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Utility of a Deep-Learning Algorithm to Guide Novices to Acquire Echocardiograms for Limited Diagnostic Use
Akhil Narang, MD; Richard Bae, MD; Ha Hong, PhD
doi : 10.1001/jamacardio.2021.0185
JAMA Cardiol. 2021;6(6):624-632
Importance Artificial intelligence (AI) has been applied to analysis of medical imaging in recent years, but AI to guide the acquisition of ultrasonography images is a novel area of investigation. A novel deep-learning (DL) algorithm, trained on more than 5 million examples of the outcome of ultrasonographic probe movement on image quality, can provide real-time prescriptive guidance for novice operators to obtain limited diagnostic transthoracic echocardiographic images.
Use of Machine Learning Models to Predict Death After Acute Myocardial Infarction
Rohan Khera, MD, MS; Julian Haimovich, MD; Nathan C. Hurley, BS
doi : 10.1001/jamacardio.2021.0122
JAMA Cardiol. 2021;6(6):633-641
Importance Accurate prediction of adverse outcomes after acute myocardial infarction (AMI) can guide the triage of care services and shared decision-making, and novel methods hold promise for using existing data to generate additional insights.
Incremental Benefits of Machine Learning—When Do We Need a Better Mousetrap?
Matthew M. Engelhard, MD, PhD; Ann Marie Navar, MD, PhD; Michael J. Pencina, PhD
doi : 10.1001/jamacardio.2021.0139
JAMA Cardiol. 2021;6(6):621-623
It is indisputable that clinical medicine has entered the age of big data. Newer, better prediction methods, such as neural networks, random forests, and other algorithms, often categorized as machine learning (ML), can probe large-scale clinical data sets to discover predictive features unavailable to their more traditional counterparts. However, when Khera et al1 pit 3 of these algorithms against the most standard generalized linear model, logistic regression, to predict death after acute myocardial infarction, none of the ML algorithms emerge as a clear winner. Two of the 3 ML algorithms improved discrimination by a slim margin and yielded “more precise calibration across the risk spectrum.”1 However, these improvements are unlikely to be clinically meaningful, and it’s unclear whether they would be sufficient to justify the corresponding loss of interpretability. Furthermore, 1 ML approach (a neural network) performed worse than logistic regression. The data set in question is undeniably big, at least in sample size. Khera et al1 draw on an American College of Cardiology registry that contains more than 750 000 records; therefore, at first glance, it appears that the promise of using ML to harness big data is not being realized. What can explain this disconnect, and does it suggest that ML is more hype than substance?
Association of Posttraumatic Stress Disorder and Incident Ischemic Heart Disease in Women Veterans
Ramin Ebrahimi, MD; Kristine E. Lynch, PhD; Jean C. Beckham, PhD
doi : 10.1001/jamacardio.2021.0227
JAMA Cardiol. 2021;6(6):642-651
Importance Posttraumatic stress disorder (PTSD) is associated with greater risk of ischemic heart disease (IHD) in predominantly male populations or limited community samples. Women veterans represent a growing, yet understudied, population with high levels of trauma exposure and unique cardiovascular risks, but research on PTSD and IHD in this group is lacking.
Exploring Posttraumatic Stress Disorder as a Cardiovascular Risk Factor in Women Veterans
Beth E. Cohen, MD, MAS
doi : 10.1001/jamacardio.2021.0236
JAMA Cardiol. 2021;6(6):651-652
The connection between emotional and physical health has long been recognized, with a great deal of research focusing on the risk of cardiovascular disease (CVD). The landmark INTERHEART study1 of nearly 30?000 people from 52 countries found that psychosocial factors, including depression and stressful life events, accounted for approximately one-third of the population-attributable risk of myocardial infarction. Subsequent studies have attempted to isolate the risk associated with psychological trauma and posttraumatic stress disorder (PTSD). Two meta-analyses2,3 have linked PTSD to increased CVD risk, with the most recent2 finding an adjusted hazard ratio (HR) of 1.46 (95% CI, 1.46-1.77). Understandably, there has been great interest in examining the association between PTSD and CVD in veterans, given their high rates of exposure to trauma and development of PTSD. Indeed, much of the early work in this area was conducted exclusively in male veterans. Although 2 large epidemiological studies4,5 have confirmed the association of posttraumatic stress and CVD in community samples of women, there remains a lack of information in women veterans.
Metabolic Cost of Exercise Initiation in Patients With Heart Failure With Preserved Ejection Fraction vs Community-Dwelling Adults
Ravi V. Shah, MD; Mark W. Schoenike, BS; Miguel ?. Armengol de la Hoz, PhD; et al.
doi : 10.1001/jamacardio.2021.0292
JAMA Cardiol. 2021;6(6):653-660
Importance Heart failure with preserved ejection fraction (HFpEF) is a joint metabolic and cardiovascular disorder with significant noncardiac contributions.
Association of Non–High-Density Lipoprotein Cholesterol Measured in Adolescence, Young Adulthood, and Mid-Adulthood With Coronary Artery Calcification Measured in Mid-Adulthood
Matthew K. Armstrong, PhD; Brooklyn J. Fraser, PhD; Olli Hartiala, MD; et al.
doi : 10.1001/jamacardio.2020.7238
JAMA Cardiol. 2021;6(6):661-668
Importance Elevated non–high-density lipoprotein cholesterol (non–HDL-C) is associated with the presence of coronary artery calcification (CAC), a marker of heart disease in adulthood. However, the relative importance of non–HDL-C levels at specific life stages for CAC remains unclear.
Derivation and Validation of a 4-Level Clinical Pretest Probability Score for Suspected Pulmonary Embolism to Safely Decrease Imaging Testing
Pierre-Marie Roy, MD, PhD; Emilie Friou, MD; Boris Germeau, MD; et al.
doi : 10.1001/jamacardio.2021.0064
JAMA Cardiol. 2021;6(6):669-677
Importance In patients with suspected pulmonary embolism (PE), overuse of diagnostic imaging is an important point of concern.
Efficacy and Safety of Dapagliflozin in Men and Women With Heart Failure With Reduced Ejection FractionA Prespecified Analysis of the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure Trial
Jawad H. Butt, MD; Kieran F. Docherty, MBChB; Mark C. Petrie, MBChB, PhD; et al.
doi : 10.1001/jamacardio.2021.0379
JAMA Cardiol. 2021;6(6):678-689.
Importance Women may respond differently to certain treatments for heart failure (HF) with reduced ejection fraction (HFrEF) than men.
Performance of the American Heart Association/American College of Cardiology Pooled Cohort Equations to Estimate Atherosclerotic Cardiovascular Disease Risk by Self-reported Physical Activity Levels
Ambarish Pandey, MD, MSCS; Anurag Mehta, MD; Amanda Paluch, PhD
doi : 10.1001/jamacardio.2021.0948
JAMA Cardiol. 2021;6(6):690-696
Importance The American Heart Association/American College of Cardiology pooled cohort equations (PCEs) are used for predicting 10-year atherosclerotic cardiovascular disease (ASCVD) risk. Pooled cohort equation risk prediction capabilities across self-reported leisure-time physical activity (LTPA) levels and the change in model performance with addition of LTPA to the PCE are unclear.
Assessment of Catheter Ablation or Antiarrhythmic Drugs for First-line Therapy of Atrial FibrillationA Meta-analysis of Randomized Clinical Trials
Mohit K. Turagam, MD; Daniel Musikantow, MD; William Whang, MD
doi : 10.1001/jamacardio.2021.0852
JAMA Cardiol. 2021;6(6):697-705
Importance Early rhythm control of atrial fibrillation (AF) with either antiarrhythmic drugs (AADs) or catheter ablation has been reported to improve cardiovascular outcomes compared with usual care; however, the optimal therapeutic modality to achieve early rhythm control is unclear.
Clinical Outcomes and Response to Vericiguat According to Index Heart Failure EventInsights From the VICTORIA Trial
Carolyn S. P. Lam, MBBS, PhD; Anna Giczewska, MS; Karen Sliwa, MD, PhD
doi : 10.1001/jamacardio.2020.6455
JAMA Cardiol. 2021;6(6):706-712
Importance The period following heart failure hospitalization (HFH) is a vulnerable time with high rates of death or recurrent HFH.
Association of Financial Hardship Because of Medical Bills With Adverse Outcomes Among Families of Children With Congenital Heart Disease
Avital B. Ludomirsky, MD, MPP; Emily M. Bucholz, MD, PhD, MPH; Jane W. Newburger, MD, MPH
doi : 10.1001/jamacardio.2020.6449
JAMA Cardiol. 2021;6(6):713-717
Importance Congenital heart disease (CHD) carries significant health care costs and out-of-pocket expenses for families. Little is known about how financial hardship because of medical bills affects families’ access to essential needs or medical care.
Association of the V122I Transthyretin Amyloidosis Genetic Variant With Cardiac Structure and Function in Middle-aged Black AdultsCoronary Artery Risk Development in Young Adults (CARDIA) Study
Arjun Sinha, MD; Yinan Zheng, PhD; Drew Nannini, PhD
doi : 10.1001/jamacardio.2020.6623
JAMA Cardiol. 2021;6(6):718-722
Importance The variant V122I is commonly enriched in the transthyretin (TTR) gene in individuals of African ancestry and associated with greater risk of heart failure (HF) in older adulthood, after age 65 years. Prevention of HF may be most effective earlier in life, but whether screening with echocardiography can identify subclinical cardiac abnormalities during middle age to risk-stratify individuals appears to be unknown.
As Old Cardiologists Fade Away
L. Samuel Wann, MD; Joseph V. Messer, MD; Roberta G. Williams, MD
doi : 10.1001/jamacardio.2021.1001
JAMA Cardiol. 2021;6(6):617-618
In 1905, Sir William Osler, MDCM, often described as the Father of Modern Medicine, opined that “the effective, moving, vitalizing work of the world is done between the ages of twenty-five and forty. It is downhill from then on. Men should retire at 60 years of age.”1 Nobel Prize winner Sir Frederick Banting, MD, discovered insulin at age 32 years. Madame Marie Curie, ScD, received the first of her 2 Nobel Prizes at age 36 years. Osler did not mention women, nor could he have anticipated that a child born in the US in 2020 has a 50:50 chance of celebrating her or his 100th birthday. Much has changed in both society and medicine since Osler made his many seminal contributions to our profession. Late-career physicians are now an indispensable part of our present-day workforce—nearly one-quarter of all cardiologists now practicing in the US are older than 65 years.2 While the adverse effects of aging on the cognitive and sensorimotor skills a physician uses to competently care for patients are undeniable,3 these changes are highly variable in their manifestations and are not easily delineated, quantified, or regulated.4
JAMA Cardiology—The Year in Review, 2020
Robert O. Bonow, MD, MS
doi : 10.1001/jamacardio.2021.0261
JAMA Cardiol. 2021;6(6):619-620
Unusual Complication of a Right Ventricular Support–Extracorporeal Membrane Oxygenation Cannula
Erin D. Unger, MD; Ranya N. Sweis, MD; Ankit Bharat, MD
doi : 10.1001/jamacardio.2021.0284
JAMA Cardiol. 2021;6(6):723-724
A previously healthy, middle-aged patient presented with rapidly increasing shortness of breath despite empirical antibiotic treatment for presumed pneumonia. A computed tomographic image of the chest was notable for diffuse, ground-glass opacities. An infectious disease workup was unrevealing, and the patient was diagnosed with acute-on-chronic respiratory failure resulting from dermatomyositis-associated interstitial lung disease. Progressive hypoxia refractory to mechanical ventilation necessitated venovenous extracorporeal membrane oxygenation (VV ECMO) using the ProtekDuo dual-lumen cannula (LivaNova). In its standard configuration, deoxygenated blood is drained from the right atrium while oxygenated blood is ejected into the main pulmonary artery, and the device serves as both a right ventricular support and an ECMO (RVS-ECMO) cannula. End-stage lung disease was established and, as part of a lung transplant evaluation, the patient underwent catheterization of the left side of the heart and coronary angiography. The left coronary artery angiogram revealed mild luminal irregularities. The right coronary artery (RCA) angiogram is shown in Figure 1 and Video 1.
Value of Discharging Heart Failure Patients Home
Peter Y. Watson, MD, MMM
doi : 10.1001/jamacardio.2021.0318
JAMA Cardiol. 2021;6(6):725
To the Editor Figueroa and colleagues1 reported that fee-for-service (FFS) Medicare and Medicare Advantage (MA) inpatients with heart failure shared similar complexity, clinical interventions, and outcomes but raised concerns that more MA inpatients were discharged home (adjusted odds ratio, 1.16; 95% CI, 1.13-1.19; P?<?.001) compared with a skilled nursing facility (SNF) as a quality difference driven mainly by MA plan cost interest. I would suggest clinically appropriate hospital-to-home discharge is a potential quality indicator aligned with Medicare patient interest.
Value of Discharging Heart Failure Patients Home—Reply
Jose F. Figueroa, MD, MPH; Rishi K. Wadhera, MD, MPP; Karen Joynt Maddox, MD, MPH
doi : 10.1001/jamacardio.2021.0324
JAMA Cardiol. 2021;6(6):725-726
In Reply We thank Watson for his insightful comments. Although our study found no significant differences across inpatient quality measures for patients hospitalized with heart failure who were enrolled in either Medicare Advantage (MA) or fee-for-service (FFS) Medicare, MA patients were more likely to be discharged directly home.1
An Excellent Model to Increase Adherence to Guideline-Directed Medical Therapy—With Far-reaching Implications
Saad Karamat, MD; Syed Awais Ahmed, MD; Syed Jaan Naqvi, MD
doi : 10.1001/jamacardio.2021.0321
JAMA Cardiol. 2021;6(6):726
To the Editor We read with great interest the study by Desai et al1 on remote optimization of guideline-directed medical therapy in patients with heart failure. This is a brilliant study that addresses the discrepancy between guidelines for heart failure management and actual practice. In just 3 short months, the authors were able to have 16.2% more patients take guideline-directed angiotensin-converting enzyme inhibitor therapy and 14.7% more patients take ?-blockers using their system of remote check-ins and algorithm-based dosing adjustments—impressive. We have not seen other means that have been so successful at increasing adherence to guideline-directed medical therapy.
An Excellent Model to Increase Adherence to Guideline-Directed Medical Therapy—With Far-reaching Implications—Reply
Akshay S. Desai, MD, MPH
doi : 10.1001/jamacardio.2021.0327
JAMA Cardiol. 2021;6(6):726-727
In Reply We appreciate the comments in support of our work1 by Karamat and colleagues and agree that the remote, algorithm-driven, navigator-led and pharmacist-led approach we used to optimize guideline-directed medical therapy for patients with heart failure and reduced ejection fraction can be readily adapted to implementation at scale or to management of other cardiovascular conditions. Indeed, additional work from our group has already highlighted that this strategy may be effective as a health care system–level intervention to improve control of lipids and blood pressure in accordance with guideline-recommended targets.2 Validation of these results in other clinical contexts along with longer-term follow-up to confirm the anticipated favorable effects on clinical outcomes and health care utilization may be needed to encourage broader adoption of this approach to cardiovascular risk reduction in clinical practice.
Notice of Retraction. Shimizu et al. Association of Genetic and Clinical Aspects of Congenital Long QT Syndrome With Life-Threatening Arrhythmias in Japanese Patients. JAMA Cardiol. 2019;4(3):246-254.
Wataru Shimizu, MD, PhD; Takeshi Aiba, MD, PhD
doi : 10.1001/jamacardio.2021.1087
JAMA Cardiol. 2021;6(6):727.
