Amanda (Host): Welcome to Health and Harmony Podcast from Temecula Valley Hospital. I'm Amanda Wilde, and my guest is Dr. Robin Abdel Malick. We're talking about diagnostic tools and tests for cardiac issues. Dr. Abdel Malick, thank you so much for being here.

Robin Abdelmalik, MD: Thank you for having me, Amanda. It's a pleasure to be here.

Amanda (Host): As a cardiologist, you treat coronary artery disease, heart failure, hypertension, high blood pressure, and taken together. These are rather common conditions. So let's start with this. What are the most common diagnostic tests used for cardiac patients and how do they differ in their purposes?

Robin Abdelmalik, MD: Yeah, so cardiology is a great field. We got a lot of cool tools at our disposal. The most basic of which would be like an EKG or an ECG, which you might have heard. And that's a simple test where they'll attach several. Sticky wires to your chest to monitor the electrical system of the heart and get a reading.

And that's a very quick, fast test that we can do to diagnose a number of conditions. It's a very, simple starting point. We have tests like ultrasound or echocardiography, which allows us to look at the overall structure of the heart and diagnose things like congestive heart failure or valve diseases.

other things. And then we have even more advanced testing or imaging. That's things like ct, cardiac, MRI, then things that are even more, on the invasive side of things, like an angiogram or procedures where we can go into the heart and really learn some more valuable information, and possibly even fix some things while we're there.

So there's a multitude of tools at our disposal, which makes the field really exciting and interesting.

Amanda (Host): Yes. So different tests measure different functions of the heart. So let's take just a couple of those more in depth. Well, I'm always confused by electrocardiograms versus echocardiograms. What role do each of those play in the diagnosis and management of cardiac disease?

Robin Abdelmalik, MD: So electrocardiograms or e EKGs are more to get a rhythm or an electrical signal of the heart. Echocardiogram is more like ultrasound of the heart, so that looks more at the structure of the heart. But an EKG is a, Useful tests that we do every day in the office or in the hospital setting.

It's maybe one of the first tests you get coming into an office or if you go into the hospital with any kind of cardiac complaints, that would be the first thing they do is do an EKG. It's a very quick, they can do it in a matter of minutes and get some valuable information about what's happening real time.

And it tells us things like arrhythmias, if you're having any kind of abnormal rhythm in the heart. If you've had a heart attack, if you have any kind of enlargement or structural changes in your heart. But overall, it's it's like a starting point and it may lead to other tests being done like an echocardiogram.

An echocardiogram is, like I said, more like an ultrasound of the heart. We can actually see real time. As the heart is moving, how things look. We can measure chamber sizes and we can look at the valves and see if there's any kind of buildup on a valve or leakage of a valve, or if there's any weakening of the heart muscle that could suggest, like heart failure.

So both are different modalities to tell us kind of different things about the heart, but both are very important.

Amanda (Host): Okay, so I was confused. One is for electrical one's more structural, what is the difference between the ECG, which you just described, and an MRI scan?

Robin Abdelmalik, MD: Yeah. So, on one end of the spectrum you have an EKG, which again, is a very quick, simple in-office test that takes a minute to do and tells us more again about. electrical abnormalities of the heart arrhythmia as we call them or if there's been other suggestion of damage or enlargement of the heart, things like that.

MRI is a, imaging test, so it's looking more at the anatomy of the heart. It's a little bit more involved. It's a very sophisticated, very complicated test that's done usually in a imaging center or in a hospital setting, allows us to look at more advanced kind of things in the heart.

Like if somebody has some rare conditions where they have like a protein buildup in the heart something called amyloidosis or things like sarcoidosis or if somebody's had, other congenital genetic defects that we can pick those things up on an MRI. So, so a more specialized test usually something we'll do if we're suspecting something more specific, more advanced.

Whereas an eek G is like an everyday test that is a starting point to the rest of the cardiac testing,

Amanda (Host): And then you mentioned proteins, and I've heard of this test for measuring proteins in The blood. The test is that significant in diagnosing heart attacks.

Robin Abdelmalik, MD: Yes, for sure. So troponins are vital in our assessment of heart attack patients. So, and someone goes to the hospital with any kind of chest pain. One of our jobs is to make sure they're not having a heart attack. And so troponin is vital in ruling that condition out or allowing us to identify that patient quickly so we can act on it.

And it's a test that's really evolved over the years when we first had troponins it would take. Six to 12 hours to get rise in the troponin. So if somebody came in with chest pain and we did a troponin right there, it may be normal, but it takes a while for that level to arise.

A troponin is a, protein that's released from heart muscle. So when there's damage to the heart muscle, like in a setting of a heart attack that. Protein is released into the blood and it's a signal that, the heart is not doing so well there's damage, that there's a heart attack, there's something else going on with the heart.

And so nowadays we have what's called high sensitivity troponin, where within a matter of an hour or two, we can know if that protein's in the blood and we can act a lot quicker to really save lives and reduce mortality and other problems.

Amanda (Host): Yeah, in your field there are constant advancements, aren't there? So it's interesting that some of these tests have been old favorites as well. My next question is about one of those old favorites, the stress test. how accurate are stress tests in identifying coronary artery disease and what are the latest advancements for stress testing in that method?

Robin Abdelmalik, MD: Yeah, so stress testing has come a long way. 50 years ago before I was a cardiologist, the treadmill was basically all we had, right? We would put people on a treadmill, hook 'em up to an ECG or EKG, and we would exercise them and, monitor their EKG to see if.

There was changes in the EKG that suggested a problem, like a blockage. Right. We still do treadmills to this day. again, they're like the starting point of our diagnostic testing for looking to rule out heart disease. And in a lower risk patient, it's a good starting point to go with.

'cause it helps to rule out any cardiac problems. Now That field has advanced significantly in, the past few years. We have a number of additions to that. So in addition to doing a treadmill, we can combine the treadmill with echocardiogram, ultrasound, imaging of the heart to get more information about whether there's potentially some blockage there that could be causing a problem and really improves our accuracy in that.

Another option would be to, combine the treadmill with something called nuclear imaging which is a whole nother field of cardiology that. Involves giving a patient an injection of something called a radiotracer, which is basically a, protein that's attached to like a radioactive chemical that. Allows us to see the blood flow under x-ray.

And so what that does allows us to see the blood flow in the heart and if whether there's any areas in the heart that are not getting sufficient blood that would suggest a blockage and may lead to other testing. More recently which is really exciting for the field of cardiology is the advent of CT scans of the heart.

And this is something that we've been doing a lot now. Not so much a stress test, but it allows us to actually see the arteries of the heart under high resolution CT scans. So we can actually say, Hey, you have a, plaque or a blockage in this artery. We need to look at this more.

Or, I like it because it helps me rule out disease. So those patients that are a little on the lower side and maybe they have a family history or. Their symptoms are not the most classic. It's a good test to just say, Hey, let's get this done. You don't have heart disease.

We're confident based on this test, and we can move on to other things. Or, it helps us identify that there is plaque there. And so that's been a huge boost to our diagnostic tools to really accurately assess. Now, each of these tests is important for their own reasons, and depending on the patient, their risk factors, their presentation, we may choose any of them.

They're all good in their own rights,

Amanda (Host): The last modality that we have not talked about that you mentioned earlier was the angiogram. How does a coronary angiogram work and what are the risks and benefits for cardiac patients with this modality?

Robin Abdelmalik, MD: Yeah, so coronary angiogram is a really important tool. It's both diagnostic and possibly therapeutic in our field. So, it is a procedure. Everything we've talked about to this point has been what we would consider a non-invasive test, and obviously in medicine and cardiology. We would like to get as much information as possible without causing more harm or more complications.

And so the benefit of stress testing and all these different cts and echoes is that they don't cause harm to patients. There's really no risk to these tests. They're all what we call non-invasive tests, right? They can be done in an office setting and get a lot of information.

That being said, cornea angiography is an invasive procedure. Meaning we have to actually put something inside the heart, inside the body to get our information. And so it is something that's done in a hospital setting. We would provide the patient with some, what we call light sedation or moderate sedation where.

it's not anesthesia, but they're comfortable and they won't really remember what's happening. And then we place a catheter through an artery, traditionally it was developed by putting a catheter through an artery in the leg called the femoral artery, and then using x-ray to guide us all the way up to the heart.

And then we inject contrast or dye. Through that catheter and take pictures with x-rays, we can actually see the arteries. And so this is considered the gold standard in terms of diagnosing heart disease, but it is an invasive procedure. So we would not do that as a first test on anybody unless there was really good reason or if the patient was really high risk or really met some criteria.

Because it is a procedure. there are risks with things. We're inside the arteries, we're inside your heart potential to cause bleeding. But low risk of things like stroke or even inducing a heart attack or potentially causing damage to the muscle or the arteries of the body. So those are all risks to be aware of.

Overall, it is generally a safe procedure but it's not indicated as like a first line for everybody necessarily. The benefit, like I said, is once we identify the blockage at the same time while we're there, we can also go in and open up the blockage with a stent or a balloon.

And. clear up what's there and improve the patient's symptoms and maybe life for that matter. So, it is sort of like at the top tier of what we would consider for diagnosing heart disease and also potentially therapeutic and longness to treat heart disease.

Amanda (Host): And so what would you assess the level of effectiveness taken together all these diagnostic tools you have? With the patients that you see.

Robin Abdelmalik, MD: Yeah. All of these tests are important. Like I said, I think with anything, with any tool, it's a matter of how you use it correctly. And none of this should take away from the clinical acumen and, and judgment of the physician. Right. I think we are in a field in cardiology, like you said, a lot of exciting things happening.

A lot of. New tools at our disposal, a lot of innovation in the field, but we still have to use that with our clinical judgment and clinical skills. I think to blanketly just order tests on patients, as great as these tests are, it still harmful and potentially, leads to unwanted procedures down the line.

And so each of these tests can be very valuable. It's not just because an angiogram. Is considered the gold standard that we should do that I, every patient in the right patient, we can gain right. Valuable information from just a simple EKG or an echo or, another less invasive option like a treadmill or, nuclear.

And so, yeah I think what people need to understand is we have a lot of resources and tools and innovation in the field of cardiology that can really. Drive the field forward and really help patients, but it still has to be used in the right context and with the right clinical judgment.

And so ultimately it's the physicians, it's the cardiologist that's deciding on these things that's gonna determine the efficacy and the accuracy of these tests.

Amanda (Host): You can't get rid of that human element but speaking of innovation and ai, how has the recent introduction of AI technologies influenced diagnostic testing for cardiac conditions?

Robin Abdelmalik, MD: with all the stuff in AI and all the amazing software and technology out there I think it's important to know the physician is still important. I think people think we're getting to a phase where, okay, the computer, you're gonna go talk to a computer and it's gonna tell you, all your problems and fix everything.

But ultimately. These are valuable tools that still need to be used with a human clinical reasoning approach. Right? But that said, yes, we have a lot of exciting stuff in ai. There's a lot of AI models being added to a lot of these tests to improve their accuracy and efficacy and, speed with which we diagnose things.

So as simple as an EKG a lot of the EKG machines now are being. Coupled with some type of AI software that allows them to accurately diagnose the EKG more quickly and give valuable information to the physician so they can act on that. One of the exciting things that's happening in CT is especially.

Is we have been able to couple CT imaging with AI software to actually give us both anatomical information, like whether there's a blockage and how bad the blockage is, and also more physiologic data to say, okay this is something we have to look at. And so what I mean by that is, trade off between a CT and a stress test is a stress test doesn't look at the actual arteries, but the stress test allows us to look at physiologically.

Is there a problem? Is there a lack of blood flow? Whereas a CT looks at the artery and says, Hey, there's a blockage there, but we can't always tell how bad that blockage or if it's actually causing a problem. And so if we can combine those two things together, we get really robust data.

And so what they're doing now is adding AI software or models to the CT imaging so we can get a CT image of an artery. And look at that artery, and then we apply the AI to it and the AI tells us, Hey, analyzing all the data points and everything that we're seeing here, this is a blockage that is important that we probably need to go after and maybe stent, or this is one that we can watch and maybe treat with more medication and lifestyle and follow up and things like that.

So it's really helping us make decisions clinically about patients in a lot of ways and really more accurate and efficient would say.

Amanda (Host): So the AI tools actually help with what you've alluded to during this entire interview, is that you're going for the lowest impact and highest success rate for each patient.

Robin Abdelmalik, MD: Yeah, so that's, exactly correct. I think the biggest impact that we're gonna have from AI is that it's gonna reduce the number of. Invasive type procedures and reduce complication rates and unnecessary procedures that otherwise we would've had with, more traditional testing. And, the reason for that, again, is as good as stress tests and nuclears and cts are, there is still a fair amount of what we would call.

A false positive rate where, we identify an abnormality and we take that patient to do a procedure, an angiogram, which is an invasive procedure, and we end up finding, oh, everything looks okay, and that happens quite a bit with things like a treadmill. Where you can get an abnormality that leads to another test, that leads to another test.

And this happens a lot in other fields of medicine. And so there's always that question of when do I stop testing? Right. And I think with ai, that's gonna help mitigate some of that a little bit because now we're adding a little bit. More of a smarter tool onboard to our clinical judgment to say, Hey, yeah, there's something there, but we don't need to be too aggressive here.

Let's watch it. Let's try medications. Let's go through this and maybe avoid some of those unnecessary procedures down the line. And so, like you said we're, using something that's less invasive and reducing potential downstream complications and, unnecessary procedures as well.

Amanda (Host): Well, Dr. Robin Abdel Malick, thank you for your time and sharing your expertise to get us up to speed on diagnostic tests for cardiac patients.

Robin Abdelmalik, MD: Thank you, Amanda. It was a pleasure talking to you. It's always exciting in cardiology and always enjoy sharing it with other people out there to educate them too, so.

Amanda (Host): For more information, visit tv heart.com. Physicians are independent practitioners who are not employees or agents of Southwest Healthcare Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians. Thanks for listening to Health and Harmony Podcast from Temecula Valley Hospital.