Hello, everyone. This is Erica Spicer Mason with
Becker's Healthcare. Thank you so much for tuning
into the Becker's Healthcare podcast series.
So today we're going to talk about transforming
coronary care and the future of cardiology.
And joining me for this important conversation are
two leaders from Baylor Scott and White, the
heart hospital.
We have with us doctor Amro Al Said,
medical director of advanced cardiac imaging,
and doctor Karim Al Azizi, medical director of
the cath lab and structural heart disease program.
Doctor Al Said, doctor Al Azizi, welcome, and
thank you so much for making time for
this today.
Thank you, Erica. Great to be here. Thank
you for having us.
Really, really happy to have you both on
the podcast. And before we get into the
heart of the conversation today, didn't mean to
make that pun, but I guess I just
did.
I would love to learn just a little
bit more about you both.
Just if you wouldn't mind sharing a little
bit more about your background in health care,
your organization, whatever you think is helpful for
our listeners to know.
Doctor Alsa, you may you could get us
started.
Yes. So, as you mentioned, I am a
cardiologist with subspecialty training in multimodality advanced cardiac
imaging. My current role as the director of,
advanced cardiac imaging at the Heart Hospital.
I, basically,
oversee the operations at multiple campuses,
for the enterprise, and I oversee things from
quality, hardware, and software
selection, workflow optimization,
and patient access to advanced imaging.
I'm also routinely involved in AI integration,
research, and fellow education.
Wonderful. It's great to have you with us,
doctor Al Sayed. And doctor Al Azizi, how
about you? Yeah. I'm an interventional cardiologist,
by training. I specialize in structural heart disease
interventions as well as complex coronary interventions.
I did train with doctor Al Said,
specifically on CT,
imaging back in training. But,
more importantly, my my role, in the organization
is to oversee again a lot of the
workflows, algorithms, as well as, quality,
assessment of,
our work, in the cath lab
and as well as the structural heart program
in Plano.
And with that, obviously, we work very closely
together between, you know, our departments, our operational
departments, and the imaging department, as you can
imagine, to streamline a lot of the clinical
work that we do.
Fantastic. Doctor Alazizi, thank you so much. And
it's just great to have the expertise from
the two of you for this conversation and
also great to know that you worked with
each other previously. So I think this is
bound to be a a great discussion.
And I wanted to start off by
really touching on this trend that we're seeing
in cardiology, and that is really this significant
demand,
across across the industry, and it's continuing to
grow as well. So in this environment of
high demand,
what key challenges has your department faced? I
would love for both of you to, to
elaborate on that.
So I can start. And, it's it's really
the initial challenge or opportunities that we've had
in imaging has been largely
about how we diagnose coronary artery disease. So,
for decades, our approach for detecting coronary artery
disease has been largely indirect. So we relied
in surrogates of, flow limiting stenosis rather than
direct disease visualization.
We've used things like symptoms and exercise testing
as proxies for risk. And the logic was
if symptoms or signs of stress induced ischemia
appear, then there must be significant narrowing.
But this model, what the problem is with,
with the is the detects late disease
and, when the problems in coronary artery disease
is already advanced.
Then historically,
calcium scoring had been used as the corner
score stone for early detection. It's convenient, reproducible,
but it doesn't really,
measure active disease. It's more of a, a
marker for chronicity of the disease rather than
active disease. And we have seen this from
from national data when you look at over
four and a half million,
patients in The US who presented with ACA
ACS in the past,
seven to eight years.
Half of them were asymptomatic
when they first presented with ACS.
Twenty two percent of them had a coronary
calcium score of zero. So these are people
who would have been missed by traditional markers
of,
of risk stratification, if you will.
Almost one in five did not even seek,
a primary care physician visits.
So despite of, decades of emphasis of risk
factors and calcium scoring, we're still missing a
large populations of patients
that have silent disease and biologically active disease.
Now,
when you look at this again, the ACC
chest pain guidelines, rightfully so, they had made
the coronary CTA,
the first class one indication for addressing patient
with acute chest pain.
But this had led to a rapid adoption
and, which is great. But, then come another
another challenge, and that was the shortage of
experienced CT readers.
Again, training pathway for CTA had been historically
very variable. It was from one week courses,
and virtual courses
to one to two years of advanced imaging
fellowship. And that's where I think AI,
based platform, something like Clearly, where it comes
in where it can provide us with automated
and reproducible
stenosis assessment and functional assessment and then adds
the piece of plaque quantification.
Again, it does not replace the physician, but
it really elevates,
the availability
of readers. And
if you may democratize the presence of,
high quality reefs even in places that are
not tertiary care centers.
And I'll stop here probably, let doctor Al
Azizi talk about what the,
procedural size in cath lab access challenges have
been.
Yeah. I I mean, you know, to add
to this, and you can imagine that the
the downstream effect of this, obviously, diagnostic
tools and and, tests have increased significantly over
the years. Coronary CTA has been adopted widely.
Once used to be an issue in getting
prior authorization to try to get it through
whether it's outpatient,
obviously, now being more acceptable in the inpatient
side.
But that has also led to a lot
of unknowns and a lot of questions and
a lot of potentially even trips to the
cath lab, but also kept other people out
of the cath lab. What was once considered
that, you know, patients would have to land
on the table were less likely to see
diagnostic
procedures done on the table
just because of the fact that those patients
were appropriately deferred and steered away from the
cath lab what was once going to the
cath lab. And so we're more likely to
get to more interventions
and more
therapeutic,
procedures rather than perhaps,
diagnostic procedures.
On that note and how important this topic
is, if you look at the opening
conference
lecture at TCT, which is our largest interventional
conference that happens every year and just happened
in, San Francisco.
Our opening,
you know, title for the opening session is
I have an abnormal coronary CTA.
What do I do now? And so this
trickles into revascularization.
This trickles into prevention. This trickles into many
things. But long story short,
this as an as a utility as a
tool essentially to detect disease has allowed us
to get to those patients sooner, has allowed
to ease the conversation from prevention and secondary
prevention, obviously, if they have plaque. And also,
more importantly, has allowed us to defer appropriately
patients that did not need to come to
the cath lab with non cardiac,
chest pain,
and choose the ones that are appropriate to
come to the cath lab for further, workup
and intervention.
I I really appreciate the overview, doctor Al
Azizi and doctor Al Said. It sounds like
some of the challenges that you're up against
really boil down to challenges in patient identification,
experiencing missed patients,
some gaps in training competencies and quality,
and also access. But at the same time,
I'm also hearing some opportunities that you're both
sharing here, whether that's a more upstream and
preventative approach in care. And then also doctor
Al Said, I know you touched on AI
briefly as well.
So I'd like to go there next. Amid
some of these challenges, how has Baylor Scott
and White, the heart hospital, leveraged tech to
drive clinical efficiencies and improvements?
And could you share an example?
Yes. Absolutely. So when I reflect on our
local campus here over the past three years,
so we have transitioned again. We adopted coronary
CTA, and we have transitioned
that we now utilize coronary CTA in nearly
90%
of our day to day CAD testing. So,
our volume have went up from about 8,000
coronary CTAs a year to over,
20,000
coronary CTAs a year. And this is, again,
really a testament about, the opportunities that you
can scale this testing modality,
even when you have
relatively stable resources.
If you compare that to a cath lab,
in order for you to scale,
such a huge volume, it will require a
much larger
resources utilization.
And what we've done is that we've implemented
AI tools, like like the platform, the Clearloop
platform,
across the selected CTAs to, study. So what
it helped us do is that it allowed
us to standardize assessment of the luminal stenosis,
whether a moderate stenosis is functionally significant,
and quantify the plaque type of burden, which
has been the recent addition to our tools
for, magic coronary artery disease.
And,
really, it allowed us,
when we were in a large system that
has,
maybe 20 readers,
across different, experience levels, it allows us to,
maintain a certain level of, quality
across the the different
readers. And, it gave us opportunities for quality
checks, areas for improvement.
And,
additionally,
this fast turnaround
time in under two hours for the processing
of studies
allowed us to,
streamline processes like acute chest pain for ER
presentation. Aside from inpatient, outpatient, triaging patients,
we we started the program where,
it takes less than three hours from the
time that the patient present to the emergency
room until we have a decision at disposition.
At that time, they would have gotten,
their EKG, troponins,
and
CT with functional assessment at that time. So
you have a clear plan and pathway for
them, and you do not need additional testing.
This what have been,
our utilization
of this. And then more recently with, like,
collaboration with our interventional colleagues like Pedro Azizi,
we're able to,
take this a step further that when we
identify disease,
how do we plan the this,
procedure?
Where do we do these,
procedures and take really,
an additional step in looking at this.
So insightful, doctor Al Said. Thank you so
much. And doctor Al Azizi, I'd be curious
to know too if if you have any,
other outcomes that you'd add as a result
of this AI driven approach,
especially from the patient care experience. Would love
to to touch on any outcomes you've seen
there.
Yeah. I think I think to add to
what doctor Al Said mentioned and to dive
a little bit further, right now, if you
look at
how much of PCI is being done outside
the hospital, it's quite a bit. And a
lot of it is being done safely with
very good outcomes. But reality is, as we
do more of these, we are able to
detect things that we don't want to be
surprised with on the cat on the table
in the cath lab, which will involve severe
calcification that require atherectomy devices, which will involve,
lithotripsy, which will involve,
potentially mechanical circulatory support or whatever it may
be that will
essentially take you from a, you know, unrevascularized,
territories to a complete revascularization.
No one wants to do a bad job,
but everyone wants to do a good job
in an appropriate setting. So in the in
the hospital setting, for example, you're more likely
to use a rotational atherectomy. You're more likely
to do advanced
procedures
given the fact that potentially you have surgical
backup and you have all the tools next
to you. Whereas, for example, in OBLs or
ambulatory surgical centers,
you are not really on an island, but
you're really not taking on any high risk
cases. And so the the beauty of, data
that you can collect from the coronary CTA
and specifically with solutions like this is that
it can tell you the degree of calcification,
length of disease,
understand bifurcation,
involvement,
even taking it a step further in planning
chronic total occlusion PCI, which is obviously done
in the hospital. I think number one, you
triage the patient appropriately to be treated in
the right setting in order to give them
the best chance for the best redascularization.
Number two, actually go in with a plan.
And that's one thing that doctor Al Said
and I and many others around the country
have really tried to work on a prescriptive
way in order to translate
the CT data
from softwares like this
onto what we are able to apply in
the cath lab and really go in with
a plan. If you look at a pilot,
no pilot flies out without a plan. And
I think more and more and even as
a structuralist,
when AMRO
refers to me a patient and we're talking
about a CT from a planning and structural
heart space, nobody goes in into a structural
procedure without CT planning,
specifically TAVRs.
But this should also translate to complex coronary,
which honestly, the room for error is very,
very small.
And the outcomes,
are very, very important in in making sure
that the patients not only get a good
acute outcome, but a more durable outcome. And
that is all really dictated by procedural,
planning and what I think or what I
call patient triaging to the appropriate setting.
Yeah. I appreciate the the add ons, doctor
Al Azizi.
Triaging to the patient to the appropriate setting,
I know that goes a long way from
a clinical and operational standpoint and also in
terms of, you know, reducing friction for patients
as well as they're moving through
potentially a difficult test finding or or something
of that nature.
I really appreciate how you both have highlighted
some of the benefits that you're seeing with
this approach.
You know, having AI and technology
help with some of these inefficiencies. And I'm
I'm sure that there are other cardiology departments
across the country that are considering
a similar implementation
to keep up with demand and to get
patients to the right place at the right
time.
What practical next steps or advice would you
offer for those organizations who are considering a
similar approach?
I would start with quality. I think, the
the really, it is the foundation having a
quality study and initial investments
in in in adequate hardware,
should be the the cornerstone
of, any,
CT based program across the country.
Historically, I would say, there have been a
limitation or initial entry fear from, hospitals that,
it requires a very high end
technology or hardware to be able to have
a coronary CTA program. This is no longer
the case. The majority of the coronary CTAs
that are,
diagnostic
and something that we can use,
with with the Clearly platform,
are,
done on bread and butter,
hardware. But, the additional point that I think
it's an
initial step that we need to focus on
is having an investment in,
staff training and protocol optimization.
Those are keys. Once you get past that
initial training phase, it's really smooth sailing from
there.
Additionally, I think it's, like, really
important to integrate quantitative plaque analysis directly to
your coronary CTA flows.
So this is the the the the newest
thing that we knew what high risk plaque
look like and what the incremental value of
low attenuation plaque and the non calcified plaque
adds to a coronary CTA. But, historically, we
have not been able to do a a
accurate quantification
for it. So these tools
now allow us to
quantify the plaque. So really,
introducing it, early on and educating your referring
physicians and your your colleagues about,
how we use this plaque data and how
we interpret this data. Allow us to add
this this second level or second tier of
personalized medicine so that it's not one size
fits all. And we already understand so much
now within this short period of time about
how,
there are
significant,
sex differences between between,
risk and plaque burdens between
men and women and how same plaque burdens
can present a very different
profile. It so it allows us to really
get personalized prevention,
across across different gender, different ethnic groups, and
it also allow us to follow-up on therapy.
When we intervene on
therapeutic intervention, we can follow the response
and be able with confidence to tell our
patient whether or not the,
the the treatment is working for them. And
lastly, I would say we have to do,
prioritization
of of workflows. So we have to do
workflow automation,
decision out making algorithm. Again, something like the,
acute chest pain ER protocol,
this allows us to streamline that process. So
it's not a lot of,
hard stops during this process and really,
speed up the adoption for the system.
Fantastic.
Doctor Al Said, I appreciate it. And doctor
Al Azizi, is there anything that you would
add here for considerations?
Yeah. I think raising awareness,
you know, beyond you know, I'm lucky enough
to to have had the chance to to
understand what is CT and work on CT.
And I don't think that it is something
hard to build on and and gain the
knowledge.
And a lot of softwares,
like, clearly, for example, that pretty much gives
you all the information that you need, makes
things very simple.
The message is societies, and there has been
a recent document released by Sky,
which, you know, Sky has been a very
important piece in really pushing,
a lot of these,
discussions,
specifically CT based or CT guided,
deferral and interventions in general
is is an is an important message for
all interventionists
that are kind of, as act as end
users or have always been on the end
user side
of these CT testing,
protocols is to actually engage more,
not specifically in the, you know, taking on
the testing piece, but actually understanding,
learning,
and reacting to it appropriately. Because if you're
given all this data as an interventionist,
it it it probably may make life much
easier. So I think that kind of these
algorithm, these workflows,
that kind of,
discussion
needs to continue to be elevated,
across different platforms being pushed from societies,
especially,
as coronary CTA continues to be really the
the leading test, and becoming a leading test
in in assessing patients either with the prior
coronary artery disease or or basically
a newly diagnosed coronary artery disease and being
used even further to plan interventions
like we do in the structural heart space.
Mhmm.
It sounds like there's so many opportunities
in taking this this kind of approach with
a tech driven platform and also at the
same time, a lot of considerations around investing
in staff training, increasing awareness,
really being grounded in that focus on quality.
Doctor Al Azizi, doctor Al Sayed, this has
been a great conversation today. I just wanna
check-in for a final thought or takeaway. Is
there anything that you'd like our listeners to
know before we close?
Thank you, Erica. It has been great. I
think my final thought will be that cardiology
is continuously evolving, so we're now in an
era of precision prevention
and personalized intervention.
And I think as a community,
similar to what oncology,
when they moved away from tumor size to
molecular
profiling,
cardiology
must move from just stenosis
and qualitative
assessment to more quantitative assessment in the plaque
biology.
Fantastic. Doctor Al Azizi, any final thoughts from
your end?
Yeah. I I think we, you know, as
a field, we continue to evolve, continue to
try to understand the dilemmas
in managing those patients. We will continue to
see younger and younger patients, unfortunately, with a
lot of soft plaque, and the science will
continue to evolve in both directions. One is
the prevention, and perhaps we may go to
a day where calcium scoring is not even
the the initial thought, but actually a CTA
in in assessing patients in an asymptomatic
way, but we need to continue to compile
data to drive us to a level of
evidence that will take us to that guideline.
And secondly, from a therapeutic standpoint, now that
you have coronary artery disease, now that you're
heading to the cath lab,
we are now I think the time has
come to actually use,
tools and tests like this to really prescribe
revascularization
in the cath lab and translate all the
imaging data. And we've seen over and over
softwares and a lot of X-ray vendors
in the cath lab trying to bring that
CT to life
in in the cath labs itself in order
to guide the operators,
to the best possible outcome for their patients.
Well, if I can take anything from this
conversation,
it's that the innovation
at which
I I should say the pace of innovation
in this space,
in cardiology seems to be just as rapid
as the field of cardiology itself is changing,
evolving, and growing. So it it's reassuring to
to hear about all these innovations, and it
would be fascinating to know a year from
now, what some of these diagnostic tests and
pathways would look like. So doctor Al Azizi,
doctor Al Sayed, thank you so much again
for making time for this and for Becker's
today. Thank you, Erica. This was great.