Sound, rhythm, rate, structure, function – countless features of the heart are measured to keep it healthy for as long as possible. Recently, an army of digital health technologies joined the forces of traditional preventive tools in cardiology to counter stroke, heart attack, heart failure or any other cardiovascular risks. In the future, minuscule sensors, digital twins, and artificial intelligence could strengthen their ranks. Let’s see what the future of cardiology might look like!

Fitness trackers, chatbots and A.I. against heart disease

Let’s say 36-year-old Maria living in Sao Paulo in 2033 decides one day that she wants to change her life and starts running for half an hour every second day. As it’s almost unimaginable to do sports without data measuring gadgets, she starts using a smartwatch. After a while, the device shows an abnormal heart rate and the notification lands in her doctor’s inbox. After a consultation, the two decide that Maria needs further insight and monitoring – so she receives a portable, recording ECG.

This is not even science fiction anymore, there’s already a study from 2019 that outlines a similar patient route for cardiac rhythm management as a viable one. Other studies are looking for the answers to determine if individuals with known atrial fibrillation (AF) who use smartwatches or wearable devices use more health care resources and achieve better AF control compared to patients not using these devices.

Further away in the future, Maria might also get tiny, implantable sensors to monitor potential symptoms – just as UConn Health’s Pat and Jim Calhoun Cardiology Center does in the case of heart failure patients. Maria might also use Babylon Health’s Healthcheck A.I.-based chatbot to give her a quick assessment of her health, but she might eventually have to go to the hospital for a 12-channel ECG or further exams to decide on preventive treatment. Since the emerging symptoms were already noticed long before anything could happen, Maria could be certain that her ticker will remain healthy for a long time. That’s the promise of technologies for the heart – which we’ll break down in the coming sections.

Cardiology and the ‘silent epidemic’

According to the WHO, cardiovascular diseases take the lives of 17.9 million people every year, which means 32 percent of all global death. Moreover, they are estimated to be the most expensive conditions to treat. Another common feature is that they are slow to show symptoms, which is why they’re called the ‘silent epidemic’.

Tobacco use, excess alcohol intake, an unhealthy diet or physical inactivity can lead to hypertension, elevated blood glucose levels, being overweight and obese – all of which will eventually manifest as heart attacks, strokes or other severe heart conditions.

Early detection would be key to prevention, but that could only happen through constant monitoring, as early signs of heart diseases are difficult to catch. That’s why it has been so challenging to take up the fight – until the appearance of pocket-sized, user-friendly digital technologies.

Fitness trackers, health sensors and wearables are not only able to measure physical activity, to give personalized dietary recommendations, help medication adherence or optimize sleep, but also monitor various parameters of the heart. The Medical Futurist hopes that with the perfection of such easy-to-use devices and their equipment with artificial intelligence, within the next couple of years, cardiology might be more about prediction and early intervention than about the treatment of full-blown diseases. So we looked around in the cardiological landscape to locate the most promising technologies and give a heads up as to what to expect in the future.

1) How to measure heart sounds?

Let’s start with diagnostics and the most common exam done by every GP: listening to heart sounds with the stethoscope, the symbol of being a doctor. Their updated version, the digital stethoscope lifts the old-fashioned device to new heights to meet the requirements of the 21stcentury.

The most well-known digital stethoscopes on the market are the EKO Core products. Small, simple, portable and smart medical devices, which let patients and doctors measure heart rate and record heart and lung sounds, saving it automatically to the app. Combining infra-red technology with Bluetooth connectivity, you can also stream the measurements to a clinician remotely, storing them for comparisons later.

An Australian company, M3DICINE was the first to create an artificially intelligent stethoscope system. They worked together with MIT researchers, clinical experts from the Mayo Clinic, nurses, cardiologists, and other health professionals. Today this feature is not unusual anymore, a wide range of digital health products – including stethoscopes – use artificial intelligence to support the diagnosis.

It remains yet to see if other solutions, like digital tattoos, can find their way into clinician work. An electronic tattoo created at the University of Illinois at Urbana-Champaign picks up on subtle noises inside the human body, including the sound of your heart, muscles, and gastrointestinal tract.

2) What to make of heart rhythm and blood pressure?

Your heart, this fist-sized powerhouse beats 100,000 times per day – about 60 to 100 times each minute, pumping five or six quarts of blood each minute. As it is not a monotonous, robotic machine, higher and lower blood pressures can occur, just as the phenomenon of your ticker skipping a beat, especially when catching Jennifer Lawrence or Ryan Gosling sipping coffee on a random Italian terrace. However, if beat-skipping or out-of-normal-range blood pressure measurements increase, the possibility of cardiovascular diseases also appears on the horizon.

While blood pressure cuffs are common inhabitants of patients’ apartments, there has been no way to record irregular heartbeats at home until recently. And let’s be honest, it was also high time to modernize the good-old cuffs. Fortunately, both issues are tackled by digital health technologies.

Pulse and heart rate are vital signs measured by all kinds of fitness trackers and wearables, from Fitbit to Apple, Garmin or Polar. Beyond the basics, numerous companies offer complex measurements making portable diagnostics for chronic heart conditions a reality.

For example, the Palo Alto-based MOCAcare’s MOCAheart device is for heart rate, blood oxygen, and pulse wave velocity monitoring. A South Korean company, Smartsound Corporation developed Skeeper, a pocket cardiologist that listens to your heartbeat with the level of the accuracy of a stethoscope, analyzes beats per minute (bpm), and heartbeat consistency. The latter helps its user manage inconsistent heart rate (arrhythmia).

They are both tiny, pocket-sized devices, but the latest trends are actually about patches – leading to digital tattoos in the future – and smartwatches measuring vital signs. A great example for the former is VitalConnect’s patch, a biosensor monitoring eight physiological measurements simultaneously – among others heart rate, heart rate variability or respiratory rate, while also functioning as a single-lead ECG.

Japanese Omron and Israeli Biobeat have been developing blood pressure monitoring systems. Some og these wearables even promise continuous blood pressure monitoring and the measurement of mean arterial pressure, pulse rate, blood saturation, stroke volume, etc.

The Medical Futurist believes that blood pressure cuffs will disappear eventually, tiny wearables, patches and digital tattoos gradually taking their place. However, we are not there yet, as of now pretty much all the devices we tested in this sub-segment came with slightly more compromise than we’d like to accept.

3) Measuring ECG to monitor atrial fibrillation while doing the dishes at home?

Your heart wants to jump out of your chest like a giraffe trying to escape from the zoo, like a criminal breaking out of jail, like a bird fleeing from a cage. Your pulse rate feels to be accelerating like a spaceship wanting to leave the gravitational field of the Earth. You don’t know what is happening and you are scared of what might be happening next. That’s usually how patients experience atrial fibrillation (AFib). In addition, it’s not only frightening, but it’s also dangerous: it can increase the risk of stroke, heart failure, and other heart-related complications.

Until recently, it was overwhelmingly difficult to deal with AFib, as it needs continuous electrocardiogram (ECG) monitoring providing data about heart rate and rhythm. That has changed with the appearance of digital health devices. For example, AliveCor’s Kardia is an FDA-approved, medical-grade ECG recorder – and the latest model is literally the size of a credit card, see our review here. It can tell you within a minute whether your ECG is normal, whether you possibly have AFib or experience some “unclassified” risks.

A study found that coupled with an Apple Watch, the Kardia was able to detect AFib with very high sensitivity. Moreover, another research has shown that when paired with artificial intelligence technology, it was able to detect high potassium levels in blood non-invasively, which could signal diabetes or heart failure.

For Apple, that was a preliminary step until it introduced its own ECG-measuring and irregular heart rhythm notification feature in 2018. Later-generation Apple Watches carry on this feature and received FDA approval on AFib detection and in 2022, for AFib history feature.

Wiwe is another smart sensor using a unique, intelligent algorithm that evaluates the properties of the ECG wave to calculate if there is a risk of AFib-related stroke and sudden cardiac arrest. It not only gives accurate data about ECG, blood oxygen level or different physical activities, but the use of the pedometer function helps reduce the risks related to heart diseases.

Another pocket-sized device, the Swedish Coala is the combination of a digital stethoscope and a high-performance ECG monitor. Similarly to the Kardia, it spits out measurements very fast: in one minute you’ll get analyses and screenings for 10 different cardiac pathologies.

However, most of these provide single-lead ECGs, commonly known as a rhythm strip; while multichannel – usually 12-lead – ECGs record information from different views of the heart, and offer a complete picture of electrical activity. So far, we know of the Kardia 6L which tries to fill this niche, formerly, a Russian company Nordavind and its ECG Dongle also targeted the same segment, but they went out of business.

We believe that in the future, patients would monitor their heart health anywhere, and the artificial intelligence-powered gadgets will only notify them and their physicians in case of abnormal health events. As a response, cardiologists could examine the patient – perhaps do a 12-lead ECG in clinical conditions, but as data from innovative gadgets will be 100 percent clinical-grade, that will be rare. Some even say that such chronic conditions as AFib or heart failure will no longer be managed by cardiologists and maybe not even by physicians but rather by highly specialized nurse practitioners.

4) How do plaques and A.I. come together?

Artificial intelligence will support cardiology mainly in its quest to provide more and more efficient tools for prevention and prediction. Within a couple of years, all devices for continuous monitoring will be equipped with smart algorithms – and predictive power may also come from unexpected medical fields and areas seemingly far away. According to a study published in Nature Biomedical Engineering, Google researchers predicted cardiovascular risk factors not previously thought to be quantifiable in retinal images using A.I. Scientists were able to identify risk factors such as age, gender, smoking status, blood pressure and major adverse cardiac events by only looking at the eye.

A.I. can not only help in continuous monitoring and the prevention of the development of cardiovascular diseases, but it can also support diagnostics, cardiac imaging or therapy selection, too. For example, Cardioexplorer is the first evidence-based A.I.-powered test which detects plaques, fatty deposits in heart arteries with higher accuracy than many standard procedures. That’s highly important since when the walls of the veins become thick and stiff, the flow of blood will be restricted – potentially resulting in a heart attack.

Arterys’ AI-powered Cardiac MR Suite allows cardiologists to view the patient’s heart in 4D, by color coding the blood flow in the heart in real time. However, the peak of showing medical images as close to reality as possible comes with the concept of the digital twin. That’s about bringing together as much data as possible and simulating the possible outcome of therapy, treatment or drug on the heart before the actual intervention. For example, Siemens Healthineers is working on creating a digital twin of the heart. The French company ExactCure does something similar in as much as it is creating a digital twin on a patient’s smartphone and simulates personalized drug response.

Now, what if we go back to Maria and the beaches of Sao Paulo spotted with palm trees? Did I mention why she decided to change her life? Well, it’s rather a sad story. Her 65-year-old dad collapsed on the beach – it turned out it was a heart attack, but the emergency services couldn’t do anything, they couldn’t save him. Maria was devastated for long months, but one day she decided that she will fight back and she will win. That’s when she put on her sneakers, started to run and placed her trust in data.