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The number two reason to come to an emergency department in the United States is chest pain after abdominal pain and chest pain is interesting. It's one of the top searches in google. So when you're at home and you have chest pain, the first thing people do is they hit the search engine to see whether they should go to hospital. The chest pain guidelines changed last year. And for the first time note that coronary cT is now class one level of evidence A. With stress testing of all types um at class one B based on the level of evidence and why did this occur? Well, there's been a, there's been almost 16, 17 years of randomized trial data that has backed this up and basically the guidelines bifurcated into preferring coronary cT and most patients, those who are less than 65 I'd say less than 75 who are not on optimal medical therapy. And in those who you are also concerned about their aorta. You're also concerned about pommery embolism in addition to their coronaries. And that's a lot of people. Um And that's in the outpatient world and also in the emergency setting. Um And one of the reasons is at the bottom, I've noted the plaque risks. The high definition of being able to see the kinds of plaques that we're looking at translates into better outcomes for the patients long term. So one of the better known studies from 2018 was published in the new England Journal called the heart study took 4000 patients and randomized them to a stress testing strategy versus a cardiac cT strategy. And if you look the curve splayed very early, they splayed and actually four or five months after randomization and sustained benefits in decreased death. And am I over the next five years. So a lot of people were debating how, why would this be the case that if you randomize a patient to attest that their death and M. I. Rates would be improved in just six, less than six months and then sustained over five years. So clearly over five years, a lot of things changed for the patients that got a coronary cT versus a stress test. They many of them got on medical therapy, but why did the benefit begin in three months, six months. One of the reasons is that wasn't really people aren't really talking about is that more patients in the Ct group underwent coronary revascularization. Almost 246 underwent revascularization is compared to 208 and the stress testing arm, anybody that's ever had a friend that had passed the stress test and then had a heart attack will know why that's the case because stress testing MRS disease. So I don't think we should apologize for appropriate revascularization when it leads to reduction and death and am I And um a lot of the author's just sort of buried that. But these are appropriate revascularization because we know nukes have been missing people and stressed has been missing people for a long time. This is borne out in large registries as well. In the Netherlands nine, almost 90,000 patients were studied, 50,000 got a stress test, 30,000 got a coronary ct. And if you follow them, you see that M I goes down and those patients that got a coronary ct and cabbage and goes up and We shouldn't apologize for that. That's appropriate bastardization. When you find obstructive disease. These are patients that are carefully followed in registries carefully following clinical trials. These are not little di extents in the D4 that are going in these are large vessel proximal stents in the emergency department. We find the same thing if you randomize patients showing up in the emergency department with chest pain. It's not a surprise that the patients get the coronary ct had better outcomes in terms of mace and other primary endpoints compared to stress testing. And what's interesting is in the emergency department by using such a fast and high precision test. That hospital mission goes down by 40% length of stay goes down by 30%. Downstream testing goes down by 60% because your definitive right up front with a sharp precise test and then cost to the hospital go down by 30% because you don't have to pack E. R. Obs with a lot of nurses. You can have a continuous pathway and unlike stress testing you can do this 24 7. So all of these data points have resulted in the guidelines being changed last year. Now the big question is implementation. How do we provide cardiac cT 24 7 around the United States over the next 10 years with few local imagers. There's there's 29,000 cardiologists, the United States and about 35,000 radiologists. And there's only about 2000 doctors in the country that can read one of these at the current moment. And there's only 30 fellowships to do an advanced imaging fellowship. So about seven years ago we founded a group to unlock efficiencies by interstate tele cardiology and that's called I. H. S. Or Innovation Health Service. And we got together doctors from all over the United States who know how to read these cardiologists and radiologists expecting that we were gonna have to pull together and the pandemic only accelerated this with the retirements of lots of doctors. So we presented our data at the American College of Cardiology a few months ago at the cardiovascular summit And showed that even before the guidelines changed because of the speed and accuracy. Our growth rate has gone up by 300% and we're kind of doubling every month now. The speed to provide an emergency coronary CT. We have gotten it down to 35 minutes. So imagine coming to the emergency department with chest pain, you get your troponin, you get an E. K. G. And then you get your coronary angiogram by CT in 35 minutes. It's changing for the emergency physicians. Love it because then if you if you're normal you can go home after your second troponin at two hours and then they can pay attention to trauma and other patients that need their help. And then if you have minor disease you can get started on therapy with a statin and an aspirin. So this is gonna be how it's going to be done over the next 10 years. So how how did we implement it? Well we pulled together radiologists and cardiologists first and some systems engineers from around the US and we designed a very complex system of technology that's in the cloud smartphone applications and wrote some databases to provide it. And our radiologists read the long coma and our cardiologists look at the electrocardiograms And then and this is actually I'm not gonna go through this but this is the detailed design by by going through what is the experience of the E. D. Physician, the nurses in the E. D. And the patients. And then what is the experience of the doctors that are reading it? We understood that doctors are running around telemetry words rounding on patients so they have to be able to read it from a google browser wherever it is without trying to find a workstation somewhere. And then we have to orchestrate the dashboards to make this work. So I think the key the key um that we that we discussed at the American College of Cardiology where that we have doctors on both both coasts including Hawaii and Japan because we have navy bases in Japan. Those are all that's all U. S. Soil. And all our doctors own the service. We believe that co ownership changes what you care about. We also provide instant video conferencing for life threatening cases. So as soon as the cases identified as life threatening, we got two or three doctors on that zoom and review the case so that we don't have to do a retrospective peer review. We do prospective peer review by getting an emergency huddle for complex cases. Um and then we have specialized ways to ping a doctor who has a specialized niche like an acute aortic syndrome or adult congenital heart disease. So we're providing this around the United States right now. And um, and we're the first national digital practice to do it and I'm sure there'll be others but and we're not trying to be the biggest, but we are trying to be the best. It's interesting that Deepak is pushing a I and I agree with him 100% and that's not just because he's good looking. I think that artificial intelligence is going to result in the second pair of eyes that scans reports increasing efficiencies and capturing physicians group knowledge. There's no question in my mind that when you sit down to look at one of these studies, it will be pre filled by an Ai algorithm and the text will be filled in for us. But I also, I'm not worried about my job, I think that doctors are not going away and at the end of the day the computer is going to assist us. But but you want another human being too To to put their name on on on the bottom 150 years of jurisprudence in the United States has also emphasized that no tech company is going to take the final liability for anyone's death. And I think the key in ai is going to be, it has to explain itself. So if if a computer says you're okay after it reviews your coronary ct, How much are you going to trust it unless you can see how does it know your okay, So in high school algebra you don't get credit for for doing a proof unless you show your work. So the same thing is gonna happen with the ai. If they can't, if the computer cannot show its work, we're not gonna send the patient home from the emergency department or send them to the operating room for an aortic dissection. There has to be, it has to lay out why it thinks something is the way it is. Thank you. Published December 7, 2022 Created by Related Presenters Mohit Bhasin, M.D. Innovation Health Services
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