Detecting CAD with Vocal Biomarkers

Beyond Verbal, an Israeli company leading the market in voice/emotion analysis software are making headlines thanks to their study with the Mayo Clinic, that shows that voice analysis can indicate the presence of coronary artery disease (CAD).

CAD is responsible for one of the highest cardiovascular mortality rates in developed countries globally, and whilst lower in developing countries, this figure is quickly rising. With this in mind, inexpensive, low-risk  and non-invasive screening methods are a very desirable prospect. Currently, ECG, Exercise Tolerance Testing (ETT), Radionuclide testing and Pharmaceutical Stress Testing are the most common procedures used to screen for CAD, but, aside from ECG, each has contraindications, and/or is fairly invasive. Again, aside really from a simple ECG, each has a middling to significant associated cost attached to it. Technology that could reduce these costs and the potential for unnecessary testing presents a possible alternative to patients being referred to chest pain clinics and such, without a sure fire reason to do so.

Beyond Verbal have already used their vocal analysis software to find audio characteristics associated with Parkinson’s disease and autism, and have now turned their technology to CAD.

The Beyond Verbal/ Mayo Clinic study hypothesised, due to the association coronary atherosclerosis has with other systemic pathologies, that vocal processes and the structures responsible may also be affected.

150 patients, 120 of which presented for angiography of the coronary arteries and 50 healthy, or non-cardiac control patients had their voice recorded prior to the test. Beyond Verbal then used a variety of their analytical software to record three 30 second voice clips from each patient; the first (R1) was a predetermined script, R2 was a description of a positive experience, and R3 was personal like R2, only a negative experience.

The analysed results show a 19-fold increase in the likelihood of CAD in R3, the negative voice clip, irrespective of traditional cardiac risk factors such as age, suggesting there is indeed a link between CAD and voice.

BV hope that future development of this technology can be used to screen patients telephonically.

 

The poster outlining the study can be found here

Beyond Verbal on the web.

The TSP resources relating to CAD can be found here and here.Heart

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Review: R-CAT ECG Analysis Badge

Price: £9.99/ $8.00

Developer: EKG Concepts (U.S. only. UK Stockist here)

I’m used to reviewing mobile apps and, to a lesser extent, PC and Mac software, so this is something of a new experience for me. I’ve frequently used rate rulers and pocket tools in the past, but the Rapid Cardiac Analysis Tool (R-CAT) is seemingly different to such an extent that I felt it made sense to put it through its paces.

This tool is designed to enable a healthcare professional of any specialism to quickly assess some of the basic criteria of a 3 or 12 lead ECG, such as heart rate, interval and segment duration as well as waveform deviation from the isoelectric baseline.

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I prefer landscape orientation, but the R-CAT accommodates portrait also.

First, the card itself; it’s well crafted, durable, flexible at the same time, is roughly the same size as an I.D. card/driving licence, and its structure and non-embossed build mean it’s easily disinfected, much the same as many other pieces of equipment you would use in a clinical environment. There are two cutaway sections that allow you to attach R-CAT to your lanyard in either a portrait or landscape orientation, and it sits snugly behind the badge holder without getting in the way.

It is, however, too large to slot into the standard NHS card holders which is a minor niggle, but this isn’t too much of a bind as it doesn’t take a huge length of time to remove, and if you have a pull-reel badge holder, it’s no problem whatsoever, as you can use it without removing the card or your lanyard.

The R-CAT focusses specifically on heart rate, segment and interval length, and baseline deviation (if you’re looking for a cardiac axis diagram, then you’ll have to keep looking, I’m afraid). The heart rate measurement works in exactly the same way as a regular rate ruler, with a similar error margin. It doesn’t have as many timing markers as similarly priced full rulers, but I guess it was a necessary concession to make in order to accommodate everything else on its small frame. Whatever the reason, you get a rough to fairly accurate indication of the true R-R interval.

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R-CAT HR circa 37bpm. The HR given by the equipment and my own calculation was 36bpm

 

The segment/interval indicators are found on the opposite side of the rate calculator, and span two of the outer edges of the card. The smallest measurement is 0.03s, and the printed values then increase from 0.04s by two, up until the largest at 0.44s. In practice, this system takes a little longer to use than simply measuring with a ruler, but once you’ve used it a couple of times, and get an eye for it, it doesn’t add too many vital seconds to quick analysis.

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R-CAT measured the PR interval at 0.36s, as did my pencil and paper, and standard rate ruler

 

The hook, as it were, that R-CAT introduces, is in the big window through the centre of the card designed to be used in ST segment and Q wave analysis.
Whereas using the edge of some paper, or a ruler can obscure or distort the view of 50% of the waveform under scrutiny, R-CAT uses a thin, red bar in the middle of a clear window, allowing for quick assessment of Q waves and ST segments simultaneously.

 

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It’s possible to view both positive and negative sections of a waveform at the same time

 

The window works well, and also functions in the presence of baseline wander, so when such an occurrence is unavoidable, it isn’t a detriment to your analysis.

The company website states it to be more accurate than marking in pencil, as graphite marks can be up to 0.4mm thick, and that is has a greater longevity than callipers, which can loosen with time, and be moved involuntarily. These are excellent points, but with wear and tear printed graphics deteriorate, so I assume that scratches on the measurement indicators could reduce the accuracy of this tool, rendering these comparisons obsolete. Nothing lasts forever, though, and out of the box it works perfectly well.

All in all, I can’t really see this product replacing already-existing products en masse, as this is £10/$8 and the analysis aids already circulating are either slightly cheaper or free, and some provide more functions, but as a learning tool the R-CAT is really effective. During my testing for this review I asked a few cardiology veterans for their immediate impressions, and all shared this opinion. New products in this category are often more of the same; a different colour here, an additional picture there, but R-CAT isn’t one of these products. It shines with its novel portability, and its gimmick; the window. I almost feel bad calling it such, as I feel the word “gimmick” detracts from the product which is, overall, a very cool bit of kit. I won’t say this is an absolutely essential purchase for current professionals who operate outside of an A&E or non-cardiac ward, but it’s certainly worth a purchase. Universities and students however, should take the plunge.

Ah what the heck, it’s unobtrusive and is genuinely helpful when you don’t have a calculator or a rate ruler to hand. If you’ve got a spare £10/$8 kicking about(!), then you should definitely buy one.

rcat-rev

 

TSP Mobile: ECG

EDIT: The Android version of TSP Mobile: ECG is available for download, but due to the way in which Google Play operates, I have been unable to offer it for free. The iOS version, when available, will be gratis for the promised 14 days however. Still no word from Apple when that will be, but I have been assured that it is being vetted as I type this, so fingers crossed!

Original article follows:

Well, that TSP mobile app I promised…

I’ve been saying I’d do it for months and, despite remaining fairly quiet with information about starting, I actually have been working on it. So much so, in fact, that the bulk of the development is finished! It’s in final stages of testing, after which it will be available on the Google Play and iOS app stores, where it will be free for the first two weeks of release, so please download it and leave some constructive feedback and a review.

The app features tutorials on ECG analysis, exercise and ambulatory ECG, cardiac flow and cycles, action potentials and useful formulae for trace analysis. Each section is laid out in an easy to follow format, with colourful diagrams and both real and illustrated ECG traces.

Heart rate and QTc calculators are included to aid analysis without leaving the app, and also access to the website blog, so you need never miss an update.

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I hate advertisements in apps, so in order to keep TSP mobile ad-free, I will charge £1 to download it after these introductory 14 days are over. In an ideal scenario, I would keep it completely free, but it has been, and continues to be, a rather expensive endeavour from both a chronological and economical standpoint especially for my shallow, student pockets, so I hope you understand why I have decided to charge.

Stay tuned to TSP via site, Twitter or email for a release date. It’s very soon!

Heart

Review: Epicardio Simulation v1.5 (Full Version)

Download for Windows/OSX:

  • Trial (Free)
  • Paid (£149-£215)
  • 60% discount for full-time students

Developer: Epicardio.Ltd

After my review of the temporary access trial of Epicardio Simulation (which offered a great deal of praise, I might add) I couldn’t wait to have a look at the full version’s features. I still can’t afford it yet even with the 60% discount offered to full-time students, but thankfully, the good people at Epicardio.Ltd allowed me to access the complete package so that I could review it. As I’ve already covered some of the functions of the program, I won’t re-tread old ground, but you can check out what I thought of the trial version here, and consider this a continuation of those original opinions.

So, what functionality is offered by the full version? Let’s go over it now.

The previously-unavailable tutorial section has some marvellous interactive elements; a view of the electrical action and a live ECG accompany the written tutorial pages, allowing the user to view the very thing they’re reading about in real-time. The procedurally generated ECGs are very accurate (I’ve measured them), but if you want to see a genuine patient-obtained trace recording, then one is included with each arrhythmia, too, which really helps with comparisons to the actual recordings one is likely to find in practice.

Almost everything you can think of is covered in some capacity, both on its own, and linked with other, relevant arrhythmias, so you really get a feel for just how interwoven some conduction and rhythm abnormalities can be.

A marvellous inclusion is the level of interactivity within the tutorials; degradation from VT to VF, for instance, is displayed live on the ECG strip and the defibrillator (that I didn’t really have cause to use in the trial version) can be charged, and a shock administered, altering the rhythm strip as it would a real patient.

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The pacing tutorials are easy to use and easy to follow; they walk you through the physics of single and dual chamber, as well as biventricular pacing. In using them to learn the basics of pacing, I can appreciate how effective the arrhythmia sections are and how useful they would have been during the early days of my studies. The interactivity of the aformentioned tutorials remains, too. Placing a pacing wire in different sites allows the user to view live rhythm changes, and sensitivity, HR and pacing rate can be toyed with so as to identify intrinsic rates and pre-pacemaker abnormalities such as 3rd° AV Block on the real-time trace.

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The test area throws generated ECGs at the student, and offers multiple answers from which to choose. Much like any degree-worthy multiple choice test, they range from incredibly easy to downright tricky, but a review section allows you to view the areas that might require further learning before each future run-through. As with the main bulk of the software, measurement calipers are useable during the test, allowing for some precise questions to be given.  Importantly, this software allows and encourages repetition; fundamental to successful learning. It may seem obvious, but I noticed that my understanding of unfamiliar areas increased the more I explored them. What won’t be obvious, is just how quickly this occurred. With the addition of the test function, the user can consolidate what they have learned at their own pace, and not have to exit the program find a different testing app.

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My time with the trial version of Epicardio only threw up a couple of minor issues. Whilst these are still present, they detract from the simulator even less than before, due to the myriad of extra content present in the full release. My only new problem came in the single chamber pacing tutorial, wherein I was instructed to reduce the pacing rate to 45bpm, yet I couldn’t lower it past 50bpm. This made it impossible to view the intrinsic rhythm of the digital patient (the point of the page in question’s existence), but only in this instance. It’s worth pointing out that regular updates exist to iron out glitches such as this, so errors needn’t remain for long.

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If, like me, your learing speed is increased by doing, as oppose to just reading or seeing, then you’ll find this tool invaluable. To be able to safely induce life-threatening ventricular rhythm is, understandably, an uncommon occurrence, so a method to facilitate this, and things like it, is always going to be welcome for students. In Epicardio, however, you get so much more than that. Pacing of all types is covered in depth, real and digitally created ECGs, and an effective test facility really do set this above any of the other programs that I’ve used. It’s also incredibly simple to get the hang of, too. The things it does well far outweigh its minor issues, so I can wholeheartedly recommend this program to everyone who wants learn about cardiac arrhythmia and interventions. Whilst the implementation of a 60% student discount brings the price down to the £59-£89 mark, it is still expensive, but you really do get what you pay for.

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Heart

Tetralogy of Fallot

Recently, in a Holter clinic, I dealt with an 8 year old patient who was on the road to recovery after a diagnosis of congenital defect, Tetralogy of Fallot. As a result, I got hold of the most interesting ECG I have recorded to date.

Background

ToF is a rare congential defect affecting the heart, that results in an insufficiency of oxygenated blood leaving the heart through the systemic circulation. Thus, it is considered a cyanotic disorder.

The disorder affects roughly 5 in 10,000 infants, and has an equal gender distribution.

Generally, four pathologies comprise ToF. Whilst all four are not always present, three can consistently be found. ToF is a progressive disorder, in that each pathology gives rise to the others.

The four principal defects are:

RVH

PVSTEN
L-R: Normal and stenotic PV

 

  • Pulmonary Stenosis
VSD
VSD supplying mixed blood via OvA

 

  • Ventricular Septal Defect
    • Hole in septum, due to malformation, causing oxygenated and deoxygenated blood to mix within cardiac structure
  • Overriding Aorta
    • Aorta is placed over VSD, transporting blood with low O2 content to wider systemic circulation

Cyanotic episodes require immediate correction, before surgical intervention.

  • High flow O2 administration
  • Physical positioning
    • Knees to chest
    • Parent cradling the child will illicit this effect naturally
  • NaCl fluid bolus
  • Vasopressor therapy
    • Increases systemic vascular resistance, shunting blood through pulmonary system.
  • Continuous ECG and SpO2 monitoring

Surgical intervention usually repairs the VSD and addresses pulmonary pathology, often at the same time.

Prognosis for ToF patients is generally very good.

  • Overall outcome improved since surgical treatment has improved
    • Survival of surgery is currently 95-99%
  • 36 year post-surgical survival is currently 96%
  • Patients who undergo surgical treatment are at greater lifelong risk of ventricular arrhythmia
  • Complications can arise as a result of a transannular patch repair, specifically;
    • RV dysfunction
    • Heart block (risk of HB has dropped to around 1%, in recent studies)
    • Heart failure
    • Recurrent or residual VSD

Hx:

  • 8 y/o
  • Previous diagnosis of ToF
    • VSD
    • PV Stenosis
    • Mild RVH
  • Treatment:
  • Transannular patch repair
  • PV Replacement

Medication:

  • Daily:
    • Atenolol
    • Aspirin

This patient was having a 24hr Holter recording to assess cardiac recovery after their most recent procedure; the PV replacement. Physical examination showed a RVOT murmur, whilst echocadiography displayed a mild RVH and PV regurgitation. Left heart functionality has been classed as excellent.

Previous ambulatory study has shown no arrhythmic action, save for that considered normal in a child of this age. No previous ECG recordings were available.

Upon monitor removal, a 12-Lead ECG was performed, the resulting trace was as follows:

ToFECG (2).png

  • Sinus rhythm with BBB morphology
  • Sokolow-Lyon value of 36mV for RVH
  • QRS & ST segment abnormalities in all leads

Ambulatory analysis relating to the most recent study did not differ greatly from previous monitoring, showing occasional sinus arrhythmia and bradycardia, five non-conducted P waves were found, and two of these gave rise to periods of sinus bradycardia. All other instances were gradual onset/offset.

Nocturnal bradycardia reached rates as low as 34bpm.

What does everyone think of this ECG and brief ambulatory report? Let us know by leaving a comment below!

Heart

 

Review: Epicardio Simulation v1.5 (Trial)

EDIT:

After writing this review, I got my hands on the full version. So this review continues here.

Epicardio offer a 60% discount to full-time students

Download for Windows/OSX:

  • Trial (Free)
  • Paid (£149-£215)

Developer: Epicardio.ltd

Studying ECG can be one hell of a mountain to climb, especially when you’re at the novice level of cardiac education. Due to how vital it is, it’s imperative that you can not only make the distinction between Mobitz II AV Block and sinus arrhythmia, but also understand the intricacies of the cardiac conduction behind them, and all of the other rhythm abnormalities. Learning these things like the back of your hand is one thing, but combining all that knowledge is, at times, overwhelming. So after 12 months of scouring the internet, trying to find a decent cardiac anatomy and 12-lead ECG simulation tool, I was over the moon to stumble upon Epicardio Simulation; a cardiac electrophysiology tutorial application, developed by Epicardio ltd.

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The program is available in 3 main forms; Epicardio ECG, ECG and Pacing, and 3-day trial. As I don’t have £149 kicking around (the price of the basic ECGcentric offering), I can’t review the full version and all of its features, but the 3 day trial version (which is £0), is well within my price range. Thus, I shall only be commenting on the features with which I have been able to sample.

Thankfully, the collection of features available to trial version users is still extensive, so I have lots to cover, and perhaps I’ll spring for the full version when funds allow. The question is: does the trial impress enough to warrant the large expense? Let’s investigate further:

Almost as soon as you open Epicardio, the vibrant display hits you; a large, anatomically accurate heart fills most of the screen as colourful depolarisation waves travel across the atria, and down through the ventricles. The live single lead ECG tracks with concordance, and the right hand menu buttons are nicely presented and clearly display exactly what they do.

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Depolarisation mechanics can be viewed through the heart as a whole, or each section on its own. Atria, ventricles, bundle branches and coronaries, can all be viewed independently whilst depolarisation occurs, so it’s possible to learn how the various components of the cardiac system operate during each cycle.

Further structural overlays can be added, in the form of the vena cava, thoracic cage and a translucent torso, further adding to the ability to understand the heart’s positioning in humans.

The electrical readout on the lower region of the screen comes with the option of cycling through all 12 leads on the standard ECG, individually, but as well the real time single lead ECG, users can also activate a live 12-lead, which again updates in real time with each cardiac cycle. This mode itself allows for different viewing styles, including the layout presented on most standard ECG printouts, which is perfect for students. It also features all the subtle morphology differences and minor, unavoidable muscle tremors that one would find on a real ECG recording. Calipers are a welcome feature, too, and they work well in Epicardio, allowing for measurements that students will definitely have to become proficient in throughout training.

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Further customisation options are numerous; the colours of the depolarisation waves are changeable, as is the colour of the backdrop. Rather than simply offering pre-set rhythms, Epicardio allows you to manually alter heart rate, and, possibly more importantly, AV delay, so it’s possible to visibly alter the depolarisation wave on the beating heart in the centre of the screen, and see the  live trace display a prolonged PR interval.

A most welcome feature is the electrode view option. A click on this button brings up a moving image of the heart within the thorax, and the standard precordial electrode sites. These electrodes can be moved anywhere and the real-time result displayed on the recorded trace, so it’s rather nice to be able to explore the difference in the voltage/time graph that occurs with electrode misplacement.

A defibrillator option allows you to shock the heart, although this was of limited use to me, as I did not have access to the fibrillatory rhythms that come with the paid version, but the artificial pacemaker below it allows the user to alter pacing pulses and observe the changes on the ECG.

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My issues with Epicardio range from those that exist simply because the version I tried is restricted, to those that are nought but minor niggles, so I shall focus on those minor niggles, as oppose to content I simply have not paid to access.

The ECG trace, whilst being incredibly customisable, would feel much more authentic if it were set against a proportional image of standard ECG paper; being able to view the trace against the background most students will see throughout studies would be a great primer in the early days of study, and considering the trace speed is adjustable, I was disappointed it wasn’t a feature.

The option buttons look lovely, offer genuine function and, once you’ve been through the tutorial and played around with them, make perfect sense. It would perhaps be helpful if a brief explanation appeared when the mouse pointer was placed over each one, however, as it was a struggle remembering what the more vague options actually did, especially for the first few hours of using the program.

However, as I stated, these are only minor gripes. Epicardio is a wonderful and genuinely fun bit of software to use. I’ve got a feel for how beneficial having this in the beginning of my studies would have been. The layout, options, functionality and simplicity of using Epicardio are all near-perfect, so I can’t wait to get a hold of the full version, complete with pacemaker-specific options. If you have a spare weekend, then follow the link at the top of the page, and download the free trial. If you have a spare £149/£215, then follow the same link and download the full version, as if it’s provides even 50% more features than the demo, I can be certain it’s worth it.

I will review the full version as soon as I can.

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Introduction to Pacing

Exams are over, coursework is in, and I’ve FINALLY got some time to devote to TSP, so I’ll endeavour to post updates with the same level of regularity as I did a few moths ago. It’s been a while since I added anything other than study pages, so it’s proving difficult to get back into the swing of reflective writing. I shall try to be clear, however.

The first week of my 15 week placement has been an interesting and challenging one. I’ve been in pacing clinics (the third of which allowed me to have some hands-on experience), tape clinics and have analysed my first full 24 hour ECG recording, so the amount of information I’ve absorbed has been of a high volume in a short space of time.

I’m not going to comment on tape analysis or clinics just yet, as I’m yet to have my completed work assessed, so I’ll wait until I’ve gained some feedback on my current performance. Pacing, however, is extracurricular, so I’ll glady share my experience.

Pacing checks were very fun; during eight or so hours of lingering/observation, I was gradually allowed to do a bit more with regards to clinical practice; analysing lead outputs and EGM readings, setting up programming equipment and learning my way around each box-specific bit of software, etc.

The majority of patients that came into the clinic were annual follow-ups, and six week post-insertion assessments, wherein the overestimated pacing parameters are altered so as to preserve battery life, and due to their nature, each was simply a case of checking each value and adjusting accordingly, meaning each 15 or 20 minute consult went off without a hitch, and I got a feel for the regular procedure and could have some of the physics explained to me. It also allowed my tutors to ask me questions and test me a bit.

The third and final clinic, however, allowed me to assume the role of primary (under strict supervision, of course) and perform threshold tests on my patient. It’s amazing how quickly it’s possible to forget everything you’ve spent the last few days learning, when it comes to actually doing it; the sudden pressure of being thrown into practical learning caused my mind to go completely blank, but with a bit of time, I settled into the role and things started to make sense as I was doing them. There’s a really overwhelming feeling of resposibility when you’re charged with manually increasing or decreasing your patient’s heart rate during threshold tests, and in addition, spotting the loss of atrial capture is, in most cases, far more difficult that that of ventricular capture. It was an exillerating experience, though, and I really felt like I had accomlished something at the end of the clinic. In three days I felt like I could quantify my progression, so the first week has left me feeling excited for the rest of the placement block.

Until this week, I’d never considered pacing as a future specialism – I was focussed on echo –  but getting some real exposure has shown me how much I could enjoy a future in the discipline. I can’t wait to do more.

I’ll write more about my own research into pacing as I do it, so keep an eye out for that.

Thanks!

 

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