Deputy Managing Editor
Carpal tunnel syndrome, persistent back pain and unexplained nerve problems could offer important clues to an underlying heart condition, says Mayo Clinic cardiologist Dr Jose Nativi Nicolau, who is urging earlier detection, more precise diagnosis and personalised treatment.
Heart failure is often associated with breathlessness, swollen feet and an inability to perform everyday activities.
However, by the time these symptoms become apparent, the disease may already have progressed significantly.
For Dr Jose Nativi Nicolau, a cardiologist specialising in heart failure and transplantation at Mayo Clinic in Jacksonville, Florida, one of the most important developments in modern cardiology is the growing ability to identify patients at risk before they begin experiencing the familiar signs of the condition.
Speaking during an interview with Caribbean and Latin American journalists last Thursday, the Panama-born specialist explained that advances in artificial intelligence (AI), diagnostic imaging and genetic research are changing how heart failure is identified and treated.
He said the focus must move beyond managing symptoms towards preventing the disease, identifying it earlier and tailoring treatment to individual patients.
“We are moving from a time when we investigated everybody the same way and the therapies were the same for everybody. The future is understanding the variables of each patient and giving specific therapy for each of them,” he said.
Warning signs beyond the heart
One of the more significant areas of Nicolau’s research involves cardiac amyloidosis, a condition in which abnormal deposits of a protein called amyloid accumulate in organs and tissues, including the heart.
He explained that transthyretin (TTR) amyloidosis occurs when a protein normally produced by the liver becomes deposited in different parts of the body. This can affect the joints, nervous system and heart.
Consequently, symptoms that might initially appear unrelated could be manifestations of the same underlying disease.
Carpal tunnel syndrome, particularly when it affects both wrists, is one such warning sign. Other possible indicators include persistent back pain, lumbar spinal stenosis and peripheral neuropathy, which can cause tingling in the hands and feet.
Nicolau said these symptoms were historically investigated separately, with patients moving between cardiologists and orthopaedic specialists without anyone necessarily connecting them.
“These symptoms may be explained by a common biological process that is amyloidosis. So, when a patient has heart failure or lumbar stenosis, you have to screen for amyloidosis,” he explained.
However, he cautioned against assuming that everyone with carpal tunnel syndrome has an underlying heart condition. It is the combination of symptoms, particularly when neurological, joint and cardiac problems occur together, that should raise suspicion.
Diagnostic advances have also made the condition easier to identify. Previously, a heart biopsy was often required to confirm cardiac amyloidosis. Nicolau said newer imaging techniques, including pyrophosphate scanning, have made it possible to establish the diagnosis without routinely requiring an invasive heart biopsy.
Artificial intelligence changing early detection
Another significant development is the use of artificial intelligence to identify possible heart disease before patients experience symptoms.
Nicolau explained that electrocardiograms (ECGs), which have been used in cardiology for decades, are now being enhanced by AI technology.
At Mayo Clinic and other centres using the technology, an ECG can be analysed against a database containing more than seven million ECG recordings.
The system identifies patterns that could indicate conditions that might otherwise go undetected, allowing doctors to investigate patients who may not yet display conventional symptoms.
He stressed, however, that AI is not a substitute for medical assessment.
“AI doesn’t give you a diagnosis. AI helps you. It gives you probabilities, but then you have to go to the doctor for an interpretation and to conduct the necessary tests to determine whether you have cardiac failure or not,” he said.
The technology can also produce false-positive and false-negative results. Researchers are therefore working towards incorporating additional information, including age, sex, blood pressure and laboratory results, to improve the accuracy of assessments.
Recognising the four stages
Nicolau explained that heart failure is classified into four stages, identified as A, B, C and D.
Stage A describes patients with risk factors such as high blood pressure, diabetes, elevated cholesterol, obesity and smoking, but without structural damage to the heart.
Stage B involves patients who already have changes in the heart but have not developed symptoms. This is an important opportunity for early intervention, including the use of emerging diagnostic technologies.
Stage C is when symptoms become apparent. These include breathlessness, fatigue, abdominal swelling and swollen feet, resulting from fluid accumulation.
Stage D represents advanced heart failure, when patients continue to experience significant symptoms despite medication and other interventions. Some may require mechanical circulatory support or heart transplantation.
He warned that patients frequently dismiss breathlessness and fatigue as normal consequences of ageing, potentially delaying medical attention.
Women also remain vulnerable to under-diagnosis, partly because their symptoms may present differently from those traditionally associated with heart disease in men.
Nicolau acknowledged that this remains an area requiring attention, with more personalised diagnostic approaches expected to help address some of the limitations.
Treatment has moved beyond managing symptoms
The specialist said treatment has changed considerably, with modern therapies targeting the biological processes responsible for the progression of heart failure rather than simply relieving symptoms.
Among the medications used are beta blockers, ACE inhibitors, aldosterone antagonists and SGLT2 inhibitors.
These treatments help counter hormonal responses triggered when the heart cannot pump sufficient blood to meet the body’s needs.
Some patients experience significant improvement in their heart’s pumping ability, measured through its ejection fraction. A patient whose heart is pumping at 20 per cent, for example, may improve to 40 or 50 per cent, while some can recover to normal levels.
However, Nicolau cautioned that recovery is not guaranteed. Even patients whose heart function does not improve can experience better quality of life and prolonged survival with appropriate treatment.
He also highlighted the relationship between heart and kidney function, explaining that fluid retention associated with heart failure can worsen kidney performance. Managing fluid levels and adjusting medication are therefore important aspects of treatment.
Prevention remains the priority
Despite advances in transplantation, medication and diagnostic technology, Nicolau believes prevention remains the most important intervention.
He encouraged people to understand their blood pressure, cholesterol and blood sugar levels, while addressing obesity, smoking and other modifiable risk factors.
He also identified the Mediterranean diet, which emphasises fruits, vegetables and lean protein sources such as fish and poultry, as an established dietary approach recommended in cardiovascular guidelines.
For patients already diagnosed with heart failure, monitoring fluid retention is particularly important. Daily weighing can help identify sudden weight changes that may indicate fluid accumulation or dehydration. Patients should follow their doctors’ advice on fluid intake and medication adjustments.
Ultimately, Nicolau believes the future of cardiology lies in combining early detection, artificial intelligence, genetic information and multidisciplinary medical expertise.
At Mayo Clinic, patients are assessed by multidisciplinary teams to develop treatment plans suited to their individual circumstances.
The objective, he said, is not simply to prolong life but to improve the quality of life of people living with heart disease.
“At Mayo Clinic, the patients are evaluated by multidisciplinary teams, and the patient, with all that information, receives one single therapy plan that is individualised based on the specific needs of each patient.”
