Ideas for Improving Cardiac Care

Overview:

1. Getting tested

2. The cost (time and money) is in the tests.

3. About the tests

4. Improvement 1: Blood Pressure Monitoring using rings.

5. Improvement 2: ECG (heart electrical signal) monitoring using watches.

6. Improvement 3: Neck artery scans with handheld devices.

7. Business Opportunities.

Link to My Detailed Research Notes

Getting Tested

After discovering high cholesterol in a routine blood test, I decided to get a full set of heart checks. All turned out well, and I’ve a much better idea of what to monitor over the coming decades. What struck me most was the time and money invested specifically in tests. I couldn’t stop thinking about potential improvements. Given that cardiac health issues are a major cause of death affecting many people, even small improvements in this area are meaningful.

The Real Cost: Tests not Consultants.

When I started this journey, I assumed consultant fees would be the primary expense. However, the most substantial costs came from the battery of tests themselves. While I have private health insurance that reimburses about half of these costs (actually less given deductibles), the total came to nearly €2,000. More importantly, the time investment was significant – equivalent to 3-4 full workdays.

Here’s a breakdown of the tests, their costs, and time requirements. The tests themselves are mostly short, but I’ve marked down the time required including to get to the place and back home. That means half a day for a given test, or one-quarter day if two tests can be done on the one visit.

Understanding the Tests

The tests can be categorised into several groups:

1. Blood tests (including cholesterol measurements)

2. Heart monitoring tests:

• 24-hour blood pressure monitoring

• 24-hour ECG (Holter monitor with 12 electrode pads)

• Stress test (monitored exercise with increasing intensity)

3. Vascular tests:

• Carotid scan (measuring blood flow in neck arteries)

Three Areas for Potential Improvement

Improvement 1: Blood Pressure Monitoring

Blood pressure measurement has remained largely unchanged for decades. The process involves inflating a cuff around your upper arm to a pressure higher than your blood pressure, temporarily stopping blood flow through the artery. As the cuff pressure gradually decreases, blood begins to flow again, creating turbulent sounds (Korotkoff sounds) that can be detected with a stethoscope or sensor. The pressure at which these sounds first appear corresponds to your systolic blood pressure (the maximum pressure during a heartbeat). As the cuff pressure continues to decrease, the sounds eventually disappear, indicating your diastolic blood pressure (the minimum pressure between heartbeats). This method measures both systolic and diastolic pressures accurately.

While investigating alternatives, I was optimistic about finding devices that could avoid waking you up when the cuff inflates. However, it’s hard to measure pressure as well as with a cuff – which is quite a direct and physical approach. The most promising alternative involves PPG (photoplethysmography), a method that uses light to measure blood vessel expansion beneath your skin. This technology can be integrated into rings, watches, or chest monitors.

The clever aspect of PPG is how it works with ECG measurements to approximate blood pressure. The system uses two key measurements:

1. The ECG signal, which travels at nearly the speed of light and indicates when your heart initiates a pulse

2. The PPG signal, which detects when that pulse physically arrives at the measurement point (like your finger or wrist)

By measuring the time difference between these two signals (pulse transit time), devices can estimate blood pressure. This works because higher blood pressure generally results in faster pulse transit times through your arteries.

BUT, this is a very indirect way to measure pressure because – while the time it takes for your pulse to go from your heart to your hand does depend on pressure, it also depends on a lot of other things – like the springiness of your arteries themselves. So, these devices almost always require periodic calibration with a traditional cuff, whether daily or monthly.

An interesting study by a South African professor working in Australia involved wearing both traditional cuffs and three PPG devices simultaneously (on their chest, wrist, and finger) for 24 hours, including while watching a rugby match! The results showed that finger-based measurements (using rings) came closest to matching cuff measurements. This makes physiological sense – fingers have a higher proportion of arterial tissue compared to wrists, which contain more diverse structures that can dilute the signal.

In short, while we’re making progress toward cuff-free monitoring, it’s just a difficult measurement to make without a cuff.

Improvement 2: (Continuous) ECG Monitoring

An ECG provides an electrical map of your heart’s performance. The standard clinical approach uses 12 probes placed strategically around your body, allowing doctors to examine your heart’s electrical activity from multiple angles. This comprehensive view helps them precisely identify which parts of your heart might not be pumping correctly from an electrical standpoint.

Modern smartwatches have introduced ECG capability, but with a significant limitation: they typically use just a two-point measurement system. When you take an ECG reading with your watch, it measures between your wrist and a finger from your opposite hand that you place on the watch during measurement. This design choice means watches rarely provide continuous ECG measurements.

However, this limitation presents an interesting opportunity for improvement. What if you could purchase an accessory for your smartwatch – perhaps even just a single additional probe that you could place on your body? This probe, working in conjunction with your watch, could enable continuous ECG measurements. While you wouldn’t get the complete 12-lead picture that a clinical ECG provides, you might capture enough data to identify major cardiac issues. This approach could make frequent ECG testing more accessible to the general population, given how many people already own smartwatches.

The potential becomes even more interesting when you consider 24-hour monitoring. Currently, this is done using a Holter monitor – a device that connects to multiple probes on your body and sits in your pocket for 24 hours. While it’s not as disruptive as a blood pressure monitor (it won’t wake you up at night), you have to pay to rent one. A smartwatch solution, enhanced with an additional probe, could provide similar monitoring capability in a much more user-friendly way. There are already some devices available that allow for continuous monitoring, although the price point is still high (around $500).

This improvement in ECG monitoring, combined with better blood pressure monitoring, opens up another interesting possibility: home-based stress testing. Instead of paying €250 for a hospital stress test, imagine following an app’s guidance to gradually increase your exertion – perhaps by jogging or climbing stairs – while your enhanced smartwatch monitors both your ECG and blood pressure. While this wouldn’t completely replace clinical stress tests, it could provide many of the same benefits at a fraction of the cost and inconvenience.

Improvement 3: Vascular Scanning

While it’s possible to examine blockages in the heart directly using ultrasound, the heart’s deeper location (and more complicated design) makes it harder to examine than an artery in your neck. So, the carotid arteries in your neck provide an excellent proxy for understanding your overall cardiovascular health, and their location just beneath the skin makes them particularly accessible for examination.

The standard today is to have a measurement taken by a trained operator at a hospital. But, it appears that handheld ultrasound devices – potentially operated at a primary care level by a nurse or doctor – allow for good levels of accuracy. I’m not entirely sure why this isn’t done already – as the technical difficulty involved is quite a lot simpler than taking an ultrasound of the heart.

As an aside, there was a Korean study – now being commercialised – whereby a smartphone was used to take short videos of a persons neck. By comparing tiny fluctuations between skin over the carotid, versus skin under one’s chin (presumably with vessels that are not blocked), it was possible to get 87% correlation with blockages detected through full traditional ultrasound screenings. This is just one study, but it highlights that the carotid measurement – of all heart measurements – is both straightforward AND tackles something very important, namely, the blockage of blood flow to the head.

Business Opportunities and Challenges

In reviewing cuffless blood pressure monitors, I was struck by how long it takes to bring new devices to market. Even with a working device, you’re looking at 2-3 years to get through FDA approval – and probably most people in the industry would think that is fast. I’m not necessarily criticizing this reality – standards matter and I’m not sure what the right approach to regulation should be here.

This got me thinking about how new technologies or products get squeezed from two directions. If you’re trying to build a product from the ground up, you need multiple years to get through regulatory clearance, which means high capital costs before you make a cent. Often this includes expensive clinical trials.

So you’re squeezed from entering at the bottom, but then you’re also squeezed from the top in an interesting way: if you want to provide a service that uses different technologies together, those technologies often only work with their own apps or interfaces – or they’re controlled by a company like Apple that owns the ecosystem. You’re basically squeezed between Apple at the top and regulatory requirements at the bottom.

I don’t know if I even disagree with how this system works. It’s easy to just criticize Apple, but maybe there should be more entrepreneurs making phone-like devices – for example, creating a dedicated health device that looks like a mobile phone but lets you control your own ecosystem.

There’s another issue with my suggestions above from a business standpoint: it’s hard to capture the benefit of bringing these improvements to patients. How do you make money to fund your business when the main benefit is preventing future health problems? Insurance companies might be best positioned to benefit from some of these ideas because they should save money on lower care costs over time. Of course, insurance incentives can get complicated (e.g. if it’s easy for people to swap provider), but this isn’t entirely new – countries like the Netherlands, Germany, or Switzerland seem to handle these incentives pretty well.

I’ve followed up with several authors from the research I read. I’m curious about their challenges commercialising their approaches and what might help move things forward. I only had about two days to dig into this (although AI helped speed things up quite a bit), so I’m just scratching the surface here. And since I don’t have a medical background, definitely let me know if you spot any errors or if this sparks other ideas.