Official Journal of the ISE
Sharen Lee: Greetings! I am Sharen Lee from Hong Kong, a member of the International Society of Electrocardiology Young Community (ISE-YC). It is my honor to have the opportunity to interview Prof. Bayes de Luna from the Autonomous University of Barcelona.
Besides publishing over 190 publications in the field of cardiology over the course of his career, Prof. Bayes de Luna reported the increased risk for atrial fibrillation amongst patients with advanced interatrial block. The association was subsequently coined as Bayés syndrome by Prof. Baranchuk. Prof. Bayes de Luna has also contributed greatly to the education and promotion in the field of electrocardiology, including writing the textbook Clinical Electrocardiology, founding the Catalan Society of Cardiology, and being the former president of the Spanish Society of Cardiology, World Heart Federation and International Society of Cardiovascular Pharmacotherapy. Prof. Bayes de Luna, may you please tell us about your motivation underlying your active contribution in the education and promotion of electrocardiology?
Prof. Bayes de Luna: My aim as a teacher has always been to help people understand difficult problems. In my traineeship in the early 60’s I had some difficulties understanding a few aspects of electrocardiology and I was looking for solutions. I realized that, in spite of excellent research performed in the field of ECG, especially in North and South America (USA, NIC Ignacio Chávez from Mexico and Rosenbaum and Elizari from Argentina), there was lacking a comprehensive textbook that would explain the origin of the ECG curves based on the correlation dipole, vector, loop and projection of the loop in positive or negative hemifield of different leads. Therefore, as I was understanding ECG myself, I thought it would be a good idea to put all this knowledge in the form of a short book containing the answers to all the questions I had in my beginnings.
Sharen Lee: What was your most memorable memory during your career?
Prof. Bayes de Luna: I am fortunate to have lived through many memorable times in my career. I remember with emotion the first patient in whom we implanted a pacemaker in Spain in 1963, or the first one in whom we implanted an ICD in the early 80’s. it was also a very emotional day when our cardiac surgeon, Dr. Caralps, performed the first heart transplant of Spain in our institution. From a scientific point of view, I would like to mention 3 publications: i) The association of advanced interatrial block with atrial arrhythmias (Eur Heart J 1988; 9: 1112-1118), the origin of Bayes Syndrome; ii) The demonstration for the first time that colchicines may prevent recurrences of pericarditis (Circulation 1990; 82: 117-1120); and iii) The confirmation that in patients post-MI the R wave in V1 was due to lateral and not posterior MI (Eur Heart J 2015; 36: 959-964).
Another highlight of my career was the set-up of our Experimental Institute of Cardiology in St. Pau Hospital directed by Prof. Lina Badimon.
I also remember with great fondness when, during my term as President of the World Heart Federation (1997-1999,) we 1) organized the World Heart Day; 2) published the White Book of World Cardiology; 3) performed a memorandum of understanding how to fight against heart diseases in developing countries; 4) incorporated mainland China to the Society while retaining Nationalist China working together through their differences; and 5) converted the old International Society and Federation of Cardiology (ISFC) to the successful World Heart Federation.
At a more personal level, I enjoy returning with my wife María Clara, the mother of our 5 children to Vic, a medieval city inland Catalonia, where we have the family house for almost 2 centuries and where I used to visit patients until very recently. I am the fourth generation of doctors, and three of my children and one grand-child are also doctors, and one grandchild is on the way.
Sharen Lee: Could you tell us about an excellent ECG paper that you have read in the past year?
Prof. Bayes de Luna: In the past few years I have very much enjoyed reading the papers related to our current topic of research: The advanced Interatrial block and Bayes Syndrome. I have particularly enjoyed the publications on this topic from the ARIC and Danish cohorts confirming in a global population cohort what we have demonstrated in different clinical settings starting with the paper of O’Neal in the Am J Cardiol (2016; 117: 1755-1759).
Sharen Lee: What do you think about the future of electrocardiology and ISE? What are some upcoming opportunities and challenges?
Prof. Bayes de Luna: The future of electrocardiology is bright and its importance will be even more relevant in the XXI Century, especially if we achieve real automation of the ECG curve. My great wish would be that all physicians have the knowledge to understand the ECG curves and, thanks to that, have greater information about ischemic heart disease, sudden death, Brugada syndrome, AV block, advanced interatial block and … many others.
Sharen Lee: ISE-YC has been actively recruiting young talents who are interested in the field of electrocardiology over the recent years. What is some advice you would like to give to these young researchers/ clinicians?
Prof. Bayes de Luna: I encourage ISE to pursue stimulating teaching and research in electrocardiology. There are many aspects that yet remain to be explained from a diagnostic and prognostic point of view, as well as many other aspects that still have to be discovered… Therefore, young talents you have in the field of electrocardiology a great future in front of you… Embrace the opportunity.
Sharen Lee: Thank you for your time and expertise!
I am very pleased and honoured to be able to review my participation in the International Congress of Electrocardiology through the years. To do so, I have to step back a little in time before the International Society of Electrocardiology was formed.
In 1959, a group of cardiologists with a specific interest in electrocardiography met in Wroclaw, Poland and they organised what was called the Colloquium Vectorcardiographicum which first met in 1960. [Please see the time lines on the Young Community website.] They met annually thereafter in Eastern Europe but I became aware of their activities when they first met in Western Europe, in Vienna, in 1967. This was the first meeting of the group which I attended. On that occasion, I always remember meeting Dr Ron Selvester and his wife Jean, who took this new boy (me!) under their wing! Ron was of course very well known even at that time. Half the papers at the meeting were presented in German and half were presented in English and so I returned home and went to night school for one year to learn the basics of the German language because I thought that if I had to attend the conference every year, it would be much better if I understood more than 50% of the presentations. As it happened, all meetings thereafter used the English language!
My next ECG, or should it be VCG, conference was in Jablonna, on the outskirts of Warsaw in 1969, and that was my first experience of travelling to Eastern Europe about 8 years after the Berlin wall was built. There were perhaps 30 people meeting in a hotel on the outskirts of Warsaw and I was invited to stay on afterwards to tour in the south of Poland (Katowice). Somehow or other I managed to change my flight home, which was rather difficult at that time. During that visit, I managed to visit Auschwitz and nervously allowed myself to be interviewed by a TV company filming the site. The following year, the meeting was held in New York as part of a symposium on vectorcardiography and was well attended.
In 1971, a 6 day meeting of single sessions was held in Brussels, with Pierre Rijlant as the organiser. He had been President of the World Congress of Cardiology in Brussels in 1967 and had a major interest in electrocardiography. In 1972, the meeting was held in Dresden and that was another adventure which involved travelling via the divided city of Berlin in order to cross to the Eastern sector, and then take a train to Dresden. There were no guide books that I could find at the time! In 1973, the meeting was in Yerevan, Armenia in the shadow of Mount Ararat. Travel was via London and Moscow. For me, this was the start of regular visits to Eastern Europe every second year, with meetings taking place in Western Europe in the intermediate years.
International Congress of Electrocardiology
In 1973 in Yerevan, Armenia, it was proposed that the name of the meeting should be changed to the International Congress of Electrocardiology and in 1974 in Wiesbaden, Western Germany, the first meeting with this title was held.
At the Wiesbaden meeting, all the greats of electrocardiology of that era attended. They included Ernst Simonson, whose book on the normal ECG published in 1961 was an absolute classic at the time. Hubert Pipberger, who was in the forefront of developing automated ECG interpretation using XYZ leads, was present as was Otto Schmitt if I recollect correctly. He was the inventor of the Schmitt trigger and also an orthogonal lead system.
These meetings up until that point alternating between east and west had been a great experience in terms of understanding a different part of the world under a different type of rule at that time. Travel could be nerve wracking and there are many stories that could be told but space does not permit. The meetings continued in east and west and in 1983, a decision was made to form the International Council on Electrocardiology. Professor Ivan Ruttkay-Nedecky from Bratislava was appointed the first President of the Council.
The meetings continued to alternate between east and west until shortly after the Berlin Wall came down in late 1989, soon after the meeting in Budapest into which many people had escaped from East Germany. I went for a jog one day and was surprised to note many TV cameras en route. They were actually pitched outside a refugee camp and were not there to capture me jogging! After the wall came down, travel between east and west then gradually became easier.
Finally, in 1993, the International Society of Electrocardiology was formed in Kananaskis, Alberta, Canada. The President of the Council and first President of the Society was Professor Fernando de Padua from Lisbon.
So the most special aspect of the Society in the early years was the continued link between East and West Europe, with the added participation of experts from the rest of the world. There was also a tremendous social aspect to the meeting with, on occasions, up to 30 spouses participating in a separate Ladies Programme. This is perhaps one of the big disappointments of the current era in that the accompanying persons programme has diminished somewhat. I placed great emphasis on this programme for the ICE meeting in Glasgow in 2013 with a visit to the world famous Edinburgh Military Tattoo at Edinburgh Castle, Stirling Castle, plus a choice of distilleries to visit, etc! Accompanying persons had their own social programme at other times.
Does electrocardiography still have a role to play?
You have asked if Electrocardiography is not as important compared to what it was. I think it is. There have been significant advances in the field in the last 25 years which have influenced clinical practice. No one ever used the term STEMI before 2002 and even ECG abnormalities such as the Brugada Pattern were not acknowledged until the 1990s. Consensus papers on the definition of early repolarization first emerged in 2015. Inverse modelling of cardiac activation was incorporated into a commercial product relatively recently. Of course, Echocardiography and Magnetic Resonance Imaging (MRI) are complementary to electrocardiography and provide different information compared to the ECG. However, many cardiac arrhythmias are certainly not reported easily with these techniques, if at all, and there is still a clear role for the ECG in many areas of medicine, given its simplicity and ease of recording and a unique ability to detect conduction defects, arrhythmias like ventricular tachycardia and so on.
Large databases are now being used with Artificial Intelligence techniques to use the ECG in a diagnostic and predictive mode, although I remain to be convinced that the specificity of the techniques will prove acceptable. Single channel ECG recording has taken off dramatically and the use of automated methods for analysis has allowed this approach to flourish, although there are limitations with the use of one lead. All in all, electrocardiography is far from being dead!
The future is difficult to predict. I have heard frequently through the years that Body Surface Mapping would replace 12 lead Electrocardiography and while there are now fantastic facilities utilising multiple electrodes in conjunction with advanced modelling, the simplicity of the 12 lead ECG remains. There is still a lack of an internationally accepted database of a large number of ECGs for assessment of automated rhythm analysis although steps are being taken to change this shortcoming. There are differences in the normal limits of the ECG in different races and to some extent, current automated methods of interpretation only scratch the surface in this area. Much remains to be done in that respect. There are gender differences in ECG limits of normality and again, more requires to be done to enhance sex dependent diagnostic criteria.
There are huge areas of the world where ECG recording has still to be implemented widely in order to influence health care. This will take years of effort if money can be found.
One point which concerns me is that if a large percentage of the population feel it is necessary to wear some form of cardiac monitor 24/7, even in the form of a wristwatch, who is going to check the thousands, or will it be millions, of sample tracings which will be sent to the cloud, for example, many with resultant interpretations which will be false positive?
It is pleasing to note that there is now a young persons’ section of ISE, the Young Community. For years, there has been a Young Investigator’s Competition at the annual ICE. More recently, the Bayes Award has been established to reward one young investigator annually for excellence in research as evidenced by publications. Thus, the formation of the Young Community is a very welcome development in the history of ISE. Hopefully, social media, the enhanced ISE website and webinars will lead to many cardiologists in training and beyond joining the Young Community, and in turn advancing the science of electrocardiology. Thanks are due to a few individuals on the ISE Council for establishing the newer awards, webinars, and upgrading the website.
The sceptics may say that electrocardiography is not a fashionable area for research. However, I have been involved in the field for over 50 years and see no reason why electrocardiography, indeed electrocardiology, should suddenly cease to be of any value! Of course there are many branches of the topic that are now available to be exploited in terms of research, so I wish all members of the Young Community every success in their future work.
Let’s hope for some resolution of the Covid pandemic in 2021 and a return to ISE meetings, certainly by 2022, which can be attended in person by all enthusiastic electrocardiologists
Adrian: Why was important to you to get involved with the ISE?
My first experience with this Society goes back to the year 1981 when I entered my PhD program in electrocardiology under the mentorship of Professor Ivan Ruttkay-Nedecky. He was one of the key personalities of the International Council of Electrocardiology. In the years 1982/1983 as PhD students we were involved in the preparation, organization and then the participation at the International Congress on Electrocardiology that was organized by Professor Ivan Ruttkay-Nedecky in Bratislava in 1983.
In that time, annual meetings under the names of Colloquium Vectorcardiographicum and later International Congress on Electrocardiology were organized alternatively in “Western” and “Eastern” countries. Considering the situation of the cold war, it was an amazing arrangement supporting contacts between scientists, exchange of ideas, discussions and collaboration. Being a part of this scientific community was a strong motivation. For young researches it was very interesting to meet personalities that were recognized only as names in publications - like opening door to the international scientific community.
It was not only the international character of the Society that has attracted me; it was the electrocardiology itself as the research field that was fascinating – the interdisciplinary science including a wide spectrum from clinical to basic research, from medicine to computer sciences.
A: What is the IRIS initiative? How did you start this project? How was working along with Galen Wagner, former Editor-in-Chief of the Journal of Electrocardiology?
IRIS - the International Research Interdisciplinary School - is a common initiative of the Journal of Electrocardiology, Anatolian Journal of Cardiology, Monitor of Medicine of the Slovak Medical Society, Balkan Medical Journal, Central Asian Medical Journal, Journal of Kyrgyz State Medical Academy, Cardiovascular Systems and Heart, Vessels and Transplantation. The IRIS program is based on the Research Practicum of the Duke University, Durham, NC, USA. It combines plenary and small group discussions, project development and class presentation, and discussion on publishing scientific papers with representatives of biomedical scientific journals.
The idea came up during one of my first stays in the Editorial office in Durham. Galen Wagner invited me to one of the university workshops and I had the opportunity to experience the way how students worked on their research protocols, using the Research Practicum protocol developed by Galen Wagner and Erick Eisenstein.
The first IRIS course (in that time it was named the International Scientific Summer School) I organized in Slovakia in 2006. The original Research Practicum was adapted for a four-day course to provide an interdisciplinary, international environment for training in the skills required to prepare research study protocols, scientific manuscripts and for facilitating international collaboration.
We did not know whether the workshop is applicable to this very different environment, the more that several modification were introduced – the participants were working in groups that were interdisciplinary and international. The common language was English - another considerable difference - since almost all participants so far were non-native English speakers. This first pilot IRIS training in Slovakia was very successful and the results and feedback from the participants exceeded our expectations. We decided to continue and the next IRIS 2007 was in Turkey just after the International Congress on Electrocardiology and since then we organize the courses every year.
Up to now (October 2017) twenty two IRIS courses were organized in twelve countries on three continents (Austria, Brazil, Croatia, Kazakhstan, Kyrgyzstan, Macedonia, Poland, Romania, Russia, Slovakia, Spain, Turkey). A total number of 344 trainees came from 33 countries (Albania, Austria, Bosnia and Herzegovina, Brazil, China, Colombia, Croatia, Czech Republic, Denmark, Egypt, Estonia, Georgia, Greece, Hong Kong, Hungary, Kazakhstan, Kosovo, Kyrgyzstan, Lithuania, Macedonia, The Netherlands, Poland, Portugal, Romania, Russia, Serbia and Montenegro, Slovakia, Spain, Sweden, Turkey, Ukraine, USA, Venezuela).
In 2014 we published an evaluation of the scientific performance of the IRIS trainees. We were pleased to see that the IRIS training was associated with identifiable increase in scientific publication activity. Also the Journal of Electrocardiology has benefited from the increased quality of submitted manuscripts as well as from the increased pool of authors and peer-reviewers.
Galen Wagner was a great supported of this initiative; he was present in almost all courses, either in person or via Skype. He was a highly qualified and passionate teacher / mentor. During my several stays in the Editorial office I had the privilege to be present at Galen’s daily mentoring of both Duke and international students. It was very different from the didactic methods I had experienced before, and very effective.
As the Editor-in-Chief of the Journal of Electrocardiology he also encouraged participants to write and submit manuscripts to scientific journals, explained how to benefit from reviewers comments and involved participants as reviewers for the Journal of Electrocardiology, stressing the review process as a tool to develop further critical thinking and also to improve one’s own writing.
A: Do you think that the ECG helps in the diagnosis of left ventricular hypertrophy? Can you give us direction on how to read the most relevant papers on this topic?
The ECG diagnosis of left ventricular hypertrophy (LVH) is an excellent example of the changing role of ECG as a diagnostic method.
LVH is defined as an increase in the size of an organ or its parts, therefore there is an understandable effort to have a diagnostic method that estimates the increased LV size.
In the case of ECG, an increased QRS voltage was observed in a patient with mitral regurgitation already in the year 1906 and since then it has been described repeatedly in a proportion of patients with LVH. A simple association has been made – the bigger the LV the higher the QRS voltage. So for years, ECG has been used as a sort of a surrogate for estimating the increased LV mass. However, in spite of a quite impressive number of recommended ECG criteria for LVH, it has been a vain effort.
By principle, ECG cannot measure the size or mass: there are now available non-invasive imaging methods that can do it. But, on the other hand, and it is of utmost importance, ECG provides a unique information on the electrical characteristics of the heart that is not provided by any other diagnostic methods.
Differences in LVM as estimated by imaging methods versus QRS voltages and other electrical phenomena indicate different manifestations of underlying anatomical versus electrical remodeling processes. The variety of QRS and T-wave changes that occur in the context of electrically remodeled myocardium reflect the added diagnostic and prognostic value of ECG.
The term “false positive" (or negative) when applied to ECG results in relation to LVH is misleading. Future ECG research must therefore be focused on identifying those characteristics of electrical phenomena associated with left ventricular hypertrophy that relate to changes in risk for ventricular arrhythmias or pump failure, i.e., conditions of potentially greater clinical importance than anatomical LVH per se.
A: Please tell us about a good ECG paper that you read in the last 12 months?
In the context of the effort for the shift in paradigm in ECG diagnosis of left ventricular hypertrophy I would like to turn you attention to these two papers that demonstrate the new trends and are opening new directions in the research of LVH:
A: You are the only female president of the ISE so far? How was your experience leading this Society? What’s your opinion on the recent paper on Gender Equity in Electrocardiology for which you are a co-author?
I become the President of ISE in 1997, and I was the first and so far the only female president of the Society. It was really an honor and in that time I did not perceive it as anything related to gender issues. Perhaps I felt a little isolated, but I attributed my feeling to the more global problems of the East-West relations. In nineties, Slovakia was a country in transition; we had our local problems to deal with. In the Society the old alternative model of organizing the meetings was not more an issue, however somehow the “West” – “East” relations (whatever it means) I feel still as a challenge.
Now, after 20 years, I see the gender issue differently – there are still little women at visible positions in science. It is a situation going beyond the Society – it is a complex social situation recognized even in developing countries. I am glad that our Society has open this issue and I will do my best and contribute in creating conditions and encouraging women in finding their careers in research.
A: As a council Member of the ISE, what should be the next steps to consolidate our Society?
The Society is a very open community, open to everybody who in interested in research in the field of Electrocardiology and has attended the International Congresses of Electrocardiology. This arrangement has its historical reason: the history of the Society goes back to fifties of the last century, when the mutual East-West scientific contacts were organized by enthusiastic personalities. Considering the political situation in that time, it was vital to keep the formal aspects of the scientific contacts as limited as possible. In spite of many limitations of this arrangement, and, on the other hand, it is possible that thanks to this arrangement, the Society functions already nearly 60 years.
Now, the technology allows free and extensive communication. I see the following possibilities:
A: How do you see the future of research? What would be your advice for a young PhD starting his academic career?
Being involved in the research in electrocardiology for years and seeing the development in science and technology in general and in electrocardiology particular I have to say that we are living in an exciting period.
We participate in re-evaluating of old diagnostic paradigms (as can be demonstrated in the case of LVH), or in defining new diagnostic categories (as e.g. Brugada syndrome and Bayes syndrome). Using new technologies we are able to image electrical processes in the heart and simulate electrical processes to understand them better. It opens endless spectrum for research.
And a message for young scientists? The clinical electrocardiography is as a top of the iceberg seen above the water. It is worth to go deeper to discover what is underneath. There are millions of ECGs recorded in the world waiting for your analysis and invention.
 Bacharova L, Kudaiberdieva G, Misak A, Hakacova N, Timuralp B, Wagner GS. The effect of International Scientific Summer School research training on scientific productivity of trainees. Int J Cardiol. 2014;176:1142-1146.
Adrian: Why was important to you to get involved with the ISE?
Tom: ISE is a very special Society for several reasons. Firstly, because this is a real international society, with researchers from different continents and countries, what give us the opportunity of having a broader view of the eletrocardiography. Secondly, it is transdisciplinary, with participation of cardiologists, electrophysiologists, physiologists, epidemiologists, engineers and IT specialists. Thirdly, there are many important voices of the electrocardiology, like Antonio Bayes de Luna, Peter MacFarlane, Wojciech Zareba and many others. These persons gave a real contribution to the development of the eletrocardiology and, in ISE meetings, you have the opportunity of talking to them and discussing critical issues in the field. Finally, because ECG is still a very fascinating topic, complex, deductive and extremely important for all who are involved in the care of cardiac conditions.
A: What will be your “personal mark” during your presidency term (2019-2021)?
T: This is very difficult question, because the Society is in a row of very active and dynamic presidents and my first task would be to maintain all the improvements you are doing to ISE. My personal experience is mostly with ECG epidemiology and with the deployment of ECG services to underserved populations, and I would be very pleased if we could foster the expansion of the access to the ECG to the populations in need in low and middle income countries, where cardiovascular diseases and hypertension are now major causes of death. For this task, would need to involve other researchers from the field of epidemiology, general cardiology, primary health care and implementation science.
A: What is the role of surface ECG in Epidemiology? How do we use it?
T: ECG has been used in Epidemiology for 70 years and epidemiological studies have a pivotal role in the use of ECG in the clinical practice. The prognostic value of many ECG abnormalities, as bundle branch blocks and left ventricular enlargement, was defined by epidemiological studies, that continue to provide information on newer syndromes, as Early Repolarization and Brugada syndrome. Now, with the spread of digital ECG machines, we expect a new surge of information coming from electronic cohorts, providing more information not only about the well-recognized ECG patterns, but also from hidden features, which could be detected only by new methods of analysis and the use of artificial intelligence. I think there is a very powerful confluence of epidemiology, electronic medical records and databases, big data methods and clinical practice that can change, in the next ten years, the way we see and think the eletrocardiology.
A: Please tell us about a good ECG paper that you read in the last 12 months?
The paper by Aro et al. (below) is a recent favorite. The authors of ths study derived a very simple score based in ECG findings, from the community-based Oregon Sudden Unexpected Death Study, validating it in the Atherosclerosis Risk in Communities (ARIC) Study. It is another example on how epidemiological studies can improve the practice of cardiology by incorporation ECG findings in the clinical evaluation.
Aro AL, Reinier K, Rusinaru C, Uy-Evanado A, Darouian N, Phan D, Mack WJ, Jui J, Soliman EZ, Tereshchenko LG, Chugh SS. Electrical risk score beyond the left ventricular ejection fraction: prediction of sudden cardiac death in the Oregon Sudden Unexpected Death Study and the Atherosclerosis Risk in Communities Study. Eur Heart J. 2017 Oct 21;38(40):3017-3025.
doi: 10.1093/eurheartj/ehx331. PMID: 28662567.
A: How do we expand our Society in country like Brazil? Who should we target to get more people involved?
T: There are a lot of opportunities of expansion of the ISE in Latin America, in general, and in Brazil, specifically. With the epidemiological transition, Cardiovascular Diseases became the most important cause of death in our region and there is lot of interest in Electrocardiology, not only from specialists, but also from physicians and nurses that work with primary care and urgencies. These professionals cold be involved in courses and activities, as academic personnel from local Universities could help in this task of dissemination of the method and expansion of the Society.
A: How do you see the future of the ISE? Any role for Social Media?
T: ISE is a relatively old society that is renewing itself, recruiting younger researchers and using the current methods to divulgate its goal and to reach the health and medical community. You are somehow an example of this renovation, since you one of youngest presidents of this Society – and your youth and energy are important drives to our change. Social media is essential for all international organizations in the world now and the ISE should improve its use. The approximation with other societies with similar and complimentary interest is also important and the partnership with ISHNE, the International Society for Holter and NonInvasive Electrocardiology, is a well succeed example on how this can work.
A: Thank you very much for your time and expertise.
T: Thank you, Adrian, for all your effort and dedication to the ISE.
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