warranted to expand our understanding of the applications of HSCA in cardiovascular research and clinical practice.

Cardiac Rehabilitation in Older u.s. Women: Challenges and Opportunities

Despite its documented benefit and Class Ia recommendations in most cardiovascular clinical practice guidelines of the American Heart Association/American College of Cardiology, cardiac rehabilitation is woefully underutilized in older U.S. women. Numerous studies document the decreased application of cardiac rehabilitation in women compared to men and in older compared to younger patients, with this intersection creating a perfect storm for older women with cardiovascular disease. This manuscript summarizes the challenges presented by this situation and offers opportunities for improvement of cardiovascular care for older women.

Cirugía cardiovascular y cardiología, situación actual en España de las dos especialidades hermanas: el estudio CARDIOXCARDIO

In recent years, there has been a notable shift in cardiovascular clinical practice within cardiology and surgery. The CARDIOXCARDIO study aimed to identify professionals’ opinions on working practices and relations between specialties. A survey was simultaneously sent to the 4442 members of the Spanish Society of Cardiovascular and Endovascular Surgery (SECCE) and the Spanish Society of Cardiology (SEC), yielding 385 valid responses. More than half (59%) of respondents were men, mostly specialists (7.3% residents), and 74.8% worked in the field of cardiology, predominantly in public centers (88.3%). Using a Likert scale ranging from 1 to 5 (worst to best), respondents rated relations between surgery and cardiology with an average of 3.57±0.9 points. Cardiologists rated surgeons with a mean score of 3.83±0.8, while surgeons gave cardiologists a mean score of 3,92±0.72. In addition, respondents provided numerous suggestions for improvement, which are discussed in detail, highlighting certain discrepancies in criteria between specialties. Implementing strategies based on the suggestions of professionals, together with a proactive approach to continuous improvement, could substantially enhance the quality of cardiovascular care in Spain.

Level of evidence supporting the chinese cardiovascular disease clinical practice guidelines and its evolution in the past two decades

Abstract Background Clinical practice is guided by guidelines in the era of evidence-based medicine to improve healthcare. The consistency between the strength of recommendations and the underlying quality of evidence in clinical guidelines and its evolution dynamically reflects the status of medical practice in important aspects. This study aimed to evaluate the levels of evidence (LOEs) supporting different classes of recommendations (CORs) in Chinese cardiovascular disease (CVD) guidelines between 2003 and 2021 and changes over time. Method Clinical guideline documents on cardiovascular topics issued by leading professional organizations were retrieved in the Databases of SinoMed and Wanfang Med Online from inception to June 2021. All guidelines were screened through abstract and full-text reading and included if satisfying the pre-specified criteria. 79 Chinese guideline documents on 12 sub-topics including a total of 5195 recommendations and the designated CORs/LOEs, were abstracted. The number of recommendations of Class I, Class II, Class III, LOE A, LOE B and LOE C were identified for each guideline document. The proportion of CORs, LOEs and COR-LOE combinations in guidelines and the changes among those with ≥2 versions. Results A total of 79 guidelines were included in the analysis. When examining the status of current guidelines, among the 3325 recommendations derived from 59 documents during 2011-2021, 735 recommendations (22.1%) were classified as LOE A, 1280 (38.5%) as LOE B, and 1310 (39.4%) as LOE C. 596 recommendations (17.9%) were characterized as Class I-LOE A, accounting for the majority of LOE A recommendations but only one-third of Class I recommendations. Evidence levels varied greatly across different sub-topics and individual guidelines. There are 9 guidelines on 5 sub-topics having ≥2 versions. When analyzing the changes over time, although an increase was observed in the total number of recommendations, the proportion of recommendations designated as Class I-LOE A did not significantly improve (19.1% [current] vs 19.0%[prior], p=0.97). Conclusions In current Chinese CVD guidelines, the high level of evidence lacks and its alignment with strong recommendations is deficient. Although it shows moderate improvements in certain major topics (e.g., Coronary artery disease, Interventional therapy, Surgery) in the past two decades, the overall proportion of Class I-LOE A recommendations remains small, suggesting that conduction, and particularly translation, of high-quality studies like RCTs addressing CVDs-related questions are still essential and demanded, especially for areas with less attention.Abstract Picture 1

Placing patient-reported outcomes at the centre of cardiovascular clinical practice: implications for quality of care and management.

Patient-reported outcomes (PROs) provide important insights into patients' own perspectives about their health and medical condition, and there is evidence that their use can lead to improvements in the quality of care and to better-informed clinical decisions. Their application in cardiovascular populations has grown over the past decades. This statement describes what PROs are, and it provides an inventory of disease-specific and domain-specific PROs that have been developed for cardiovascular populations. International standards and quality indices have been published, which can guide the selection of PROs for clinical practice and in clinical trials and research; patients as well as experts in psychometrics should be involved in choosing which are most appropriate. Collaborations are needed to define criteria for using PROs to guide regulatory decisions, and the utility of PROs for comparing and monitoring the quality of care and for allocating resources should be evaluated. New sources for recording PROs include wearable digital health devices, medical registries, and electronic health record. Advice is given for the optimal use of PROs in shared clinical decision-making in cardiovascular medicine, and concerning future directions for their wider application.

Recasting Current Knowledge of Human Fetal Circulation: The Importance of Computational Models.

Computational hemodynamic simulations are becoming increasingly important for cardiovascular research and clinical practice, yet incorporating numerical simulations of human fetal circulation is relatively underutilized and underdeveloped. The fetus possesses unique vascular shunts to appropriately distribute oxygen and nutrients acquired from the placenta, adding complexity and adaptability to blood flow patterns within the fetal vascular network. Perturbations to fetal circulation compromise fetal growth and trigger the abnormal cardiovascular remodeling that underlies congenital heart defects. Computational modeling can be used to elucidate complex blood flow patterns in the fetal circulatory system for normal versus abnormal development. We present an overview of fetal cardiovascular physiology and its evolution from being investigated with invasive experiments and primitive imaging techniques to advanced imaging (4D MRI and ultrasound) and computational modeling. We introduce the theoretical backgrounds of both lumped-parameter networks and three-dimensional computational fluid dynamic simulations of the cardiovascular system. We subsequently summarize existing modeling studies of human fetal circulation along with their limitations and challenges. Finally, we highlight opportunities for improved fetal circulation models.

Level of evidence supporting the Chinese cardiovascular disease clinical practice guidelines and its evolution in the past two decades

Clinical practice is guided by guidelines in the era of evidence-based medicine to improve healthcare. The consistency between the strength of recommendations and the underlying quality of evidence in clinical guidelines and its evolution dynamically reflects the status of medical practice in important aspects. This study aimed to evaluate the levels of evidence (LOEs) supporting different classes of recommendations (CORs) in Chinese cardiovascular disease (CVD) guidelines between 2003 and 2021, and changes over time. Clinical guideline documents on cardiovascular topics issued by leading professional organizations were retrieved in the Databases of SinoMed and Wanfang Med Online from inception to June 2021. All guidelines were screened through abstract and full-text reading, and included if satisfying the pre-specified criteria. 79 Chinese guideline documents on 12 sub-topics including a total of 5195 recommendations and the designated CORs/LOEs, were abstracted. The number of recommendations of Class Ⅰ, Class Ⅱ, Class Ⅲ, LOE A, LOE B, and LOE C were identified for each guideline document. The proportion of CORs, LOEs, and COR-LOE combinations in guidelines and the changes among those with ≥2 versions. A total of 79 guidelines were included in the analysis. When examining the status of current guidelines, among the 3325 recommendations derived from 59 documents during 2011-2021, 735 recommendations (22.1%) were classified as LOE A, 1280 (38.5%) as LOE B, and 1310 (39.4%) as LOE C. 596 recommendations (17.9%) were characterized as Class Ⅰ-LOE A, accounting for the majority of LOE A recommendations but only one-third of Class I recommendations. Evidence levels varied greatly across different sub-topics and individual guidelines. There are 9 guidelines on 5 sub-topics having ≥2 versions. When analyzing the changes over time, although an increase was observed in the total number of recommendations, the proportion of recommendations designated as Class Ⅰ-LOE A did not significantly improve (19.1% [current] vs 19.0% [prior], p=0.97). In current Chinese CVD guidelines, the high level of evidence lacks, and its alignment with strong recommendations is deficient. Although it shows moderate improvements in certain major topics (e.g., coronary artery disease, interventional therapy, surgery) in the past two decades, the overall proportion of Class I-LOE A recommendations remains small, suggesting that conduction, and particularly translation, of high-quality studies like RCTs addressing CVDs-related questions are still essential and demanded, especially for areas with less attention. This study was supported by Beijing Nova Program from Beijing Municipal Science & Technology Commission (Z211100002121063, Z201100006820002); Fundamental Research Funds for the Central Universities (3332022023); National Key R&D Program of China (2020YFC2004705); CAMS Innovation Fund for Medical Sciences (2021-I2M-5-003); National Natural Science Foundation of China (81825003, 91957123, 82270376).

Deep Learning for Echocardiography: Introduction for Clinicians and Future Vision: State-of-the-Art Review.

Exponential growth in data storage and computational power is rapidly narrowing the gap between translating findings from advanced clinical informatics into cardiovascular clinical practice. Specifically, cardiovascular imaging has the distinct advantage in providing a great quantity of data for potentially rich insights, but nuanced interpretation requires a high-level skillset that few individuals possess. A subset of machine learning, deep learning (DL), is a modality that has shown promise, particularly in the areas of image recognition, computer vision, and video classification. Due to a low signal-to-noise ratio, echocardiographic data tend to be challenging to classify; however, utilization of robust DL architectures may help clinicians and researchers automate conventional human tasks and catalyze the extraction of clinically useful data from the petabytes of collected imaging data. The promise is extending far and beyond towards a contactless echocardiographic exam-a dream that is much needed in this time of uncertainty and social distancing brought on by a stunning pandemic culture. In the current review, we discuss state-of-the-art DL techniques and architectures that can be used for image and video classification, and future directions in echocardiographic research in the current era.

Structural repurposing of SGLT2 inhibitor empagliflozin for strengthening anti-heart failure activity with lower glycosuria.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been reapproved for heart failure (HF) therapy in patients with and without diabetes. However, the initial glucose-lowering indication of SGLT2i has impeded their uses in cardiovascular clinical practice. A challenge of SGLT2i then becomes how to separate their anti-HF activity from glucose-lowering side-effect. To address this issue, we conducted structural repurposing of EMPA, a representative SGLT2 inhibitor, to strengthen anti-HF activity and reduce the SGLT2-inhibitory activity according to structural basis of inhibition of SGLT2. Compared to EMPA, the optimal derivative JX01, which was produced by methylation of C2-OH of the glucose ring, exhibited weaker SGLT2-inhibitory activity (IC50>100nmol/L), and lower glycosuria and glucose-lowering side-effect, better NHE1-inhibitory activity and cardioprotective effect in HF mice. Furthermore, JX01 showed good safety profiles in respect of single-dose/repeat-dose toxicity and hERG activity, and good pharmacokinetic properties in both mouse and rat species. Collectively, the present study provided a paradigm of drug repurposing to discover novel anti-HF drugs, and indirectly demonstrated that SGLT2-independent molecular mechanisms play an important role in cardioprotective effects of SGLT2 inhibitors.

Frailty and Cardiovascular Mortality: A Narrative Review.

The goal of the narrative review is to provide an overview of the epidemiology of frailty in cardiovascular disease and cardiovascular mortality and discuss applications of frailty in cardiovascular care of older adults. Frailty is highly prevalent in older adults with cardiovascular disease and is a robust, independent predictor of cardiovascular death. There is a growing interest in using frailty to inform management of cardiovascular disease either through pre- or post-treatment prognostication or by delineating treatment heterogeneity in which frailty serves to distinguish patients with differential harms or benefits from a given therapy. Frailty can enable more individualized treatment in older adults with cardiovascular disease. Future studies are needed to standardize frailty assessment across cardiovascular trials and enable implementation of frailty assessment in cardiovascular clinical practice.

Актуальные вопросы применения в клинической практике шкал кардиоваскулярного риска у пациентов с сердечно-сосудистой патологией

Актуальные вопросы применения в клинической практике шкал кардиоваскулярного риска у пациентов с сердечно-сосудистой патологией

Development of knowledge-based clinical decision support system for the management of cardiovascular diseases

Abstract Background Knowledge-based clinical decision support systems (CDSS) are technological tools that analyze patient information and present justified diagnostic and therapeutic suggestions to the user. They improve adherence to evidence-based medicine and reduce medical errors. Material and methods We have developed an advanced CDSS with the following components: 1. Knowledge Management System, which allows the introduction of interoperable clinical variables organized in taxonomies, and the generation, validation and direct maintenance of decision rules by experts doctors. 2. Smart Assistant for Medical Reports Generation, which facilitates user interaction for the introduction of clinical data (natural language and/or data entry forms) and decission making supported by real-time suggestions that are automatically generated by 3. Inference Engine. Rules and variables derived from the most relevant cardiovascular Clinical Practice Guidelines (CPGs) are introduced by cardiologists into the system. The rules undergo a process of peer review and internal and external validation with anonymized clinical cases. Results More than 2,000 clinical variables and more than 5,000 rules corresponding to more than 80 CPGs and consensuns papers have been created and validated. An internal and external pilot validation of the system has been successfully carried out for the main cardiovascular problems, such as heart failure, atrial fibrillation, valvulopathies, coronary syndromes, cardiomyopathies, hypertension, diabetes and dyslipidaemias, using more than 400 cases. Conclusion Our CDSS is capable of providing real-time diagnostic and therapeutic recommendations for complex scenarios in cardiovascular disease, combining thousands of variables and decision rules in a single system. Prospective evaluation of the system in real clinical environments, certification and integration in Electronic Medical Records for clinical use is required. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): DILEMMA solutions, SL

Edoxaban in cardiovascular medicine from scientific evidence to clinical practice

Direct oral anticoagulants have become a reasonable treatment option replacing warfarin in preventing stroke in patients with non-valvular atrial fibrillation and in treating and preventing venous thromboembolism. This article aims to summarize the rationale behind the development of direct oral anticoagulants and to review the key pharmacological properties, clinical and reallife data of the factor Xa inhibitor edoxaban, that may contribute to improving patient outcomes in cardiovascular clinical practice.

Development of knowledge-based clinical decision support system for the management of cardiovascular diseases

Abstract Background Knowledge-based clinical decision support systems (CDSS) are technological tools that analyze patient information and present justified diagnostic and therapeutic suggestions to the user. They improve adherence to evidence-based medicine and reduce medical errors. Material and methods We have developed an advanced CDSS with the following components: 1. Knowledge Management System, which allows the introduction of interoperable clinical variables organized in taxonomies, and the generation, validation and direct maintenance of decision rules by experts doctors. 2. Smart Assistant for Medical Reports Generation, which facilitates user interaction for the introduction of clinical data (natural language and/or data entry forms) and decission making supported by real-time suggestions that are automatically generated by 3. Inference Engine. Rules and variables derived from the most relevant cardiovascular Clinical Practice Guidelines (CPGs) are introduced by cardiologists into the system. The rules undergo a process of peer review and internal and external validation with anonymized clinical cases. Results More than 2,000 clinical variables and more than 5,000 rules corresponding to more than 80 CPGs and consensuns papers have been created and validated. An internal and external pilot validation of the system has been successfully carried out for the main cardiovascular problems, such as heart failure, atrial fibrillation, valvulopathies, coronary syndromes, cardiomyopathies, hypertension, diabetes and dyslipidaemias, using more than 400 cases. Conclusion Our CDSS is capable of providing real-time diagnostic and therapeutic recommendations for complex scenarios in cardiovascular disease, combining thousands of variables and decision rules in a single system. Prospective evaluation of the system in real clinical environments, certification and integration in Electronic Medical Records for clinical use is required. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): DILEMMA solutions, SL