Cardiovascular Precision Medicine: Bridging Academia and Industry For A Cardiac Moonshot.

At this year's 2016 State of the Union Address  President Obama announced a new national effort, "Let's make America the country that cures cancer once and for all . The Government is committing funding into precision medicine initiatives  that  promise  to harness all the latest technology at our disposal to diagnose,sequence cancer genes and finally targeted personalized treatment .

Cardiovascular diseases like cancer continues to accounts for millions of death and lost productivity in the USA  so finding a moonshot to cure cardiovascular disease and cancer  could be the defining moments in medicine  as was the discovery of penicillin to fight infection about half a century ago. Precision medicine could be the key to making these  moonshots possible . harnessing the  power of genomics,targeted drug discovery,point of care diagnostics and remote monitoring  could be the key ingredients in a precision medicine initiative to address how we manage population health and chronic disease management  in the near future. 

The article seeks to lay out a clear vision on how we can  achieve a cardiac moonshot by harnessing the  power of genomics,targeted drug discovery,point of care diagnostics ,remote monitoring ,BIG DATA science,robotics,3D printing ,augmented reality ,simulation technology and other technologies within a  preferable biomedical hub leveraging academia, science,biotech industry and venture capital world within a dedicated institution.

 Genomics:

Genomics  would enable us to risk profile and determine an individuals bio print. Risk stratification using genomics will help us better identify at risk  targets for  correcting  defective genes  of individuals  and could also best be applied to individuals as well as population risk stratification .Through whole genome sequencing and/or whole-exome sequencing in well-defined patient and population cohorts various groups are working to discover novel rare variants in cardiovascular diseases, such as pulmonary arterial hypertension aortic aneurysm syndromes , stroke,coronary disease , platelet disorders  and cardiac arrhythmia . Further analysis will identify common and rare potential genetic and epigenetic modifiers of disease penetrance, severity and clinical course. suggesting attractive drug targets for cardiovascular and metabolic disease.

Genome editing technologies& Targeted Drug Therapy: 

New targets which include  iPSC-derived relevant cells (e.g. vascular smooth muscle, endothelium, macrophages, platelets) and unbiased whole genome transcriptomics and epigenetic profiling  will help identify distinct nodal pathogenic pathways and key regulators of disease-specific phenotypes using genome editing techniques, and drug screening. The expectation is that this interdisciplinary approach using patient cohorts, stem cell technology, and genomics  and harnessing the strength of  molecular biology, computational biology, bioinformatics and epidemiology to probe these poorly understood regions of the genome to determine the genetic and epigenetic contributions to metabolic status, systemic inflammation, and circulating proteome  metabolome, and clinical phenotypes  will pave the way for novel therapeutic targets  for personalized drugs in cardiovascular diseases such as NP6A a heart failure drug developed from mathematical modeling by Norvopyxis 

Point of Care Diagnostics & Liquid Biopsies:

Point of Care diagnostics seeks to  revolutionize  laboratory testing by  using advanced micro-fluiditic technologies to detect various biomarkers in urine ,blood or sputum with a single drop of blood and validate the technology with standard laboratory testing devices currently used by laboratory services. Companies  like Ymir genomics  and BBB technologies are leading the front in the are point of care blood testing  over several disease specific bio-markers with a single drop of blood for detection of heart failure (BNP) Pulmonary embolism (D-Dimer) ,myocardial infarction (troponin) to name a few  Point of care testing would enable disease detection and monitoring in real time beyond hospital care and using cloud health platforms would enable real time monitoring of chronic diseases states like diabetes 

Remote Monitoring Technologies and Wearable :

Through the use of remote monitoring technologies we can continuously monitor those at highest risk for recurrent medical events or re-admissions into the acute care setting. Prior to an anticipated life threatening event ,machine learning platforms  can alert or send an early warning sign to the individual or the care provider in real time  enabling  a rapid response  intervention. CoreVigil  is one such company using machine learning software to address the US $6 billion atrial fibrillation market by using a wearable platform to detect and monitor continuous atrial fibrillation .The Core Vigil wearable  matches  real time symptoms by asking prompted questions and combining with the wearable data   and using machine learning algorithms and predictive analytics send notification to the care provider  for rapid intervention .Locent a platform technology uses  automated tracking ,automated encrypted messaging and  medication reminders,symptoms check ,patient feedback as well as  tracking financial  data tin real time enabling health care organizations to  provide  and monitor real time real time value  

3D Printing 

Work is  being done  on bio printing of organs and tissue regeneration  One exciting concept is the ability to combine 3D imaging data sets  to reconstruct a heart valve and then bio-print a valve prosthesis for repairing a damaged heart valve  through minimal invasive heart surgery.We can take a  patient's 3D ultrasound data of a patient and print a 3D model of a patient's customized prosthetic heart valve ring  that could be used to  simulate a repair a non functional or damaged heart valve. The basic concepts outlined could be streamlined and scaled using cloud computing software technology to model patient heart valve rings for personalized medicine. The detailed process of generating  3D dataset visible is termed a 3D display and results in either multiple 2D image planes or the creation of a 3D graphic reproduction.Three-dimensional graphic reproduction is the product of graphic rendering, a 2-step computer graphics technique. The first step is segmentation, which separates within the 3D echocardiographic dataset the object to be rendered from surrounding structures by specifically differentiating cardiac tissue from blood, pericardial fluid, and air. This step delineates the 3D surfaces of cardiac tissue.After segmentation, the 3D dataset undergoes 1 of the 3 increasingly complex rendering techniques to create a visible 3D object: wireframe rendering, surface rendering, or volume rendering

Internet of Things Health Data Ecosystem

The quantified self movement is in full swing with 69% of U.S. adults keep track of at least one health indicator such as weight, diet, exercise routine, or symptom according to Pew Internet and American Life Project’s report back in January. Of those, half track “in their heads,” one-third keep notes on paper, and one in five use technology to keep tabs on their health status. Research by the Center for Medicare and Medicaid Services shows national health care expenditures are nearing $3 trillion dollars per year.By making so many things intelligent with embedded networked sensors, we can add intelligence to almost anything.  All of those sensors will continue to create rapidly increasing amounts of data which so far has not found its way into our electronic  health medical records  EHMR  but hopefully will with such personalized medicine initiatives.In an effort to reduce rising healthcare costs and improve patient care, digital health is emerging as a key driver in the transformation of healthcare. Healthcare organizations and  payers are quickly integrating digital health tools for healthcare professionals and consumers.

Robotics and Augmented Reality

Virtual reality techniques allow a pre-operative 3D visualization of the patient that can be manipulated in real time through the use of a patient-specific surgical simulation .In addition, augmented reality techniques superimpose this 3D image on the real image .Thanks to augmented reality it is thus possible to compensate the lack of the sense of touch with visualization of these forces by providing an artificial 3D view included transparency.The combination of visualization software, augmented reality and robotic technology should overcome the current limitations of minimal access surgery and perform extremely safe procedures with no scars. The goal is to develop Virtual Patient Modeling software that uses patient-specific data to enable pre-operative assessment ,diagnosis and a personalized plan for surgery. Virtual planning software would enable patient specific  navigation and tool positioning within 3D images that can be reconstructed from any multimedia-equipped computer for a virtualized personalized surgery using enhanced robotic techniques.

In conclusion the future of cardiovascular medicine is exciting and personalized. The cure for heart disease  is a moonshot that is attainable if we  can harness the power of genomics,targeted drug discovery,wearable platforms,point of care testing ,3D printing,robotics,BIG DATA Science and machine learning platforms. A couple of government funded initiatives to address such moonshots. Success would  be achievable if f we can break down the traditional silos that exists between academia,industry ,venture capitalist,health insurers with value to the patient and the population as the ultimate goal.