036 - New tools for Cardiovascular plaque detection

Hello and welcome to The Imaging Wire Show. My name is Brian Casey. I'm managing editor of The Imaging Wire. Got a great episode for you today. Our topic is new tools for cardiovascular plaque detection, and our guest is Dr. John Osborne of Cleer Cardio. Dr. Osborne, thanks for being with us today.

My pleasure, Brian. It is a pleasure and an honor. Thanks for having me on.

You bet. So can you tell us a little bit about yourself and a little bit about Cleer Cardio? Sure.

So I like to call myself a preventative cardiologist. That's really been my passion for nearly 30 years, really spanning 2 important aspects in prevention imaging, which is absolutely critical to preventive cardiology, which I think we're going to talk a lot about. And then the other side of things, which is probably not good to talk about, is what we do with that data and what we do with the imaging data to translate that to less strokes, less heart attacks, less cardiovascular events, or as I like to say, my ultimate goal goal is that we eliminate heart disease. But I will say we are not gonna be able to do that without imaging. And I think that's a great segue into kind of what I think what we're gonna be talking about.

All right, great. Well, let's go. So one of the, the most important things that has kind of developed with detecting early detection of heart disease is, is this concept of cardiovascular plaque. And we've known about cardiovascular plaque for a long time, but can you tell us a little bit about what exactly it is and, and why we think it's a risk factor?

Sure. In the natural history of heart disease, right? And of course, lots of things can go wrong with your heart, but probably the single most common thing that happens with your heart is the development of plaque in the blood vessels. And we've known from animal studies, from human studies, from natural history studies, that plaque begins to form decades before we ever have any symptoms from it, complications from it. Angina, chest pain, stress test, flunk a stress test, or whatever. The problem is we just did not have adequate imaging tools to be able to pick up that early asymptomatic preclinical atherosclerosis. The big revolution over the last— and every revolution starts decades before you think of it— the revolution of that ability to be able to look and detect that. really started about 20-plus years ago when we began to have commercially available, at least to outside of just research organizations and academia, the multi-slice CT machines. They really began to come online and commercially available back in 2005. Of course, we were one of the first to get one of those back then, and it really was unbelievably enlightening The ability to diagnose stuff that we knew was going on, but we simply could not detect in a living human being. We could see it great on the autopsy, but be able to see this and detect it in people that had no symptoms. We could show them that the plaque has begun literally years or even decades before they ever began to have symptoms or problems from the disease. So, Like all revolutions, it really goes back a number of years. But I like to say back in 2005 era, we had the iPhone 1 version of technology, and it's wonderful. Now, a little over 20 years later, we now have the— I like to call it the iPhone 17 version of this imaging technology.

That's awesome.

And we're going to talk a little bit more about imaging in a minute.

Now, it seems like originally we thought that calcified plaque, you know, kind of really hard plaque, was the most dangerous. But now we're learning that it's a lot more complicated than that. And the composition of the plaque is what really could lead to a cardiovascular event.

Can you talk about what, what are the plaque components that make it dangerous? Sure. So the initial plaque that's laid down, if you look at it over time, is what we call the lipid or soft plaque. Okay. That literally is that lipid soft plaque, that buttery, waxy type stuff that begins to form in the arteries of the vessel. That is not seen or detected with a calcium score. So it is invisible. Now, over time, or actually with treatment, that invisible lipid-rich plaque can convert to the hard calcified, quote, stable plaque. Or as I like to say to my patients, the soft lipid-rich plaque, I called that the lava. Like lava over time can convert into the hard extinct volcano. When we do calcium scores, which again, we've been doing since the 1980s, by the way, You know, someone said, hey, this plaque has calcium in it. We can see that with CT scanners. Let's put people in a scanner without contrast and see if they have calcified plaque. So we could see that. However, that really is the tip of the iceberg because calcified plaque generally is the stable plaque. It's the older plaque. We can kind of carbon date plaque, I like to say, by seeing the hard calcified plaque. It is the older plaque, the inactive plaque. What was invisible until we had cardiac CT and high-resolution, both temporal and spatial resolution CT, is to be able to see the precursor, the more important plaque, the softer lipid-rich plaque that always precedes the calcified plaque. And again, that was invisible on our calcium scores, but now with the tools we have available, we can readily both see and detect, and now with AI, quantify that plaque and literally be able to see that soft lipid-rich plaque, the dangerous plaque, the stuff that can break off, flake off, cause heart attacks. That really is the critical plaque. If you see calcium on a calcium score or incidentally that says yes, that person 100% has plaque. But the problem is we're only seeing the hard plaque. The inactive plaque tells us nothing about the lipid-rich plaque.

Now, you mentioned AI, and AI is having such a big impact in medical imaging. How is it being applied to this issue of diagnosing and figuring out what's going on with that plaque in the arteries?

Sure. So we're using AI every day across the entire chain of imaging. We certainly use it in our Atlas 960 machine, which is an amazing machine. We have a really significant upgrade, really exploiting a lot of the AI technologies to add to the quality of images. And at the same time, not only getting better quality out of the CT machine, higher resolution and better quality images, less— greater signal-to-noise ratios, but also then using that AI from the raw data coming out of the CT machine, but then using other AI to post-process that CT data to be able to really highlight the kinds of plaque, the soft plaque, the hard plaque, characterize that plaque, and now quantify that plaque as well. There are, of course, a number of AI add-on programs we use. We use Cleerly, but there are others we do. But that combination of this incredibly high-resolution raw data coming out of the CT machine, again, using AI to really clean up and give us beautiful pictures, but then further processing that with AI that allows us to quantify and to detect and quantify and now actually to track over time is really one of the biggest revolutions in cardiac CT in the last several years.

That's amazing. Let's dive a little bit more into the CT technology that's being used because acquiring the images That AI is using to analyze. So you were an early adopter of United Imaging and the UCT Atlas scanner. What attracted your attention to United Imaging and how did you feel like the Atlas scanner was right for your practice?

Tough questions because honestly there's so many aspects of that. But in brief, a company that has been around, they have a massive installed base worldwide. I will say, I'm very proud to say we were the very first Atlas 960 install in North America. So very proud of that a few years ago. But really what swayed our decision, we looked at all of the other legacy vendors. They have great products, but the things that really stood out, 16-centimeter whole organ acquisition, lower radiation because of that. We don't have to, to Tie together various slices anymore. So that's no longer an issue. Misregistration errors and all that, no longer an issue. Again, very high both temporal and spatial resolution. Very, very quick acquisition, of course. Dramatically improved our ability to capture great images even at higher heart rates and do all of that at a very low radiation cost, if you will. Also to a beautifully developed system, both across the hardware itself for image acquisition at the CT level, but also the image acquisition and processing ability with the workstation as well. Beautifully engineered, put together, extremely thoughtful. The resolution, the image quality, the ease of use, and even training. I will admit to you I have never been trained on your workstation. I use it every day. I've never been trained on it. Didn't need it. That's how intuitive it was. I've never been trained on it. And even for my CT techs, the training process, which I've used many other CT machines in the past, it was long, it was arduous. They disappear for a week or two, they come back, they'd still have people to work with them getting beautiful pictures. Uh, Our techs never left our building. All of the training was done on-site. Quick, rapid, simple. Just a testament to the beautiful UI and ergonomics of the user interface with the console for image acquisition as well. All of that and many other reasons, it was a very easy, simple decision for us to acquire the Atlas 960.

Awesome. Now, do you feel having the UCT Atlas has changed the way you use cardiac CT, especially for maybe like more complex conditions or structural heart patients? Yeah, absolutely.

I mean, use it for everything. I will say, since we acquired our Atlas, I used to cath people. I don't cath people anymore. So there is no such thing as the diagnostic cath. It's all done with, you know, now with cardiac CT, I can see better, more accurately define plaque, measure plaque, quantify plaque, all in a way that was impossible in the cath lab and really seeing where plaque is really active, which is in the wall of the vessel. Not the channel or the lumen, just what we see in angiography, plus any structural aspect of the heart, valvular heart disease, cardiac anomalies, coronary anomalies, congenital heart disease, holes in the heart, VSDs, ASDs, again, valve disease, mitral, tricuspid valve, aortic, just unbelievably well imaged and really understood at that anatomical level. With high-resolution, 3-dimensional, now even 4-dimensional cardiac CT that we obtained from the Atlas. So it's dramatically changed how we approach heart disease, both those people that have symptoms, secondary prevention, or they have significant symptoms and are having problems, or again, also the individuals that appear to be normal, feel fine, but we can put them in machine and either reassure them they really don't have issues or detect problems, that early asymptomatic atherosclerosis, and then absolutely detect it. I call our CT machine It is a binary tool. Either have a problem, you don't. We see it, you don't. Whereas before in cardiology, there's a huge amount of maybe, could be, possibly. With this, it's a binary tool. It's zeros and ones. You have it or you don't.

A lot more definitive.

Yeah, absolutely.

United Imaging also has a lot of great radiation dose-lowering technologies, and there's been so much attention toward reducing radiation dose. Can you talk about how you balance dose and image quality for cardiac and aortic studies and Has it changed your threshold for ordering CT instead of other tests?

Sure.

Yeah.

So, I mean, the base hardware really, you know, whole heart acquisition, 16-centimeter, very fast acquisition, high temporal and spatial resolution offered us from the get-go the ability to minimize radiation dose. But I will say, as the software has evolved and continues to evolve, and again, of course, everything in our world AI being applied to that. We had a major upgrade, R3300 upgrade, a few months ago that was just mind-blowing. I mean, it accomplished what is usually really impossible to do— better quality images, signal-to-noise ratio with our images, and at the same time, much lower radiation. So it really continues to remove any obstacles or barriers, either on the clinical side or the patient side, Where, you know, of course, is always something we want to use the least of, get the least radiation. But with this hardware-software combination now, the real augmented use of AI, we can routinely obtain cardiac CT images, beautiful quality, at doses that are really shockingly low. So yes, it really has changed. You know, nowadays, to be honest, I don't use stress testing anymore. We can do a better job acquiring anatomic data. Plus we have, of course, tools as well. I have all of the tools that we used to use functional testing to do, but instead with one test, cardiac CT, I have anatomy, quantitative analysis, plaque detection, quantitative plaque analysis, and CTFFR in one quick, fast tool. So it really has dramatically impacted just the diagnostic approach. to the detection and early detection of cardiovascular disease.

That's amazing. So let's talk a little bit about the services that Clear Cardio offers. Can you talk about that and, and kind of your approach and maybe how it's a little bit different from maybe a, a general medical practice?

Sure. So obviously I'm a preventive cardiologist. My passion in preventive cardiology goes back nearly 30 years. I was fortunate enough to, to have not just an MD but also a PhD. I love the basic science as well. Did all my training at Harvard after my MD and PhD, came down to Texas because, frankly, I'll admit, in Boston, people are relatively healthy. But I will say, unfortunately, I mean, I'm not here to diss my Texas colleagues, and I love them, and I'll never move from Texas. But in Texas, basically had barbecue smoking and no sidewalks. So Texas is going to be a better place for me to help save the world from cardiovascular disease. And at Clear Cardio, it's really just the manifestation of 30 years in the realm of preventative cardiology, which is leveraged upon 2 things. One, imaging, which obviously we have the apex of, and then also just how we fix and stop plaque. And I will say, Clear Cardio is not a scanning company. It's not an imaging company. It is a cardiovascular detection and prevention organization leveraged on tools such as high-resolution imaging with cardiac CT, also using multiple different forms of AI to give us the clearest possible pictures and images, uh, of what's happening with the patient, both at the clinical level, but also too, one thing that we do 100% of our time with our patients is we share those images with our patients. We just don't say, well, the study comes back this way and we have blockages or narrowings or whatever. We literally show the pictures. They're really almost cinematic pictures of the stuff, the plaque, the valves, or whatever is the issue with the heart with the patients, which is incredibly, I think, for the patient and motivating and really educates the patient better than I can ever do with words to literally show them. their heart. And I will use a term that my staff always tells me to be careful with, and they don't like it, but I will use it. I call cardiac CT, with all the incredible AI imaging now and the beautiful pictures, I call it the virtual autopsy. Emphasis on the virtual, but it allows me to literally show patients their heart, their plaque, their valve, whatever is relevant to the patient, in a way that was impossible to do with prior imaging. So Clear Cardio, Imaging is critical to that, but we're not a scanning company. We're not an imaging company. We're really a cardiac detection, assessment, and prevention organization. So our ultimate goal is to eliminate heart disease as we know it.

And that's a worthy goal. Any closing thoughts? How do you see the role of AI and cardiovascular plaque analysis evolving in the future?

I think it's going to be the dominant approach. I think what we're doing, frankly, I like to say I, I'm just talking to you from 2035. This is what everybody does. We don't do functional testing. Not really worthwhile. I don't do it anymore. I stopped cathing people. I can do all the stuff I need this card— to do as a cardiologist without invasive angiography. So in 2035, I like to say in the future, and I keep coming back to 2026 telling you this, this is the dominant approach. This is what everyone will be doing. Right now we're one of the sole people doing it, but I think this is going to be the dominant evolving approach in the future. I just hope people that— hope that more people get involved with this and do this so that it is going to break through that glass barrier of how we are really going to detect disease early, stop it, treat it, so that we can really begin to dramatically approach what I love to do. And what I always profess to do is to eliminate heart disease. We are not going to do it with stress testing, with functional testing, with the angiogram, with, with diagnostic cath, it's gonna happen with cardiac CT coupled with AI.

Very good. Now, for, for cardiologists or imagers that are thinking about moving to United Imaging, the UCT system, what practical tips do you have or guidance would you give them and their team for getting the most out of these systems?

Again, another one of the beautiful things, things we love about the Atlas system is its ease of use. And you can quickly become extremely confident both on the reader side, as far as I call it the nut behind the wheel, the people that read the pictures and process it clinically and share it with patients. But again, also on the technician side, you have to have technicians that are really great, that equal the equipment hardware, because to get these beautiful pictures, you need 3 legs of that stool: the right equipment, right tech taking the pictures, and the right nut behind the wheel. And I think with the hardware and software integration, the ease of use, the AI now that maximizes the quality of the images coupled with very low radiation doses, it's really hard not to fall in love with the Oura Atlas systems.

Awesome. Well, great to hear that. Well, thank you so much to John Osborne of Cleer Cardio for being with us today. It's been a pleasure talking to you and good luck with Cleer Cardio and eliminating heart disease.

We appreciate it. One day at a time. Thank you again, Brian.

Signing off for The Imaging Wire, my name is Brian Casey.