Prof. Sundeep Mishra  gives an insight as to what one should look forward to in this new year in the field of cardiology.

 

 

 

 

 

 

What lies ahead in 2019 for medicine / cardiovascular medicine is the question?

Year 2019 is likely to be an exciting time in cardiology and while it is patients who stand to benefit most there will be important advances for the care-givers as well. Technological advances and social evolution / movement is impacting every aspect of human condition and medicine in general and cardiology in particular cannot be any exception to this phenomenon; thus whatever is happening in these areas gets reflected in health-care sector as well.

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The Year of Wearable Devices – Paradise Tomorrow

With increasing health awareness world-wide, sick and healthy individuals are seeking to take full control of their health issues, and the year 2019 is likely to be the year of wearable devices. These devices will measure everything from heart rate and rhythm to blood pressure, sleep quality and duration, and physical activity, in other words anything that could have a positive impact on health and disease outcome, by day-to-day, minute-to-minute monitoring of vital data.

These devices could be specialised watches, gloves, or something already widespread in daily use i.e. mobile based devices, “mHealth.” At least 6 major trials are on anvil expected this year; OSICAT, AIRLESS, CommwellPG, VIDA etc. Currently, there are thousands of wearable devices available in the market and choosing among them could be a challenge.

Most popular devices deal with

1. Staying fit – Fitbit Surge: is a touch-screen wristwatch which not only tracks steps and sleep, but also alerts to incoming phone calls and text messages, keeps tabs on heart rate with a built-in optical heart rate monitor and uses GPS to track outdoor activity.
2. Night sleep – Android sleep App, Pebble Sleep
3. Reducing stress – PIP
4. Optimal blood pressure – Withings Blood Pressure: it consists of an app connecting through Bluetooth to the blood pressure monitor itself. The app measures heart rate, blood pressure and also counts the steps taken weekly.
5. Keeping track of weight – Fitbit Aria
6. Monitoring heart – Alivecor heart monitor: a mobile phone based electrocardiogram. The tiny, slim and simple device attaches to phone case. Its app has three main divisions: ECG recording, collected data, and a great educational portion.
7. Measuring body temperature – Viatom Checkme
8. Meditation – Muse Headband
9. Effective exercise – Gymwatch Fitness Tracker
10. Diet – Noom diet: an app based diet

 

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Caregiver is the Key – My True North

While currently one of the most maligned professions, medicine is also one of the most hazardous professions as well.

This year the spotlight is likely to also be on the caregiver; doctors, nurses, pharmacists and other paramedical workforce as there is a realisation that for the patient to get healthy, the care - givers themselves must be healthy physically, mentally and medically.

With troubling reports emerging about various occupational hazards faced by medical professionals; nurses, physicians, cardiologists particularly interventional cardiologists and cath lab workers i.e. those related to radiation (cath lab and imaging) and sleep deprivation (for those on frequent night duties) it has become imperative to take cognizance of this problem and take ameliorative steps:

1. Awareness of the problem
2. Better radiation protocols
3. Better scanning equipment
4. Better radiation protection equipment: radiation protection shields, aprons, glasses, skull caps and thyroid shields

Several trials will report effects of radiation injury in developing neurological cancers, cataracts etc; BRAIN, PROTECT, IC-CATARACT etc.

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Drug Therapy – The Constant Gardener

This area is concerned with developing medications to fight cardiovascular diseases from new angles and development of less-invasive procedures to replace invasive surgical options. However, this year the break-through is not likely to be in new cutting-edge technology or new drug but rather in defining the niche areas where the already discovered technology could be used or expanding their indications.

Like before most represented will be fields which have either widespread prevalence or grave prognosis; atrial fibrillation (NOACs and VKA), heart failure, dyslipidemia (statins and PCSK-9 inhibitors), coronary artery disease etc. TWILIGHT, Monitor-AF, ATTENTION, EKVASIS, NOAH, Presage-Aco, SULTAN and ACFA are some of the major trials likely to be presented.

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Interventional Cardiology – Cardiology got Talent

Like pharmaco - therapeutics the area of interventional cardiology is also not likely to witness any new device, but only in better defining and expanding the use of already existing devices like those for TAVR or mitral valve. Several trials comparing one drug eluting stent against another are also likely to be presented. Some trials worth watching could be TVTR, TMVR, IMPROVE-FMR and Resolute and stent studies but also PARACHUTE, PARACHUTEIII, PIII PV Loop, PFO Detection.

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Healthcare Delivery and Outcomes – The Accidental Topper

The big story of 2019 is not likely to be any drug or device, rather holistic health or healthcare outcomes. The focus is likely to be on improvement in delivery of health-care, with nearly 1/3rd of the 90 or so major trials in cardiology to be presented in 2019 focusing on this aspect. CRAC, DeQCAD, G-COACH, PHMEV, ACCP, RYTHM-UP AOD, TimePoints, and a bunch of other studies will be presented this year. There will be focus on analyzing the “big data” and developing algorithms and protocols for efficient health-care delivery in both hospitals and out-of-hospitals. Interestingly, the narrative will involve not only “best care practices” but also a discussion of health economics of many therapies, a trend which already started last year with ACC/AHA guidelines of dyslipidemia focusing on cost of PCSK-9 inhibitor therapy. GAINE LASER is likely to be presented this year.

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Genomics & Molecular Diagnostics and Therapies – See Saw, Hee Haw

Despite long incubation period and a rather major technical and moral controversy in Gene Editing “CRISPR Baby” emanating from China last year, genomics and gene related therapies are likely to see some resurgence.

IMPACT-CARD, TuePIC, GPAD-3 could be some of the trials worth watching. In line with direction in previous years several applications of bio-markers are also likely to be presented; proCORE.

 

 

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Non Invasive Diagnostics – Connecting the Unconnected

Newer non-invasive imaging modalities will get established but older techniques like CT Angiography will also witness an expanding indication. MID-EPIC, RAPID-CTCA, CAPRI are some of the major trials in this area expected this year.

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Elderly and Very Young – Old Mother Forest

Moving from women who were in focus in 2018, this year the focus will be on either very old or very young. These groups typically have highest risk but also the highest chance of benefit. Several trials on each and every aspect are likely to be presented, HFF-ED, FRAPICA, NPC-QIC to name a few.

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Lifestyle Modification – Taken for Granted

In line with the trend seen with previous years several trials on lifestyle modification; diet, exercise and even alternative therapies would be presented. Prominent among them will be PIM, WholeLIFE and ALIMS trial.

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Artificial Intelligence – The Color of Imagination

Human kind seems to be on cusp of migration, moving from “age of machines” to an “age of information”: to now “age of artificial intelligence.” Artificial intelligence (AI) is the theory and development of computer based systems able to perform tasks normally requiring human intelligence, such as deep analysis, visual perception, speech recognition, translation between languages and even decision-making, and. It can involve

1. Machine Learning - Machine learning is an application of AI that provides systems the ability to automatically learn and improve from experience without being explicitly programmed and perform specific tasks based on it. Recognizing patterns and forming a memory of patterns.
2. Deep Learning - Deep learning is part of a broader family of machine learning methods based on learning data representations, as opposed to task-specific algorithms.
3. Artificial Neural networks (ANN) are most advanced computational algorithms intended to simulate the behavior of biological systems composed of “neurons”. ANNs are computational models inspired by an human central nervous systems, capable of machine learning as well as pattern recognition. 

This technology can be applied to practically all stages of patient-care; prevention, diagnosis, monitoring and treatment and all aspects of medicine from sophisticated data interpretation, streaming mobile device biometrics, developing efficient treatment pathways and protocols,, improving operational efficiency of health-care system, providing personalized patient care to even whole-genome-sequencing. On a immediate practical basis it can be most useful with wearable devices providing important feed-back to the wearer as also treating physician helping to monitor, interpret, and respond to various types of biomedical data which could be collected automatically and remotely.

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