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Mark Nicholls reports from the ESC Digital Summit 2021.

Delegates to the online ESC Digital Summit 2021 heard that patients must be central to the digital healthcare revolution in cardiology, with a pivotal role in co-designing devices and shaping new therapeutic approaches and products.

The 3-day online summit cast a forward-looking eye over digital health and how technology can impact on cardiovascular care, attracting faculty from across the world, including a session with the World Heart Federation (WHF), as well as representation from the European Space Agency (ESA) offering an insight into lessons that can be learned from ‘beyond our planet’.

The role of wearables, artificial intelligence (AI), and the impact of digital health on heart failure (HF), atrial fibrillation (AF), and acute cardiovascular care were also key tracks.

The summit has grown from a small digital presence at ESC 2017 to an in-person Digital Health Summit in 2019 and the online digital health week of 2020, with the topic boosted by the launch of European Heart Journal—Digital Health.

Professor Martin Cowie, Professor of Cardiology at the Brompton Hospital, London, and Chair of the ESC Digital Health Committee (Figure 1), hosted the summit and acknowledged that COVID-19 had ‘accelerated the acceptability of digital technology for both patients and healthcare professionals’.

Martin Cowie, Dipak Kotecha, and Dorairaj Prabhakaran.
Figure 1

Martin Cowie, Dipak Kotecha, and Dorairaj Prabhakaran.

Several ESC associations were involved in organizing specific sessions at the congress, which had a theme of ‘let’s design a future together’, with ESC President Stephan Achenbach emphasizing during the inaugural session that the ESC must not be a bystander in the digital process.

Evolution of electrocardiography

The evolution of electrocardiography (ECG), from paper printouts to AI analysis, came under examination with speakers discussing how digital technology is advancing the field.

While AI analysis of ECG signals could offer more detail, Dr Dilaveris Polychronis from the University of Athens Medical School and chairperson of the ESC e-cardiology Working Group, explained that moves to digitize paper printed ECGs remain problematic as the process introduces changes to the ECG signal, reducing the reliability of some sensitive parameters.

But he added that with a high number of clinically valuable ECGs still stored on paper records, there was a need for ‘reliable tools to digitize these valuable tracings for storage into digital databases’.

Algorithms proposed for achieving this conversion task have shown varying degrees of success.

Professor Pyotr Platonov from Lund University Hospital in Sweden examined the challenge of ‘retrieving hidden information in the digitally recorded ECG’, emphasizing that digital ECGs do not give answers to all questions and there is still the need for clinicians to define, and agree upon, specific ECG phenomena.

Quality of life

New and upcoming technologies are capable of having a significant impact on the quality of life for HF patients and also support early detection.

In a session focused on technology in this field, Professor Offer Amir from the Heart Institute at the Hadassah Medical Center in Jerusalem, Israel, discussed new technologies for HF management, from those for haemodynamic measurements, through to others analysing exhaled breath to detect possible signs of HF through an innovative ‘breathprint’.

Dr Mateusz Sokolski from the Institute of Heart Diseases at Wroclaw Medical University in Poland emphasized the importance of optimizing information from implantable and wearable devices in HF patients but stressed that factors such as regulation and reimbursement, standardization of parameters and technologies, integration into workflow, the need for tailored therapeutic strategies, and the use of AI should all be considered.

The issue of data transfer and cybersecurity surrounding devices such as pacemakers, wearables, and other monitoring devices was highlighted by Dr Tuvia Ben Gal from the Heart Failure Unit of the Rabin Medical Center in Petach Tikva, Israel, who warned that healthcare providers are often unfamiliar with methods for evaluating those security risks.

Atrial fibrillation in the digital era

Digital technologies are having an increasingly important role in AF diagnosis. With an expected increase in prevalence and related co-morbidities such as stroke and rising costs for health systems, Dr David Duncker from the Hannover Heart Rhythm Center in Germany, said e-health expands opportunities for cardiac rhythm analysis, diagnosis, and monitoring. With wearables being available for photoplethysmography (PPG) and ECG recording, he said they are feasible and cost-effective solutions for opportunistic and systematic AF screening, suggesting the two will ultimately blend.

Dr Dominik Linz from Maastricht University Medical Center turned the conversation to managing AF during the digital era, highlighting the TeleCheck-AF teleconsultation concept, and use of an on-demand PPG-based heart rate and rhythm monitoring app that led to comprehensive AF management to maintain care delivery to patients during COVID-19. By September, 41 clinical centres had embraced TeleCheck-AF, with 4068 patients enrolled. He also emphasized the importance of patient engagement and education in the process.

Professor Sanjiv Narayan, co-director of the Arrythmia Center at Stanford University, looked at future directions in machine learning and AI for AF in classifying complex data and use computer models to explain mechanisms and guide therapy.

The role of artificial intelligence

The role of AI in imaging and daily practice came under the spotlight during a number of sessions at the summit.

Dr Dipak Kotecha, Professor of Cardiology from the Institute of Cardiovascular Sciences at the University of Birmingham, highlighted the various challenges and opportunities for using AI in daily practice, particularly for HF patients.

With different patient factors, antecedents, and risk factors all interacting with different effects on haemodynamics and prognosis, he said ‘developments in the digital sphere are perfectly applicable to help physicians treat patients with complex conditions like heart failure’.

His presentation covered an array of consumer wearable devices—from remote sensing vests to assess intrathoracic volume through to smart mirrors to assess blood flow, as well as the use of AI to understand data from these devices, innovative trials (which make cost-effective use of the data currently available such as from electronic health records), and tech integration.

‘The real key to developments in AI is that they are letting us look at a whole plethora of factors that are affecting our patients’, he said. ‘It is the interaction of factors that are making the difference’.

While integrated technology is a major advance, he said it needs to be better applied—to predict pre-disease states, alerting people to seek risk factor modification or treatment and allowing for early diagnosis, and improved monitoring of HF.

But Dr Kotecha stressed the importance of co-creation with patients, the public, regulators, and healthcare professionals.

In a separate session hosted with the European Association of Cardiovascular Imaging, speakers addressed the future of cardiovascular imaging and asked if AI would replace clinicians.

Professor Rhodri Davies from University College London, who set about ‘demystifying AI’, said that while AI could transform cardiovascular imaging, those who suggest it can replace humans have not taken into account the complexities of healthcare and issues such as ethics, regulation, governance, and engagement with staff.

Professor Partho Sengupta, Chief of the Division of Cardiology at the Rutgers Robert Wood Johnson Medical School in New Jersey, explored the opportunities and challenges within the AI revolution, saying it has enormous potential, perhaps to even ‘redefine how we understand cardiology’.

External views

The summit also tapped into external expertise with keynote speakers from Amazon and the ESA.

Dr Rowland Illing, Director and Chief Medical Officer from Amazon Web Services, spoke about Global Trends in Digital Health, focusing on industry challenges and trends in healthcare spending.

He said that the major industry challenges were an ageing population, a lack of capacity in healthcare, workforce shortages, increasing volumes of digital healthcare data, an ongoing drive to improve efficiency, and increasingly sophisticated security breaches.

While these challenges existed prior to COVID-19, they have been amplified by factors including increases in acutely ill patients, a strained workforce, and cost pressures.

Year on year, growth on relative market size in areas such as imaging, medical records, genomics, telehealth, population health management, and clinical analytics (including AI and machine learning) is massive.

But while the burgeoning AI industry is moving faster and faster across all of the specialities, questions remain about the practical implementation of AI.

Key trends internationally, he said, are of diagnostic prediction, operations and personalization, mobile health and democratization, and access to data and tools, though he suggested industry challenges are already being met by AI, and that cloud technology will be fundamental in enabling scalability and democratization.

ESA medical engineer Arnaud Runge offered an insight into how developments in space can support advances in healthcare on Earth. In his presentation, ‘lessons from beyond our planet’, he said space offers a unique environment for research, supported by new, smaller, faster, and lighter technologies.

Other sessions included digital health in acute cardiovascular care, looking at areas such as whether AI can detect cardiac arrest via voice recognition analysis before the ambulance dispatcher detects it, as well as advances in robotics in cardiology and cardiac surgery.

Digital is international

Highlighting the international nature of digital innovation within cardiology, a special session hosted with the WHF featured WHF President Prof Fausto Pinto, cardiologist Carolyn Lam from Singapore, and Dr Dorairaj Prabhakaran from Public Health India.

Prof Pinto described how the WHF is developing a digital health roadmap to work with communities to improve how digital health can be implemented at the global level while finding solutions for the needs of local populations.

As co-chair of the WHF digital roadmap committee, Prof Lam said cardiology lends itself well to digital health strategies.

Highlighting the importance of advocacy for patients, policymakers, doctors, and community stakeholders in the roadmap, Dr Prabhakaran explained: ‘The roadmap outlines what the roadblocks are for a particular disease in terms of prevention and management, and the facilitators that are available for us to get over those roadblocks’.

He felt that the COVID pandemic had democratized healthcare and also shown that patients do not always have to attend clinics to receive care.

The session emphasized that digital healthcare was not only about expensive technologies but cheaper and simpler wearable technologies too. It also stressed the need for accessibility, feasibility, affordability, and social acceptance of digital health.

Delegates heard the need for: practitioners to be open to change when embracing digital health; for tools to be validated, reliable, and accurate; to balance patient data protection and security, but without being too restrictive on the benefits of digital health; and hear the patient voice in co-design of digital health technologies.

Co-design in digital health

The importance of working with patients in co-designing digital health was a constant theme. Examples showcased included virtual yoga sessions, where heart patients were an integral part of the process; engaging patients and their needs in the design and use of wearable trackers; and the importance of keeping the consumer at the centre of digital health innovation.

In reflecting on summit highlights, cardiologist and co-host Dr Laura Corr said patients, and the need to involve them in co-design of tools, remained central to the summit.

Announcing plans for a digital summit in 2022 and a digital track at the ESC Congress 2022 from 26 to 29 August (online and onsite) in Barcelona, Prof Cowie acknowledged the breadth and global input of the conference, adding that ‘the future is bright, but the future has to be co-designed’.

Conflict of interest

none declared.

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