Siddharth Singh, M.D., director of the COVID-19 heart program, staff cardiologist and echocardiographer, Cedars-Sinai Hospital, explains how they work up cardiac patients in the Cedars-Sinai long-COVID clinic. He goes through the list of exams  and labs they use in these patients.

Cardiac patients at the Cedar-Sinai long-COVID clinic are evaluated with a basic physical exam, extensive family and medical history, an ECG, basic labs that include troponin and BNP, D-dimer, A1C, lipid panel and a metabolic profile since many patients have become much less active during the pandemic. Patients with symptoms are evaluated with an echocardiogram, including global longitudinal strain. If patients have abnormalities on the echo, or if there is suspected pericarditis or myocarditis, the patient is referred for a cardiac MRI with contrast. 

Watch more of this interview in the VIDEO: Cardiac Presentations in COVID Long-haulers at Cedars-Sinai Hospital 

Related Long-COVID Content:

What We Know About Cardiac Long-COVID Two Years Into the Pandemic 

VIDEO: Long-term Cardiac Impacts of COVID-19 Two Years Into The Pandemic — Interview with Aaron Baggish, M.D.

VIDEO: Long-COVID Presentations in Cardiology at Beaumont Hospital — Interview with Justin Trivax, M.D.

VIDEO: Cardiac Presentations in COVID Long-haulers at Cedars-Sinai Hospital — Interview with Siddharth Singh, M.D.

Find more COVID news and video

Aaron Baggish, M.D., director of the cardiovascular performance program, Mass General Hospital, has been involved in the care of cardiac COVID-19 long-hauler patients and monitoring athletes recovering from COVID the past two years.

He spoke to DAIC a year ago in late 2020 about the beginning of the Mass General monitoring of long-COVID patients and he shares what they have learned over the past year. He said the common long-term issues include arrhythmias, brain fog and other issues. Baggish also explains what they do to evaluate post-COVID infection patients with complaints or odd presentations weeks or months after their acute phase of infection ended.

Watch the 2020 interview with Baggish on long-COVID — VIDEO: Lingering Myocardial Involvement After COVID-19 Infection

Related Long-COVID Content:

What We Know About Cardiac Long-COVID Two Years Into the Pandemic 

VIDEO: Long-term Cardiac Impacts of COVID-19 Two Years Into The Pandemic — Interview with Aaron Baggish, M.D.

VIDEO: Long-COVID Presentations in Cardiology at Beaumont Hospital — Interview with Justin Trivax, M.D.

VIDEO: Examination of Cardiac COVID Long-Haulers — Interview with Siddharth Singh, M.D.

VIDEO: What Are The Long-term Cardiac Impacts of COVID-19 Infection — Interview with Todd Hurst, M.D.

VIDEO: Cardiac Presentations in COVID Long-haulers at Cedars-Sinai Hospital — Interview with Siddharth Singh, M.D.

Find more COVID news and video

Susan Cheng, M.D., MPH, director of the Institute for Research on Healthy Aging in the Department of Cardiology at Cedars-Sinai, moderated the Best Science in Cardiovascular Genetics and Genomics: Building Blocks to Better Outcomes, at the American Heart Association (AHA) 2021 meeting. She is an expert in cardiac genetic testing and said tailoring LDL-lowering drug therapy based on routine genetic tests is coming, but is still a few years off.

Find more AHA 2021 late-breaking studies and video

A new ultrasound imaging technology that may offer novel ways to diagnose and better understand cardiac diseases using dynamic blood flow imaging. This allows imaging of individual blood cells or contrast bubbles as they travel through the heart and vessels, showing detail in how the blood moves and swirls. These motions, including the formation of vortices, may offer new insight into different disease states and allow earlier diagnosis and a understand better when to intervene.

The examples shown in this short video are from Hitachi and GE Healthcare, both of which have highlighted this technology at the American Society of Echocardiography (ASE) annual meetings over the past four years.

Ultrasound vendors use different technology approaches, including vector flow imaging, particle imaging velocimetry and blood speckle tracking. All of them show small lines or arrows to indicate the direction the blood cells or bubbles are traveling, and color codes to indicate velocity. Some vendors offer quantification for some new measures of blood flow, but as of yet, there are no guidelines or standardized indexes as to what these numbers mean.

This technology has been discussed in research sessions at the IEEE and the ASE over the past several years. However, more research is needed to show the prognostic value of the technology. Research to date shows it is possible that the swirling of blood can indicate less efficient flow, which may have implications in the development of heart failure, pulmonary hypertension and advancement of valvular disease. In the coronary arteries, research has shown there may be a connection between sheer stresses and disrupted blood flow in the formation of plaques on artery walls.

Companies that have developed echo blood flow dynamics imaging on their ultrasound systems to date include Hitachi, GE Healthcare, Fujifilm, Mindray and BK Medical. 

Read more about this technology from ASE 2021 in the article Development of Echo Blood Flow Dynamics Imaging.
 

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Robert Kowal, M.D., chief medical officer of the Medtronic cardiac rhythm and heart failure division, said there has been a large increase in interest in remote monitoring and programing capabilities of implantable electrophysiology (EP) devices since the start of the COVID-19 pandemic. 

Cardiologists are looking for ways to care for their patients without the need to have them come into the office for close, personal meetings and interrogation of their implanted EP devices. Remote monitoring of these devices has been around for a decade and the Heart Rhythm Society (HRS) urged use of this technology in a 2015 consensus statemement. However, it has been COVID that has really pushed clinicians and patients to use this technolgy to its fullest as a way to watch patients closely from a distance and not require them to have to come into the office. It also enables EP practices to reprogram devices or alerts remotely where ever the have access to an internet connection. 

Find more EP news and video

Steven Lubitz, M.D., MPH, cardiac electrophysiologist, Massachusetts General Hospital, presented the late-breaking VITAL-AF Trial at the 2020 American Heart Association (AHA) virtual meeting this week. The study looked at screening for atrial fibrillation (AF) in older adults at primary care visits using the AliveCor single-lead electrocardiogram (ECG) device that interfaces with a smartphone or iPad.

The study found screening for AF using a single-lead ECG at primary care visits was not associated with a significant increase in new AF diagnoses among individuals aged 65 years or older compared to usual care. However, screening may be associated with an increased likelihood of diagnosing AF among individuals aged 85 years or older. 

Undiagnosed AFib is associated with increased risk of stroke. There is uncertainty about how best to screen for AF and guidelines differ regarding screening using ECGs. Methods: We conducted a cluster-randomized trial to evaluate whether screening using single-lead ECGs at primary care visits is effective for diagnosing AF. 

Sixteen clinics were randomized 1:1 to an AF screening intervention which offered an AliveCor single-lead ECG to patients aged 65 years or older during routine vital sign assessments, or usual care. AliveCor readings were over-read by cardiologists. Confirmatory diagnostic testing and treatment decisions were made by the primary care provider. 

New AF diagnoses were ascertained based on electronic case identification and manually adjudicated by a clinical endpoint committee. Results: 35,308 patients were included in the trial (n=17,643 intervention [91% screened], n=17,655 control). Patient characteristics were well-balanced between the intervention and control groups, including 12.7% versus 13.2% with prevalent AF, respectively. At one year, 1.52% of individuals in the screening group had new AF diagnosed versus 1.39% in the control group (relative risk [RR] 1.10; 95% confidence interval [CI] 0.92-1.30; P=0.30). New AF diagnoses in the screening and control groups varied by age (0.95% versus 1.00% for age 65-74; P=0.74; 1.84% versus 1.70% for age 75-84; P=0.58; 4.05% versus 2.68% for age 85+; P=0.02) (see figure). New anticoagulation was prescribed in 2.98% versus 2.90% of individuals in the screening and control groups, respectively, overall (RR 1.03; 95%CI 0.91-1.18; P=0.61), and in 72.8% versus 71% with new AF diagnoses (RR 1.02; 95%CI 0.92-1.14; P=0.70).

Find more AHA news, video and late-breakers

Deepika Thacker, M.D., a pediatric cardiologist with Nemours Children’s Health System, Wilmington, Del., helped discover one of the first cases of multisystem inflammatory syndrome in children (MIS-C) in the United States. She explains how they treated the first and subsequent pediatric patients with the COVID-19 related syndrome. Read more about the first case of MIS-C Nemours treated in the article Case Study Describes One of the First U.S. Cases of MIS-C.

The dangerous Kawasaki Disease-like syndrome occurs in a small number of children exposed to the COVID-19 (SARS-CoV-2) virus. MIS-C is an autoimmune reaction where the COVID appears asymptomatic, but the immune system overeacts to the virus and begins attacking health tissues in the body. It causes severe causes inflammation of the heart, lungs and other vital organs.

CDC Reports 800 U.S. Children Diagnosed With MIC-C

The Centers for Disease Control and Prevention (CDC) reported as of Sept. 10, 2020, there have been 792 confirmed cases in the United States of the rare MIS-C condition in children that is linked to COVID-19.

The agency also reported there have been 16 deaths reported from the MIS-C cases reported in 42 states, New York City and Washington, D.C., as of Sept. 3. Nearly all cases of MIS-C occurred in children who tested positive for the new coronavirus, while the remainder were in children who were around a person with COVID-19.

The CDC report also gave the following statistics:

   • Most cases are in children between the ages of 1 and 14 years, with an average age of 8 years.
   • Cases have occurred in children from <1 year old to 20 years old.
   • More than 70% of reported cases have occurred in children who are Hispanic/Latino (276 cases) or non-Hispanic Black (230 cases).
   • 99% of cases (783) tested positive for SARS CoV-2, the virus that causes COVID-19. The remaining 1% were around someone with COVID-19.
   • Most children developed MIS-C 2-4 weeks after infection with SARS-CoV-2.
   • Slightly more than half (54%) of reported cases were male.
 

Find additional CDC statistics on U.S. MIS-C cases

Related Content on MIS-C:

Kawasaki-like Inflammatory Disease Affects Children With COVID-19

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NIH-funded Project Wants to Identify Children at Risk for MIS-C From COVID-19

Interview with Andrew D. Krahn, M.D.,FHRS, head of the division of cardiology at St. Paul’s Hospital, and professor of medicine at the University of British Columbia, and vice president of the Heart Rhythm Society (HRS). He is an expert in long QT syndrome (LQTS) and is involved with the National Long QT Registry. He explains the issues with the drugs being used to treat coronavirus (COVID-19, SARS-CoV-2) patients and why these combined with the cardiac impact of the virus is causing prolonged ECG QT segment prolongation, leading to deadly arrhythmias. COVID-19 can cause myocarditis that causes QT prolongation and the front-line COVID drugs hydroxychloroquine and azithromycin also cause QT prolongation.

The U.S. Food and Drug Administration (FDA) issued a Drug Safety Communication April 23, 2020, reminding doctors there are serious side effects when using hydroxychloroquine and chloroquine in the off-label use to treat COVID-19 patients. This includes potentially life-threatening heart rhythm problems. The FDA said case reports from the FDA Adverse Event Reporting System database, published medical literature and the American Association of Poison Control Centers National Poison Data System are reporting serious heart-related adverse events and patient deaths. Read more about this alert.

The FDA warning confirmed fears from the American Heart Association (AHA), the American College of Cardiology (ACC) and the Heart Rhythm Society (HRS). These societies April 8 jointly published a new guidance, “Considerations for Drug Interactions on QTc in Exploratory COVID-19 (Coronavirus Disease 19) Treatment,” to detail critical cardiovascular considerations in the use of hydroxychloroquine and azithromycin for the treatment of COVID-19. The societies warned that use of  these agents in a large number of patients in combination would results in arrhythmias and deaths. Read more.

However, there are numerous advocates that argue hydroxychloroquine needs to be used in less sick patients who are not already hypoxic to treat COVID, but it is being used primarily in very sick patients where it is not effective. Advocates also argue the drug can be used to help prevent coronavirus, similar to the drug's effect in preventing malaria. In terms of drug safety, advocates argue the drug has been used in millions of patients for more than 50 years without a high risk of arrhythmias. Several trials are now underway in the United States to test its use against COVID-19, but enrollment has been hampered because of the FDA warning. There will likely be more interest in hydroxychloroquine after it was revealed May 18, 2020, that President Trump is taking the drug for prophylaxis against COVID-19.

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James Udelson, M.D., chief of the division of cardiology, Tufts Medical Center, explains how cardiac computed tomography (CT) scans are being used to create image-derived fractional flow reserve (FFR) values to determine if a coronary lesion is flow limiting. The FFR-CT can help determine if the patient needs a stent, or if the disease can be treated with medication. Tufts uses FFR-CT evaluations on non-emergency chest pain patients to reduce the need for diagnostic catheterizations. 

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Find more news and video from Tufts Medical Center

Interview with Thomas Maddox, M.D., MSc, FACC, the chairman of the American College of Cardiology (ACC) Science and Quality Committee, which recently created the ACC document on novel coronavirus (COVID-19) clinical guidance for the cardiovascular care team. He explains the document and what cardiologists and the cardiac care team needs to know about caring for COVID-19 patients. The document points out COVID-19 combined with the comorbidity of cardiovascular disease has the mortality of any comorbidity, as high as 10.5 percent.

He explains the need for more serious attention to protective equipment, cardiovascular complications seen in COVID-19 (SARS‐CoV‐2) patients, suggestions on how to mitigate exposure if an echo or cath is required, and other considerations for the CV care team. He said the document will be updated on a regular bases and the committee is drafting other sets of related COVID-19 guidelines for cardiology departments.

Updates regarding COVID-19 and cardiology will be posted on the ACC COVID-19 Hub page.

Maddox is also the executive director of the Healthcare Innovation Lab of BJC Healthcare and Washington University School of Medicine, St. Louis. He is also an assistant professor of cardiology at Washington University.

Read more on ACC COVID-19 recommendations for the cardiovascular care team.

Additional COVID-19 Resources for Clinicians:

   World Health Organization (WHO) COVID-19 situation reports

   World Health Organization (WHO) coronavirus information page

   U.S. Food and Drug Administration (FDA) COVID-19 information page

   Centers for Disease Control (CDC) COVID-19 information page

   Centers for Medicare and Medicaid Services (CMS) frequently asked questions and answers (FAQs) for healthcare providers regarding COVID-19 related payments
 

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Piotr J. Slomka, Ph.D., FACC, research scientist in the Artificial Intelligence in Medicine Program, Department of Medicine at Cedars-Sinai, and professor of medicine in-residence of the David Geffen School of Medicine, UCLA. He explains how his team at Cedars-Sinai is working on intelligent patient risk prediction algorithms that will automatically extract information from medical imaging. He spoke on artificial intelligence (AI) development for medical imaging in sessions at the 2019 American Society of Nuclear Cardiology (ASNC) annual meeting. 

Find more articles and video on AI

This is an example of an automated calcium scoring software to speed review of coronary artery calcium (CAC) scoring cardiac computed tomography (CT) scans. This advanced visualization software from Ziosoft uses artificial intelligence to segment the coronary vessels, identify valves and the aorta and then color code tag the calcium deposits and quantify the amount of calcified plaque in each vessel. It tallies the score into a table and computes an overall Agatston risk score. This risk score correlates to that patient's risk for a heart attack in the future. The software notes calcium in the heart outside the coronaries in valve leaflets and the aorta, but excludes this data. This type of automation is now offered by most advanced visualization and CT system vendors. This automation can save a large amount of post-processing time and make it easier for hospitals to offer low-cost CAC CT screening programs. 

CAC scans can be used to determine if a patient needs to go on statin therapy. An Agatston score of zero means the patient has no risk of coronary disease. 

Calcium in arteries is a marker for damage caused by vessel wall inflammation from atherosclerosis. Calcium can form from previously ruptured necrotic, lipid core plaques, also referred to as vulnerable plaques. These are the types of plaque responsible for heart attacks. When the core of these plaques rupture, the blood reacts to the exposed core similar to a wound and begins to clot, forming a thrombus in the vessel, which can block the blood flow. When the vessel heals over time it calcifies, leaving behind an easily identifiable marker on CT imaging. 

This example of software was demonstrated on the expo floor at the 2019 Society of Cardiovascular Computed Tomography (SCCT) meeting. 

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VIDEO: The History of CT Calcium Scoring — Interview with Arthur Agatston, M.D.

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Arthur Agatston, M.D., clinical professor of medicine, Florida International University, Herbert Wertheim College of Medicine, is the name-sake of the Agatston score used in CT calcium scoring. He explains the history of the scoring system from the early 1990s and the evolution of CT technology for cardiac imaging. The latest American Heart Association (AHA) 2018 cholesterol guidelines now include the use of CT calcium scoring, which was a big topic at the Society of Cardiovascular Computed Tomography (SCCT) 2019 meeting.

Read the article How the Agatston Calcium Score Was Created and its Impact on Heart Attack Prevention.

See a quick example of a CT calcium scoring exam in the VIDEO: Example of an Automated CT Cardiac Calcium Scoring Exam.

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Find more SCCT news and videos

Partho Sengupta, M.D., MBBS, chief of cardiology, West Virginia Heart and Vascular Institute, explains how wearable, smartphone-based apps and medical devices, and artificial intelligence (AI) might be used to cost-effectively triage larger numbers of patients in rural areas and in the developing world for serious diseases. He spoke at the 2019 American Society Of Echocardiography (ASE) meeting.

Sengupta is involved with a pilot program using the Butterfly app and transducer to turn a smartphone into an inexpensive ultrasound system. He said the idea is to have novice ultrasound users screen more patients with these types of devices and the exams either being sent to a remote hospital for reading. He said AI algorithms also could be used to help flag any exams that show abnormalities, which would greatly speed reads and getting these patients treatment. 

Watch the related VIDEO: How Smartphones May Revolutionize Healthcare in the Developing World — Interview with Jacques Kpodonu, M.D.,

Find more news and video from ASE 2019

Sanjaya Gupta, M.D., electrophysiologist, St. Luke's Mid America Heart Institute, and assistant professor, University of Missouri–Kansas City School of Medicine, explains how his center developed an artificial intelligence (AI) application to automatically risk stratify atrial fibrillation (AFib) patients. The Epic-based app stratifies patients into those who should be placed on anticoagulation and those who are candidates for left atrial appendage (LAA) occlusion. He spoke at the 2019 AI-Med Cardiology conference. 

His center hopes to develop similar guidelines based AI apps for other types of cardiac risk scoring. Gupta said he is looking for other centers to partner with to co-develop and test these AI apps.    

Related Cardiology AI Content:

VIDEO: Overview of Artificial Intelligence and its Use in Cardiology — Interview with Anthony Chang, M.D.

VIDEO: ACC Efforts to Advance Evidence-based Implementation of AI in Cardiovascular Care — Interview with John Rumsfeld, M.D.

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VIDEO: How Hospitals Should Prepare for Artificial Intelligence Implementation — Interview with Paul Chang, M.D.

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Kim Allan Williams, Sr., M.D., chief of the Division of Cardiology and the James B. Herrick Professor at Rush University Medical Center, , and former American College of cardiology (ACC) president, discusses the importance of a plant-based diet to improve cardiovascular health and why he went vegan.

Other Interviews With Dr. Williams:

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Karl Poterack, M.D., medical director, applied clinical informatics, Mayo Clinic, explains the role wearable devices will play in healthcare. He presented in several sessions at the 2019 Healthcare Information Management and Systems Society at (HIMSS) conference.

Poterack said there is a brewing tsunami of data in wearable technologies that healthcare systems will have to figure out how to integrate in the coming years. He said the key issue with wearable data is that there needs to be outcomes data showing the value of how many steps a patient accumulates, changes in heart rate over time, or blood pressure changes in patients with specific aliments. Without this , he said there is limited value in the information. 

Watch the related VIDEO: Use of Wearable Medical Devices for Cardiac Rehabilitation.

Look through a photo gallery of other new technologies at HIMSS19. 

Find news and videos from HIMSS 2019.

Anthony Chang, M.D., chief intelligence and innovation officer, Children's Hospital of Orange County (CHOC), and medical director of the Sharon Disney Lund Medical Intelligence and Innovation Institute. He is expert in artificial intelligence (AI). He spoke in several sessions at Healthcare Information and Management Systems Society (HIMSS) 2019 meeting on the integration of AI in healthcare. 

He said AI will play a big roll in imaging assessments of adult congenital heart disease to help relieve the burden on the small number of congenital cardiologists. 

Chang also explained there is a tsunami of data about to wash over healthcare as wearable devices begin to be integrated into patient care. AI will play a key role in sorting through all this data by monitoring the information to identify trends or disease markers and alert clinicians and the patient.

He was a keynote speaker at HIMSS19 with his session "Synergies Between Man and Machine — Future AI apps can be directed to help mitigate physician burnout by decreasing the EHR burden, improving medical education, and automating quality improvement."

Chang is head of the artificial intelligence organization AIMed, which hosts educational sessions and an annual meeting on AI applications in medicine.

Listen to Chang in the PODCAST: Fitting Artificial Intelligence Into Cardiology.
 

Read the article 6 Key Health Information Technology Trends at HIMSS 2019.

Look through a photo gallery of other new technologies at HIMSS19. 

Find news and videos from HIMSS 2019.

How wearable devices will play a role in healthcare was a big topic at the Healthcare Information Management and Systems Society (HIMSS) 2019 meeting. The biggest question is how to attached the data from consumer devices into a usable format for clinicians that interfaces with the electronic medical record (EMR). A good example of how wearables are being integrated in clinical care was demonstrated by the company Datos. It offers software that can integrate data from a wide variety of wearable devices from several makers into a mobile app, It can transfer the information to an EMR. The app also offers two way communication between the patient and the doctor’s office. It can prompt patients with a list of things they need to do each day to reach physician specified goals and displays analytics on a patient’s health data, including charts and graphs.

The system is used by Sheba Medical Center in Israel for a remote cardiac rehabilitation program. It now remotely monitors hundreds of patients and does not require them to come to the hospital for sessions, which has helped increase patient satisfaction and aided in increasing physical activity compliance. Watch the VIDEO: Use of Wearable Medical Devices for Cardiac Rehabilitation — an interview with Robert Klempfner, M.D., director of the Cardiovascular Prevention Institute, Sheba Medical Center.
 

Look through a photo gallery of other new technologies at HIMSS19. 

Find news and videos from HIMSS 2019.

James Januzzi, M.D., Hutter Family Professor at Harvard Medical School and a cardiologist at Mass General Hospital,, Boston, spoke at the 2018 American Heart Association (AHA) meeting about blood biomarkers that can aid in assessing reverse remodeling in heart failure patients with reduced ejection fraction (HFrEF). 

Januzzi mentions the use of high sensitivity troponin in this video. Watch a VIDEO interview with Januzzi on his research with high sensitivity troponin.