Artificial Intelligence-Based Clinical Decision Support Systems in Cardiovascular Diseases

Despite all the advancements in science, medical knowledge, healthcare, and the healthcare industry, cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide. The main reasons are the inadequacy of preventive health services and delays in diagnosis due to the increasing population, the failure of physicians to apply guide-based treatments, the lack of continuous patient follow-up, and the low compliance of patients with doctors' recommendations. Artificial intelligence (AI)-based clinical decision support systems (CDSSs) are systems that support complex decision-making processes by using AI techniques such as data analysis, foresight, and optimization. Artificial intelligence-based CDSSs play an important role in patient care by providing more accurate and personalized information to healthcare professionals in risk assessment, diagnosis, treatment optimization, and monitoring and early warning of CVD. These are just some examples, and the use of AI for CVD decision support systems is rapidly evolving. However, for these systems to be fully reliable and effective, they need to be trained with accurate data and carefully evaluated by medical professionals.

Perspectives on the Use of Digital Health Technologies in Cardiology Among Specialists from an ESC Member Country: Results from a Survey

OBJECTIVE

In this study, we aimed to identify the reasons for and perceived challenges associated with the use of digital health technologies (DHT) in cardiology.

METHOD

We distributed an online survey to Turkish Society of Cardiology member cardiologists (n = 2789) between January 10 and March 3, 2022.

RESULTS

A total of 308 subjects responded (27.6% females, 62.0% aged 30-44 years). Of these, 42.5% worked at university hospitals, and 44.8% at state hospitals. Smart devices were used by 44.2% (136/308) for personal health monitoring. Additionally, 40.3% (117/290) used social media to provide medical information to patients, while 64.6% (193/299) did so for communication with other physicians. The self-reported recommendation frequencies of wearables, cardiac implantable electronic device telemonitorization, mobile health applications, and teleconsultation/televisit technologies were lower than the proportion of respondents who found DHT beneficial for both patients and physicians. The most frequently mentioned barriers for physicians were increased work burden and responsibilities (78.8%, 193/245), lack of financial compensation (66.9%, 164/245), and lack of relevant training (66.5%, 163/245). For patients, low technological adaptability (81.6%, 200/245), low health literacy (80.4%, 197/245), and low affordability (79.6%, 195/245) were the most frequently mentioned barriers. Additionally, the cost of technologies (69.4%, 170/245), concerns regarding data privacy and security (57.6%, 141/245), and data storage challenges (48.2%, 118/245) were the most significant technical impediments.

CONCLUSION

The findings suggest that although the majority of physicians believe DHT to be beneficial for both themselves and their patients, the frequency of recommendations to patients remains low. A large-scale joint effort is required to address these issues and facilitate the integration of DHT into clinical practice.

Percutaneous nephrostomy in infants: a 20-year single-center experience

PURPOSE

To investigate the safety and efficacy of the imaging-guided percutaneous nephrostomy (PCN) procedure in infants.

METHODS

A total of 75 (50 boys; 66.7%) patients with a mean age of 121 days (range, 1-351 days) who underwent PCN over a period of 20 years were included in this retrospective study. For each patient, PCN indications, catheter size, the mean duration of catheterization, complications, and the procedure performed following nephrostomy were recorded. Technical success was determined based on the successful placement of the nephrostomy catheter within the pelvicalyceal system. Clinical success was defined as the complete resolution of hydronephrosis and improvement in renal function tests during follow-up. In patients with urinary leakage, technical and clinical success was determined based on the resolution of leakage.

RESULTS

The technical success rate was 100%, and no procedure-related mortality was observed. In 11 patients (14.7%), bilateral PCN was performed. The most frequent indication of PCN was ureteropelvic junction obstruction (n = 41, 54.7%). Procedure-related major complications were encountered in two patients (methemoglobinemia and respiratory arrest caused by the local anesthetic agent in one patient and the development of urinoma caused by urinary leakage from the puncture site in the other). Mild urinary leakage was the only minor complication that occurred and only in one patient. Catheter-related complications were managed through replacement or revision surgery in 16 patients (21.3%).

CONCLUSION

Imaging-guided PCN is a feasible and effective procedure with high technical success and low major complication rates, and it is useful for protecting kidney function in infants.

Evaluation of abdominal computed tomography findings in patients with COVID-19: a multicenter study

PURPOSE

To evaluate the frequency of abdominal computed tomography (CT) findings in patients with coronavirus disease-2019 (COVID-19) and interrogate the relationship between abdominal CT findings and patient demographic features, clinical findings, and laboratory test results as well as the CT atherosclerosis score in the abdominal aorta.

METHODS

This study was designed as a multicenter retrospective study. The abdominal CT findings of 1.181 patients with positive abdominal symptoms from 26 tertiary medical centers with a positive polymerase chain-reaction test for severe acute respiratory syndrome coronavirus 2 were reviewed. The frequency of ischemic and non-ischemic CT findings as well as the association between CT findings, clinical features, and abdominal aortic calcific atherosclerosis score (AA-CAS) were recorded.

RESULTS

Ischemic and non-ischemic abdominal CT findings were detected in 240 (20.3%) and 328 (27.7%) patients, respectively. In 147 patients (12.4%), intra-abdominal malignancy was present. The most frequent ischemic abdominal CT findings were bowel wall thickening (n = 120; 10.2%) and perivascular infiltration (n = 40; 3.4%). As for non-ischemic findings, colitis (n = 91; 7.7%) and small bowel inflammation (n = 73; 6.2%) constituted the most frequent disease processes. The duration of hospital stay was found to be higher in patients with abdominal CT findings than in patients without any positive findings (13.8 ± 13 vs. 10.4 ± 12.8 days, P < 0.001). The frequency of abdominal CT findings was significantly higher in patients who did not survive the infection than in patients who were discharged after recovery (41.7% vs. 27.4%, P < 0.001). Increased AA-CAS was found to be associated with a higher risk of ischemic conditions in abdominal CT examinations.

CONCLUSION

Abdominal symptoms in patients with COVID-19 are usually associated with positive CT findings. The presence of ischemic findings on CT correlates with poor COVID-19 outcomes. A high AA-CAS is associated with abdominal ischemic findings in patients with COVID-19.

Cough-induced bubbles formation in the heart: Is it related with a poor prognosis?

In current practice, it is not well-known whether the development of air bubbles spontaneously in the heart during routine transthoracic echocardiography examination has a clinical consequence. Even though there have been published case reports regarding the formation of air bubbles due to iatrogenic reasons, we could not find a case of a patient demonstrating spontaneous air bubbles formation due to only coughing. Thus, in this report, we present a case of an adult patient who had unexpected air bubbles in the heart after coughing. Furthermore, the patient experienced a catastrophic cerebrovascular accident after diagnosing such an event in the same day. We thought that spontaneously occurring air bubbles in the heart might have resulted in cerebrovascular accident by passing through patent foramen ovale, which we have diagnosed after we had seen that the spontaneously occurred air bubbles had also appeared in left chambers. To our knowledge, this might be the first case of such a patient in the literature. <Learning objective: The appearance of cough-induced air bubbles in the left heart might be a precursor to peripheral air embolism, and thus, predictive of very poor prognosis. Thus, medical workers should be aware of this poor finding.>.

Effect of a mobile application and smart devices on heart rate variability in diabetic patients with high cardiovascular risk: A sub-study of the LIGHT randomized clinical trial

BACKGROUND

This investigation aims to evaluate the effect of a mobile application and smart devices on frequency and time domains of heart rate variability (HRV) in diabetic patients in 1-year follow-up.

METHODS

This is post-hoc analysis of a diabetic subgroup of "Lifestyle Intervention usinG mobile technology in patients with high cardiovascular risk: a pragmatic randomized clinical Trial" (LIGHT). One hundred and nine and 118 patients were enrolled in two arms: the intervention plus usual care and the usual care arm. The study outcome was the 1-year HRV parameters adjusted to the baseline HRV parameters. HRV measures were recorded for every patient at the randomization and final visits with 24-hour Holter monitoring.

RESULTS

There was an improvement in the standard deviation of normal to normal (SDNN) R-R intervals 24-hour by 4.8 (adjusted treatment effect 4.8, 95% confidence interval [CI], 0.1-9.5; P = 0.044) in the intervention-plus-usual-care arm compared to usual care after a 1-year follow-up. The improvement was also experienced in other HRV time domains including standard deviation of the mean R-R intervals calculated over a 5-minute period, SDNN, square root of the mean squared difference of successive R-R intervals, and the percentage of the differences between adjacent normal R-R intervals exceeding 50 milliseconds. A significant enhancement was also detected in HRV frequency domains of total power low frequency and high frequency in the intervention plus usual care compared to usual care after a 1-year follow-up.

CONCLUSIONS

The mobile application and smart device technology compared to usual care alone improved HRV parameters in diabetic patients at 1-year follow-up.

Predictive Value of CAR for In-Hospital Mortality in Patients with COVID-19 Pneumonia: A Retrospective Cohort Study

Background

In the current literature, there is a growing evidence that supports the significant role of inflammation in the progression of viral pneumonia, including patients with coronavirus disease 2019 (COVID-19).

Aim

The present study aimed to investigate the predictive value of C-reactive protein/albumin ratio (CAR) for in-hospital mortality in patients with COVID-19.

Material and Methods

This retrospective study included the data of 275 consecutive COVID-19 patients who were hospitalized in a referral pandemic center. The CAR ratio was obtained by dividing the CRP level with albumin level. The study population was divided into tertiles (T1, T2, and T3) according to their admission CAR values. The endpoint of the study was a composite outcome of in-hospital mortality.

Results

During the in-hospital course, 33 (12%) patients died. The patients classified into T3 group had significantly higher CAR compared those classified into T2 and T1 groups. After the adjustment for the confounders, T3 group had 8.2 (95% CI: 4.2–48.1) times higher rates of in-hospital mortality compared to T1 group (the reference group) in a logistic regression model using CAR values.

Conclusion

To the best of our knowledge, this is the first study to demonstrate the predictive value of CAR for in-hospital mortality in COVID-19 patients.

Lifestyle intervention using mobile technology and smart devices in patients with high cardiovascular risk: A pragmatic randomised clinical trial

BACKGROUND AND AIMS

Mobile technology-based solutions present promising effects against cardiovascular diseases. Long-term follow-up in mobile phone-based interventions has not yet been elucidated as a primary prevention technique for cardiovascular diseases. The objective of the present trial is to evaluate the effectiveness of lifestyle intervention on the change in the atherosclerotic cardiovascular disease (ASCVD) risk score in a 1-year follow-up using smart phone technology in patients with high cardiovascular risk.

METHODS

This prospective, randomised, single-centre clinical investigation enrolled 242 and 241 patients to the intervention plus usual care and usual care arms, respectively. The primary outcome of this study was the 1-year ASCVD risk score adjusted to baseline ASCVD risk score. ASCVD risk scores were calculated for every study participant at the randomisation and final stages.

RESULTS

After a 1-year follow-up, the intervention plus usual care reduced the ASCVD score by 2.7% (adjusted treatment effect -2.7, 95% confidence interval (CI): -2.2,-3.3, p<0.0001). An improvement was observed in favour of the intervention plus usual care arm in the majority of the pre-specified secondary endpoints. The high sensitive troponin and high sensitive C-reactive protein levels at 1 year were similar between the two arms. The treatment effect was homogenous for diabetes mellitus, gender, systolic blood pressure, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides and body mass index; however, heterogeneity in the treatment effect was observed for age.

CONCLUSIONS

The lifestyle intervention using smart phone technology compared to usual care alone in patients with high cardiovascular risk reduced the ASCVD score at 1-year follow-up.

The characteristics of left atrial diverticula in normal sinüs rhythm patients

PURPOSE

The purpose of this study was to evaluate the prevalence, location, size and morphological characteristics of left atrial diverticula using electrocardiographically gated multi-detector computed tomography in patients with normal sinus rhythm.

METHODS

Electrocardiographically gated cardiac multi-detector computed tomography was performed in 93 patients with normal sinus rhythm. The prevalence, number, size, morphological characteristics and location of left atrial diverticula were recorded.

RESULTS

A total of 72 left atrial diverticula were diagnosed in 45 (48.4%) of the 93 patients in this study. Of these 72 diverticula, 66 (91.7%) were cystiform and 6 (8.3%) were tubiform. Anterosuperior wall, left lateral wall and septum were the most common locations of these left atrial diverticula (n = 42, 58.3%; n = 22, 15.3% and n = 7, 9.7%, respectively).

CONCLUSION

Diverticula are common variations. The discovery of these structures is relatively new and their clinical significance remains unclear. They are generally asymptomatic but although not supported by many studies, in some case reports they are claimed to be associated with arrhythmias and thromboembolism. In addition, it is theoretically reasonable to think that they may cause complications during interventional procedures. Better understanding of these structures has the potential to improve management strategies and reduce potential complications. Therefore, they should be reported during routine cardiac computed tomography.

Comparison of CT methods for determining graft steatosis in living donor liver transplantation

PURPOSE

To evaluate and compare the diagnostic performance of non-enhanced computed tomography (NECT) and contrast-enhanced CT (CECT) attenuation indices in the assessment of hepatic steatosis by using biopsy as the reference standard.

MATERIALS AND METHODS

This retrospective study was approved by our Institutional Review Board. 55 Potential donors who underwent both NECT and triphasic CECT and core liver biopsy, were included the study. Average attenuation measurements that were obtained from multiple regions in liver, spleen, and psoas muscle on both unenhanced and CECT were used for analysis. Hepatic attenuation measurements were analyzed with and without normalization with the spleen and psoas muscle. Linear regression and receiver operating characteristic (ROC) curve analysis were used to evaluate the statistical association between CT indices and steatosis at histology.

RESULTS

Linear regression analysis confirmed the strongest correlation between steatosis and normalized measurements of hepatic attenuation with splenic attenuations on hepatic venous phase of CECT scan (R 0.821; R² 0.674 and R 0.816; R² 0.665, respectively). The use of ROC curve analysis also demonstrated that normalized measurements of hepatic attenuation with splenic attenuations on hepatic venous phase of CECT showed high diagnostic performance regarding the qualitative distinction of steatosis (AUC values greater than 0.9).

CONCLUSION

Attenuation measurements of liver normalized with spleen on hepatic venous phase may be useful in evaluating steatosis in donor candidates with moderate to severe steatosis who are unacceptable for liver donation. In this manner unnecessary liver biopsy may be avoided in those donor candidates.

Analysis of risk factors affecting coagulopathy after donor hepatectomy in a newly established liver transplant center

OBJECTIVE

As might be expected, living donor liver surgery is associated with serious morbidity and mortality risks. Coagulopathy after donor hepatectomy is an important risk factor affecting morbidity. In this study, risk factors affecting the development of coagulopathy after donor hepatectomy was evaluated in a newly-established liver transplant center.

MATERIAL AND METHODS

A retrospective evaluation of 46 liver donors to whom hepatectomy was applied in Medipol Universty of School of Medicine Department of Organ Transplantation between April 2014 and July 2015 was made. Coagulopathy was defined as prothrombin time ≥15 sec. or platelet count <80000/mm³ on postoperative day 3. Donors were separated into 2 groups as those with (n=24) and without (n=22) coagulopathy. Preoperative, intraoperative and postoperative factors acting on coagulopathy were analyzed.

RESULTS

In the intergroup analysis, it was seen that remnant liver volume, remnant liver volume % and remnant liver volume to body weight ratio were factors associated with coagulopathy. The cut-off values for these 3 parameters were calculated as 773.5 cm³, 40.5% and 0.915 cm³/kg, respectively. Only remnant liver volume % was determined as a risk factor for coagulopathy after donor hepatectomy on multiple logistic regression analysis.

CONCLUSION

The results of this study showed that the most important risk factors affecting coagulopathy after donor hepatectomy were the parameters associated with remnant liver volume.

Effect of surgeon's judgement on the diagnosis of acute appendicitis

OBJECTIVE

The accuracy of a surgeon's judgement still remains to be controversial in the diagnosis of acute appendicitis, which is a diagnosis usually based on laboratory data and imaging tests.

MATERIAL AND METHODS

Patients with a possible diagnosis of acute appendicitis were reviewed retrospectively with regard to demographic variables, laboratory and imaging results, and treatment modalities.

RESULTS

There were 128 patients with a mean age of 31.2±14 years. The mean white blood cell count and the proportion of polymorphonuclear leukocytes were 11403±4669/mm(3) and 75±11%, respectively. Appendectomy was performed on 66 (51.6%) patients. Conservative management was applied to 62 (48.4%) patients. Statistical analysis showed that patients with appendicitis have a higher white blood cell count (p=0.015) and a higher proportion of polymorphonuclear leukocytes (p=0.023). Sensitivity, specificity and accuracy rates were 84.6%, 63.7% and 74.3% for ultrasound and 100%, 86.7% and 92.2% for computed tomography, respectively.

CONCLUSION

Diagnosis based on patients' laboratory and imaging data, in combination with, the surgeon's judgement appears to yield the best outcomes in patients with suspicion of acute appendicitis.