Machine Learning and the Future of Cardiovascular Care: JACC State-of-the-Art Review

Explainable machine learning model for assessing health status in patients with comorbid coronary heart disease and depression: Development and validation study

BACKGROUND

Coronary heart disease (CHD) and depression frequently co-occur, significantly impacting patient outcomes. However, comprehensive health status assessment tools for this complex population are lacking. This study aimed to develop and validate an explainable machine learning model to evaluate overall health status in patients with comorbid CHD and depression.

METHODS

Utilizing data from the 2021-2022 Behavioral Risk Factor Surveillance System, we developed and externally validated machine learning models to predict overall health status, defined as having both poor physical and mental health for ≥ 14 days in the past 30 days. Eleven machine learning algorithms were evaluated, including artificial neural networks, support vector machines, and ensemble methods. The SHapley Additive exPlanations (SHAP) method was employed to enhance model interpretability. Model performance was assessed using discrimination, calibration, and decision curve analysis.

RESULTS

The study included 9,747 participants in the derivation cohort and 8,394 in the external validation cohort. Among the eleven algorithms evaluated, an optimized XGBoost model with eight key features demonstrated balanced performance. SHAP analysis revealed that employment status, physical activity, income, and age were the most influential predictors. The model maintained good discrimination (AUC 0.712, 95% CI 0.703-0.721 in derivation; AUC 0.711, 95% CI 0.701-0.721 in validation), calibration and clinical utility across both cohorts.

CONCLUSION

Our explainable machine learning model provides a novel, comprehensive approach to assessing health status in patients with comorbid CHD and depression, offering valuable insights for personalized management strategies.

Advances in the Application of Artificial Intelligence in the Ultrasound Diagnosis of Vulnerable Carotid Atherosclerotic Plaque

Vulnerable atherosclerotic plaque is a type of plaque that poses a significant risk of high mortality in patients with cardiovascular disease. Ultrasound has long been used for carotid atherosclerosis screening and plaque assessment due to its safety, low cost and non-invasive nature. However, conventional ultrasound techniques have limitations such as subjectivity, operator dependence, and low inter-observer agreement, leading to inconsistent and possibly inaccurate diagnoses. In recent years, a promising approach to address these limitations has emerged through the integration of artificial intelligence (AI) into ultrasound imaging. It was found that by training AI algorithms with large data sets of ultrasound images, the technology can learn to recognize specific characteristics and patterns associated with vulnerable plaques. This allows for a more objective and consistent assessment, leading to improved diagnostic accuracy. This article reviews the application of AI in the field of diagnostic ultrasound, with a particular focus on carotid vulnerable plaques, and discusses the limitations and prospects of AI-assisted ultrasound. This review also provides a deeper understanding of the role of AI in diagnostic ultrasound and promotes more research in the field.

Machine-learning versus traditional approaches to predict all-cause mortality for acute coronary syndrome: a systematic review and meta-analysis

BACKGROUND

Acute coronary syndrome (ACS) remains one of the leading causes of death globally. Accurate and reliable mortality risk prediction of ACS patients is essential for developing targeted treatment strategies and improve prognostication. Traditional models for risk stratification such as the GRACE and TIMI risk scores offer moderate discriminative value, and do not incorporate contemporary predictors of ACS prognosis. Machine learning (ML) models have emerged as an alternate method that may offer improved risk assessment. This article aims to compare machine learning models with traditional risk scores for predicting all-cause mortality in patients with ACS.

METHODS

PubMed, EMBASE, Web of Science, Cochrane, CINAHL, Scopus and iEEE XPlore databases were searched until 30th October 2024, as well as Google Scholar and manual screening of reference lists from included studies and the grey literature for studies comparing ML models with traditional statistical methods for event prediction of ACS patients. Best-performing ML models demonstrated superior discrimination of all-cause mortality for ACS patients compared to traditional risk scores. The primary outcome was comparative discrimination measured by C-statistics with 95% confidence intervals in estimating risk of all-cause mortality.

RESULTS

Twelve studies were included (250,510 patients). The summary C-statistic of best-performing ML models across all endpoints was 0.88 (95% CI, 0.86-0.91), compared to traditional methods 0.82 (95% CI, 0.80-0.85). The difference in C-statistic between ML models and traditional methods was 0.06 (p<0.0007). Five studies undertook external validation. PROBAST tool demonstrated high risk of bias for all studies. Common sources of bias included reporting bias and selection bias. Best-performing ML models demonstrated superior discrimination of all-cause mortality for ACS patients compared to traditional risk scores.

CONCLUSION

Despite outperforming well-established prognostic tools such as the GRACE and TIMI scores, current clinical applications of ML approaches remain uncertain, particularly in view of the need for greater model validation.

Super-resolution left ventricular flow and pressure mapping by Navier-Stokes-informed neural networks

Intraventricular vector flow mapping (VFM) is an increasingly adopted echocardiographic technique that derives time-resolved two-dimensional flow maps in the left ventricle (LV) from color-Doppler sequences. Current VFM models rely on kinematic constraints arising from planar flow incompressibility. However, these models are not informed by crucial information about flow physics; most notably the forces within the fluid and the resulting accelerations. This limitation has rendered VFM unable to combine information from different time frames in an acquisition sequence or derive fluctuating pressure maps. In this study, we leveraged recent advances in artificial intelligence (AI) to develop AI-VFM, a vector flow mapping modality that uses physics-informed neural networks (PINNs) encoding mass conservation and momentum balance inside the LV, and no-slip boundary conditions at the LV endocardium. AI-VFM recovers the flow and pressure fields in the LV from standard echocardiographic scans. It performs phase unwrapping and recovers flow data in areas without input color-Doppler data. AI-VFM also recovers complete flow maps at time points without color-Doppler input data, producing super-resolution flow maps. We validate AI-VFM using physiological simulated LV data and show that informing the PINNs with momentum balance is essential for achieving temporal super-resolution and significantly increases the accuracy of AI-VFM compared to informing the PINNs only with mass conservation. AI-VFM is solely informed by each patient's flow physics; it does not utilize explicit smoothness constraints or incorporate data from other patients or flow models. AI-VFM takes 15 min to run in off-the-shelf graphics processing units and its underlying PINN framework could be extended to map other flow-associated metrics such as blood residence time or the concentration of coagulation species.

Machine learning to detect recent recreational drug use in intensive cardiac care units

BACKGROUND

Although recreational drug use is a strong risk factor for acute cardiovascular events, systematic testing is currently not performed in patients admitted to intensive cardiac care units, with a risk of underdetection. To address this issue, machine learning methods could assist in the detection of recreational drug use.

AIMS

To investigate the accuracy of a machine learning model using clinical, biological and echocardiographic data for detecting recreational drug use in patients admitted to intensive cardiac care units.

METHODS

From 07 to 22 April 2021, systematic screening for all traditional recreational drugs (cannabis, opioids, cocaine, amphetamines, 3,4-methylenedioxymethamphetamine) was performed by urinary testing in all consecutive patients admitted to intensive cardiac care units in 39 French centres. The primary outcome was recreational drug detection by urinary testing. The framework involved automated variable selection by eXtreme Gradient Boosting (XGBoost) and model building with multiple algorithms, using 31 centres as the derivation cohort and eight other centres as the validation cohort.

RESULTS

Among the 1499 patients undergoing urinary testing for drugs (mean age 63±15 years; 70% male), 161 (11%) tested positive (cannabis: 9.1%; opioids: 2.1%; cocaine: 1.7%; amphetamines: 0.7%; 3,4-methylenedioxymethamphetamine: 0.6%). Of these, only 57% had reported drug use. Using nine variables, the best machine learning model (random forest) showed good performance in the derivation cohort (area under the receiver operating characteristic curve=0.82) and in the validation cohort (area under the receiver operating characteristic curve=0.76).

CONCLUSIONS

In a large intensive cardiac care unit cohort, a comprehensive machine learning model exhibited good performance in detecting recreational drug use, and provided valuable insights into the relationships between clinical variables and drug use through explainable machine learning techniques.

Deep learning for cardiac imaging: focus on myocardial diseases, a narrative review

The integration of computational technologies into cardiology has significantly advanced the diagnosis and management of cardiovascular diseases. Computational cardiology, particularly, through cardiovascular imaging and informatics, enables a precise diagnosis of myocardial diseases utilizing techniques such as echocardiography, cardiac magnetic resonance imaging, and computed tomography. Early-stage disease classification, especially in asymptomatic patients, benefits from these advancements, potentially altering disease progression and improving patient outcomes. Automatic segmentation of myocardial tissue using deep learning (DL) algorithms improves efficiency and consistency in analyzing large patient populations. Radiomic analysis can reveal subtle disease characteristics from medical images and can enhance disease detection, enable patient stratification, and facilitate monitoring of disease progression and treatment response. Radiomic biomarkers have already demonstrated high diagnostic accuracy in distinguishing myocardial pathologies and promise treatment individualization in cardiology, earlier disease detection, and disease monitoring. In this context, this narrative review explores the current state of the art in DL applications in medical imaging (CT, CMR, echocardiography, and SPECT), focusing on automatic segmentation, radiomic feature phenotyping, and prediction of myocardial diseases, while also discussing challenges in integration of DL models in clinical practice.

Machine learning approaches for risk prediction after percutaneous coronary intervention: a systematic review and meta-analysis

Aims

Accurate prediction of clinical outcomes following percutaneous coronary intervention (PCI) is essential for mitigating risk and peri-procedural planning. Traditional risk models have demonstrated a modest predictive value. Machine learning (ML) models offer an alternative risk stratification that may provide improved predictive accuracy.

Methods and results

This study was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies and Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis guidelines. PubMed, EMBASE, Web of Science, and Cochrane databases were searched until 1 November 2023 for studies comparing ML models with traditional statistical methods for event prediction after PCI. The primary outcome was comparative discrimination measured by C-statistics with 95% confidence intervals (CIs) between ML models and traditional methods in estimating the risk of all-cause mortality, major bleeding, and the composite outcome major adverse cardiovascular events (MACE). Thirty-four models were included across 13 observational studies (4 105 916 patients). For all-cause mortality, the pooled C-statistic for top-performing ML models was 0.89 (95%CI, 0.84-0.91), compared with 0.86 (95% CI, 0.80-0.93) for traditional methods (P = 0.54). For major bleeding, the pooled C-statistic for ML models was 0.80 (95% CI, 0.77-0.84), compared with 0.78 (95% CI, 0.77-0.79) for traditional methods (P = 0.02). For MACE, the C-statistic for ML models was 0.83 (95% CI, 0.75-0.91), compared with 0.71 (95% CI, 0.69-0.74) for traditional methods (P = 0.007). Out of all included models, only one model was externally validated. Calibration was inconsistently reported across all models. Prediction Model Risk of Bias Assessment Tool demonstrated a high risk of bias across all studies.

Conclusion

Machine learning models marginally outperformed traditional risk scores in the discrimination of MACE and major bleeding following PCI. While integration of ML algorithms into electronic healthcare systems has been hypothesized to improve peri-procedural risk stratification, immediate implementation in the clinical setting remains uncertain. Further research is required to overcome methodological and validation limitations.

Comprehensive Analysis of Cardiovascular Diseases: Symptoms, Diagnosis, and AI Innovations

Cardiovascular diseases are some of the underlying reasons contributing to the relentless rise in mortality rates across the globe. In this regard, there is a genuine need to integrate advanced technologies into the medical realm to detect such diseases accurately. Moreover, numerous academic studies have been published using AI-based methodologies because of their enhanced accuracy in detecting heart conditions. This research extensively delineates the different heart conditions, e.g., coronary artery disease, arrhythmia, atherosclerosis, mitral valve prolapse/mitral regurgitation, and myocardial infarction, and their underlying reasons and symptoms and subsequently introduces AI-based detection methodologies for precisely classifying such diseases. The review shows that the incorporation of artificial intelligence in detecting heart diseases exhibits enhanced accuracies along with a plethora of other benefits, like improved diagnostic accuracy, early detection and prevention, reduction in diagnostic errors, faster diagnosis, personalized treatment schedules, optimized monitoring and predictive analysis, improved efficiency, and scalability. Furthermore, the review also indicates the conspicuous disparities between the results generated by previous algorithms and the latest ones, paving the way for medical researchers to ascertain the accuracy of these results through comparative analysis with the practical conditions of patients. In conclusion, AI in heart disease detection holds paramount significance and transformative potential to greatly enhance patient outcomes, mitigate healthcare expenditure, and amplify the speed of diagnosis.

Artificial Intelligence Algorithms in Cardiovascular Medicine: An Attainable Promise to Improve Patient Outcomes or an Inaccessible Investment?

PURPOSE OF REVIEW

This opinion paper highlights the advancements in artificial intelligence (AI) technology for cardiovascular disease (CVD), presents best practices and transformative impacts, and addresses current concerns that must be resolved for broader adoption.

RECENT FINDINGS

With the evolution of digitization in data collection, large amounts of data have become available, surpassing the human capacity for processing and analysis, thus enabling the application of AI. These models can learn complex spatial and temporal patterns from large amounts of data, providing patient-specific outputs. These advantages have resulted, at the moment, in more than 900 AI-based devices being approved, today, by regulatory entities, for clinical use, with similar to improved performance and efficiency compared to traditional technologies. However, issues such as model generalization, bias, transparency, interpretability, accountability, and data privacy remain significant barriers for broad adoption of these technologies. AI shows great promise in enhancing CVD care through more accurate and efficient approaches. Yet, widespread adoption is hindered by unresolved concerns of interested stakeholders. Addressing these challenges is crucial for fully integrating AI into clinical practice and shaping the future of CVD prevention, diagnosis and treatment.

Antihypertensive Drug Recommendations for Reducing Arterial Stiffness in Patients With Hypertension: Machine Learning-Based Multicohort (RIGIPREV) Study

BACKGROUND

High systolic blood pressure is one of the leading global risk factors for mortality, contributing significantly to cardiovascular diseases. Despite advances in treatment, a large proportion of patients with hypertension do not achieve optimal blood pressure control. Arterial stiffness (AS), measured by pulse wave velocity (PWV), is an independent predictor of cardiovascular events and overall mortality. Various antihypertensive drugs exhibit differential effects on PWV, but the extent to which these effects vary depending on individual patient characteristics is not well understood. Given the complexity of selecting the most appropriate antihypertensive medication for reducing PWV, machine learning (ML) techniques offer an opportunity to improve personalized treatment recommendations.

OBJECTIVE

This study aims to develop an ML model that provides personalized recommendations for antihypertensive medications aimed at reducing PWV. The model considers individual patient characteristics, such as demographic factors, clinical data, and cardiovascular measurements, to identify the most suitable antihypertensive agent for improving AS.

METHODS

This study, known as the RIGIPREV study, used data from the EVA, LOD-DIABETES, and EVIDENT studies involving individuals with hypertension with baseline and follow-up measurements. Antihypertensive drugs were grouped into classes such as angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), β-blockers, diuretics, and combinations of diuretics with ACEIs or ARBs. The primary outcomes were carotid-femoral and brachial-ankle PWV, while the secondary outcomes included various cardiovascular, anthropometric, and biochemical parameters. A multioutput regressor using 6 random forest models was used to predict the impact of each antihypertensive class on PWV reduction. Model performance was evaluated using the coefficient of determination (R2) and mean squared error.

RESULTS

The random forest models exhibited strong predictive capabilities, with internal validation yielding R2 values between 0.61 and 0.74, while external validation showed a range of 0.26 to 0.46. The mean squared values ranged from 0.08 to 0.22 for internal validation and from 0.29 to 0.45 for external validation. Variable importance analysis revealed that glycated hemoglobin and weight were the most critical predictors for ACEIs, while carotid-femoral PWV and total cholesterol were key variables for ARBs. The decision tree model achieved an accuracy of 84.02% in identifying the most suitable antihypertensive drug based on individual patient characteristics. Furthermore, the system's recommendations for ARBs matched 55.3% of patients' original prescriptions.

CONCLUSIONS

This study demonstrates the utility of ML techniques in providing personalized treatment recommendations for antihypertensive therapy. By accounting for individual patient characteristics, the model improves the selection of drugs that control blood pressure and reduce AS. These findings could significantly aid clinicians in optimizing hypertension management and reducing cardiovascular risk. However, further studies with larger and more diverse populations are necessary to validate these results and extend the model's applicability.

[Coronary CT Angiography-Based Mechanomics Predicts Atherosclerotic Plaque Formation in Regions Proximal to Myocardial Bridging]

Objective

To assess with machine learning the predictive value of mechanomics derived from coronary CT angiography (CCTA) for atherosclerotic plaque formation in regions proximal to myocardial bridging (MB) in the left anterior descending coronary artery (LAD).

Methods

This retrospective study included a cohort of patients with MB in LAD and no atherosclerotic plaque formation in LAD as confirmed by two CCTA conducted between January 2007 and April 2021 at our hospital. The interval between the two CCTA examinations was more than 3 months. The primary endpoint was the formation of atherosclerotic plaques in regions proximal to the myocardial bridging. Patient demographic characteristics and clinical risk factors were documented. Then, the patients were matched by age and sex in a 1-to-1 ratio and divided into two groups, those with plaque formation and those without plaque formation. Computational fluid dynamics analysis was performed based on CCTA. Key anatomical parameters of MB, including location, length, depth, and systolic compression index, were meticulously measured on the CCTA images. Mechanomic data were extracted from the region proximal to the MB. A multivariate Cox regression analysis was performed to identify significant features. A random forest algorithm was used to select mechanomic features for subsequent modeling and to assign scores for each patient's mechanomic features. The log-rank test and Kaplan-Meier curves were used to investigate the mechanomic model's predictive performance concerning plaque formation. Additionally, the operator characteristic curves were applied to evaluate how well the model could predict plaque formation across various myocardial bridge subgroups.

Results

A total of 104 patients with LAD MB were recruited. The mean age of the subjects were (54.56±10.56) years and 75.00% (78/104) of them were male. Among them, 52 developed plaque formation over a median follow-up period of 3.0 years. Apart from a smoking history, which was more prevalent in the group with plaque formation than that in the group without plaque formation (21.15% vs. 5.77%, P=0.04), no significant differences between the groups were observed in terms of the other clinical or anatomical characteristics (all P≤0.05). The participants were divided into a training set (n=74) and a validation set (n=30) at a 7∶3 ratio. With the mechanomics model constructed using the random forest algorithm, the patients were classified into a high-score group (≥0.46) and a low-score group (<0.46) based on a cutoff score of 0.46. The mechanomics model achieved a sensitivity of 0.87 (0.58-0.98) and an accuracy of 0.63 (0.44-0.79) in the validation set. The multivariate Cox regression model revealed a strong positive association between mechanomics and plaque formation (hazards ratio [HR]: 10.58; 95% confidence interval [CI]: 3.23-34.64, P<0.001). The log-rank test showed that the high-score group in the mechanomics model was more likely to develop plaques at the proximal regions of the myocardial bridge compared to the low-score group (P<0.001). The area under the curve (AUC) for plaque formation, as predicted by the model, was 0.88 (95% CI: 0.82-0.95) for the entire population, 0.89 (95% CI: 0.82-0.96) for the training set, 0.86 (95% CI: 0.74-0.99) for the validation set, 0.92 (95% CI: 0.86-0.97) for the superficial MB group, 0.86 (95% CI: 0.74-0.98) for the long MB group, and 0.91 (95% CI: 0.83-0.98) for the short MB group.

Conclusion

The mechanomic assessment holds substantial potential as a predictive tool for atherosclerotic plaque formation in regions proximal to MB in LAD.

Machine learning for pacemaker implantation prediction after TAVI using multimodal imaging data

Pacemaker implantation (PMI) after transcatheter aortic valve implantation (TAVI) is a common complication. While computed tomography (CT) scan data are known predictors of PMI, no machine learning (ML) model integrating CT with clinical, ECG, and transthoracic echocardiography (TTE) data has been proposed. This study investigates the contribution of ML methods to predict PMI after TAVI, with a focus on the role of CT imaging data. A retrospective analysis was conducted on a cohort of 520 patients who underwent TAVI. Recursive feature elimination with SHAP values was used to select key variables from clinical, ECG, TTE, and CT data. Six ML models, including Support Vector Machines (SVM), were trained using these selected variables. The model's performance was evaluated using AUC-ROC, F1 score, and accuracy metrics. The PMI rate was 18.8%. The best-performing model achieved an AUC-ROC of 92.1% ± 4.7, an F1 score of 71.8% ± 9.9, and an accuracy of 87.9% ± 4.7 using 22 variables, 9 of which were CT-based. Membranous septum measurements and their dynamic variations were critical predictors. Our ML model provides robust PMI predictions, enabling personalized risk assessments. The model is implemented online for broad clinical use.

Machine-learning based risk prediction of in-hospital outcomes following STEMI: the STEMI-ML score

Background

Traditional prognostic models for ST-segment elevation myocardial infarction (STEMI) have limitations in statistical methods and usability.

Objective

We aimed to develop a machine-learning (ML) based risk score to predict in-hospital mortality, intensive care unit (ICU) admission, and left ventricular ejection fraction less than 40% (LVEF < 40%) in STEMI patients.

Methods

We reviewed 1,863 consecutive STEMI patients undergoing primary percutaneous coronary intervention (pPCI) or rescue PCI. Eight supervised ML methods [LASSO, ridge, elastic net (EN), decision tree, support vector machine, random forest, AdaBoost and gradient boosting] were trained and validated. A feature selection method was used to establish more informative and nonredundant variables, which were then considered in groups of 5/10/15/20/25/30(all). Final models were chosen to optimise area under the curve (AUC) score while ensuring interpretability.

Results

Overall, 128 (6.9%) patients died in hospital, with 292 (15.7%) patients requiring ICU admission and 373 (20.0%) patients with LVEF < 40%. The best-performing model with 5 included variables, EN, achieved an AUC of 0.79 for in-hospital mortality, 0.78 for ICU admission, and 0.74 for LVEF < 40%. The included variables were age, pre-hospital cardiac arrest, robust collateral recruitment (Rentrop grade 2 or 3), family history of coronary disease, initial systolic blood pressure, initial heart rate, hypercholesterolemia, culprit vessel, smoking status and TIMI flow pre-PCI. We developed a user-friendly web application for real-world use, yielding risk scores as a percentage.

Conclusions

The STEMI-ML score effectively predicts in-hospital outcomes in STEMI patients and may assist with risk stratification and individualising patient management.

The potential for large language models to transform cardiovascular medicine

Cardiovascular diseases persist as the leading cause of death globally and their early detection and prediction remain a major challenge. Artificial intelligence (AI) tools can help meet this challenge as they have considerable potential for early diagnosis and prediction of occurrence of these diseases. Deep neural networks can improve the accuracy of medical image interpretation and their outputs can provide rich information that otherwise would not be detected by cardiologists. With recent advances in transformer models, multimodal AI, and large language models, the ability to integrate electronic health record data with images, genomics, biosensors, and other data has the potential to improve diagnosis and partition patients who are at high risk for primary preventive strategies. Although much emphasis has been placed on AI supporting clinicians, AI can also serve patients and provide immediate help with diagnosis, such as that of arrhythmia, and is being studied for automated self-imaging. Potential risks, such as loss of data privacy or potential diagnostic errors, should be addressed before use in clinical practice. This Series paper explores opportunities and limitations of AI models for cardiovascular medicine, and aims to identify specific barriers to and solutions in the application of AI models, facilitating their integration into health-care systems.

Revolutionising Acute Cardiac Care With Artificial Intelligence: Opportunities and Challenges

This article reviews the application of artificial intelligence (AI) in acute cardiac care, highlighting its potential to transform patient outcomes in the face of the global burden of cardiovascular diseases. It explores how AI algorithms can rapidly and accurately process data for the prediction and diagnosis of acute cardiac conditions. The review examines AI's impact on patient health across various diagnostic tools such as echocardiography, electrocardiography, coronary angiography, cardiac computed tomography, and magnetic resonance imaging, discusses the regulatory landscape for AI in health care, and categorises AI algorithms by their risk levels. Furthermore, it addresses the challenges of data quality, generalisability, bias, transparency, and regulatory considerations, underscoring the necessity for inclusive data and robust validation processes. The review concludes with future perspectives on integrating AI into clinical workflows and the ongoing need for research, regulation, and innovation to harness AI's full potential in improving acute cardiac care.

Development of interpretable machine learning models to predict in-hospital prognosis of acute heart failure patients

AIMS

In recent years, there has been remarkable development in machine learning (ML) models, showing a trend towards high prediction performance. ML models with high prediction performance often become structurally complex and are frequently perceived as black boxes, hindering intuitive interpretation of the prediction results. We aimed to develop ML models with high prediction performance, interpretability, and superior risk stratification to predict in-hospital mortality and worsening heart failure (WHF) in patients with acute heart failure (AHF).

METHODS AND RESULTS

Based on the Kyoto Congestive Heart Failure registry, which enrolled 4056 patients with AHF, we developed prediction models for in-hospital mortality and WHF using information obtained on the first day of admission (demographics, physical examination, blood test results, etc.). After excluding 16 patients who died on the first or second day of admission, the original dataset (n = 4040) was split 4:1 into training (n = 3232) and test datasets (n = 808). Based on the training dataset, we developed three types of prediction models: (i) the classification and regression trees (CART) model; (ii) the random forest (RF) model; and (iii) the extreme gradient boosting (XGBoost) model. The performance of each model was evaluated using the test dataset, based on metrics including sensitivity, specificity, area under the receiver operating characteristic curve (AUC), Brier score, and calibration slope. For the complex structure of the XGBoost model, we performed SHapley Additive exPlanations (SHAP) analysis, classifying patients into interpretable clusters. In the original dataset, the proportion of females was 44.8% (1809/4040), and the average age was 77.9 ± 12.0. The in-hospital mortality rate was 6.3% (255/4040) and the WHF rate was 22.3% (900/4040) in the total study population. In the in-hospital mortality prediction, the AUC for the XGBoost model was 0.816 [95% confidence interval (CI): 0.815-0.818], surpassing the AUC values for the CART model (0.683, 95% CI: 0.680-0.685) and the RF model (0.755, 95% CI: 0.753-0.757). Similarly, in the WHF prediction, the AUC for the XGBoost model was 0.766 (95% CI: 0.765-0.768), outperforming the AUC values for the CART model (0.688, 95% CI: 0.686-0.689) and the RF model (0.713, 95% CI: 0.711-0.714). In the XGBoost model, interpretable clusters were formed, and the rates of in-hospital mortality and WHF were similar among each cluster in both the training and test datasets.

CONCLUSIONS

The XGBoost models with SHAP analysis provide high prediction performance, interpretability, and reproducible risk stratification for in-hospital mortality and WHF for patients with AHF.

Leveraging Artificial Intelligence to Optimize the Care of Peripheral Artery Disease Patients

Peripheral artery disease is a major atherosclerotic disease that is associated with poor outcomes such as limb loss, cardiovascular morbidity, and death. Artificial intelligence (AI) has seen increasing integration in medicine, and its various applications can optimize the care of peripheral artery disease (PAD) patients in diagnosis, predicting patient outcomes, and imaging interpretation. In this review, we introduce various AI applications such as natural language processing, supervised machine learning, and deep learning, and we analyze the current literature in which these algorithms have been applied to PAD.

Coronary CTA-based vascular radiomics predicts atherosclerosis development proximal to LAD myocardial bridging

AIMS

Cardiac cycle morphological changes can accelerate plaque growth proximal to myocardial bridging (MB) in the left anterior descending artery (LAD). To assess coronary computed tomography angiography (CCTA)-based vascular radiomics for predicting proximal plaque development in LAD MB.

METHODS AND RESULTS

Patients with repeated CCTA scans showing LAD MB without proximal plaque in index CCTA were included from Jinling Hospital as a development set. They were divided into training and internal testing in an 8:2 ratio. Patients from four other tertiary hospitals were set as external validation set. The endpoint was proximal plaque development of LAD MB in follow-up CCTA. Four vascular radiomics models were built: MB centreline (MB CL), proximal MB CL (pMB CL), MB cross-section (MB CS), and proximal MB CS (pMB CS), whose performances were evaluated using area under the receiver operating characteristic curve (AUC), integrated discrimination improvement (IDI), and net reclassification improvement (NRI). In total, 295 patients were included in the development (n = 192; median age, 54 ± 11 years; 137 men) and external validation sets (n = 103; median age, 57 ± 9 years; 57 men). The pMB CS vascular radiomics model exhibited higher AUCs in training, internal test, and external sets (AUC = 0.78, 0.75, 0.75) than the clinical and anatomical model (all P < 0.05). Integration of the pMB CS vascular radiomics model significantly raised the AUC of the clinical and anatomical model from 0.56 to 0.75 (P = 0.002), along with enhanced NRI [0.76 (0.37-1.14), P < 0.001] and IDI [0.17 (0.07-0.26), P < 0.001] in the external validation set.

CONCLUSION

The CCTA-based pMB CS vascular radiomics model can predict plaque development in LAD MB.

Artificial Intelligence in Identifying Patients With Undiagnosed Nonalcoholic Steatohepatitis

Background: Although increasing in prevalence, nonalcoholic steatohepatitis (NASH) is often undiagnosed in clinical practice. Objective: This study identified patients in the Veterans Affairs (VA) health system who likely had undiagnosed NASH using a machine learning algorithm. Methods: From a VA data set of 25 million adult enrollees, the study population was divided into NASH-positive, non-NASH, and at-risk cohorts. We performed a claims data analysis using a machine learning algorithm. To build our model, the study population was randomly divided into an 80% training subset and a 20% testing subset and tested and trained using a cross-validation technique. In addition to the baseline model, a gradient-boosted classification tree, naïve Bayes, and random forest model were created and compared using receiver operator characteristics, area under the curve, and accuracy. The best performing model was retrained on the full 80% training subset and applied to the 20% testing subset to calculate the performance metrics. Results: In total, 4 223 443 patients met the study inclusion criteria, of whom 4903 were positive for NASH and 35 528 were non-NASH patients. The remainder was in the at-risk patient cohort, of which 514 997 patients (12%) were identified as likely to have NASH. Age, obesity, and abnormal liver function tests were the top determinants in assigning NASH probability. Conclusions: Utilization of machine learning to predict NASH allows for wider recognition, timely intervention, and targeted treatments to improve or mitigate disease progression and could be used as an initial screening tool.

Fed-CL- an atrial fibrillation prediction system using ECG signals employing federated learning mechanism

Deep learning has shown great promise in predicting Atrial Fibrillation using ECG signals and other vital signs. However, a major hurdle lies in the privacy concerns surrounding these datasets, which often contain sensitive patient information. Balancing accurate AFib prediction with robust user privacy remains a critical challenge to address. We suggest Federated Learning , a privacy-preserving machine learning technique, to address this privacy barrier. Our approach makes use of FL by presenting Fed-CL, a advanced method that combines Long Short-Term Memory networks and Convolutional Neural Networks to accurately predict AFib. In addition, the article explores the importance of analysing mean heart rate variability to differentiate between healthy and abnormal heart rhythms. This combined approach within the proposed system aims to equip healthcare professionals with timely alerts and valuable insights. Ultimately, the goal is to facilitate early detection of AFib risk and enable preventive care for susceptible individuals.

Phenotypic clustering of repaired Tetralogy of Fallot using unsupervised machine learning

Objective

Repaired Tetralogy of Fallot (rTOF), a complex congenital heart disease, exhibits substantial clinical heterogeneity. Accurate prediction of disease progression and tailored patient management remain elusive. We aimed to categorize rTOF patients into distinct phenotypes based on clinical variables and variables obtained from cardiac magnetic resonance (CMR) imaging.

Methods

A retrospective observational cohort study of rTOF patients with at least two CMR assessments between 2005 and 2022 was performed. From patient records, clinical variables, CMR measurements, and electrocardiogram data were collected and processed. Baseline and follow-up variables between subsequent CMR studies were used to assess both inter- and intrapatient disease heterogeneity. Subsequently, unsupervised machine learning was performed, involving dimensionality reduction using principal component analysis and K-means clustering to identify different phenotypic clusters.

Results

In total, 155 patients (54.2 % male, median 14.9 years) were included and followed for a median duration of 9.9 years. A total of 459 CMR studies were included in analysis for the identification of phenotypic clusters. Following analysis, we identified four distinct rTOF phenotypes: (1) stable/slow deteriorating, (2) deteriorating, structural remodeling, (3) deteriorated indicated for pulmonary valve replacement, and lastly (4) younger patients with coexisting anomalies. These phenotypes exhibited differential clinical profiles (p < 0.01), cardiac remodeling patterns (p < 0.01), and intervention rates (p < 0.01).

Conclusions

Unsupervised machine learning analysis unveiled four discrete phenotypes within the rTOF population, elucidating the substantial disease heterogeneity on both a population- and patient-level. Our study underscores the potential of unsupervised machine learning as a valuable tool for characterizing complex congenital heart disease and potentially tailoring interventions.

Social Phenotyping for Cardiovascular Risk Stratification in Electronic Health Registries

PURPOSE OF REVIEW

Evaluation of social influences on cardiovascular care requires a comprehensive analysis encompassing economic, societal, and environmental factors. The increased utilization of electronic health registries provides a foundation for social phenotyping, yet standardization in methodology remains lacking. This review aimed to elucidate the primary approaches to social phenotyping for cardiovascular risk stratification through electronic health registries.

RECENT FINDINGS

Social phenotyping in the context of cardiovascular risk stratification within electronic health registries can be separated into four principal approaches: place-based metrics, questionnaires, ICD Z-coding, and natural language processing. These methodologies vary in their complexity, advantages and limitations, and intended outcomes. Place-based metrics often rely on geospatial data to infer socioeconomic influences, while questionnaires may directly gather individual-level behavioral and social factors. Z-coding, a relatively new approach, can capture data directly related to social determinant of health domains in the clinical context. Natural language processing has been increasingly utilized to extract social influences from unstructured clinical narratives-offering nuanced insights for risk prediction models. Each method plays an important role in our understanding and approach to using social determinants data for improving population cardiovascular health. These four principal approaches to social phenotyping contribute to a more structured approach to social determinant of health research via electronic health registries, with a focus on cardiovascular risk stratification. Social phenotyping related research should prioritize refining predictive models for cardiovascular diseases and advancing health equity by integrating applied implementation science into public health strategies.

Machine learning-based coronary artery calcium score predicted from clinical variables as a prognostic indicator in patients referred for invasive coronary angiography

OBJECTIVES

Utilising readily available clinical variables, we aimed to develop and validate a novel machine learning (ML) model to predict severe coronary calcification, and further assessed its prognostic significance.

METHODS

This retrospective study enrolled patients who underwent coronary CT angiography and subsequent invasive coronary angiography. Multiple ML algorithms were used to train the models for predicting severe coronary calcification (cardiac CT-measured coronary artery calcium [CT-CAC] score ≥ 400). The ML-based CAC (ML-CAC) score derived from the ML predictive probability was stratified into quartiles for prognostic analysis. The primary endpoint was a composite of all-cause death, nonfatal myocardial infarction, or nonfatal stroke.

RESULTS

Overall, 5785 patients were divided into training (80%) and test sets (20%). For clinical practicability, we selected the nine-feature support vector machine model with good and satisfactory performance regarding both discrimination and calibration based on five repetitions of the 10-fold cross-validation in the training set (mean AUC = 0.715, Brier score = 0.202), and based on the test in the test set (AUC = 0.753, Brier score = 0.191). In the test set cohort (n = 1137), the primary endpoint was observed in 50 (4.4%) patients during a median 2.8 years' follow-up. The ML-CAC system was significantly associated with an increased risk of the primary endpoint (adjusted hazard ratio for trend 2.26, 95% CI 1.35-3.79, p = 0.002). There was no significant difference in the prognostic value between the ML-CAC and CT-CAC systems (C-index, 0.67 vs. 0.69; p = 0.618).

CONCLUSION

ML-CAC score predicted from clinical variables can serve as a novel prognostic indicator in patients referred for invasive coronary angiography.

CLINICAL RELEVANCE STATEMENT

In patients referred for invasive coronary angiography who have not undergone preoperative CT-measured coronary artery calcium scoring, machine learning-based coronary artery calcium score assessment can serve as an alternative for predicting the prognosis.

KEY POINTS

• The coronary artery calcium (CAC) score, a solid prognostic indicator, can be predicted using non-CT methods. • We developed a machine learning (ML)-CAC model utilising nine clinical variables to predict severe coronary calcification. • The ML-CAC system offers significant prognostic value in patients referred for invasive coronary angiography.

Prospective Human Validation of Artificial Intelligence Interventions in Cardiology: A Scoping Review

Background

Despite the potential of artificial intelligence (AI) in enhancing cardiovascular care, its integration into clinical practice is limited by a lack of evidence on its effectiveness with respect to human experts or gold standard practices in real-world settings.

Objectives

The purpose of this study was to identify AI interventions in cardiology that have been prospectively validated against human expert benchmarks or gold standard practices, assessing their effectiveness, and identifying future research areas.

Methods

We systematically reviewed Scopus and MEDLINE to identify peer-reviewed publications that involved prospective human validation of AI-based interventions in cardiology from January 2015 to December 2023.

Results

Of 2,351 initial records, 64 studies were included. Among these studies, 59 (92.2%) were published after 2020. A total of 11 (17.2%) randomized controlled trials were published. AI interventions in 44 articles (68.75%) reported definite clinical or operational improvements over human experts. These interventions were mostly used in imaging (n = 14, 21.9%), ejection fraction (n = 10, 15.6%), arrhythmia (n = 9, 14.1%), and coronary artery disease (n = 12, 18.8%) application areas. Convolutional neural networks were the most common predictive model (n = 44, 69%), and images were the most used data type (n = 38, 54.3%). Only 22 (34.4%) studies made their models or data accessible.

Conclusions

This review identifies the potential of AI in cardiology, with models often performing equally well as human counterparts for specific and clearly scoped tasks suitable for such models. Nonetheless, the limited number of randomized controlled trials emphasizes the need for continued validation, especially in real-world settings that closely examine joint human AI decision-making.

Role of Artificial Intelligence and Machine Learning to Create Predictors, Enhance Molecular Understanding, and Implement Purposeful Programs for Myocardial Recovery

Heart failure (HF) affects millions of individuals and causes hundreds of thousands of deaths each year in the United States. Despite the public health burden, medical and device therapies for HF significantly improve clinical outcomes and, in a subset of patients, can cause reversal of abnormalities in cardiac structure and function, termed "myocardial recovery." By identifying novel patterns in high-dimensional data, artificial intelligence (AI) and machine learning (ML) algorithms can enhance the identification of key predictors and molecular drivers of myocardial recovery. Emerging research in the area has begun to demonstrate exciting results that could advance the standard of care. Although major obstacles remain to translate this technology to clinical practice, AI and ML hold the potential to usher in a new era of purposeful myocardial recovery programs based on precision medicine. In this review, we discuss applications of ML to the prediction of myocardial recovery, potential roles of ML in elucidating the mechanistic basis underlying recovery, barriers to the implementation of ML in clinical practice, and areas for future research.

Automatic detection of cardiac conditions from photos of electrocardiogram captured by smartphones

BACKGROUND

Researchers have developed machine learning-based ECG diagnostic algorithms that match or even surpass cardiologist level of performance. However, most of them cannot be used in real-world, as older generation ECG machines do not permit installation of new algorithms.

OBJECTIVE

To develop a smartphone application that automatically extract ECG waveforms from photos and to convert them to voltage-time series for downstream analysis by a variety of diagnostic algorithms built by researchers.

METHODS

A novel approach of using objective detection and image segmentation models to automatically extract ECG waveforms from photos taken by clinicians was devised. Modular machine learning models were developed to sequentially perform waveform identification, gridline removal, and scale calibration. The extracted data were then analysed using a machine learning-based cardiac rhythm classifier.

RESULTS

Waveforms from 40 516 scanned and 444 photographed ECGs were automatically extracted. 12 828 of 13 258 (96.8%) scanned and 5399 of 5743 (94.0%) photographed waveforms were correctly cropped and labelled. 11 604 of 12 735 (91.1%) scanned and 5062 of 5752 (88.0%) photographed waveforms achieved successful voltage-time signal extraction after automatic gridline and background noise removal. In a proof-of-concept demonstration, an atrial fibrillation diagnostic algorithm achieved 91.3% sensitivity, 94.2% specificity, 95.6% positive predictive value, 88.6% negative predictive value and 93.4% F1 score, using photos of ECGs as input.

CONCLUSION

Object detection and image segmentation models allow automatic extraction of ECG signals from photos for downstream diagnostics. This novel pipeline circumvents the need for costly ECG hardware upgrades, thereby paving the way for large-scale implementation of machine learning-based diagnostic algorithms.

Rural-urban stroke mortality gaps in the United States

INTRODUCTION

Disparities in stroke outcomes, influenced by the use of systemic thrombolysis, endovascular therapies, and rehabilitation services, have been identified. Our study assesses these disparities in mortality after stroke between rural and urban areas across the United States (US).

METHODS

We analyzed the CDC data on deaths attributed to cerebrovascular disease from 1999 to 2020. Data was categorized into rural and urban regions for comparative purposes. Age-adjusted mortality rates (AAMR) were computed using the direct method, allowing us to examine the ratios of rural to urban deaths for the cumulative population and among demographic subpopulations. Linear regression models were used to assess temporal changes in mortality ratios over the study period, yielding beta-coefficients (β).

RESULTS

There was a total of 628,309 stroke deaths in rural regions and 2,556,293 stroke deaths within urban regions. There were 1.13 rural deaths for each one urban death per 100,000 population in 1999 and 1.07 in 2020 (β = -0.001, ptrend = 0.41). The rural-urban mortality ratio in Hispanic populations decreased from 1.32 rural deaths for each urban death per 100,000 population in 1999 to 0.85 in 2020 (β = -0.011, ptrend < 0.001). For non-Hispanic populations, mortality remained stagnant with 1.12 rural deaths for each urban death per 100,000 population in 1999 and 1.07 in 2020 (β = -0.001, ptrend = 0.543). Regionally, the Southern US exhibited the highest disparity with a urban-rural mortality ratio of 1.19, followed by the Northeast (1.13), Midwest (1.04), and West (1.01).

CONCLUSIONS

Our findings depict marked disparities in stroke mortality between rural and urban regions, emphasizing the importance of targeted interventions to mitigate stroke-related disparities.

An Automated Heart Shunt Recognition Pipeline Using Deep Neural Networks

Automated recognition of heart shunts using saline contrast transthoracic echocardiography (SC-TTE) has the potential to transform clinical practice, enabling non-experts to assess heart shunt lesions. This study aims to develop a fully automated and scalable analysis pipeline for distinguishing heart shunts, utilizing a deep neural network-based framework. The pipeline consists of three steps: (1) chamber segmentation, (2) ultrasound microbubble localization, and (3) disease classification model establishment. The study's normal control group included 91 patients with intracardiac shunts, 61 patients with extracardiac shunts, and 84 asymptomatic individuals. Participants' SC-TTE images were segmented using the U-Net model to obtain cardiac chambers. The segmentation results were combined with ultrasound microbubble localization to generate multivariate time series data on microbubble counts in each chamber. A classification model was then trained using this data to distinguish between intracardiac and extracardiac shunts. The proposed framework accurately segmented heart chambers (dice coefficient = 0.92 ± 0.1) and localized microbubbles. The disease classification model achieved high accuracy, sensitivity, specificity, F1 score, kappa value, and AUC value for both intracardiac and extracardiac shunts. For intracardiac shunts, accuracy was 0.875 ± 0.008, sensitivity was 0.891 ± 0.002, specificity was 0.865 ± 0.012, F1 score was 0.836 ± 0.011, kappa value was 0.735 ± 0.017, and AUC value was 0.942 ± 0.014. For extracardiac shunts, accuracy was 0.902 ± 0.007, sensitivity was 0.763 ± 0.014, specificity was 0.966 ± 0.008, F1 score was 0.830 ± 0.012, kappa value was 0.762 ± 0.017, and AUC value was 0.916 ± 0.006. The proposed framework utilizing deep neural networks offers a fast, convenient, and accurate method for identifying intracardiac and extracardiac shunts. It aids in shunt recognition and generates valuable quantitative indices, assisting clinicians in diagnosing these conditions.

Coronary plaque phenotype associated with positive remodeling

BACKGROUND

Positive remodeling is an integral part of the vascular adaptation process during the development of atherosclerosis, which can be detected by coronary computed tomography angiography (CTA).

METHODS

A total of 426 patients who underwent both coronary CTA and optical coherence tomography (OCT) were included. Four machine learning (ML) models, gradient boosting machine (GBM), random forest (RF), deep learning (DL), and support vector machine (SVM), were employed to detect specific plaque features. A total of 15 plaque features assessed by OCT were analyzed. The variable importance ranking was used to identify the features most closely associated with positive remodeling.

RESULTS

In the variable importance ranking, lipid index and maximal calcification arc were consistently ranked high across all four ML models. Lipid index and maximal calcification arc were correlated with positive remodeling, showing pronounced influence at the lower range and diminishing influence at the higher range. Patients with more plaques with positive remodeling throughout their entire coronary trees had higher low-density lipoprotein cholesterol levels and were associated with a higher incidence of cardiovascular events during 5-year follow-up (Hazard ratio 2.10 [1.26-3.48], P ​= ​0.004).

CONCLUSION

Greater lipid accumulation and less calcium burden were important features associated with positive remodeling in the coronary arteries. The number of coronary plaques with positive remodeling was associated with a higher incidence of cardiovascular events.

Machine Learning Identifies Higher Survival Profile In Extracorporeal Cardiopulmonary Resuscitation

OBJECTIVES

Extracorporeal cardiopulmonary resuscitation (ECPR) has been shown to improve neurologically favorable survival in patients with refractory out-of-hospital cardiac arrest (OHCA) caused by shockable rhythms. Further refinement of patient selection is needed to focus this resource-intensive therapy on those patients likely to benefit. This study sought to create a selection model using machine learning (ML) tools for refractory cardiac arrest patients undergoing ECPR.

DESIGN

Retrospective cohort study.

SETTING

Cardiac ICU in a Quaternary Care Center.

PATIENTS

Adults 18-75 years old with refractory OHCA caused by a shockable rhythm.

METHODS

Three hundred seventy-six consecutive patients with refractory OHCA and a shockable presenting rhythm were analyzed, of which 301 underwent ECPR and cannulation for venoarterial extracorporeal membrane oxygenation. Clinical variables that were widely available at the time of cannulation were analyzed and ranked on their ability to predict neurologically favorable survival.

INTERVENTIONS

ML was used to train supervised models and predict favorable neurologic outcomes of ECPR. The best-performing models were internally validated using a holdout test set.

MEASUREMENTS AND MAIN RESULTS

Neurologically favorable survival occurred in 119 of 301 patients (40%) receiving ECPR. Rhythm at the time of cannulation, intermittent or sustained return of spontaneous circulation, arrest to extracorporeal membrane oxygenation perfusion time, and lactic acid levels were the most predictive of the 11 variables analyzed. All variables were integrated into a training model that yielded an in-sample area under the receiver-operating characteristic curve (AUC) of 0.89 and a misclassification rate of 0.19. Out-of-sample validation of the model yielded an AUC of 0.80 and a misclassification rate of 0.23, demonstrating acceptable prediction ability.

CONCLUSIONS

ML can develop a tiered risk model to guide ECPR patient selection with tailored arrest profiles.

Machine Learning-Based Etiologic Subtyping of Ischemic Stroke Using Circulating Exosomal microRNAs

Ischemic stroke is a major cause of mortality worldwide. Proper etiological subtyping of ischemic stroke is crucial for tailoring treatment strategies. This study explored the utility of circulating microRNAs encapsulated in extracellular vesicles (EV-miRNAs) to distinguish the following ischemic stroke subtypes: large artery atherosclerosis (LAA), cardioembolic stroke (CES), and small artery occlusion (SAO). Using next-generation sequencing (NGS) and machine-learning techniques, we identified differentially expressed miRNAs (DEMs) associated with each subtype. Through patient selection and diagnostic evaluation, a cohort of 70 patients with acute ischemic stroke was classified: 24 in the LAA group, 24 in the SAO group, and 22 in the CES group. Our findings revealed distinct EV-miRNA profiles among the groups, suggesting their potential as diagnostic markers. Machine-learning models, particularly logistic regression models, exhibited a high diagnostic accuracy of 92% for subtype discrimination. The collective influence of multiple miRNAs was more crucial than that of individual miRNAs. Additionally, bioinformatics analyses have elucidated the functional implications of DEMs in stroke pathophysiology, offering insights into the underlying mechanisms. Despite limitations like sample size constraints and retrospective design, our study underscores the promise of EV-miRNAs coupled with machine learning for ischemic stroke subtype classification. Further investigations are warranted to validate the clinical utility of the identified EV-miRNA biomarkers in stroke patients.

Artificial Intelligence for Cardiovascular Care-Part 1: Advances: JACC Review Topic of the Week

Recent artificial intelligence (AI) advancements in cardiovascular care offer potential enhancements in diagnosis, treatment, and outcomes. Innovations to date focus on automating measurements, enhancing image quality, and detecting diseases using novel methods. Applications span wearables, electrocardiograms, echocardiography, angiography, genetics, and more. AI models detect diseases from electrocardiograms at accuracy not previously achieved by technology or human experts, including reduced ejection fraction, valvular heart disease, and other cardiomyopathies. However, AI's unique characteristics necessitate rigorous validation by addressing training methods, real-world efficacy, equity concerns, and long-term reliability. Despite an exponentially growing number of studies in cardiovascular AI, trials showing improvement in outcomes remain lacking. A number are currently underway. Embracing this rapidly evolving technology while setting a high evaluation benchmark will be crucial for cardiology to leverage AI to enhance patient care and the provider experience.

[Digitalization and clinical decision tools]

Digitalization in cardiovascular emergencies is rapidly evolving, analogous to the development in medicine, driven by the increasingly broader availability of digital structures and improved networks, electronic health records and the interconnectivity of systems. The potential use of digital health in patients with acute chest pain starts even in the prehospital phase with the transmission of a digital electrocardiogram (ECG) as well as telemedical support and digital emergency management, which facilitate optimization of the rescue pathways and reduce critical time intervals. The increasing dissemination and acceptance of guideline apps and clinical decision support tools as well as integrated calculators and electronic scores are anticipated to improve guideline adherence, translating into a better quality of treatment and improved outcomes. Implementation of artificial intelligence to support image analysis and also the prediction of coronary artery stenosis requiring interventional treatment or impending cardiovascular events, such as heart attacks or death, have an enormous potential especially as conventional instruments frequently yield suboptimal results; however, there are barriers to the rapid dissemination of corresponding decision aids, such as the regulatory rules related to approval as a medical product, data protection issues and other legal liability aspects, which must be considered.

Optimizing Acute Coronary Syndrome Patient Treatment: Leveraging Gated Transformer Models for Precise Risk Prediction and Management

BACKGROUND

Acute coronary syndrome (ACS) is a severe cardiovascular disease with globally rising incidence and mortality rates. Traditional risk assessment tools are widely used but are limited due to the complexity of the data.

METHODS

This study introduces a gated Transformer model utilizing machine learning to analyze electronic health records (EHRs) for an enhanced prediction of major adverse cardiovascular events (MACEs) in ACS patients. The model's efficacy was evaluated using metrics such as area under the curve (AUC), precision-recall (PR), and F1-scores. Additionally, a patient management platform was developed to facilitate personalized treatment strategies.

RESULTS

Incorporating a gating mechanism substantially improved the Transformer model's performance, especially in identifying true-positive cases. The TabTransformer+Gate model demonstrated an AUC of 0.836, a 14% increase in average precision (AP), and a 6.2% enhancement in accuracy, significantly outperforming other deep learning approaches. The patient management platform enabled healthcare professionals to effectively assess patient risks and tailor treatments, improving patient outcomes and quality of life.

CONCLUSION

The integration of a gating mechanism within the Transformer model markedly increases the accuracy of MACE risk predictions in ACS patients, optimizes personalized treatment, and presents a novel approach for advancing clinical practice and research.

Cardiovascular computed tomography in cardiovascular disease: An overview of its applications from diagnosis to prediction

Cardiovascular computed tomography angiography (CTA) is a widely used imaging modality in the diagnosis of cardiovascular disease. Advancements in CT imaging technology have further advanced its applications from high diagnostic value to minimising radiation exposure to patients. In addition to the standard application of assessing vascular lumen changes, CTA-derived applications including 3D printed personalised models, 3D visualisations such as virtual endoscopy, virtual reality, augmented reality and mixed reality, as well as CT-derived hemodynamic flow analysis and fractional flow reserve (FFRCT) greatly enhance the diagnostic performance of CTA in cardiovascular disease. The widespread application of artificial intelligence in medicine also significantly contributes to the clinical value of CTA in cardiovascular disease. Clinical value of CTA has extended from the initial diagnosis to identification of vulnerable lesions, and prediction of disease extent, hence improving patient care and management. In this review article, as an active researcher in cardiovascular imaging for more than 20 years, I will provide an overview of cardiovascular CTA in cardiovascular disease. It is expected that this review will provide readers with an update of CTA applications, from the initial lumen assessment to recent developments utilising latest novel imaging and visualisation technologies. It will serve as a useful resource for researchers and clinicians to judiciously use the cardiovascular CT in clinical practice.

The potential use of artificial intelligence for venous thromboembolism prophylaxis and management: clinician and healthcare informatician perspectives

Venous thromboembolism (VTE) is the leading cause of preventable death in hospitalized patients. Artificial intelligence (AI) and machine learning (ML) can support guidelines recommending an individualized approach to risk assessment and prophylaxis. We conducted electronic surveys asking clinician and healthcare informaticians about their perspectives on AI/ML for VTE prevention and management. Of 101 respondents to the informatician survey, most were 40 years or older, male, clinicians and data scientists, and had performed research on AI/ML. Of the 607 US-based respondents to the clinician survey, most were 40 years or younger, female, physicians, and had never used AI to inform clinical practice. Most informaticians agreed that AI/ML can be used to manage VTE (56.0%). Over one-third were concerned that clinicians would not use the technology (38.9%), but the majority of clinicians believed that AI/ML probably or definitely can help with VTE prevention (70.1%). The most common concern in both groups was a perceived lack of transparency (informaticians 54.4%; clinicians 25.4%). These two surveys revealed that key stakeholders are interested in AI/ML for VTE prevention and management, and identified potential barriers to address prior to implementation.

The Need for Artificial Intelligence Curriculum in Military Medical Education

The success of deep-learning algorithms in analyzing complex structured and unstructured multidimensional data has caused an exponential increase in the amount of research devoted to the applications of artificial intelligence (AI) in medicine in the past decade. Public release of large language models like ChatGPT the past year has generated an unprecedented storm of excitement and rumors of machine intelligence finally reaching or even surpassing human capability in detecting meaningful signals in complex multivariate data. Such enthusiasm, however, is met with an equal degree of both skepticism and fear over the social, legal, and moral implications of such powerful technology with relatively little safeguards or regulations on its development. The question remains in medicine of how to harness the power of AI to improve patient outcomes by increasing the diagnostic accuracy and treatment precision provided by medical professionals. Military medicine, given its unique mission and resource constraints,can benefit immensely from such technology. However, reaping such benefits hinges on the ability of the rising generations of military medical professionals to understand AI algorithms and their applications. Additionally, they should strongly consider working with them as an adjunct decision-maker and view them as a colleague to access and harness relevant information as opposed to something to be feared. Ideas expressed in this commentary were formulated by a military medical student during a two-month research elective working on a multidisciplinary team of computer scientists and clinicians at the National Library of Medicine advancing the state of the art of AI in medicine. A motivation to incorporate AI in the Military Health System is provided, including examples of applications in military medicine. Rationale is then given for inclusion of AI in education starting in medical school as well as a prudent implementation of these algorithms in a clinical workflow during graduate medical education. Finally, barriers to implementation are addressed along with potential solutions. The end state is not that rising military physicians are technical experts in AI; but rather that they understand how they can leverage its rapidly evolving capabilities to prepare for a future where AI will have a significant role in clinical care. The overall goal is to develop trained clinicians that can leverage these technologies to improve the Military Health System.

The role of machine learning in advancing diabetic foot: a review

Background

Diabetic foot complications impose a significant strain on healthcare systems worldwide, acting as a principal cause of morbidity and mortality in individuals with diabetes mellitus. While traditional methods in diagnosing and treating these conditions have faced limitations, the emergence of Machine Learning (ML) technologies heralds a new era, offering the promise of revolutionizing diabetic foot care through enhanced precision and tailored treatment strategies.

Objective

This review aims to explore the transformative impact of ML on managing diabetic foot complications, highlighting its potential to advance diagnostic accuracy and therapeutic approaches by leveraging developments in medical imaging, biomarker detection, and clinical biomechanics.

Methods

A meticulous literature search was executed across PubMed, Scopus, and Google Scholar databases to identify pertinent articles published up to March 2024. The search strategy was carefully crafted, employing a combination of keywords such as "Machine Learning," "Diabetic Foot," "Diabetic Foot Ulcers," "Diabetic Foot Care," "Artificial Intelligence," and "Predictive Modeling." This review offers an in-depth analysis of the foundational principles and algorithms that constitute ML, placing a special emphasis on their relevance to the medical sciences, particularly within the specialized domain of diabetic foot pathology. Through the incorporation of illustrative case studies and schematic diagrams, the review endeavors to elucidate the intricate computational methodologies involved.

Results

ML has proven to be invaluable in deriving critical insights from complex datasets, enhancing both the diagnostic precision and therapeutic planning for diabetic foot management. This review highlights the efficacy of ML in clinical decision-making, underscored by comparative analyses of ML algorithms in prognostic assessments and diagnostic applications within diabetic foot care.

Conclusion

The review culminates in a prospective assessment of the trajectory of ML applications in the realm of diabetic foot care. We believe that despite challenges such as computational limitations and ethical considerations, ML remains at the forefront of revolutionizing treatment paradigms for the management of diabetic foot complications that are globally applicable and precision-oriented. This technological evolution heralds unprecedented possibilities for treatment and opportunities for enhancing patient care.

Super-resolution Left Ventricular Flow and Pressure Mapping by Navier-Stokes-Informed Neural Networks

Intraventricular vector flow mapping (VFM) is a growingly adopted echocardiographic modality that derives time-resolved two-dimensional flow maps in the left ventricle (LV) from color-Doppler sequences. Current VFM models rely on kinematic constraints arising from planar flow incompressibility. However, these models are not informed by crucial information about flow physics; most notably the pressure and shear forces within the fluid and the resulting accelerations. This limitation has rendered VFM unable to combine information from different time frames in an acquisition sequence or derive fluctuating pressure maps. In this study, we leveraged recent advances in artificial intelligence (AI) to develop AI-VFM, a vector flow mapping modality that uses physics-informed neural networks (PINNs) encoding mass conservation and momentum balance inside the LV, and no-slip boundary conditions at the LV endocardium. AI-VFM recovers the flow and pressure fields in the LV from standard echocardiographic scans. It performs phase unwrapping and recovers flow data in areas without input color-Doppler data. AI-VFM also recovers complete flow maps at time points without color-Doppler input data, producing super-resolution flow maps. We show that informing the PINNs with momentum balance is essential to achieving temporal super-resolution and significantly increases the accuracy of AI-VFM compared to informing the PINNs only with mass conservation. AI-VFM is solely informed by each patient's flow physics; it does not utilize explicit smoothness constraints or incorporate data from other patients or flow models. AI-VFM takes 15 minutes to run in off-the-shelf graphics processing units and its underlying PINN framework could be extended to map other flow-associated metrics like blood residence time or the concentration of coagulation species.

Predicting operative time for metabolic and bariatric surgery using machine learning models: a retrospective observational study

BACKGROUND

Predicting operative time is essential for scheduling surgery and managing the operating room. This study aimed to develop machine learning (ML) models to predict the operative time for metabolic and bariatric surgery (MBS) and to compare each model.

METHODS

The authors used the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database between 2016 and 2020 to develop ML models, including linear regression, random forest, support vector machine, gradient-boosted tree, and XGBoost model. Patient characteristics and surgical features were included as variables in the model. The authors used the mean absolute error, root mean square error, and R 2 score to evaluate model performance. The authors identified the 10 most important variables in the best-performing model using the Shapley Additive exPlanations algorithm.

RESULTS

In total, 668 723 patients were included in the study. The XGBoost model outperformed the other ML models, with the lowest root mean square error and highest R 2 score. Random forest performed better than linear regression. The relative performance of the ML algorithms remained consistent across the models, regardless of the surgery type. The surgery type and surgical approach were the most important features to predict the operative time; specifically, sleeve gastrectomy (vs. Roux-en-Y gastric bypass) and the laparoscopic approach (vs. robotic-assisted approach) were associated with a shorter operative time.

CONCLUSIONS

The XGBoost model best predicted the operative time for MBS among the ML models examined. Our findings can be useful in managing the operating room scheduling and in developing software tools to predict the operative times of MBS in clinical settings.

Development and validation of a machine learning prediction model for perioperative red blood cell transfusions in cardiac surgery

OBJECTIVE

Several machine learning (ML) models have been used in perioperative red blood cell (RBC) transfusion risk for cardiac surgery with limited generalizability and no external validation. Hence, we sought to develop and comprehensively externally validate a ML model in a large dataset to estimate RBC transfusion in cardiac surgery with cardiopulmonary bypass (CPB).

DESIGN

A retrospective analysis of a multicenter clinical trial (NCT03782350).

PATIENTS

The study patients who underwent cardiac surgery with CPB came from four cardiac centers in China and Medical Information Mart for Intensive Cared (MIMIC-IV) dataset.

MEASUREMENTS

Data from Fuwai Hospital were used to develop an individualized prediction model for RBC transfusion. The model was externally validated in the data from three other centers and MIMIC-IV dataset. Twelve models were constructed.

MAIN RESULTS

A total of 11,201 eligible patients were included in the model development (2420 in Fuwai Hospital) and external validation (563 in the other three centers and 8218 in the MIMIC-IV dataset). A significant difference was observed between the Logistic Regression and CatboostClassifier (0.72 Vs. 0.74, P = 0.031) or RandomForestClassifier (0.72 Vs. 0.75 p = 0.012) in the external validation and MIMIV-IV datasets (age ≤ 70:0.63 Vs. 0.71, p < 0.001; age > 70:0.63 Vs. 0.70, 0.63 Vs. 0.71, p < 0.001). The CatboostClassifier and RandomForestClassifier model was comparable in development (0.83 Vs. 0.82, p = 0.419), external (0.74 Vs. 0.75, p = 0.268), and MIMIC-IV datasets (age ≤ 70: 0.71 Vs. 0.71, p = 0.574; age > 70: 0.70 Vs. 0.71, p = 0.981). Of note, they outperformed other ML models with excellent discrimination and calibration. The CatboostClassifier and RandomForestClassifier models achieved higher area under precision-recall curve and lower brier loss score in validation and MIMIC-IV datasets. Additionally, we confirmed that low preoperative hemoglobin, low body mass index, old age, and female sex increased the risk of RBC transfusion.

CONCLUSIONS

In our study, enrolling a broad range of cardiovascular surgeries with CPB and utilizing a restrictive RBC transfusion strategy, robustly validates the generalizability of ML algorithms for predicting RBC transfusion risk. Notably, the CatboostClassifier and RandomForestClassifier exhibit strong external clinical applicability, underscoring their potential for widespread adoption. This study provides compelling evidence supporting the efficacy and practical value of ML-based approaches in enhancing transfusion risk prediction in clinical practice.

Application of machine learning methods for predicting under-five mortality: analysis of Nigerian demographic health survey 2018 dataset

BACKGROUND

Under-five mortality remains a significant public health issue in developing countries. This study aimed to assess the effectiveness of various machine learning algorithms in predicting under-five mortality in Nigeria and identify the most relevant predictors.

METHODS

The study used nationally representative data from the 2018 Nigeria Demographic and Health Survey. The study evaluated the performance of the machine learning models such as the artificial neural network, k-nearest neighbourhood, Support Vector Machine, Naïve Bayes, Random Forest, and Logistic Regression using the true positive rate, false positive rate, accuracy, precision, F-measure, Matthew's correlation coefficient, and the Area Under the Receiver Operating Characteristics.

RESULTS

The study found that machine learning models can accurately predict under-five mortality, with the Random Forest and Artificial Neural Network algorithms emerging as the best models, both achieving an accuracy of 89.47% and an AUROC of 96%. The results show that under-five mortality rates vary significantly across different characteristics, with wealth index, maternal education, antenatal visits, place of delivery, employment status of the woman, number of children ever born, and region found to be the top determinants of under-five mortality in Nigeria.

CONCLUSIONS

The findings suggest that machine learning models can be useful in predicting U5M in Nigeria with high accuracy. The study emphasizes the importance of addressing social, economic, and demographic disparities among the population in Nigeria. The study's findings can inform policymakers and health workers about developing targeted interventions to reduce under-five mortality in Nigeria.

Incremental value of machine learning for risk prediction in tetralogy of Fallot

OBJECTIVE

Machine learning (ML) can facilitate prediction of major adverse cardiovascular events (MACEs) in repaired tetralogy of Fallot (rTOF). We sought to determine the incremental value of ML above expert clinical judgement for risk prediction in rTOF.

METHODS

Adult congenital heart disease (ACHD) clinicians (≥10 years of experience) participated (one cardiac surgeon and four cardiologists (two paediatric and two adult cardiology trained) with expertise in heart failure (HF), electrophysiology, imaging and intervention). Clinicians identified 10 high-yield variables for 5-year MACE prediction (defined as a composite of mortality, resuscitated sudden death, sustained ventricular tachycardia and HF). Risk for MACE (low, moderate or high) was assigned by clinicians blinded to outcome for adults with rTOF identified from an institutional database (n=25 patient reviews conducted by five independent observers). A validated ML model identified 10 variables for risk prediction in the same population.

RESULTS

Prediction by ML was similar to the aggregate score of all experts (area under the curve (AUC) 0.85 (95% CI 0.58 to 0.96) vs 0.92 (0.72 to 0.98), p=0.315). Experts with ≥20 years of experience had superior discriminative capacity compared with <20 years (AUC 0.98 (95% CI 0.86 to 0.99) vs 0.80 (0.56 to 0.93), p=0.027). In those with <20 years of experience, ML provided incremental value such that the combined (clinical+ML) AUC approached ≥20 years (AUC 0.85 (95% CI 0.61 to 0.95), p=0.055).

CONCLUSIONS

Robust prediction of 5-year MACE in rTOF was achieved using either ML or a multidisciplinary team of ACHD experts. Risk prediction of some clinicians was enhanced by incorporation of ML suggesting that there may be incremental value for ML in select circumstances.

Predicting hypertension control using machine learning

Hypertension is a widely prevalent disease and uncontrolled hypertension predisposes affected individuals to severe adverse effects. Though the importance of controlling hypertension is clear, the multitude of therapeutic regimens and patient factors that affect the success of blood pressure control makes it difficult to predict the likelihood to predict whether a patient's blood pressure will be controlled. This project endeavors to investigate whether machine learning can accurately predict the control of a patient's hypertension within 12 months of a clinical encounter. To build the machine learning model, a retrospective review of the electronic medical records of 350,008 patients 18 years of age and older between January 1, 2015 and June 1, 2022 was performed to form model training and testing cohorts. The data included in the model included medication combinations, patient laboratory values, vital sign measurements, comorbidities, healthcare encounters, and demographic information. The mean age of the patient population was 65.6 years with 161,283 (46.1%) men and 275,001 (78.6%) white. A sliding time window of data was used to both prohibit data leakage from training sets to test sets and to maximize model performance. This sliding window resulted in using the study data to create 287 predictive models each using 2 years of training data and one week of testing data for a total study duration of five and a half years. Model performance was combined across all models. The primary outcome, prediction of blood pressure control within 12 months demonstrated an area under the curve of 0.76 (95% confidence interval; 0.75-0.76), sensitivity of 61.52% (61.0-62.03%), specificity of 75.69% (75.25-76.13%), positive predictive value of 67.75% (67.51-67.99%), and negative predictive value of 70.49% (70.32-70.66%). An AUC of 0.756 is considered to be moderately good for machine learning models. While the accuracy of this model is promising, it is impossible to state with certainty the clinical relevancy of any clinical support ML model without deploying it in a clinical setting and studying its impact on health outcomes. By also incorporating uncertainty analysis for every prediction, the authors believe that this approach offers the best-known solution to predicting hypertension control and that machine learning may be able to improve the accuracy of hypertension control predictions using patient information already available in the electronic health record. This method can serve as a foundation with further research to strengthen the model accuracy and to help determine clinical relevance.

Optimizing ensemble U-Net architectures for robust coronary vessel segmentation in angiographic images

Automated coronary angiography assessment requires precise vessel segmentation, a task complicated by uneven contrast filling and background noise. Our research introduces an ensemble U-Net model, SE-RegUNet, designed to accurately segment coronary vessels using 100 labeled angiographies from angiographic images. SE-RegUNet incorporates RegNet encoders and squeeze-and-excitation blocks to enhance feature extraction. A dual-phase image preprocessing strategy further improves the model's performance, employing unsharp masking and contrast-limited adaptive histogram equalization. Following fivefold cross-validation and Ranger21 optimization, the SE-RegUNet 4GF model emerged as the most effective, evidenced by performance metrics such as a Dice score of 0.72 and an accuracy of 0.97. Its potential for real-world application is highlighted by its ability to process images at 41.6 frames per second. External validation on the DCA1 dataset demonstrated the model's consistent robustness, achieving a Dice score of 0.76 and an accuracy of 0.97. The SE-RegUNet 4GF model's precision in segmenting blood vessels in coronary angiographies showcases its remarkable efficiency and accuracy. However, further development and clinical testing are necessary before it can be routinely implemented in medical practice.

Decreased plasma miR-140-3p is associated with coronary artery disease

Background

Although many circulating miRNAs (c-miRNAs) are associated with coronary artery disease (CAD), they are far from being the biomarker for CAD diagnosis or risk prediction. Therefore, novel c-miRNAs discovery and validation are still required, especially evaluating their prediction capacity.

Objectives

Identify novel CAD-related c-miRNAs and evaluate its risk prediction capacity for CAD. Methods: miRNAs associated with CAD were preliminarily investigated in three paired samples representing pre-CAD stage and CAD stage of three female individuals using the Applied Biosystems miRNA TaqMan® Low-Density Array (TLDA). Then, the candidate miRNAs were further verified in an independent case-control study including 129 CAD patients and 76 controls, and their potential practical value in prediction for CAD was evaluated using a machine learning (ML) algorithm. The accuracy of classification and prediction was assessed with the area under the receiver operating characteristic curve (AUC).

Results

TLDA analysis shows that miR-140-3p decreased significantly in CAD-stage (FC = -3.01, P = 0.007). Further study shows that miR-140-3p was significantly lower in CAD group [1.26 (0.68, 2.01)] than in control group [2.07 (1.19, 3.21)] (P < 0.001) and independently associated with CAD (P < 0.001). The addition of miR-140-3p to the variables including smoking history, HDL-c, and APOA1 improved the accuracy of classification by logistic regression and of prediction for CAD by ML models. The ML models built with miR-140-3p and HDL-c, respectively, had a similar prediction accuracy. The feature importance of miR-140-3p and HDL-c in the ML models was also similar. Decision curve analysis showed that miR-140-3p and HDL-c had almost identical net benefits.

Conclusion

Reduced levels of miR-140-3p is linked to CAD, and it is possible to use the plasma level of miR-140-3p as a means of evaluating the risk of CAD.

The Role of Artificial Intelligence and Machine Learning in the Prediction of Right Heart Failure after Left Ventricular Assist Device Implantation: A Comprehensive Review

One of the most challenging and prevalent side effects of LVAD implantation is that of right heart failure (RHF) that may develop afterwards. The purpose of this study is to review and highlight recent advances in the uses of AI in evaluating RHF after LVAD implantation. The available literature was scanned using certain key words (artificial intelligence, machine learning, left ventricular assist device, prediction of right heart failure after LVAD) was scanned within Pubmed, Web of Science, and Google Scholar databases. Conventional risk scoring systems were also summarized, with their pros and cons being included in the results section of this study in order to provide a useful contrast with AI-based models. There are certain interesting and innovative ML approaches towards RHF prediction among the studies reviewed as well as more straightforward approaches that identified certain important predictive clinical parameters. Despite their accomplishments, the resulting AUC scores were far from ideal for these methods to be considered fully sufficient. The reasons for this include the low number of studies, standardized data availability, and lack of prospective studies. Another topic briefly discussed in this study is that relating to the ethical and legal considerations of using AI-based systems in healthcare. In the end, we believe that it would be beneficial for clinicians to not ignore these developments despite the current research indicating more time is needed for AI-based prediction models to achieve a better performance.

The role of computational methods in cardiovascular medicine: a narrative review

Background and Objective

Computational models of the cardiovascular system allow for a detailed and quantitative investigation of both physiological and pathological conditions, thanks to their ability to combine clinical-possibly patient-specific-data with physical knowledge of the processes underlying the heart function. These models have been increasingly employed in clinical practice to understand pathological mechanisms and their progression, design medical devices, support clinicians in improving therapies. Hinging upon a long-year experience in cardiovascular modeling, we have recently constructed a computational multi-physics and multi-scale integrated model of the heart for the investigation of its physiological function, the analysis of pathological conditions, and to support clinicians in both diagnosis and treatment planning. This narrative review aims to systematically discuss the role that such model had in addressing specific clinical questions, and how further impact of computational models on clinical practice are envisaged.

Methods

We developed computational models of the physical processes encompassed by the heart function (electrophysiology, electrical activation, force generation, mechanics, blood flow dynamics, valve dynamics, myocardial perfusion) and of their inherently strong coupling. To solve the equations of such models, we devised advanced numerical methods, implemented in a flexible and highly efficient software library. We also developed computational procedures for clinical data post-processing-like the reconstruction of the heart geometry and motion from diagnostic images-and for their integration into computational models.

Key Content and Findings

Our integrated computational model of the heart function provides non-invasive measures of indicators characterizing the heart function and dysfunctions, and sheds light on its underlying processes and their coupling. Moreover, thanks to the close collaboration with several clinical partners, we addressed specific clinical questions on pathological conditions, such as arrhythmias, ventricular dyssynchrony, hypertrophic cardiomyopathy, degeneration of prosthetic valves, and the way coronavirus disease 2019 (COVID-19) infection may affect the cardiac function. In multiple cases, we were also able to provide quantitative indications for treatment.

Conclusions

Computational models provide a quantitative and detailed tool to support clinicians in patient care, which can enhance the assessment of cardiac diseases, the prediction of the development of pathological conditions, and the planning of treatments and follow-up tests.

A bibliometric analysis in venous thromboembolism nursing (1999-2022): Current status and future prospects

Research on venous thromboembolism (VTE) in nursing has garnered significant attention. This study aimed to examine the characteristics of VTE nursing publications, offering valuable insights into the current state of the field and forecasting future trends. A comprehensive screening of global publications up to 2022 was conducted using the Web of Science Core Collection database to investigate VTE nursing. The search incorporated keywords such as 'venous thromboembolism', 'deep vein thrombosis', and 'pulmonary embolism' to identify relevant studies. A bibliometric analysis of these publications was performed using various visualisation tools such as VOSviewer and R software. A total of 675 papers on VTE nursing were identified, with the earliest publication dating back to 1999. The research involved 971 institutions from 43 countries, with the United States leading by contributing to 261 articles. Harvard University emerged as the most productive institution, and Heit, with 17 publications, was the most cited author. The journal Thrombosis Research published the highest number of papers (11). The frontiers of VTE nursing research are anticipated to continue focusing on topics such as epidemiology, risk factors, and VTE prevention and management.