KRASIMIRA HRISTOVA: EXAMINING THE SECRETS OF OUR HEARTS

We take our cardiovascular health as given until we realise that our heart might have some problems. Luckily, modern echocardiography is more than capable of helping. When qualified professionals are using the most advanced technologies in this field, correct diagnosis and proper treatment are possible.

Dr Krasimira Hristova, MD, PhD, FESC, knows in great detail the potential of modern echocardiography. She has over 25 years of experience as cardiologist and specialises in the rapidly developing medical field of echocardiography. She was an expert in echocardiography in National Heart Hospital and now is the Medical Director in Medical Center for Cardiovascular Diseases. Her scientific interests are in application of new echocardiography methods for evaluation of myocardial deformation in patients with acute myocardial infarct.

Dr Hristova is also active in a number of Bulgarian and international organisations and never stops from improving her professional qualifications. She is the Chairperson of the Bulgarian Association of Cardiovascular Imaging. Dr Hristova has been the President of the International College of Cardiology (ІСС) and today is its Secretary General. She is also a Fellow of the European Society of Cardiology, an honourable member of the International Association of Cardiovascular Sciences (IACS), and a member of the Board of Directors of the World Hypertension League. She is also a guest professor at the Creighton University, Omaha, Nebraska, the US. In 2021, she graduated from a Women Leadership Program in Oxford.

Dr Hristova is also the first Bulgarian cardiologist invited to give lectures at Johns Hopkins University and is included in its Gold Book.

Dr Hristova's professional and personal mission is to inspire more positive change in the Bulgarian healthcare system and to help more people realise the need of taking care of their cardiovascular health, how to do it best and when to seek professional help.

Echocardiography has been your vocation for years. Why did you choose to specialise in this field?

Echocardiography is a medical specialisation performed by qualified cardiologists who use ultrasound to assess how the heart works. It is instrumental for the diagnosis and follow-up of different heart diseases.

Echocardiography won my interest and admiration because it is a non-invasive and safe way to visualise the heart and to assess how it works, and because it requires additional knowledge in physics and hemodynamics, which can be used to explain many diseases. The heart is a "pump" and the hemodynamic processes in it are explained by different laws of physics. Knowing these allows us to predict the prognosis of a disease and to treat the patient properly. This procedure allows us to see changes in the heart structure, valve or rhythmic disturbances and other heart problems. Echocardiography has long expanded the limitations of being just a method to measure the heart's size.

Echocardiography is also important to patients as they are properly diagnosed and can receive suitable treatment and follow-up of how their disease progresses. This can improve their quality of life and can help the prevention of serious complications.

For me, as a cardiologist, it has always been interesting to learn more about medical procedures and technologies that improve people's good health and wellbeing. My love for echocardiography was additionally unlocked by the contact with my colleagues that I met during my specialisation at KU Leuven University, at different conferences and specialisations that make an important part of my work and expertise.

How did this field of medicine change since you started working in it? What is the biggest scientific discovery or innovation that you would single out?

In the past 20 years echocardiography significantly evolved and changed, becoming a very attractive medical field. These changes contributed for the better diagnosis and treatment of heart conditions and for the better understanding of how the heart functions. This helped physicians to give better care and an improved quality of life to patients with heart diseases. Here are some of these changes:

1. Technological improvement: The implementation of new technologies and the improvement of ultrasound equipment made echocardiography more precise and detailed. The machines are more powerful, with higher resolution of the image and with better options for 3D and 4D visualisation of the heart.

2. Broader application: Echocardiography is now increasingly used for other goals beyond diagnosis of heart conditions. It is used to assess the heart function of athletes, for measuring of cardiovascular parameters in pregnant women, for guidance of implantable cardioverter-defibrillators, evaluation of cardiotoxicity in patients undergoing chemotherapy and others.

3. Development of new methods: The modern methods for echocardiography, like Doppler ultrasound, stress echocardiography (made during physical exercise) and transesophageal ultrasound become more used and offer additional information on the heart function. The new methodologies for assessment of the myocardium function allows for quick and correct diagnosis in many diseases.

4. Better education and specialisation: In the past couple of years we are witnessing an increased interest in echocardiography among young doctors and cardiologists who want to be in line with the new technologies and non-invasive methods for assessment of the heart function. All of this is linked to the new and modern equipment and the additional knowledge and certification of colleagues.

Which are the three main things that we have to know and do to reduce the risk of cardiovascular diseases?

To reduce the risk of cardiovascular diseases it is crucial to follow these core principles:

1. Healthy eating: Eating properly is fundamental for keeping one's heart healthy. We should strive for a diverse diet, including fruit, vegetables, whole grain products, poultry, fish, nuts and healthy fats such as avocado and olive oil. Reducing the consumption of saturated fats, cholesterol and added sugar is also important.

2. Regular physical activity: Staying active is a key factor for keeping one's heart healthy. The recommended amount is at least 150 minutes of averagely intensive or 75 minutes of very intensive exercises every week, or just making 5,000-6,000 steps each day. This can be walking, running, biking, swimming or hitting the gym. Regular physical activity helps for improving the cardiovascular function, controls the blood pressure and the cholesterol levels and reduces the risk of cardiovascular diseases.

3. Quitting smoking and drinking: Smoking and excess alcohol consumption are linked to increased risk of cardiovascular diseases. We have to avoid even the so-called "safe" e-cigarettes and vapes and if we are smokers we should quit them. Alcohol should be consumed with measure – the daily spirits intake for women is 30 ml and for men – 70 ml.

These three principles – healthy eating, regular physical activity and quitting bad habits, are instrumental for keeping one's heart in a good condition and reducing the risk of cardiovascular diseases. Still, if you already have a heart disease, it is best to consult with a physician for personalised advice and guidance for your health.

Dr Hristova and Doctor in Residency Nikolay Tselov with Cardiopulmonary Stress-Test System (CPET) for total assessment of the cardiovascular and respiratory system. The Center for Cardiovascular Diseases is the only in Bulgaria certified by the Harvard Medical School for this type of evaluation

At the Medical Centre for Cardiovascular Diseases you already work with 4D echocardiography using AI. What are the advantages and capabilities of this technology?

Seven years ago, when we were creating the medical centre, my colleagues and I wanted to work and make modern medicine and cardiology, to give independent opinions to the patients and to offer them the most precise diagnosis and the best treatment possible. This is why we targeted our efforts to provide modern and quality technology that can make even university and specialised hospitals envy. We were not that interested in luxury interiors, our goal was and remains to work with the best equipment for non-invasive diagnosis. We were the first in Bulgaria who purchased a high-tech 4D echocardiography device with AI. It gives us significant advantages in the data analysis and the interpretation of the images.

1. Automatic recognition of structures and anomalies: AI can be trained to recognise different structures of the heart like the wall of the chambers, valves and blood vessels. It can also find anomalies and discrepancies in the heart structure that can be linked to heart diseases.

2. Automatic segmentation of heart structures: Segmentation of heart structures, for example chamber walls and valves, is important for the better analysis of heart images. AI can be used for automated segmentation by extraction and recognition of different heart structures. This helps for the more precise and effective interpretation of the data.

3. Help in diagnosis and prognosis: AI can be trained to analyse and interpret large data collected with 4D echocardiography. This allows it to find hidden correlations and specimens that physicians could miss. AI can help for the better diagnosis of heart diseases and prognosis of how the patient's disease will progress.

4. Improved speed and effectivity: By using AI, the analysis of 4D echocardiography could be sped up and optimised. AI can perform automated processes and execute complex algorithms faster than the human brain. This improves the effectiveness of the interpretation and allows physicians to make faster and more precise diagnoses.

AI has immense potential in the field of 4D echocardiography by providing new opportunities for correct diagnosis and follow-up of heart diseases. Despite this, we should remember that physicians should always be part of the process of analysis and interpretation of data to ensure reliable and competent assessment of patients' heart health.

For two years in a row Bulgaria hosted the International Echocardiography Congress. How Bulgaria and its professionals in the field deserved this recognition?

The fact that Bulgaria was chosen for the second time in a row to host the International Echocardiography Congress reflects the recognition of the competency and contribution of the Bulgarian professionals in this field. This is a big recognition for me as well, and I want to express my gratitude to all the colleagues that made possible these incredibly important meetings for echocardiography in Bulgaria. There are many factors that explain why Bulgaria was given this honour:

1. Expertise and quality of the medical professionals: Bulgaria has highly qualified and competent specialists in echocardiography. They have extensive experience and expertise in diagnosis and treatment of heart diseases and use of modern technologies and methods, including 4D echocardiography. Many Bulgarian lecturers are now confident and experienced enough to talk on such forums – this is not to be underestimated as a way to present and communicate, to create a public image and to build public speaking behaviour. Because, speaking at such a forum is possible only after lots of effort and convincingly explaining why your topic is worthy of public presentation.

2. Infrastructure and technologies: Bulgaria has plenty of medical centres and hospitals that could offer to the patients quality diagnosis and expertise, but unfortunately the old equipment impedes quality expertise. It stops professionals, regardless of their competency levels, from making high-quality examinations and offering correct and reliable data for the diagnosis and treatment of heart diseases. Sometimes, their assessment can be even harmful to the patient. Another problem with certification of colleagues at the moment is that anyone can purchase a certificate in echocardiography without any real expertise. This is why my colleagues and I, as the Chairperson of the Bulgarian Association of Cardiovascular Imaging, have set as a goal the implementation of the standards for the European Association of Cardiovascular Imaging for specialisation and examination in echocardiography that could be equal to an European certificate, and the certification of centres that will be equipped with high-quality equipment. There, colleagues could train and patients could receive quality non-invasive diagnosis.

3. The congresses in Bulgaria are a recognition for the international expertise of Bulgarian echocardiography professionals. On the other hand, it can also help to establish Bulgaria as a scientific tourism destination because of its excellent organisational expertise and experience in organisation of international medical congresses and events. The previous World Congress in Echocardiography, which took place in Albena Resort in 2018, was successfully organised and gave participants the opportunity to meet leading professionals from all over the world.

These factors helped us to host the event for a second time, and reflected the high quality of medical care and scientific research in echocardiography in Bulgaria.

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