A Counterblast to Pessimists and Naysayers – Intelligent Echocardiography Remains the Foundation Stone of Evidence-Based Clinical Cardiology

Abstract

Provocative comments can entertain and instruct as long as they are used to stimulate a civilized discussion, and it is fun to embrace an opportunity to change one’s mind (and learn). I am therefore delighted to respond to Adrian Ionescu’s comments, although I think he has got it wrong—as I will aim to demonstrate. In the spirit of this debate, please indulge me while I too let off some steam! I have always disliked the fact that one of the subspecialties within cardiology, which did not exist when I qualified in the 1970s, has come to be known as “cardiac imaging.” Cardiac diagnosis is not about pictures, although some conditions are indeed instantly recognizable. Usually, what we need to know to understand disease is how the heart is functioning, much more than what it looks like. That is true for coronary arteriography as much as for non-invasive imaging. If I am forced to adopt a subspeciality label, then I would much prefer to be considered a clinical pathophysiologist. Accurate diagnosis is the sine qua non of logical evidence-based clinical practice, yet we often get it wrong. And there remain many patients with disease that we cannot diagnose precisely because we do not understand it sufficiently. Why does this patient with heart failure with reduced ejection fraction have impaired left ventricular function? Why does that patient with normal blood pressure have left ventricular hypertrophy? In this patient in sinus rhythm, which particular aspects of cardiovascular function will influence the development of dementia? Cardiologists who are expert in performing, analyzing, and interpreting detailed echocardiographic and cardiovascular investigations are needed to give us the best chance of answering such questions. They cannot be replaced by an uninterpretable computer algorithm when no-one yet knows the answer—but by staying in control, researchers can use artificial intelligence (AI) to help their thinking.