Invent: Health

IH_S2E6 Cardiac Health: Prevention or Intervention?
Speakers: Matt Parker, Stephen Leslie, & Simon Calcutt
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Matt: Hello and welcome to Invent: Health, a podcast from technology and product development company, TTP. I'm your host, Matt Parker.
Over the course of this season, we're going to be exploring the fascinating future of health technologies. Today we ask: prevention or intervention. What does the future look like for cardiac health?
The human heart, it's the engine that powers our bodies, beating an average of a hundred thousand times a day, pumping nearly 2000 gallons of blood through a vast network of arteries and veins.
But it's also an engine prone to misfiring, especially as people grow older or continue with lifestyle factors that degrade its capabilities. In fact, cardiovascular diseases are the leading global cause of death. The WHO estimates they take some 17.9 million lives annually.
As such, monitoring heart health alongside creating new medical devices that react to cardiac events are some of the most studied and innovative areas of healthcare.
There are two ways to look at this, preventative and interventional approaches. The former looks to manage cardiac disease through effective monitoring and sensing of the heart, as well as focusing on lifestyle factors and behavioural change.
And the latter involves devices and systems that intervene during or following a cardiac event to correct abnormalities, like a pacemaker does.
Today, I want to explore both of these different approaches, the reactive versus the proactive. As technologies advance in both fields from more effective ECGs to new pacemakers and the rise of telehealth, how can we combine all of this progression to create an ecosystem that's effective for cardiovascular diseases as a whole?
To find out, I started off by speaking to someone who's working in the clinic to get a working doctor's view of what it takes to deal with heart diseases. Thanks Steve, for joining us.
Stephen: Yeah. Well, thanks Matt, for inviting me as a consultant, interventional cardiologist for 16 years. I am passionate about this. It's a great area to be working in and a great topic to discuss today.
Matt: Professor Stephen Leslie has been an interventional cardiologist with NHS Highland since 2006 and has led research interests that include heart failure and remote and rural service provision.
Alongside his clinical work, Stephen's also an honorary professor with the University of Highlands and Islands and the University of Stirling.
First, we talked about the basics of cardiac disease, as well as how doctors actually go about helping patients manage it in the day-to-day.
I wonder if you could start us off Steve, by talking to us a little bit about cardiac disease as a disease state and maybe why it has such a high patient burden.
Stephen: Yeah. Obviously, it's one of the biggest killers in terms of actual death. It's one of the most popular diseases (if you like), to get and as treatments get better and people survive, more and more people are actually living with heart disease.
So, we're a victim of our own success in some ways, that patients are not dying of a heart attack as often as they did in the past, but now they're living longer with the consequences of that disease and having an increase in heart failure and symptoms and therefore needing more help and support with that.
Matt: And what does some of that help and support look like? I guess I wonder if you could outline some of the sort of the different treatments that if you have had maybe a cardiac event or you've had something similar. What kinds of treatments sort of are there that are being deployed today?
Stephen: Yeah, so if we just think about heart attacks. So, if we look back in the literature, they didn't really exist a hundred years ago. There was lots of chat about other diseases, but not so much heart attacks because people tended to die of other things.
So, now people are living longer, their hearts are ageing and then they're exposed to aging process, but also some of the lifestyle choices that people make.
And so, if you have a heart attack, the treatment of that has been revolutionised in the last few years. So, even from when I was a medical student, patients would spend 7 to 10 days in hospital.
But now if you have a heart attack, you come in, you go straight to our operating theatre, you get the artery opened, the next morning you're getting an ultrasound scan of your heart, you're getting evidence-based medication started and really being sent home day two or three.
So, the turnover of patients, and that's fantastic for patient care. Fewer days in hospital is great. You don't pick up infections and other things. But it sometimes just doesn't give patients the opportunity to psychologically cope with what's happened to them.
So, a lot of what we are now doing is looking at the aftercare. We're looking at cardiac rehabilitation. We're contacting people and we're trying to get them back onto the road for a healthier, happier life in the future.
Matt: So, I guess this kind of the rise and this being such a prevalent condition is that twofold thing of we are living longer. We're not dying of other things, which I guess is a great success for medicine.
But also, we're getting better. There's efficiencies in treating things that maybe once would've been fatal, actually is now a relatively routine. And we have a pathway and a very efficient pathway by the sound of things of treating that and pushing people through the system.
Stephen: Absolutely. And the thresholds of who we are treating. So again, if you look back in time, many people over a certain age really wouldn't have access to these treatments.
But modern healthcare, many people are living longer and healthier that we’re now actively treating patients in their 80s and 90s. And that becomes a societal discussion because there's an awful lot of money talking about healthcare, what we can provide, the costs involved.
And I don't want to take away from the personalised care that we deliver, but there are certainly at a societal and government level, a discussion to be had about how we spend our money.
Matt: And so, you mentioned the sort of the support and the education piece there as well. When someone turns up with a heart attack, you're managing to sort of intervene relatively quickly now, but that isn't sort of the end of the end of treatment though.
What are some of the things that you might do to sort of follow up with that patient over time as you're sort of monitoring their cardiac health over the coming months or even years?
Stephen: Yeah, so there's certain treatments that are required urgently. And we would embark on that at the time. But there are other treatments that need a slower approach.
So, some of the medications, for example, that we start a small dose, and we work the dose up depending on the patient response to that or how they tolerate the medication. So, there's certainly a tweaking of care to optimise it as best as possible over the subsequent weeks and months.
Matt: And I guess, how much contact would someone have with their cardiologist after event like this? Is there something that needs sort of weekly follow-ups? Is it monthly? What's the kind of level of intervention that's needed? Or does that vary from patient to patient as well?
Stephen: Well, that's a great question. So, I think what we've got to do in healthcare is assess the impact of what we do. And there's a cost effectiveness. So, do you need to see a cardiologist again?
Certainly, when you come into hospital, it's useful to see a cardiologist and we know that that has a mortality benefit. So, people are less likely to die with a heart attack if you're treated by a cardiologist, that makes sense. But actually, you need to have evidence to support that.
And to be honest with you, we're not expecting any ongoing problems in the vast majority of our patients with regard to the cardiac, the medical care.
So, the majority of people who have a heart attack will never see me again. And that's to be celebrated. They don't need to see me, get on with your life. But what they will have contact with is with our department and our cardiac rehabilitation nurses and perhaps with their GP.
And there's also a broad range of supportive things in the community through charities, British Heart Foundation, Chest, Heart & Stroke, these sorts of charities that can help people.
But a lot of what we're trying to do is to empower people to take control of their lives, take responsibility, and to move on and better their lives because people are better to do that themselves rather than necessarily be told what to do.
People don't like being told what to do, and it's often a waste of breath telling people what to do. You need to find out what they want to do and help and support them as best you can.
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Matt: Patients taking control of their own health is a trend we’re seeing across the healthcare spectrum. But even so, it did surprise me that after having a heart attack, many of Stephen's patients won't need to see their cardiologist again, even for regular check-ups. Perhaps this speaks to the efficiency of home monitoring that's available now, something we'll get onto later.
But equally, health tech is becoming increasingly advanced in both sensing and monitoring of heart conditions, and not just with devices like pacemakers that we're all familiar with. There are other solutions to monitoring out there as well, which are fascinatingly forward-thinking.
So next, I wanted to speak to someone who's been working on creating them. And as ever at TTP we have just the person, Simon Calcutt.
Simon's been working with us as a consultant for the past eight years. Across that time, he's been working across medical devices from drug delivery to surgical systems and active implantable devices.
His current focus is around implantable devices and utilising sensor technology for real-time or near real-time monitoring. This all enables more personalised medicine, remote patient monitoring and improved standards of care. And cardiac health is one of his main specialties.
I asked him to talk me through the patient journey of someone with cardiac issues, to see where monitoring and intervention are the most useful solutions.
Thank you for joining us, Simon, to talk about cardiovascular disease and some of the impact that has in the world and some of the exciting things that are going on in the space.
Simon: It's a pleasure to be here.
Matt: I guess maybe we could start a bit by talking a little bit about when maybe someone presents at a clinic at a physician’s, and they are diagnosed with their cardiac condition. What are some of the sort of the treatment options that are available?
I think most people listening will be familiar with pacemakers. Are these new treatments, are these something that's been around for a long time or is there sort of development in this space?
Simon: So, there's constant improvement and development in all of the different treatments and the way they're applied. I think the major categories of treatment have now been around for quite a while.
Medication is often an earlier place to start. It's less interventional. The far end of that spectrum is going towards pacemakers where you are implanting devices in patients and they end up being reliant on these implantable devices working.
Pacemakers are the first implantable device that got off and took off with widespread adoption. And so, has been around for a number of years.
Things tend to start earlier stage with medication and treatment programs. And again, they are trying to manage the underlying problems.
So, one of the common problems that is causing heart disease is build-up of plaque in your arteries and in the blood vessels. And that's restricting blood flow and hence oxygen flow to different parts of the body. But in this case, particularly to the heart. And that can lead to degradation.
So, the treatments that can fundamentally resolve that either lifestyle changes can help. But beyond that, the medications and the procedures that can help clear out those blood vessels help to improve the condition before needing to go to the more fully interventional techniques and implantable devices.
Matt: So, here we're looking at sort of the ablation catheters, these kind of procedures and is I guess, the big push there to make those less impactful procedures make them more reliable and sort of go in a more minimally evasive fashion.
Simon: Yes, and that's the big push to catheter-based procedures. So, either procedures using catheters that are clearing out the blood vessels, or as you mentioned there, going to ablation catheters where some of these conditions lead to arrhythmias in the heart, and where that is often caused by the way the electrical signal propagates through the heart.
So, as your heart's beating, you have an electrical path and the electrical signal's flowing around the heart, which is controlling the heartbeat and the specific orientation to get the right pumping action.
And if you have issues that cause potentially death of cells or degradation of cells through that electrical pathways, you can end up with that electrical pathway through the heart not running through the correct cycle.
So, your electrical current ends up flowing down the wrong path. And there are procedures like ablation procedures can help to correct that and realign. And so, the electrical signals flow in the correct direction around the heart and restore a more normal heartbeat.
Matt: I wonder if the bigger impact of cardiovascular disease or some of the biggest improvements here are going to be by improving some of these catheter techniques and the technologies here, improving pacemakers and how they're implanted.
Or is it kind of going to be by intervening much earlier in the condition before it's progressed to a point where these technologies interventions are required? What do you think, I guess on balance, the biggest opportunity is there?
Simon: I'd say the biggest opportunity there is towards the early stage, if you're looking at, I guess both the overall mortality rate, but also if you're looking at the overall cost of healthcare system. And it is also a massive part of the impact of cardiovascular diseases.
The more that we can do at the earlier stage, almost before you really get to medicine, helping patients with lifestyle changes, helping with education that encourages people to have better diets, to take more exercise will have the biggest impact in reducing the number of people who are going to be at risk of developing these conditions.
And we need to continue making the strives and the advances in the treatments and the devices that can help patients with these conditions, because it's not all lifestyle. That's what we've focused on, but there are genetic factors that make some people at a greater risk than others.
So, we need to continue and there will continue to be developments in those treatment options that help throughout the whole treatment pathway.
But in terms of, if you look at where would be the best place for investments to be made, then upfront at that prevention end is likely to have the largest bang for buck and largest impact in overall mortality rate.
Matt: That's really interesting to hear, and I think it'd be great to dive into that a little bit deeper. I'm really interested to understand sort of how is this sort of early intervention, how does that work in the real world? How is sort of the onset of cardiovascular diseases detected? What are some of the different ways that's done currently in healthcare systems?
Simon: So, I guess firstly there's a part that starts with identifying people are at higher risk. So, there's a starting point working with your GP or your other healthcare professional to understand who is at risk and to monitor them more closely.
And from there, there's a battery of tests essentially that allow understanding and diagnosis of these conditions. So, the standard one that is probably most widely known about is ECG testing.
So, you can do that from a simple, sat in a room doing an ECG test to get a basic characteristic of your heart's performance and the heartbeat.
Matt: And is that looking at the electrical signals that your heart is being fed or produces?
Simon: So, that's looking at the electrical signals that your heart produces as it's going through its regular heartbeat cycle. You start with those at rest, and you can move on to monitoring those while you're under stress. So, maybe while you're running on a treadmill or monitoring them over a longer time period.
So, in a lot of cases, there are signals that appear occasionally, and so you can't just monitor them at a single point in time. And you need to move to sending patients home with a set of pads strapped onto their chest and a wearable device that's monitoring that over a period of week or so. And you take back that data and analyse it and understand.
And then when you move forwards from that, looking into some of the causes, there's other procedures moving towards medical imaging whereby MRI or CT scans of the heart can give you a better understanding of what's happening or introducing dyes under X-ray imaging in order to see the blood pathways.
And that helps you to identify if there are blockages or restrictions in the various blood vessels around the heart.
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Matt: New methods of real-time monitoring are some of the most fast-moving areas in cardiac health. Being able to get real-time information and data allows for so much more precision and unlocks much greater prediction of potential future issues.
However, in the past, this has required patients going into the clinic to get checked. So, what of patients who live in remote areas and cannot travel easily or need to be assessed over a long period of time, how do clinicians ensure that monitoring can remain effective outside of the clinic?
Next, I wanted to find out some more about telehealth, meaning healthcare provided virtually to see how patients are benefiting from being monitored for their heart conditions remotely.
Stephen has a fascinating perspective on this. Given he works with NHS Highland in Scotland, which serves some of the UK's most remote communities.
You work with one of the most sort of dispersed populations anywhere in the UK. Are you seeing particular advantages of these technologies allow patients to take control of their health in their own home, just because of some of the distances involved in having to travel to clinics?
Stephen: Absolutely. So, we've been very early adopters (and this has gone back for the last decade really), of home monitoring for special pacemakers.
So, some of our pacemakers are called defibrillators. So, you've seen footballers collapsing on the field and requiring a defibrillator because of their heart written problems.
So, we have many patients in these with these devices. But the problem, of course is they can misfire sometimes. And also, patients can have an appropriate shock, but don't necessarily need to come to hospitals.
So, some of my patients can make a six-hour or longer round trip to see me. Some involve ferry journeys, so you don't want to go to the hospital if you don't need to.
So, the phenomenal thing about these devices are that it will send us an email, the device will send an email to us and show us all of the ECGs remotely. And we can then decide is this patient in ongoing danger? Has this been an inappropriate shock or has the pacemaker been just doing what it's supposed to do, and we can leave the patient at home?
So, a very good example was a patient had a shock from their defibrillator, and we knew about it, and we phoned her the next day and said, “Are you okay? You had a shock yesterday.” And she'd kind of forgotten that we had home monitoring. It didn't bother people really. We keep your eye on them.
And she had forgotten to replace her script for her beta blocker tablet. And was too embarrassed to phone the department. And she had a cardiac arrest. She'd survived her cardiac arrest but had been embarrassed to phone the department.
So, we were able to contact her, speak to the GP and the pharmacist, get her medications and leave her at home, which is quite phenomenal to think that somebody can have a cardiac arrest and just we can manage them at home. And that's technology. It's amazing.
Matt: It's amazing what it can do. And I think what you've just described there is a really interesting sort of vision for what this looks like, where actually you don't necessarily need to come in.
Is there a sort of a risk there between I guess the sort of the technology and the remote monitoring and that face-to-face personal relationship with your doctor that do you see a risk of these technology solutions disrupt that or replace that?
Stephen: I don't think so. I think they enhance it. And I think that another example is our outpatient, return patients come back to hospital and again, with a distances we've had to reflect.
And COVID as well, has been very good at making us reflect on who actually needs to come to a hospital, who needs to be seen and who doesn't need to be seen. And we used to bring a lot of people back for really what was quite pointless surveillance.
And what you need to do is reassure people, and people can become a little bit attached to that. So, if they don't have their annual review by their cardiologist, suddenly they're not going to be so well, but actually we pick up very little on an annual review. And what's much better is to empower your patients to be able to phone back in or to contact us if there's a problem.
So nowadays, I have a little business card, it's a little bit cheesy, but if I'm discharging a patient, I will say, “You are better. Or you've got a chronic condition, it's stable. I do not need to see you again, but if you need to see me, here's my card.”
And it's amazing how patients are quite happy, really happy with that. They don't need to see me, and they can go away knowing they've got a little Steve in their back pocket, and they can contact me should they need to, and it works spectacularly well.
Matt: Well, I guess coming back to, I guess the technology angle, a lot of what we've discussed has been sort of after the fact interventions you can follow up and monitor with someone who's had a cardiac event.
But we also see I guess a number of things in that front end space, look at helping people with lifestyle factors, tools that support that. Do you have a view on whether you think technology is the answer on that side to sort of help people become more healthy, so they ultimately don't maybe need to see you?
Stephen: I think there's a lot that is going to come. I think if we look forward a hundred years now, I'd love to just sort of bump forward a hundred years to see what we see what we're doing.
I think right back to the basics of genetics. So, I suspect that that genetics and AI, interrogating people's genome and looking at where they live, what their family history is, what their personal genetics are, will help us decide who best to focus on in terms of if we have limited resources, who do we actually need to screen who might be at risk?
Although, we can know that already. If you take a look in the mirror and think about your own family history, that's genetics and society interacting in real life. And maybe it doesn't need to be too fancy to know who's at risk.
I think there's some fantastic technologies coming up that can pick up disease in society. So, one that I saw recently was that all of our faces actually beat in time with our heartbeat.
Matt: Oh, wow.
Stephen: Now, if you take a video of someone's face and you computer enhance it, and you can increase the differential between the red and the pink and the less pink in the face, you can actually make a person's face beat in real time.
And then just by taking a video of their face, you can work out what their heart rhythm is. And that's amazing.
So, for example, imagine you were going to get some money out of the wall, though money will no longer exist. But if you're putting your card in the machine, there's a camera in all of those. Imagine that camera could tell you whether you had atrial fibrillation, which is one of these irregular heart rhythms that increases your risk of stroke.
That's a slightly esoteric example, but you can see how routinely collected data that's out there could potentially be used to inform people about their risk.
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Matt: Jump forward 10 years, let alone the hundred that Stephen mentions. And I suspect the priority on self-monitoring and telehealth will have advanced an enormous amount.
You can already see it today in the rise of wearables with health tech capabilities, the kind of watches often created by large tech companies that can monitor your heartbeat and more. These are allowing people to take control, their own monitoring.
But of course, there are pros and cons here. They're incredibly well designed. Everyone knows how to use them, but are they really going to use implantable devices created by health tech companies? Are they reliable? Do they give enough detail? And where does the data even go once it's been recorded? I went back to Simon to find out.
I guess those technologies, sort of the Apple watch, and I guess a lot of people have smartwatches and fitness watches now. They kind of grew out of a kind of not a medical context, about a kind of a wellness context.
And I wonder if that's an interesting sort of lens to look at this from, actually to what extent are these technologies useful for intervening in these conditions versus actually some of their earlier uses where we were just using them to help support lifestyle and behaviour change.
And given that these companies are now bridging that gap and starting to jump upwards towards the medical devices, where actually do you think we might get the biggest impact here?
Simon: So, I'd say overall, and this is coming back to what I think would make the biggest impact, it's the prevention rather than the detection.
So, those devices that, as you say, promote healthy exercise your Fitbit, that buzzes, if you've been sat still for too long to remind you to go and take a quick walk or move around.
That step counter that nags you and gives you a little target to aim for, so you get that little sense of achievement every day. And turning those small bits of exercise into an achievement in a way that can then really provide extra motivation to help people make better and healthier lifestyle choices, I think is a great benefit of those devices.
Matt: I think, these have sort of exploded in popularity recently. Is that being driven by people sort of actively seeking this out? Or is this kind of a little bit of tech push?
Simon: So, I think there's probably two sides, I think from some of the hardware that's coming out. There's probably some initial technology push, the reality of these development of these devices. People are trying to create the next generation of device that includes more functionality, better functionality at the end of the day to help encourage you to buy the next generation of the device.
But I think putting that hardware platform in front of people creates a vast opportunity for people developing the apps and the software that sits behind it to create systems that gamify this process and that really help motivate people and provide some of the analysis that you described.
Matt: Guess we sort of touched on Apple watch there, starting to bring, I think it's AFib detection and being able to do ECGs. What other data can we currently get from these consumer style products? And actually, what could it unlock if there were some new things that we could detect using these?
Simon: So, these consumer wearable devices currently have a suite of sensors on them. You probably break that down into a few core areas. So, you have essentially motion detection, which is going to give you activity detection, your step count.
You have optical sensors that are probably the core of what's giving you most of your, your long-term measurements. So, they're giving you your heart rate, your blood oxygenation levels.
Then you've got ECG that's built on top of that, that gives you a much better capture of the heart signal, but can't be made, just sat on your wrist. So, if you look at the Apple smartwatch, in order to make those ECG measurements, you actually have to take your other hand and touch the side of the watch.
So, it provides better data, but it's not something that is running continuously in the background 24/7.
Matt: And I guess what's currently been done with the data that's generated here, does it go back and live in a silo or is it accessible to the healthcare systems?
Simon: So, I think the system there is not as joined up as you'd like it to be. The data is taken back and owned ultimately by the companies making the apps and developing the hardware or is held by the companies making the apps and developing the hardware for those systems.
And there's options for you to take that to your doctor to share into a medical context. But there are huge amount of regulations around protecting data as soon as it becomes medical data, that creates its own set of challenges.
And we're certainly not anywhere near a stage where I think we have a joined-up system that's connecting those consumer products into the healthcare system. And there's a huge number of challenges to think through how that data's managed, how it's collected, how it's transferred, in order to make that connection.
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Matt: The challenge created by the amount of data these wearables produce is really significant and actually quite fraught. There is, it turns out such a thing as too much data because too many pings from an Apple watch or similar device can overload conditions.
This is a surprisingly tricky problem, especially as it brings up an ethical question over the responsibility for clinicians, who exactly should be responsible for combing through all of this data?
I asked both Stephen and Simon for some of their final thoughts on this and about how to navigate a future world where the amount of data being created by patients is only going to grow.
What is the responsibility of clinicians in the healthcare system once they get that data?
Stephen: It's a moving field and I think that our data security concerns, our legislation or our guidance is outdated almost before the ink is dried on the page, society's moved on.
And I think that we need to just be flexible as we move with the times. For example, WhatsApp's a good example. So, we are not allowed to use WhatsApp to share patient information. Even though it's very secure.
The alternative workaround is that you have to then scan an ECG and find a flatbed scanner somewhere in the hospital at three o'clock in the morning. You then got to get it uploaded to a email address and then sent to a consultant, then has to get out of their bed and go to their computer log on, manage to see it and make sure it's in a format that's possible.
And then have a discussion about a patient who is critically sick versus a quick WhatsApp picture. Now obviously we never take WhatsApp pictures. I couldn't possibly say that that's what we do, but what do you want?
Do you want your doctors speaking to each other instantly and giving you the best care? Or do you want them to trot off to try and find a flatbed scanner in some … or some secretary’s office at three o'clock in the morning?
Matt: So, how would Simon overcome these challenges Stephen outlines? How would he create a cardiac process where wearables and other methods of telehealth are used for efficiency, but that also ensures that patients get the human-centred care they need.
So, what do you think a sort of effective new paradigm for cardiac care would look like?
Simon: So, I think this is an initial state going to be driven by those algorithmic improvements that we've talked about.
But if we can get to a stage where those algorithmic improvements are good enough, that we can accurately and reliably detect the events and only the events that are truly in need of follow up.
And we can get that technology spread across everyone who's identified as being at risk, either through genetic conditions, through their current lifestyles, that's going to allow us to detect and catch these events earlier and put them on the pathway to treatments that can be non-invasive or less invasive because they've been caught earlier in the process.
And hopefully that will ultimately put us on the path towards helping to reduce the overall burden of cardiovascular diseases.
Matt: That's fantastic. Thank you very much Simon. I've really enjoyed that.
Simon: Thank you very much. It's been a pleasure to talk to you.
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Matt: Thanks so much for listening to this week's episode of Invent: Health from TTP. And a big thanks to Stephen and Simon for their input.
We'll be back next time with a new episode on rapid innovation, looking at the challenges that both engineers and health systems face when trying to bring new innovations to patients faster.
If you enjoyed this episode and you want to let us know, please do get in touch on LinkedIn, Twitter, or Instagram. You can find us at TTP.
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