"There are many more young patients with high cardiovascular risk"
Obesity, metabolic disorders, physical inactivity, and chronic stress can trigger the development of cardiovascular diseases long before the first symptoms appear. On World Heart Day, the head of the Department of Cardiology and Cardiovascular Surgery at the University Clinic of the Lomonosov Moscow State University Medical Research and Educational Institute, Deputy Chairman of the Department of Cardiology and Cardiovascular Surgery, told about how artificial intelligence helps to detect hidden changes in the heart, what new drugs for obesity give, and how close treatment is that can permanently lower cholesterol after one procedure. The Scientific Committee of the National Prize in the field of future technologies "Challenge", Academician of the Russian Academy of Sciences Simon Matskeplishvili.
"The very picture of cardiovascular diseases is changing"
— Cardiovascular diseases remain the main cause of death in Russia. Is their structure changing? Are there any diseases that get younger?
— I would use the word "getting younger" carefully. This is not to say that a heart attack suddenly moved massively from the age of 60 to the age of 40. But something else is obvious: there are indeed many more young patients with high cardiovascular risk.
We are increasingly seeing obesity, high blood pressure, metabolic disorders of sugar and cholesterol in people aged 30-40. Such a person does not consider himself a cardiologist's patient yet — and he is not. But the processes that can lead to a heart attack or heart failure in 10 or 20 years have already been started.
And here there is a very important change in medicine itself. Cardiology is moving from photography to film. Previously, we were primarily interested in what was happening to a person at the moment: what was his blood pressure, cholesterol, electrocardiogram, and how the heart was contracting. Today, we are increasingly trying to understand the trajectory of where this person is going, what will happen to his heart in five, 10, 20 years. And the main thing is whether we can change this trajectory before the disease occurs.
At the same time, we have learned to save people with acute cardiovascular events much better, and to treat many cardiac and non-cardiac diseases. This has led to an increase in the number of patients who have been living with coronary artery disease, heart failure, rhythm disorders, a combination of heart disease with diabetes, obesity, and kidney disease for decades. Not only is the patient's age changing, but the very picture of cardiovascular diseases is changing.
— What factors most strongly change the age structure of patients: obesity, diabetes, physical inactivity, stress, smoking, sleep disorders? Do gadgets affect these processes?
— If you choose one of the most serious problems, I would name obesity and related metabolic disorders. Today we understand that adipose tissue, especially visceral fat around internal organs, is an active tissue. With visceral obesity, it becomes a source of substances that support chronic inflammation. In addition, it helps to reduce insulin sensitivity, increase blood pressure and impaired lipid metabolism, and affects the condition of blood vessels and the heart.
But almost never does one factor act separately from the others. A person moves less, gains weight, sleeps worse, and experiences chronic stress. Blood pressure increases, sugar and fat metabolism is disrupted. These factors begin to reinforce each other.
As for gadgets, I would not demonize them. A smartphone by itself does not cause cardiovascular disease. The question is, what does he displace from our lives? If the screen takes away sleep and movement, it's bad. If a watch or phone makes a person walk more, monitor their pulse and blood pressure, or detect a heart rhythm disorder in time, this is already a useful medical tool.
— Which scientific developments of the last two years are most important for cardiology? What will really change clinical practice in the next 5-10 years?
— Now several directions are developing simultaneously, which until recently looked almost fantastic. Very noticeable changes are taking place in cardiometabolic medicine. Drugs that were developed to treat diabetes and obesity have proven to have a positive effect on the course of cardiovascular diseases.
Genetic technologies are developing rapidly. We are already discussing the possibility of permanently altering the level of certain atherogenic lipids, substances directly involved in the development of atherosclerosis, by a single intervention in the genome. Such approaches have already emerged from the laboratory and have begun to be tested in patients. We are interested in controlling the activity of genes without changing the DNA sequence itself. We want to explore the possibilities of this approach. We are also planning to start serious research in this area very soon.
Research continues in the field of cellular technologies, restoration of the heart muscle, and stimulation of the growth of new blood vessels.
But if we talk about the next five to ten years, I would especially look closely at those methods that have already come out of the laboratory and have begun to be tested in clinical trials in real patients.
"One of the main purposes of artificial intelligence is not to replace a doctor, but to help him not to miss important things"
— How does AI help to detect heart diseases? Do you use it in your work? How soon will a conventional ECG algorithm be able to detect heart failure before symptoms appear?
— Yes, we are studying and testing such technologies, primarily as a decision support tool. For me, artificial intelligence is not an electronic doctor, but a very attentive second opinion.
The analogy between photography and film works well here. An ordinary electrocardiogram is like a photograph of the electrical work of the heart at a specific moment. The doctor looks at her and sees the rhythm, conduction disturbances, signs of ischemia, and other known changes. But for a computer, this is not a few teeth, but a huge array of numerical information. If you compare the electrocardiograms of hundreds of thousands of people with what happened to them a few years later, the algorithm can detect combinations of signs that the human eye simply does not distinguish. Today, there are systems that can identify people with an increased risk of future heart failure using a conventional ECG.
It almost sounds like predicting the future. But there is no mysticism here. The computer does not see the future — it sees today's signs, the meaning of which we do not yet know how to recognize. And this is a very important difference.
But high risk is not a diagnosis yet. You can't tell a person, "You're going to have heart failure in five years." You can tell the doctor, "Pay special attention to this person." This is what I see as one of the main purposes of artificial intelligence — not to replace a doctor, but to help him not to miss important things.
— New drugs for the treatment of obesity are already changing the approach to cardiovascular risk. Can we expect that a cardiologist will prescribe them to prevent heart failure?
— This is already happening in a certain group of patients. And, in my opinion, this is one of the most important changes in recent years. Previously, weight loss was perceived primarily as an additional benefit: a person lost weight, it was easier for him to move, blood pressure decreased, and sugar metabolism improved. Today, we see that in certain patients, exposure to obesity can change the course of the cardiovascular disease itself. In recent large-scale international studies, drugs developed for the treatment of diabetes and obesity have reduced the risk of cardiovascular complications in patients with pre-existing heart and vascular diseases. And in patients with heart failure and obesity, they reduced the risk of deterioration. This is a fundamentally different view.
A cardiologist no longer treats kilograms. It affects the metabolic processes that are involved in heart damage. This concept is especially interesting in heart failure, when the heart seems to be contracting normally, but the patient has all its manifestations — severe shortness of breath, weakness, exercise intolerance — and obesity becomes one of the mechanisms of the disease.
But you can't get euphoric here. These are serious drugs, they have indications, limitations, and undesirable effects. They should not turn into a universal pill, or rather, an injection "to protect the heart." The doctor's task is to determine which patient's metabolic change will actually change the cardiovascular prognosis.
— Until recently, genome editing in relation to cardiovascular diseases seemed fantastic, and now the first clinical studies of CRISPR approaches for correcting lipid metabolism have appeared. How realistic is the scenario in which a single intervention is enough for a person to reduce the risk of atherosclerosis for years?
— As I said above, today this scenario has already moved from a theoretical possibility to the first human studies. Today, certain genes are known that are involved in the regulation of cholesterol and lipid levels in the blood. Modern technologies make it possible to change the work of such a gene directly in liver cells. A person receives treatment once, and the level of atherogenic lipids can decrease significantly for a long time. In the first clinical trials, after one infusion, it was possible to achieve a marked decrease in the level of "bad" cholesterol, and the effect persisted for months. It really resembles the "one intervention instead of decades of treatment" model.
But it is especially important to maintain scientific caution here. It's one thing to show that cholesterol has decreased after the intervention. It is quite another thing to prove that in 10 or 20 years these people will actually have fewer heart attacks, strokes and other complications. In addition, an intervention based on CRISPR technology is then almost impossible to simply cancel, like a pill. Therefore, the safety requirements must be extremely high. ""We want to explore the possibility of "turning on" and "turning off" the necessary genes without editing the genome itself.
Most likely, the first patients will be people with severe hereditary disorders of lipid metabolism, for whom existing treatment methods are insufficient. But the fact that we are already seriously discussing such an approach shows how fast medicine is changing. We are starting not just to treat the consequences of the disease, but to try to change the very biological trajectory of risk. But before widespread use, it is necessary to make sure that long-term modification of the gene is safe and really helps the patient to live longer and better.
— What is your approach, which you call "bypass surgery without bypass surgery", and at what stage is this direction?
— The name is intentionally a bit provocative. Imagine that the large artery of the heart is gradually narrowing. The body is trying to protect itself — collaterals begin to develop, blood vessels through which blood can reach the heart muscle in a different way, not through a narrowed artery. This process is called the development of collateral circulation: nature itself is trying to create a bypass route. The problem is that the disease often develops faster than the body has time to form a full-fledged network of such vessels.
Our idea is to help him do this faster and more efficiently. Not to sew on a new vessel, as with conventional coronary bypass surgery, but to stimulate the development of the patient's own vascular network. Hence the expression "bypass surgery without bypass surgery."
— Another area of your work is studying the mechanics of myocardial contraction and perfusion. Will the doctor be able to receive not just an ejection fraction, but a kind of "mechanical passport" of the patient's heart in the future?
— I really like the expression "mechanical passport" of the heart. The ejection fraction was and remains one of the most important indicators of its operation. But the heart cannot be fully described in one digit. Imagine two patients. Both have a normal ejection fraction, say 55%. Formally, it is the same indicator. But one heart can work effectively, while the other already hides disorders that one ejection fraction does not show. After all, the heart muscle contracts in different directions, twists, relaxes. At the same time, she must receive a sufficient amount of blood through the coronary vessels.
Today, we can measure these processes much more accurately and compare the mechanics of the heart with its blood supply. Therefore, the future, it seems to me, is not about finding one new "ideal number." It is behind the multidimensional individual profile of the heart. The doctor will see how the heart contracts, how efficiently it performs its work, which areas receive less blood, and how all this changes with exertion and after treatment. And then the expression "mechanical passport of the heart" can really become quite a medical concept.
— You are the deputy chairman of the scientific committee of the National Prize in the field of future technologies "Challenge". How does this award help the domestic healthcare sector?
— I would expand the question a bit. The "Challenge" Award supports not only medicine. It supports science and technology, from which the medicine of the future will later grow. The history of science shows that decades sometimes pass between a fundamental discovery and the appearance of a new treatment method. What cardiologists will use to treat patients in 15 years may today look like research in the field of molecular biology, physics or mathematics, completely far from the clinic.
First, someone discovers a new mechanism in the cell, a new material, a new mathematical principle. Then suddenly it turns out that it can be used to make a medicine, diagnostic method, or medical technology. Therefore, sometimes the best way to help healthcare in the future is to support good basic science today.
— If we are not talking about the distant future: which technology or idea do you consider capable of significantly changing the fate of patients with cardiovascular diseases - and what prevents its introduction into Russian practice?
— If you force me to choose only one idea, I will not name a specific drug or a specific device. I will choose the opportunity to see the trajectory of the disease before the person feels sick. Today, cardiology is still following the event in many ways. A heart attack has occurred — we open an artery, heart failure has appeared — we begin to treat it, arrhythmia has developed — we implant a device or perform ablation.
But the real medicine of the future should work differently. A person feels well, and we already understand that in five or 10 years they will have a significantly increased risk of illness. The main thing is to move from photographing the current condition to understanding the trajectory of the disease. In many cases, we already know what can be done now to change this trajectory.
The criterion in medicine is ultimately very simple. If, thanks to a new technology, we have changed the fate of a particular patient and the person has lived longer and better, then this technology has really taken place.
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