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Houston AD, Brunger H, White T, Ellis H, Dharm-Datta S, Brockman K, Ladlow P. Introducing heart rate variability technology into the UK defence mild traumatic brain injury service. BMJ Mil Health 2024; 170:78-79. [PMID: 35584851 DOI: 10.1136/bmjmilitary-2022-002113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/05/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Andrew David Houston
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre (DMRC) Stanford Hall, Loughborough, UK
| | - H Brunger
- Neurorehabilitation Unit, Defence Medical Rehabilitation Centre (DMRC) Stanford Hall, Loughborough, UK
| | - T White
- Neurorehabilitation Unit, Defence Medical Rehabilitation Centre (DMRC) Stanford Hall, Loughborough, UK
| | - H Ellis
- Neurorehabilitation Unit, Defence Medical Rehabilitation Centre (DMRC) Stanford Hall, Loughborough, UK
| | - S Dharm-Datta
- Neurorehabilitation Unit, Defence Medical Rehabilitation Centre (DMRC) Stanford Hall, Loughborough, UK
| | - K Brockman
- Neurorehabilitation Unit, Defence Medical Rehabilitation Centre (DMRC) Stanford Hall, Loughborough, UK
| | - P Ladlow
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre (DMRC) Stanford Hall, Loughborough, UK
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Sinha A, Dutta U, Demir OM, De Silva K, Ellis H, Belford S, Ogden M, Li Kam Wa M, Morgan HP, Shah AM, Chiribiri A, Webb AJ, Marber M, Rahman H, Perera D. Rethinking False Positive Exercise Electrocardiographic Stress Tests by Assessing Coronary Microvascular Function. J Am Coll Cardiol 2024; 83:291-299. [PMID: 38199706 PMCID: PMC10790243 DOI: 10.1016/j.jacc.2023.10.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/10/2023] [Accepted: 10/13/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Exercise electrocardiographic stress testing (EST) has historically been validated against the demonstration of obstructive coronary artery disease. However, myocardial ischemia can occur because of coronary microvascular dysfunction (CMD) in the absence of obstructive coronary artery disease. OBJECTIVES The aim of this study was to assess the specificity of EST to detect an ischemic substrate against the reference standard of coronary endothelium-independent and endothelium-dependent microvascular function in patients with angina with nonobstructive coronary arteries (ANOCA). METHODS Patients with ANOCA underwent invasive coronary physiological assessment using adenosine and acetylcholine. CMD was defined as impaired endothelium-independent and/or endothelium-dependent function. EST was performed using a standard Bruce treadmill protocol, with ischemia defined as the appearance of ≥0.1-mV ST-segment depression 80 ms from the J-point on electrocardiography. The study was powered to detect specificity of ≥91%. RESULTS A total of 102 patients were enrolled (65% women, mean age 60 ± 8 years). Thirty-two patients developed ischemia (ischemic group) during EST, whereas 70 patients did not (nonischemic group); both groups were phenotypically similar. Ischemia during EST was 100% specific for CMD. Acetylcholine flow reserve was the strongest predictor of ischemia during exercise. Using endothelium-independent and endothelium-dependent microvascular dysfunction as the reference standard, the false positive rate of EST dropped to 0%. CONCLUSIONS In patients with ANOCA, ischemia on EST was highly specific of an underlying ischemic substrate. These findings challenge the traditional belief that EST has a high false positive rate.
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Affiliation(s)
- Aish Sinha
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom. https://twitter.com/AishSinha1
| | - Utkarsh Dutta
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Ozan M Demir
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Kalpa De Silva
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Howard Ellis
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Samuel Belford
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Mark Ogden
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Matthew Li Kam Wa
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Holly P Morgan
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Ajay M Shah
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Amedeo Chiribiri
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Andrew J Webb
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Michael Marber
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Haseeb Rahman
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom.
| | - Divaka Perera
- British Heart Foundation Center of Excellence and National Institute for Health Research Biomedical Research Center at the School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom. https://twitter.com/divaka_perera
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Sinha A, Rahman H, Douiri A, Demir OM, De Silva K, Clapp B, Webb I, Gulati A, Pinho P, Dutta U, Ellis H, Shah AM, Chiribiri A, Marber M, Webb AJ, Perera D. ChaMP-CMD: A Phenotype-Blinded, Randomized Controlled, Cross-Over Trial. Circulation 2024; 149:36-47. [PMID: 37905403 PMCID: PMC10752262 DOI: 10.1161/circulationaha.123.066680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/09/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Angina with nonobstructive coronary arteries is a common condition for which no effective treatment has been established. We hypothesized that the measurement of coronary flow reserve (CFR) allows identification of patients with angina with nonobstructive coronary arteries who would benefit from anti-ischemic therapy. METHODS Patients with angina with nonobstructive coronary arteries underwent blinded invasive CFR measurement and were randomly assigned to receive 4 weeks of amlodipine or ranolazine. After a 1-week washout, they crossed over to the other drug for 4 weeks; final assessment was after the cessation of study medication for another 4 weeks. The primary outcome was change in treadmill exercise time, and the secondary outcome was change in Seattle Angina Questionnaire summary score in response to anti-ischemic therapy. Analysis was on a per protocol basis according to the following classification: coronary microvascular disease (CMD group) if CFR<2.5 and reference group if CFR≥2.5. The study protocol was registered before the first patient was enrolled (International Standard Randomised Controlled Trial Number: ISRCTN94728379). RESULTS Eighty-seven patients (61±8 years of age; 62% women) underwent random assignment (57 CMD group and 30 reference group). Baseline exercise time and Seattle Angina Questionnaire summary scores were similar between groups. The CMD group had a greater increment (delta) in exercise time than the reference group in response to both amlodipine (difference in delta, 82 s [95% CI, 37-126 s]; P<0.001) and ranolazine (difference in delta, 68 s [95% CI, 21-115 s]; P=0.005). The CMD group reported a greater increment (delta) in Seattle Angina Questionnaire summary score than the reference group in response to ranolazine (difference in delta, 7 points [95% CI, 0-15]; P=0.048), but not to amlodipine (difference in delta, 2 points [95% CI, -5 to 8]; P=0.549). CONCLUSIONS Among phenotypically similar patients with angina with nonobstructive coronary arteries, only those with an impaired CFR derive benefit from anti-ischemic therapy. These findings support measurement of CFR to diagnose and guide management of this otherwise heterogeneous patient group.
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Affiliation(s)
- Aish Sinha
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
| | - Haseeb Rahman
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
| | - Abdel Douiri
- Department of Medical Statistics, School of Life Course & Population Sciences (A.D.), King’s College London, UK
| | - Ozan M. Demir
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
| | - Kalpa De Silva
- Guys’ and St. Thomas’ NHS Foundation Trust, London, UK (K.D.S., B.C., I.W., A.G., P.P., A.J.W., D.P.)
| | - Brian Clapp
- Guys’ and St. Thomas’ NHS Foundation Trust, London, UK (K.D.S., B.C., I.W., A.G., P.P., A.J.W., D.P.)
| | - Ian Webb
- Guys’ and St. Thomas’ NHS Foundation Trust, London, UK (K.D.S., B.C., I.W., A.G., P.P., A.J.W., D.P.)
- King’s College Hospital NHS Foundation Trust, London. UK (I.W., A.M.S.)
| | - Ankur Gulati
- Guys’ and St. Thomas’ NHS Foundation Trust, London, UK (K.D.S., B.C., I.W., A.G., P.P., A.J.W., D.P.)
| | - Pedro Pinho
- Guys’ and St. Thomas’ NHS Foundation Trust, London, UK (K.D.S., B.C., I.W., A.G., P.P., A.J.W., D.P.)
| | - Utkarsh Dutta
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
| | - Howard Ellis
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
| | - Ajay M. Shah
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
- King’s College Hospital NHS Foundation Trust, London. UK (I.W., A.M.S.)
| | - Amedeo Chiribiri
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
| | - Michael Marber
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
| | - Andrew J. Webb
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
- Guys’ and St. Thomas’ NHS Foundation Trust, London, UK (K.D.S., B.C., I.W., A.G., P.P., A.J.W., D.P.)
| | - Divaka Perera
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences (A.S., H.R., O.M.D., U.D., H.E., A.M.S., A.C., M.M., A.J.W., D.P.), King’s College London, UK
- Guys’ and St. Thomas’ NHS Foundation Trust, London, UK (K.D.S., B.C., I.W., A.G., P.P., A.J.W., D.P.)
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Sinha A, Rahman H, Rajani R, Demir OM, Li KamWa M, Morgan H, Ezad SM, Ellis H, Hogan D, Gulati A, Shah AM, Chiribiri A, Webb AJ, Marber M, Perera D. Characterizing Mechanisms of Ischemia in Patients With Myocardial Bridges. Circ Cardiovasc Interv 2024; 17:e013657. [PMID: 37929596 PMCID: PMC10782941 DOI: 10.1161/circinterventions.123.013657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/31/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Myocardial bridges (MBs) are prevalent and can be associated with acute and chronic ischemic syndromes. We sought to determine the substrates for ischemia in patients with angina with nonobstructive coronary arteries and a MB in the left anterior descending artery. METHODS Patients with angina with nonobstructive coronary arteries underwent the acquisition of intracoronary pressure and flow during rest, supine bicycle exercise, and adenosine infusion. Coronary wave intensity analysis was performed, with perfusion efficiency defined as accelerating wave energy/total wave energy (%). Epicardial endothelial dysfunction was defined as a reduction in epicardial vessel diameter ≥20% in response to intracoronary acetylcholine infusion. Patients with angina with nonobstructive coronary arteries and a MB were compared with 2 angina with nonobstructive coronary arteries groups with no MB: 1 with coronary microvascular disease (CMD: coronary flow reserve, <2.5) and 1 with normal coronary flow reserve (reference: coronary flow reserve, ≥2.5). RESULTS Ninety-two patients were enrolled in the study (30 MB, 33 CMD, and 29 reference). Fractional flow reserve in these 3 groups was 0.86±0.05, 0.92±0.04, and 0.94±0.05; coronary flow reserve was 2.5±0.5, 2.0±0.3, and 3.2±0.6. Perfusion efficiency increased numerically during exercise in the reference group (65±9%-69±13%; P=0.063) but decreased in the CMD (68±10%-50±10%; P<0.001) and MB (66±9%-55±9%; P<0.001) groups. The reduction in perfusion efficiency had distinct causes: in CMD, this was driven by microcirculation-derived energy in early diastole, whereas in MB, this was driven by diminished accelerating wave energy, due to the upstream bridge, in early systole. Epicardial endothelial dysfunction was more common in the MB group (54% versus 29% reference and 38% CMD). Overall, 93% of patients with a MB had an identifiable ischemic substrate. CONCLUSIONS MBs led to impaired coronary perfusion efficiency during exercise, which was due to diminished accelerating wave energy in early systole compared with the reference group. Additionally, there was a high prevalence of endothelial and microvascular dysfunction. These ischemic mechanisms may represent distinct treatment targets.
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Affiliation(s)
- Aish Sinha
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Haseeb Rahman
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Ronak Rajani
- Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom (R.R., D.H., A.G., D.P.)
| | - Ozan M. Demir
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Matthew Li KamWa
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Holly Morgan
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Saad M. Ezad
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Howard Ellis
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Dexter Hogan
- Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom (R.R., D.H., A.G., D.P.)
| | - Ankur Gulati
- Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom (R.R., D.H., A.G., D.P.)
| | - Ajay M. Shah
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Amedeo Chiribiri
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Andrew J. Webb
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Michael Marber
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
| | - Divaka Perera
- British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (A.S., H.R., O.M.D., M.L.K., H.M., S.M.E., H.E., A.M.S., A.C., A.J.W., M.M., D.P.)
- Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom (R.R., D.H., A.G., D.P.)
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Dutta U, Sinha A, Demir OM, Ellis H, Rahman H, Perera D. Coronary Slow Flow Is Not Diagnostic of Microvascular Dysfunction in Patients With Angina and Unobstructed Coronary Arteries. J Am Heart Assoc 2022; 12:e027664. [PMID: 36565193 PMCID: PMC9973578 DOI: 10.1161/jaha.122.027664] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Guidelines recommend that coronary slow flow phenomenon (CSFP), defined as corrected thrombolysis in myocardial infarction frame count (CTFC) >$$ > $$27, can diagnose coronary microvascular dysfunction (CMD) in patients with angina and nonobstructed coronary arteries. CSFP has also historically been regarded as a sign of coronary endothelial dysfunction (CED). We sought to validate the utility of CTFC, as a binary classifier of CSFP and as a continuous variable, to diagnose CMD and CED. Methods and Results Patients with angina and nonobstructed coronary arteries had simultaneous coronary pressure and flow velocity measured using a dual sensor-tipped guidewire during rest, adenosine-mediated hyperemia, and intracoronary acetylcholine infusion. CMD was defined as the inability to augment coronary blood flow in response to adenosine (coronary flow reserve <2.5) and CED in response to acetylcholine (acetylcholine flow reserve ≤1.5); 152 patients underwent assessment using adenosine, of whom 82 underwent further acetylcholine testing. Forty-six patients (30%) had CSFP, associated with lower flow velocity and higher microvascular resistance as compared with controls (16.5±$$ \pm $$6.9 versus 20.2±$$ \pm $$6.9 cm/s; P=0.001 and 6.26±$$ \pm $$1.83 versus 5.36±$$ \pm $$1.83 mm Hg/cm/s; P=0.009, respectively). However, as a diagnostic test, CSFP had poor sensitivity and specificity for both CMD (26.7% and 65.2%) and CED (21.1% and 56.0%). Furthermore, on receiver operating characteristics analyses, CTFC could not predict CMD or CED (area under the curve, 0.41 [95% CI, 0.32%-0.50%] and 0.36 [95% CI, 0.23%-0.49%], respectively). Conclusions In patients with angina and nonobstructed coronary arteries, CSFP and CTFC are not diagnostic of CMD or CED. Guidelines supporting the use of CTFC in the diagnosis of CMD should be revisited.
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Affiliation(s)
- Utkarsh Dutta
- School of Cardiovascular Medicine and SciencesBritish Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College LondonLondonUK
| | - Aish Sinha
- School of Cardiovascular Medicine and SciencesBritish Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College LondonLondonUK
| | - Ozan M. Demir
- School of Cardiovascular Medicine and SciencesBritish Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College LondonLondonUK
| | - Howard Ellis
- School of Cardiovascular Medicine and SciencesBritish Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College LondonLondonUK
| | - Haseeb Rahman
- School of Cardiovascular Medicine and SciencesBritish Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College LondonLondonUK
| | - Divaka Perera
- School of Cardiovascular Medicine and SciencesBritish Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College LondonLondonUK
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Ryan M, De Silva K, Morgan H, O’Gallagher K, Demir OM, Rahman H, Ellis H, Dancy L, Sado D, Strange J, Melikian N, Marber M, Shah AM, Chiribiri A, Perera D. Coronary Wave Intensity Analysis as an Invasive and Vessel-Specific Index of Myocardial Viability. Circ Cardiovasc Interv 2022; 15:e012394. [PMID: 36538582 PMCID: PMC9760472 DOI: 10.1161/circinterventions.122.012394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/28/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Coronary angiography and viability testing are the cornerstones of diagnosing and managing ischemic cardiomyopathy. At present, no single test serves both needs. Coronary wave intensity analysis interrogates both contractility and microvascular physiology of the subtended myocardium and therefore has the potential to fulfil the goal of completely assessing coronary physiology and myocardial viability in a single procedure. We hypothesized that coronary wave intensity analysis measured during coronary angiography would predict viability with a similar accuracy to late-gadolinium-enhanced cardiac magnetic resonance imaging. METHODS Patients with a left ventricular ejection fraction ≤40% and extensive coronary disease were enrolled. Coronary wave intensity analysis was assessed during cardiac catheterization at rest, during adenosine-induced hyperemia, and during low-dose dobutamine stress using a dual pressure-Doppler sensing coronary guidewire. Scar burden was assessed with cardiac magnetic resonance imaging. Regional left ventricular function was assessed at baseline and 6-month follow-up after optimization of medical-therapy±revascularization, using transthoracic echocardiography. The primary outcome was myocardial viability, determined by the retrospective observation of functional recovery. RESULTS Forty participants underwent baseline physiology, cardiac magnetic resonance imaging, and echocardiography, and 30 had echocardiography at 6 months; 21/42 territories were viable on follow-up echocardiography. Resting backward compression wave energy was significantly greater in viable than in nonviable territories (-5240±3772 versus -1873±1605 W m-2 s-1, P<0.001), and had comparable accuracy to cardiac magnetic resonance imaging for predicting viability (area under the curve 0.812 versus 0.757, P=0.649); a threshold of -2500 W m-2 s-1 had 86% sensitivity and 76% specificity. CONCLUSIONS Backward compression wave energy has accuracy similar to that of late-gadolinium-enhanced cardiac magnetic resonance imaging in the prediction of viability. Coronary wave intensity analysis has the potential to streamline the management of ischemic cardiomyopathy, in a manner analogous to the effect of fractional flow reserve on the management of stable angina.
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Affiliation(s)
- Matthew Ryan
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Kalpa De Silva
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Holly Morgan
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Kevin O’Gallagher
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Ozan M. Demir
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Haseeb Rahman
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Howard Ellis
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Luke Dancy
- Cardiology Department, King’s College Hospital, London, UK (L.D., D.S., N.M.)
| | - Daniel Sado
- Cardiology Department, King’s College Hospital, London, UK (L.D., D.S., N.M.)
| | | | | | - Michael Marber
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Ajay M. Shah
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Amedeo Chiribiri
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
- Imaging Sciences Division, King’s College London, UK (A.C.)
| | - Divaka Perera
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
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7
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Ryan M, Morgan H, O'Gallagher K, Demir O, Rahman H, Ellis H, Dancy L, Sado D, Strange J, Melikian N, Marber M, Shah A, De Silva K, Chiribiri A, Perera D. Coronary wave energy to predict functional recovery in patients with ischemic left ventricular dysfunction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Invasive coronary angiography and non-invasive viability testing are the cornerstones of diagnosing and managing ischemic left ventricular dysfunction. At present there is no single test which serves both needs but, if developed, could revolutionise investigation of this condition. Coronary wave intensity analysis (cWIA) interrogates both contractility and microvascular physiology of the subtended myocardium [1,2] and therefore has the potential to fulfil this goal.
Objectives
We hypothesized that cWIA measured during coronary angiography would predict functional recovery with a similar accuracy to late gadolinium enhanced cardiac magnetic resonance imaging (LGE-CMR).
Methods
Patients with a left ventricular ejection fraction ≤40% and extensive coronary disease were enrolled. cWIA, fractional flow reserve and microvascular resistance were assessed with a simultaneous coronary Doppler and pressure-sensing guidewire during cardiac catheterization at rest, during hyperaemia and during low-dose dobutamine stress. Viability was assessed using LGE-CMR. Regional left ventricular function was assessed at baseline and 6-month follow up after optimization of medical therapy +/− revascularization, using transthoracic echocardiography. The primary outcome was regional functional recovery.
Results
Forty participants underwent baseline physiology, LGE-CMR and thirty had echocardiography at baseline and 6 months; 21/42 territories demonstrated functional recovery. Resting backward compression wave energy was significantly greater in recovering than non-recovering territories (−5240±3772 vs. −1873±1605 W m–2 s–1, p=0.099, Figure 1), and had comparable diagnostic accuracy to CMR (area under the curve 0.812 vs. 0.757, p=0.649, Figure 2); a threshold of −2500 W mm–2 s–1 had 86% sensitivity and 76% specificity at predicting recovery. Backward expansion wave energy did not predict recovery. FFR was numerically higher in recovering territories (0.81±0.17 vs. 0.71±0.16, p=0.058), whilst hyperaemic microvascular resistance did not differentiate recovering from non-recovering territories (1.97±0.73 vs. 2.29±1.00, p=0.287). The likelihood of functional recovery was similar in revascularised and non-revascularised territories (15/29 vs. 6/13 respectively, p=0.739). Low-dose dobutamine stress increased the energy of all waves, but did not improve the accuracy of cWIA in predicting recovery. In a regression model, resting backward compression wave energy and optimization of medical therapy predicted functional recovery; fractional flow reserve and hyperemic microvascular resistance did not.
Conclusions
Backward compression wave energy has similar accuracy to LGE-CMR in the prediction of functional recovery. cWIA has the potential to revolutionise the management of ischaemic left ventricular dysfunction, in a manner analogous to the effect of fractional flow reserve on the management of stable angina.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): The British Heart Foundation Clinical Research Training Fellowship
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Affiliation(s)
- M Ryan
- King's College London , London , United Kingdom
| | - H Morgan
- King's College London , London , United Kingdom
| | | | - O Demir
- King's College London , London , United Kingdom
| | - H Rahman
- King's College London , London , United Kingdom
| | - H Ellis
- King's College London , London , United Kingdom
| | - L Dancy
- King's College Hospital NHS Foundation Trust , London , United Kingdom
| | - D Sado
- King's College Hospital NHS Foundation Trust , London , United Kingdom
| | - J Strange
- Bristol Heart Institute , Bristol , United Kingdom
| | - N Melikian
- King's College Hospital NHS Foundation Trust , London , United Kingdom
| | - M Marber
- King's College London , London , United Kingdom
| | - A Shah
- King's College London , London , United Kingdom
| | - K De Silva
- King's College London , London , United Kingdom
| | - A Chiribiri
- King's College London , London , United Kingdom
| | - D Perera
- King's College London , London , United Kingdom
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8
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Sinha A, Demir OM, Ellis H, Perera D. Dizziness in an avid cyclist: an unusual presentation of a common problem. Eur Heart J Case Rep 2021; 5:ytab459. [PMID: 34993402 PMCID: PMC8728714 DOI: 10.1093/ehjcr/ytab459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/29/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022]
Abstract
Background Presyncope and syncope are common presentations with a wide range of differential diagnoses; when it occurs primarily on exertion, a cardiovascular cause is more likely. Structural abnormalities and primary rhythm disturbances are the usual culprits in these patients. Case summary A 75-year-old gentleman presented with a history of progressive exertional presyncope. His investigations demonstrated normal cardiac structure, function, and rhythm. He underwent an exercise stress test, which demonstrated a significant reduction in peak blood pressure with equivocal electrocardiogram changes and absence of ischaemic symptoms. In view of his age and gender, a computerized tomography coronary angiogram (CTCA) was organized to exclude obstructive coronary artery disease (CAD). Intriguingly, the CTCA demonstrated a severe proximal left anterior descending (LAD) artery stenosis. This stenosis was confirmed to be functionally significant using invasive coronary physiology and was treated with percutaneous coronary intervention. At follow-up, there was no recurrence of exertional presyncope and the patient was continuing to return to his baseline function. Conclusion Presyncope and/or syncope as the sole manifestation of obstructive CAD, in the presence of normal ventricular function and valves, has rarely been reported. Myocardial ischaemia-mediated presyncope and/or syncope may be secondary to numerous mechanisms, which are described in this case report. Revascularization of the functionally significant proximal LAD stenosis resulted in cessation of exertional presyncope in our patient. The long-term outcome of revascularization in patients with presyncope and syncope needs to be further investigated.
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Affiliation(s)
- Aish Sinha
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London , Westminster Bridge Rd, London SE1 7EH, UK
| | - Ozan M Demir
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London , Westminster Bridge Rd, London SE1 7EH, UK
| | - Howard Ellis
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London , Westminster Bridge Rd, London SE1 7EH, UK
| | - Divaka Perera
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London , Westminster Bridge Rd, London SE1 7EH, UK
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9
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O'Sullivan O, Allsopp L, Mitchell J, Price L, Tourle K, Ellis H. Review of neurological rehabilitation for Multiple Sclerosis in the British Military. BMJ Mil Health 2021; 168:324-328. [PMID: 34253640 DOI: 10.1136/bmjmilitary-2021-001852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/07/2021] [Indexed: 01/09/2023]
Abstract
Multiple sclerosis (MS) is a progressive neurological disorder, classically presenting in working age adults, including those in the Armed Forces. The Defence Medical Rehabilitation Centre (DMRC) Stanford Hall offers vocationally focused neurorehabilitation services for service personnel (SP) with MS, with the goal to minimise disability, maximise independence and remain able to work.This paper has two aims. First, it briefly provides a clinical update of MS, focusing on pathology, presentation, diagnosis and management. Finally, it will describe the role of DMRC and data from the last decade in the management of MS.Our findings suggest not all SP with MS are being referred to DMRC, and some of those who do have significant delays, potentially impacting on patient support, symptom management and occupational outcomes. It is hoped that this paper will improve awareness and recognition of MS for Armed Forces personnel.
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Affiliation(s)
- Oliver O'Sullivan
- Academic Department of Military Rehabilitation, DMRC Stanford Hall, Loughborough, UK .,Headquarters Army Medical Services (HQ AMS), Camberley, UK
| | - L Allsopp
- Neuro-Rehabilitation Department, DMRC Stanford Hall, Loughborough, UK
| | - J Mitchell
- Academic Department of Military Rehabilitation, DMRC Stanford Hall, Loughborough, UK.,Metabolic Neurology, University of Birmingham Institute of Metabolism and Systems Research, Birmingham, UK
| | - L Price
- Neuro-Rehabilitation Department, DMRC Stanford Hall, Loughborough, UK
| | - K Tourle
- Neuro-Rehabilitation Department, DMRC Stanford Hall, Loughborough, UK
| | - H Ellis
- Neuro-Rehabilitation Department, DMRC Stanford Hall, Loughborough, UK
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10
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Modi BN, Demir OM, Rahman H, Ryan M, Abou Sherif S, Ellis H, Colombo A, Perera D. Clinical Utility of Novel Fractional Flow Reserve Pullback for Individual Lesion Contribution in Serial Disease. J Invasive Cardiol 2021; 33:E491-E496. [PMID: 34148866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Fractional flow reserve (FFR) pullback is frequently used to assess serially diseased arteries, but has been shown to be inaccurate due to physiological interaction between individual lesions. We evaluated the clinical utility of a novel solution that improves estimation of true FFR contribution of each stenosis in the presence of serial disease. METHODS Ten interventional cardiologists were presented with tiered information for 18 elective patients with serial coronary disease and submitted revascularization strategies and assessment of lesion significance. Operators were first shown clinical and angiographic information only (Angio); then, conventional practice FFR (FFRnorm); and finally, pullback with corrected FFR contributions of each stenosis (FFRpred). RESULTS The treatment strategy agreement between operators was k=0.39, k=0.64, and k=0.77 using Angio, FFRnorm, and FFRpred, respectively (P<.001). Lesion significance uncertainty was 26%, 28%, and 3%, respectively. The number of stents per patient was 1.49 ± 0.57, 1.50 ± 0.57, and 1.3 ± 0.5, respectively (P<.001). In total, percutaneous coronary intervention (PCI) strategy changed in over 50% of cases analyzed, with participants opting for shorter stent length with FFRpred (29.5 ± 15.2 mm) compared with FFRnorm (34.1 ± 14.4 mm; P<.001) and Angio (34.6 ± 14.3; P=.04). This was accompanied by significantly less interobserver variability. CONCLUSION The ability to quantify the contribution of individual lesions with the novel FFR pullback-based solution significantly increases operator confidence regarding PCI strategy, reduces heterogeneity in practice, and can reduce the planned number of stents and total stent length.
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Affiliation(s)
| | | | | | | | | | | | | | - Divaka Perera
- Cardiovascular Division, Rayne Institute, St. Thomas' Hospital, London, SE1 7EH, United Kingdom.
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11
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Patterson T, Rivolo S, Burkhoff D, Schreuder J, Briceno N, Williams R, Arri S, Asrress KN, Allen C, Joseph J, McConkey HZR, Ellis H, Pavlidis A, Clapp B, Perera D, Lee J, Marber MS, Redwood SR. Impact of coronary artery disease on contractile function and ventricular-arterial coupling during exercise: Simultaneous assessment of left-ventricular pressure-volume and coronary pressure and flow during cardiac catheterization. Physiol Rep 2021; 9:e14768. [PMID: 34042307 PMCID: PMC8157768 DOI: 10.14814/phy2.14768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 01/18/2021] [Accepted: 01/26/2021] [Indexed: 01/09/2023] Open
Abstract
Coronary artery disease (CAD) can adversely affect left ventricular (LV) performance during exercise by impairment of contractile function in the presence of increasing afterload. By performing invasive measures of LV pressure–volume and coronary pressure and flow during exercise, we sought to accurately measure this with comparison to the control group. Sixteen patients, with CCS class >II angina and CAD underwent invasive simultaneous measurement of left ventricular pressure–volume and coronary pressure and flow velocity during cardiac catheterization. Measurements performed at rest were compared with peak exercise using bicycle ergometry. The LV contractile function was measured invasively using the end‐systolic pressure–volume relationship, a load independent marker of contractile function (Ees). Vascular afterload forces were derived from the ratio of LV end‐systolic pressure to stroke volume to generate arterial elastance (Ea). These were combined to assess cardiovascular performance (ventricular‐arterial [VA] coupling ratio [Ea/Ees]). Eleven patients demonstrated flow‐limiting (FL) CAD (hyperemic Pd/Pa <0.80; ST‐segment depression on exercise); five patients without flow‐limiting (NFL) CAD served as the control group. Exercise in the presence of FL CAD was associated impairment of Ees, increased Ea, and deterioration of VA coupling. In the control cohort, exercise was associated with increased Ees and improved VA coupling. The backward compression wave energy directly correlated with the magnitude contraction as measured by dP/dTmax (r = 0.88, p = 0.004). This study demonstrates that in the presence of flow‐limiting CAD, exercise to maximal effort can lead to impairment of LV contractile function and a deterioration in VA coupling compared to a control cohort.
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Affiliation(s)
- Tiffany Patterson
- Cardiovascular Division, King's College London, St. Thomas' Hospital, London, UK
| | - Simone Rivolo
- Department of Imaging Science, King's College London, St. Thomas' Hospital, London, UK
| | | | - Jan Schreuder
- CD Leycom, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Natalia Briceno
- Cardiovascular Division, King's College London, St. Thomas' Hospital, London, UK
| | - Rupert Williams
- Cardiovascular Division, King's College London, St. Thomas' Hospital, London, UK
| | - Satpal Arri
- Cardiovascular Division, King's College London, St. Thomas' Hospital, London, UK
| | - Kaleab N Asrress
- Cardiovascular Division, King's College London, St. Thomas' Hospital, London, UK
| | - Christopher Allen
- Cardiovascular Division, King's College London, St. Thomas' Hospital, London, UK
| | - Jubin Joseph
- Cardiovascular Division, King's College London, St. Thomas' Hospital, London, UK
| | - Hannah Z R McConkey
- Cardiovascular Division, King's College London, St. Thomas' Hospital, London, UK
| | - Howard Ellis
- Cardiovascular Division, King's College London, St. Thomas' Hospital, London, UK
| | - Antonis Pavlidis
- Cardiothoracic Department, St. Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Brian Clapp
- Cardiothoracic Department, St. Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Divaka Perera
- Cardiovascular Division, King's College London, St. Thomas' Hospital, London, UK
| | - Jack Lee
- Department of Imaging Science, King's College London, St. Thomas' Hospital, London, UK
| | - Michael S Marber
- Cardiovascular Division, King's College London, St. Thomas' Hospital, London, UK
| | - Simon R Redwood
- Cardiovascular Division, King's College London, St. Thomas' Hospital, London, UK
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12
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Ellis H, Iliff HA, Lahloub FMF, Smith DRK, Rees GJ. Unexpected difficult tracheal intubation secondary to subglottic stenosis leading to emergency front-of-neck airway. Anaesth Rep 2021; 9:90-94. [PMID: 33982001 DOI: 10.1002/anr3.12115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 12/19/2022] Open
Abstract
A 26-year-old woman presenting for an elective day case procedure under general anaesthesia had undiagnosed subglottic stenosis leading to a life threatening airway emergency requiring emergency front-of-neck airway. We outline the case and discuss key anaesthetic considerations in subglottic stenosis, including concerning features of a medical/anaesthetic history and the potential for rapid deterioration of a stenotic airway following manipulation. We also consider the effect of anaesthesia on the calibre of subglottic stenosis and the effects of positive pressure ventilation. Subglottic stenosis is a rare condition with congenital, acquired and idiopathic origins; however, iatrogenic trauma is the most common cause. We are aware of a small number of published case reports of previously undiagnosed subglottic stenosis in adults discovered after induction of anaesthesia; situational deterioration to 'cannot intubate, cannot oxygenate' scenarios appear even rarer.
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Affiliation(s)
- H Ellis
- Department of Anaesthesia Royal Glamorgan Hospital Merthyr Tydfil UK
| | - H A Iliff
- Department of Anaesthesia Prince Charles Hospital Llantrisant UK
| | | | - D R K Smith
- Department of Ear, Nose and Throat Surgery Royal Glamorgan Hospital Merthyr Tydfil UK
| | - G J Rees
- Department of Anaesthesia Prince Charles Hospital Llantrisant UK
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13
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Patterson T, Rivolo S, Burkhoff D, Schreuder J, Briceno N, Allen C, Williams R, Arri S, Asrress KN, Joseph J, McConkey HZR, Ellis H, Pavlidis A, Clapp B, Perera D, Lee J, Marber MS, Redwood SR. Physiological Impact of Afterload Reduction on Cardiac Mechanics and Coronary Hemodynamics Following Isosorbide Dinitrate Administration in Ischemic Heart Disease. J Cardiovasc Transl Res 2021; 14:962-974. [PMID: 33721195 PMCID: PMC8575737 DOI: 10.1007/s12265-021-10112-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/16/2021] [Indexed: 01/09/2023]
Abstract
Understanding the cardiac-coronary interaction is fundamental to developing treatment strategies for ischemic heart disease. We sought to examine the impact of afterload reduction following isosorbide dinitrate (ISDN) administration on LV properties and coronary hemodynamics to further our understanding of the cardiac-coronary interaction. Novel methodology enabled real-time simultaneous acquisition and analysis of coronary and LV hemodynamics in vivo using coronary pressure-flow wires (used to derive coronary wave energies) and LV pressure-volume loop assessment. ISDN administration resulted in afterload reduction, reduced myocardial demand, and increased mechanical efficiency (all P<0.01). Correlations were demonstrated between the forward compression wave (FCW) and arterial elastance (r=0.6) following ISDN. In the presence of minimal microvascular resistance, coronary blood flow velocity exhibited an inverse relationship with LV elastance. In summary this study demonstrated a reduction in myocardial demand with ISDN, an inverse relationship between coronary blood flow velocity and LV contraction-relaxation and a direct correlation between FCW and arterial elastance. The pressure volume-loop and corresponding parameters b The pressure volume loop before (solid line) and after (broken line) Isosorbide dintrate.
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Affiliation(s)
- Tiffany Patterson
- Cardiovascular Division, King's College London, St. Thomas' Hospital, Westminster Bridge Road, SE1 7EH, London, UK.
| | - Simone Rivolo
- Department of Imaging Science, St. Thomas' Hospital, King's College London, London, UK
| | | | - Jan Schreuder
- Thoraxcenter Erasmus University Medical Center, Rotterdam, Netherlands
| | - Natalia Briceno
- Cardiovascular Division, King's College London, St. Thomas' Hospital, Westminster Bridge Road, SE1 7EH, London, UK
| | - Christopher Allen
- Cardiovascular Division, King's College London, St. Thomas' Hospital, Westminster Bridge Road, SE1 7EH, London, UK
| | - Rupert Williams
- Cardiovascular Division, King's College London, St. Thomas' Hospital, Westminster Bridge Road, SE1 7EH, London, UK
| | - Satpal Arri
- Cardiovascular Division, King's College London, St. Thomas' Hospital, Westminster Bridge Road, SE1 7EH, London, UK
| | - Kaleab N Asrress
- Cardiovascular Division, King's College London, St. Thomas' Hospital, Westminster Bridge Road, SE1 7EH, London, UK
| | - Jubin Joseph
- Cardiovascular Division, King's College London, St. Thomas' Hospital, Westminster Bridge Road, SE1 7EH, London, UK
| | - Hannah Z R McConkey
- Cardiovascular Division, King's College London, St. Thomas' Hospital, Westminster Bridge Road, SE1 7EH, London, UK
| | - Howard Ellis
- Cardiovascular Division, King's College London, St. Thomas' Hospital, Westminster Bridge Road, SE1 7EH, London, UK
| | - Antonis Pavlidis
- Cardiothoracic Department, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Brian Clapp
- Cardiothoracic Department, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Divaka Perera
- Cardiovascular Division, King's College London, St. Thomas' Hospital, Westminster Bridge Road, SE1 7EH, London, UK
| | - Jack Lee
- Department of Imaging Science, St. Thomas' Hospital, King's College London, London, UK
| | - Michael S Marber
- Cardiovascular Division, King's College London, St. Thomas' Hospital, Westminster Bridge Road, SE1 7EH, London, UK
| | - Simon R Redwood
- Cardiovascular Division, King's College London, St. Thomas' Hospital, Westminster Bridge Road, SE1 7EH, London, UK
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14
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Rahman H, Scannell CM, Demir OM, Ryan M, McConkey H, Ellis H, Masci PG, Perera D, Chiribiri A. High-Resolution Cardiac Magnetic Resonance Imaging Techniques for the Identification of Coronary Microvascular Dysfunction. JACC Cardiovasc Imaging 2020; 14:978-986. [PMID: 33248969 DOI: 10.1016/j.jcmg.2020.10.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/01/2020] [Accepted: 10/14/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study assessed the ability to identify coronary microvascular dysfunction (CMD) in patients with angina and nonobstructive coronary artery disease (NOCAD) using high-resolution cardiac magnetic resonance (CMR) and hypothesized that quantitative perfusion techniques would have greater accuracy than visual analysis. BACKGROUND Half of all patients with angina are found to have NOCAD, while the presence of CMD portends greater morbidity and mortality, it now represents a modifiable therapeutic target. Diagnosis currently requires invasive assessment of coronary blood flow during angiography. With greater reliance on computed tomography coronary angiography as a first-line tool to investigate angina, noninvasive tests for diagnosing CMD warrant validation. METHODS Consecutive patients with angina and NOCAD were enrolled. Intracoronary pressure and flow measurements were acquired during rest and vasodilator-mediated hyperemia. CMR (3-T) was performed and analyzed by visual and quantitative techniques, including calculation of myocardial blood flow (MBF) during hyperemia (stress MBF), transmural myocardial perfusion reserve (MPR: MBFHYPEREMIA / MBFREST), and subendocardial MPR (MPRENDO). CMD was defined dichotomously as an invasive coronary flow reserve <2.5, with CMR readers blinded to this classification. RESULTS A total of 75 patients were enrolled (57 ± 10 years of age, 81% women). Among the quantitative perfusion indices, MPRENDO and MPR had the highest accuracy (area under the curve [AUC]: 0.90 and 0.88) with high sensitivity and specificity, respectively, both superior to visual assessment (both p < 0.001). Visual assessment identified CMD with 58% accuracy (41% sensitivity and 83% specificity). Quantitative stress MBF performed similarly to visual analysis (AUC: 0.64 vs. 0.60; p = 0.69). CONCLUSIONS High-resolution CMR has good accuracy at detecting CMD but only when analyzed quantitatively. Although omission of rest imaging and stress-only protocols make for quicker scans, this is at the cost of accuracy compared with integrating rest and stress perfusion. Quantitative perfusion CMR has an increasingly important role in the management of patients frequently encountered with angina and NOCAD.
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Affiliation(s)
- Haseeb Rahman
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Cian M Scannell
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Ozan M Demir
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Matthew Ryan
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Hannah McConkey
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Howard Ellis
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Pier Giorgio Masci
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom.
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
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15
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Wilkins D, O'Sullivan O, Sayer J, Penny L, Roiz de Sa D, Ellis H, Dharm-Datta S. Neurological rehabilitation following heat illness in the UK Armed Forces. BMJ Mil Health 2020; 168:320-323. [DOI: 10.1136/bmjmilitary-2020-001602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/25/2020] [Accepted: 08/28/2020] [Indexed: 11/04/2022]
Abstract
Heat illness remains a significant threat to health in the UK Armed Forces despite recent improvements in the prevention of cases. A small number of heat illness survivors develop long-term neurological sequelae. Here we briefly review the background literature and present our experience of treating UK Armed Forces patients with neurological consequences of heat illness. In our cohort of patients, we observed significant improvements in subjective symptoms and objective assessments following a period of neurological rehabilitation at the Defence Medical Rehabilitation Centre. We conclude with recommendations for further research and for the incorporation of screening for neurological disability following heat illness into service policy.
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16
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Modi BN, Rahman H, Ryan M, Ellis H, Pavlidis A, Redwood S, Clapp B, Chowienczyk P, Perera D. Comparison of fractional flow reserve, instantaneous wave-free ratio and a novel technique for assessing coronary arteries with serial lesions. EUROINTERVENTION 2020; 16:577-583. [PMID: 31543499 DOI: 10.4244/eij-d-19-00635] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
AIMS Physiological indices such as fractional flow reserve (FFR), instantaneous wave-free ratio (iFR) and resting distal coronary to aortic pressure (Pd/Pa) are increasingly used to guide revascularisation. However, reliable assessment of individual stenoses in serial coronary disease remains an unmet need. This study aimed to compare conventional pressure-based indices, a reference Doppler-based resistance index (hyperaemic stenosis resistance [hSR]) and a recently described mathematical correction model to predict the contribution of individual stenoses in serial disease. METHODS AND RESULTS Resting and hyperaemic pressure wire pullbacks were performed in 54 patients with serial disease. For each stenosis, FFR, iFR, and Pd/Pa were measured by the translesional gradient in each index and the predicted FFR (FFRpred) derived mathematically from hyperaemic pullback data. "True" stenosis significance by each index was assessed following PCI of the accompanying stenosis or measurements made in a large disease-free branch. In 27 patients, Doppler average peak flow velocity (APV) was also measured to calculate hSR (hSR=∆P/APV, where ∆P=translesional pressure gradient). FFR underestimated individual stenosis severity, inversely proportional to cumulative FFR (r=0.5, p<0.001). Mean errors for FFR, iFR and Pd/Pa were 33%, 20% and 24%, respectively, and 14% for FFRpred (p<0.001). Stenosis misclassification rates based on FFR 0.80, iFR 0.89 and Pd/Pa 0.91 thresholds were not significantly different (17%, 24% and 20%, respectively) but were higher than FFRpred (11%, p<0.001). Apparent and true hSR correlated strongly (r=0.87, p<0.001, mean error 0.19±0.3), with only 7% of stenoses misclassified. CONCLUSIONS Individual stenosis severity is significantly underestimated in the presence of serial disease, using both hyperaemic and resting pressure-based indices. hSR is less prone to error but challenges in optimising Doppler signals limit clinical utility. A mathematical correction model, using data from hyperaemic pressure wire pullback, produces similar accuracy to hSR and is superior to conventional pressure-based indices.
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Affiliation(s)
- Bhavik N Modi
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, London, United Kingdom
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Rahman H, Demir OM, Ryan M, McConkey H, Scannell C, Ellis H, Webb A, Chiribiri A, Perera D. Optimal Use of Vasodilators for Diagnosis of Microvascular Angina in the Cardiac Catheterization Laboratory. Circ Cardiovasc Interv 2020; 13:e009019. [PMID: 32519879 PMCID: PMC7299228 DOI: 10.1161/circinterventions.120.009019] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Among patients with angina and nonobstructive coronary artery disease, those with coronary microvascular dysfunction have a poor outcome. Coronary microvascular dysfunction is usually diagnosed by assessing flow reserve with an endothelium-independent vasodilator like adenosine, but the optimal diagnostic threshold is unclear. Furthermore, the incremental value of testing endothelial function has never been assessed before. We sought to determine what pharmacological thresholds correspond to exercise pathophysiology and myocardial ischemia in patients with coronary microvascular dysfunction.
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Affiliation(s)
- Haseeb Rahman
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre (H.R., O.M.D., M.R., H.M., H.E., A.W., D.P.), King's College London, United Kingdom
| | - Ozan M Demir
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre (H.R., O.M.D., M.R., H.M., H.E., A.W., D.P.), King's College London, United Kingdom
| | - Matthew Ryan
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre (H.R., O.M.D., M.R., H.M., H.E., A.W., D.P.), King's College London, United Kingdom
| | - Hannah McConkey
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre (H.R., O.M.D., M.R., H.M., H.E., A.W., D.P.), King's College London, United Kingdom
| | - Cian Scannell
- School of Biomedical Engineering and Imaging Sciences (C.S., A.C.), King's College London, United Kingdom
| | - Howard Ellis
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre (H.R., O.M.D., M.R., H.M., H.E., A.W., D.P.), King's College London, United Kingdom
| | - Andrew Webb
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre (H.R., O.M.D., M.R., H.M., H.E., A.W., D.P.), King's College London, United Kingdom
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences (C.S., A.C.), King's College London, United Kingdom
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre (H.R., O.M.D., M.R., H.M., H.E., A.W., D.P.), King's College London, United Kingdom
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Rahman H, Demir OM, Khan F, Ryan M, Ellis H, Mills MT, Chiribiri A, Webb A, Perera D. Physiological Stratification of Patients With Angina Due to Coronary Microvascular Dysfunction. J Am Coll Cardiol 2020; 75:2538-2549. [PMID: 32439003 PMCID: PMC7242900 DOI: 10.1016/j.jacc.2020.03.051] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/10/2020] [Accepted: 03/17/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) is defined by diminished flow reserve. Functional and structural CMD endotypes have recently been described, with normal and elevated minimal microvascular resistance, respectively. OBJECTIVES This study determined the mechanism of altered resting and maximal flow in CMD endotypes. METHODS A total of 86 patients with angina but no obstructive coronary disease underwent coronary pressure and flow measurement during rest, exercise, and adenosine-mediated hyperemia and were classified as the reference group or as patients with CMD by a coronary flow reserve threshold of 2.5; functional or structural endotypes were distinguished by a hyperemic microvascular resistance threshold of 2.5 mm Hg/cm/s. Endothelial function was assessed by forearm blood flow (FBF) response to acetylcholine, and nitric oxide synthase (NOS) activity was defined as the inverse of FBF reserve to NG-monomethyl-L-arginine. RESULTS Of the 86 patients, 46 had CMD (28 functional, 18 structural), and 40 patients formed the reference group. Resting coronary blood flow (CBF) (24.6 ± 2.0 cm/s vs. 16.6 ± 3.9 cm/s vs. 15.1 ± 4.7 cm/s; p < 0.001) and NOS activity (2.27 ± 0.96 vs. 1.77 ± 0.59 vs. 1.30 ± 0.16; p < 0.001) were higher in the functional group compared with the structural CMD and reference groups, respectively. The structural group had lower acetylcholine FBF augmentation than the functional or reference group (2.1 ± 1.8 vs. 4.1 ± 1.7 vs. 4.5 ± 2.0; p < 0.001). On exercise, oxygen demand was highest (rate-pressure product: 22,157 ± 5,497 beats/min/mm Hg vs. 19,519 ± 4,653 beats/min/mm Hg vs. 17,530 ± 4,678 beats/min/mm Hg; p = 0.004), but peak CBF was lowest in patients with structural CMD compared with the functional and reference groups. CONCLUSIONS Functional CMD is characterized by elevated resting flow that is linked to enhanced NOS activity. Patients with structural CMD have endothelial dysfunction, which leads to diminished peak CBF augmentation and increased demand during exercise. The value of pathophysiologically stratified therapy warrants investigation.
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Affiliation(s)
- Haseeb Rahman
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, Kings College London, London, United Kingdom
| | - Ozan M Demir
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, Kings College London, London, United Kingdom
| | - Faisal Khan
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, Kings College London, London, United Kingdom
| | - Matthew Ryan
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, Kings College London, London, United Kingdom
| | - Howard Ellis
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, Kings College London, London, United Kingdom
| | - Mark T Mills
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, Kings College London, London, United Kingdom
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Andrew Webb
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, Kings College London, London, United Kingdom
| | - Divaka Perera
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, Kings College London, London, United Kingdom.
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Ryan M, Modi B, Rahman H, Williams R, Arri S, Asrress K, Lumley M, Ellis H, Redwood S, Perera D. Do Fractional Flow Reserve and Instantaneous Wave-Free Ratio Correlate With Exercise Coronary Physiology? Circ Cardiovasc Interv 2020; 13:e008415. [PMID: 32089003 DOI: 10.1161/circinterventions.119.008415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Matthew Ryan
- Cardiovascular Division, King's College London, United Kingdom
| | - Bhavik Modi
- Cardiovascular Division, King's College London, United Kingdom
| | - Haseeb Rahman
- Cardiovascular Division, King's College London, United Kingdom
| | - Rupert Williams
- Cardiovascular Division, King's College London, United Kingdom
| | - Satpal Arri
- Cardiovascular Division, King's College London, United Kingdom
| | - Kaleab Asrress
- Cardiovascular Division, King's College London, United Kingdom
| | - Matthew Lumley
- Cardiovascular Division, King's College London, United Kingdom
| | - Howard Ellis
- Cardiovascular Division, King's College London, United Kingdom
| | - Simon Redwood
- Cardiovascular Division, King's College London, United Kingdom
| | - Divaka Perera
- Cardiovascular Division, King's College London, United Kingdom
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Rahman H, Demir O, Ryan M, McConkey H, Ellis H, Scannell C, Chiribiri A, Webb A, Perera D. Mechanisms of exertional angina in patients with normal coronary arteries. Clin Med (Lond) 2020; 20:s44-s45. [PMID: 32409366 PMCID: PMC7243519 DOI: 10.7861/clinmed.20-2-s44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rahman H, Ryan M, Lumley M, Modi B, McConkey H, Ellis H, Scannell C, Clapp B, Marber M, Webb A, Chiribiri A, Perera D. Coronary Microvascular Dysfunction Is Associated With Myocardial Ischemia and Abnormal Coronary Perfusion During Exercise. Circulation 2019; 140:1805-1816. [PMID: 31707835 PMCID: PMC6882540 DOI: 10.1161/circulationaha.119.041595] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 10/15/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Coronary microvascular dysfunction (MVD) is defined by impaired flow augmentation in response to a pharmacological vasodilator in the presence of nonobstructive coronary artery disease. It is unknown whether diminished coronary vasodilator response correlates with abnormal exercise physiology or inducible myocardial ischemia. METHODS Patients with angina and nonobstructive coronary artery disease had simultaneous coronary pressure and flow velocity measured using a dual sensor-tipped guidewire during rest, supine bicycle exercise, and adenosine-mediated hyperemia. Microvascular resistance (MR) was calculated as coronary pressure divided by flow velocity. Wave intensity analysis quantified the proportion of accelerating wave energy (perfusion efficiency). Global myocardial blood flow and subendocardial:subepicardial perfusion ratio were quantified using 3-Tesla cardiac magnetic resonance imaging during hyperemia and rest; inducible ischemia was defined as hyperemic subendocardial:subepicardial perfusion ratio <1.0. Patients were classified as having MVD if coronary flow reserve <2.5 and controls if coronary flow reserve ≥2.5, with researchers blinded to the classification. RESULTS Eighty-five patients were enrolled (78% female, 57±10 years), 45 (53%) were classified as having MVD. Of the MVD group, 82% had inducible ischemia compared with 22% of controls (P<0.001); global myocardial perfusion reserve was 2.01±0.41 and 2.68±0.49 (P<0.001). In controls, coronary perfusion efficiency improved from rest to exercise and was unchanged during hyperemia (59±11% vs 65±14% vs 57±18%; P=0.02 and P=0.14). In contrast, perfusion efficiency decreased during both forms of stress in MVD (61±12 vs 44±10 vs 42±11%; both P<0.001). Among patients with a coronary flow reserve <2.5, 62% had functional MVD, with normal minimal MR (hyperemic MR<2.5 mmHg/cm/s), and 38% had structural MVD with elevated hyperemic MR. Resting MR was lower in those with functional MVD (4.2±1.0 mmHg/cm/s) than in those with structural MVD (6.9±1.7 mmHg/cm/s) or controls (7.3±2.2 mmHg/cm/s; both P<0.001). During exercise, the structural group had a higher systolic blood pressure (188±25 mmHg) than did those with functional MVD (161±27 mmHg; P=0.004) and controls (156±30 mmHg; P<0.001). Functional and structural MVD had similar stress myocardial perfusion and exercise perfusion efficiency values. CONCLUSION In patients with angina and nonobstructive coronary artery disease, diminished coronary flow reserve characterizes a cohort with inducible ischemia and a maladaptive physiological response to exercise. We have identified 2 endotypes of MVD with distinctive systemic vascular responses to exercise; whether endotypes have a different prognosis or require different treatments merits further investigation.
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Affiliation(s)
- Haseeb Rahman
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Matthew Ryan
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Matthew Lumley
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Bhavik Modi
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Hannah McConkey
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Howard Ellis
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Cian Scannell
- Biomedical Engineering & Imaging Sciences (A.C., C.S.), King’s College London, United Kingdom
| | - Brian Clapp
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Michael Marber
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Andrew Webb
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Amedeo Chiribiri
- Biomedical Engineering & Imaging Sciences (A.C., C.S.), King’s College London, United Kingdom
| | - Divaka Perera
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
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Modi BN, Rahman H, Kaier T, Ryan M, Williams R, Briceno N, Ellis H, Pavlidis A, Redwood S, Clapp B, Perera D. Revisiting the Optimal Fractional Flow Reserve and Instantaneous Wave-Free Ratio Thresholds for Predicting the Physiological Significance of Coronary Artery Disease. Circ Cardiovasc Interv 2019; 11:e007041. [PMID: 30562079 DOI: 10.1161/circinterventions.118.007041] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND There has been a gradual upward creep of revascularization thresholds for both fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), before the clinical outcome trials for both indices. The increase in revascularization that has potentially resulted is at odds with increasing evidence questioning the benefits of revascularizing stable coronary disease. Using an independent invasive reference standard, this study primarily aimed to define optimal thresholds for FFR and iFR and also aimed to compare the performance of iFR, FFR, and resting distal coronary pressure (Pd)/central aortic pressure (Pa). METHODS AND RESULTS Pd and Pa were measured in 75 patients undergoing coronary angiography±percutaneous coronary intervention with resting Pd/Pa, iFR, and FFR calculated. Doppler average peak flow velocity was simultaneously measured and hyperemic stenosis resistance calculated as hyperemic stenosis resistance=Pa-Pd/average peak flow velocity (using hyperemic stenosis resistance >0.80 mm Hg/cm per second as invasive reference standard). An FFR threshold of 0.75 had an optimum diagnostic accuracy (84%), whereas for iFR this was 0.86 (76%). At these thresholds, the discordance in classification between indices was 11%. The accuracy of contemporary thresholds (FFR, 0.80; iFR, 0.89) was significantly lower (78.7% and 65.3%, respectively) with a 25% rate of discordance. The optimal threshold for Pd/Pa was 0.88 (77.3% accuracy). When comparing indices at optimal thresholds, FFR showed the best diagnostic performance (area under the curve, 0.91 FFR versus 0.79 iFR and 0.77 Pd/Pa, P=0.002). CONCLUSIONS Contemporary thresholds provide suboptimal diagnostic accuracy compared with an FFR threshold of 0.75 and iFR threshold of 0.86 (cutoffs in derivation studies). Whether more rigorous thresholds would result in selecting populations gaining greater symptom and prognostic benefit needs assessing in future trials of physiology-guided revascularization.
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Affiliation(s)
- Bhavik N Modi
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Haseeb Rahman
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Thomas Kaier
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Matthew Ryan
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Rupert Williams
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Natalia Briceno
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Howard Ellis
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Antonis Pavlidis
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Simon Redwood
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Brian Clapp
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
| | - Divaka Perera
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, United Kingdom
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Abstract
BACKGROUND Influenza causes large outbreaks every year. Professionals outside healthcare, including social care staff and non-care giving roles, have a key role in protecting their clients and sustaining operational productivity through influenza vaccination. There has been little research on non-healthcare staff working with vulnerable people and those working in non-caregiving settings regarding influenza and influenza vaccination. AIMS To understand the practices, experiences, perceptions and motivations of local authority staff regarding influenza and influenza vaccination. METHODS Semi-structured focus groups were carried out with local authority staff in Gloucestershire. Transcripts were thematically analysed. RESULTS Participants tended to perceive influenza as a serious illness, where a person had a specific risk factor or during pandemics. They did not feel vulnerable unless they had previous experience of infection or had an underlying health condition. Motivation to vaccinate was based on previous experience of influenza, where they had a close family member at risk or when working directly with vulnerable clients. Beliefs about negative side effects of the vaccine were the strongest reason for vaccine refusal. Ease of access to vaccination through on-site clinics is key to uptake. Management are perceived as key motivators or blockers to vaccine uptake. CONCLUSIONS Workers outside healthcare settings do not feel vulnerable to influenza and have low motivation to vaccinate, unless they have previous experience of infection or an underlying health condition. Vaccination programmes must proactively address workers' beliefs and motivations to ensure their participation in flu vaccination programmes.
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Affiliation(s)
- D Mc Conalogue
- Public Health Team, Gloucestershire County Council Shire Hall, Gloucester, UK
| | - N Verle
- Older People Hub, Gloucestershire County Council Shire Hall, Gloucester, UK
| | - H Ellis
- Children and Families Hub, Gloucestershire County Council, Gloucester, UK
| | - S Scott
- Public Health Team, Gloucestershire County Council Shire Hall, Gloucester, UK
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Rahman H, Ryan M, Lumley M, McConkey H, Khan F, Ellis H, Clapp B, Marber M, Chiribiri A, Webb A, Perera D. 2380Mechanisms of myocardial ischemia during exercise in microvascular angina. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Coronary microvascular dysfunction (MVD) is defined by impaired flow augmentation in response to a vasodilator, the pathophysiological basis of which is unclear. This study sought to address two major gaps in our understanding of MVD: firstly, whether diminished flow reserve is due to structural changes within the microvasculature or potentially reversible dysfunction and secondly to unravel the mechanism of exercise-induced ischemia in the absence of obstructive disease.
Methods
Simultaneous intracoronary pressure and flow velocity recordings were made in the left anterior descending artery of patients with angina and no obstructive epicardial disease (Fractional Flow Reserve >0.80). Measurements were made at rest, during adenosine-mediated hyperaemia and supine bicycle exercise. Wave intensity analysis was used to quantify waves that accelerate and decelerate coronary blood flow, coronary perfusion efficiency being defined as the proportion of total wave energy that accelerates blood flow. Patients were prospectively classified into MVD (coronary flow reserve <2.5) and controls with researchers blinded to the classification throughout the protocol. Myocardial perfusion and vascular function were assessed by 3T cardiac MRI and venous occlusion plethysmography with forearm blood flow (FBF) assessment during serial infusions of acetylcholine, adenosine and the nitric oxide synthase inhibitor NG-monomethyl-L-arginine (L-NMMA).
Results
78 patients were enrolled (42 patients had MVD and 36 were controls), with no differences in cardiovascular risk factors between groups. The MVD group had elevated coronary blood flow (21.3±6.4 vs. 15.1±4.5cm s–1; p<0.001) and global myocardial perfusion (1.36±0.37 vs. 1.13±0.22ml/min/g; p=0.01) at rest. Maximum coronary and myocardial blood flow during hyperaemia was similar in both groups. During exercise, MVD patients achieved similar peak flow (30.5±10.0 vs. 26.3±7.7cm s–1; p=0.07) despite a higher rate-pressure product (20777±5205 vs. 17450±4710bpm.mmHg; p=0.01). Coronary perfusion efficiency, decreased with exercise in the MVD group (61±11% vs. 44±10% p<0.001) but was unchanged in controls. On MRI, MVD had lower hyperaemic endo-epicardial perfusion ratio than controls (0.94±0.08 vs. 1.04±0.13; p=0.001). Augmentation of FBF with acetylcholine was attenuated in MVD patients compared to controls (p=0.02) but the response to adenosine was similar (p=0.13). Infusion of L-NMMA caused a significantly greater reduction in FBF in MVD patients compared to controls (p<0.001).
Exercise Physiology in MVD
Conclusion
Impaired flow reserve in MVD represents a dysfunctional state, characterised by inappropriately elevated resting flow due to increased nitric-oxide synthase mediated vasodilatation. There is abnormal flow distribution in the myocardium predisposing to subendocardial ischaemia, associated with and exacerbated by impaired cardiac-coronary coupling during exercise. These novel findings may represent distinct therapeutic targets.
Acknowledgement/Funding
British Heart Foundation
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Affiliation(s)
- H Rahman
- King's College London, British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas Hospital, London, United Kingdom
| | - M Ryan
- King's College London, British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas Hospital, London, United Kingdom
| | - M Lumley
- King's College London, British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas Hospital, London, United Kingdom
| | - H McConkey
- King's College London, British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas Hospital, London, United Kingdom
| | - F Khan
- King's College London, British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas Hospital, London, United Kingdom
| | - H Ellis
- King's College London, British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas Hospital, London, United Kingdom
| | - B Clapp
- King's College London, British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas Hospital, London, United Kingdom
| | - M Marber
- King's College London, British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas Hospital, London, United Kingdom
| | - A Chiribiri
- King's College London, British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas Hospital, London, United Kingdom
| | - A Webb
- King's College London, British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas Hospital, London, United Kingdom
| | - D Perera
- King's College London, British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas Hospital, London, United Kingdom
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McConkey HZR, Marber M, Lee J, Ellis H, Joseph J, Allen C, Rahman H, Patterson T, Scannell C, Pibarot P, Chiribiri A, Redwood S, Prendergast BD. P6484Invasive and non-invasive characterisation of low gradient aortic stenosis. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.1074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Low gradient severe aortic stenosis (LGAS) is associated with unfavourable outcomes when compared to high gradient aortic stenosis (HGAS), yet the contributing pathophysiology is poorly understood.
Methods
Symptomatic LGAS and HGAS patients undergoing trans-catheter aortic valve implantation (TAVI) underwent 3T stress perfusion cardiac magnetic resonance imaging (CMR) pre-(within 24 hours) and post-(4–6 months) TAVI. Left ventricular (LV) contractility and coronary flow/pressure were measured during hyperaemia and rapid pacing, immediately before and after TAVI, using a conductance LV catheter and dual-pressure and Doppler sensor–tipped guidewire in the mid-left anterior descending coronary artery.
Results
24 patients were recruited resulting in 19 suitable datasets (LGAS N=9, HGAS N=10, equally matched for comorbidities and B-natriuretic peptide level). LGAS patients had a smaller LV end diastolic volume index (p=0.035) and lower LV mass index (LVMI) (p=0.037). Pre-TAVI stress global endocardium-epicardium gradient was 0.88±0.09 and global myocardial perfusion reserve (MPR) 2.0±0.48 in 14 patients (6 LGAS and 8 HGAS patients, no difference between groups). Pre-TAVI, baseline coronary data demonstrated lower augmentation pressure (AP, p=0.035) and augmentation index (AIx, p=0.02) in the LGAS group. LGAS patients also exhibited a shorter ejection time (p=0.015), larger forward compression waves during rest, hyperaemia and rapid pacing, and smaller backward expansion waves (BEW) (p=0.001). Lower baseline end systolic pressure (p=0.004), inotropy (dP/dt+, p=0.045), lusitropy (dP/dt-, p=0.069), and stroke work (p=0.019) were observed in the LGAS group. Whilst LV size was smaller the LGAS group, rapid pacing induced a more significant drop in end systolic volume (p=0.045) and ejection fraction (p=0.015) in patients with HGAS. Post-TAVI, the hyperaemic BEW fell sharply (p<0.001), along with coronary VTI (p=0.02), and average pulse velocity (p=0.028), and AP and AIx remained lower (p=0.034 and p=0.031, respectively). The forward expansion wave was reduced in LGAS during rapid pacing. The HGAS group displayed a more profound drop in dP/dt+ (p=0.011) and dP/dt- p=0.014) at rest following intervention. Repeat CMR demonstrated statistically significant reduction in LV size and LVMI (p=0.012 and p<0.001, respectively) with significant increase in 3D global peak radial, circumferential and longitudinal strain (p=0.004, p=0.001 and p=0.018, respectively). Post-TAVI stress global endocardium-epicardium gradient was 0.88±0.13 and MPR 2.46±0.59 (improved from pre-TAVI, p=0.05). There was no difference in remodelling patterns or perfusion between the two groups.
Conclusion
This is the first study detailing the combined invasive and CMR pathophysiological changes in LGAS. Despite invasive parameters indicating a disease of less severe AS, the level of perfusion abnormality is disproportionate which may in part, relate to their adverse prognosis.
Acknowledgement/Funding
This research is funded by a Clinical Research Training Fellowship grant from the British Heart Foundation (FS/16/51/32365).
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Affiliation(s)
- H Z R McConkey
- Kings College London, British Heart Foundation Centre of Excellence, The Rayne Institute, London, United Kingdom
| | - M Marber
- Kings College London, British Heart Foundation Centre of Excellence, The Rayne Institute, London, United Kingdom
| | - J Lee
- Kings College London, School of Biomedical Engineering and Imaging Sciences, London, United Kingdom
| | - H Ellis
- Kings College London, British Heart Foundation Centre of Excellence, The Rayne Institute, London, United Kingdom
| | - J Joseph
- Kings College London, British Heart Foundation Centre of Excellence, The Rayne Institute, London, United Kingdom
| | - C Allen
- Kings College London, British Heart Foundation Centre of Excellence, The Rayne Institute, London, United Kingdom
| | - H Rahman
- Kings College London, British Heart Foundation Centre of Excellence, The Rayne Institute, London, United Kingdom
| | - T Patterson
- Kings College London, British Heart Foundation Centre of Excellence, The Rayne Institute, London, United Kingdom
| | - C Scannell
- Kings College London, School of Biomedical Engineering and Imaging Sciences, London, United Kingdom
| | - P Pibarot
- Centre de Recherche de lInstitut Universitaire de Cardiologie et de Pneumologie de Quebec, Department of Medicine, Laval University, Quebec, Canada
| | - A Chiribiri
- Kings College London, School of Biomedical Engineering and Imaging Sciences, London, United Kingdom
| | - S Redwood
- Kings College London, British Heart Foundation Centre of Excellence, The Rayne Institute, London, United Kingdom
| | - B D Prendergast
- Kings College London, British Heart Foundation Centre of Excellence, The Rayne Institute, London, United Kingdom
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Modi BN, Rahman H, Arri S, Ellis H, Mills MT, Williams R, Asrress K, Clapp B, Redwood S, Perera D. Resting Coronary Flow Varies With Normal Cardiac Catheter Laboratory Stimuli. Cardiovasc Revasc Med 2019; 20:669-673. [PMID: 30415969 DOI: 10.1016/j.carrev.2018.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 09/28/2018] [Accepted: 10/08/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Growing evidence supports physiology-guided revascularization, with Fractional Flow Reserve (FFR) the most commonly used invasive measure of coronary blood flow impairment at the time of diagnostic angiography. Recently, there has been growing interest in stenosis severity indices measured at rest, such as Instantaneous Wave Free Ratio (iFR) and the ratio of distal coronary to aortic pressure at rest (resting Pd/Pa). Their reliability may, theoretically, be more susceptible to changes in microvascular tone and coronary flow. This study aimed to assess variability of resting coronary flow with normal catheter laboratory stimuli. METHODS Simultaneous intracoronary pressure (Pd) and Doppler Average Peak Flow Velocity (APV) recordings were made at rest and following the verbal warning preceding an intravenous adenosine infusion. RESULTS 72 patients undergoing elective angiography were recruited (mean age 62 years, 52.7% male) with a wide range of coronary artery disease severity (FFR 0.86 ± 0.09). Average peak flow velocity varied significantly between measurements at rest and just prior to commencement of adenosine, with a mean variation of 10.2% (17.82 ± 9.41 cm/s vs. 19.63 ± 10.44 cm/s, p < 0.001) with an accompanying significant drop in microvascular resistance (6.27 ± 2.73 mm Hg·cm-1·s-1 vs. 5.8 ± 2.92 mm Hg·cm-1·s-1, p < 0.001). These changes occurred without significant change in systemic hemodynamic measures. Whilst there was a trend for an associated change in the resting indices, Pd/Pa and iFR, this was statistically and clinically not significant (0.92 ± 0.08 vs. 0.92 ± 0.08, p = 0.110; and 0.90 ± 0.11 vs. 0.89 ± 0.12, p = 0.073). CONCLUSION Resting coronary flow and microvascular resistance vary significantly with normal catheter laboratory stimuli, such as simple warnings. The clinical impact of these observed changes on indices of stenosis severity, particularly those measured at rest, needs further assessment within larger cohorts.
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Affiliation(s)
- Bhavik N Modi
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Haseeb Rahman
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Satpal Arri
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Howard Ellis
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Mark T Mills
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Rupert Williams
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Kaleab Asrress
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Brian Clapp
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Simon Redwood
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom
| | - Divaka Perera
- Cardiovascular Division, St Thomas' Hospital Campus, King's College London, United Kingdom.
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Rahman H, Ryan M, McConkey H, Scannell C, Ellis H, Clapp B, Chiribiri A, Perera D. DIAGNOSTIC THRESHOLDS FOR CORONARY MICROVASCULAR DYSFUNCTION. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)32155-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Rahman H, Khan F, Ryan M, Ellis H, Clapp B, Webb A, Perera D. DISTINCT CLINICAL AND PHYSIOLOGICAL SUBTYPES OF CORONARY MICROVASCULAR DYSFUNCTION. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)32026-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Modi BN, Sankaran S, Kim HJ, Ellis H, Rogers C, Taylor CA, Rajani R, Perera D. Predicting the Physiological Effect of Revascularization in Serially Diseased Coronary Arteries. Circ Cardiovasc Interv 2019; 12:e007577. [PMID: 30722688 PMCID: PMC6794156 DOI: 10.1161/circinterventions.118.007577] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 12/19/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Fractional flow reserve (FFR) is commonly used to assess the functional significance of coronary artery disease but is theoretically limited in evaluating individual stenoses in serially diseased vessels. We sought to characterize the accuracy of assessing individual stenoses in serial disease using invasive FFR pullback and the noninvasive equivalent, fractional flow reserve by computed tomography (FFRCT). We subsequently describe and test the accuracy of a novel noninvasive FFRCT-derived percutaneous coronary intervention (PCI) planning tool (FFRCT-P) in predicting the true significance of individual stenoses. METHODS AND RESULTS Patients with angiographic serial coronary artery disease scheduled for PCI were enrolled and underwent prospective coronary CT angiography with conventional FFRCT-derived post hoc for each vessel and stenosis (FFRCT). Before PCI, the invasive hyperemic pressure-wire pullback was performed to derive the apparent FFR contribution of each stenosis (FFRpullback). The true FFR attributable to individual lesions (FFRtrue) was then measured following PCI of one of the lesions. The predictive accuracy of FFRpullback, FFRCT, and the novel technique (FFRCT-P) was then assessed against FFRtrue. From the 24 patients undergoing the protocol, 19 vessels had post hoc FFRCT and FFRCT-P calculation. When assessing the distal effect of all lesions, FFRCT correlated moderately well with invasive FFR ( R=0.71; P<0.001). For lesion-specific assessment, there was significant underestimation of FFRtrue using FFRpullback (mean discrepancy, 0.06±0.05; P<0.001, representing a 42% error) and conventional trans-lesional FFRCT (0.05±0.06; P<0.001, 37% error). Using FFRCT-P, stenosis underestimation was significantly reduced to a 7% error (0.01±0.05; P<0.001). CONCLUSIONS FFR pullback and conventional FFRCT significantly underestimate true stenosis contribution in serial coronary artery disease. A novel noninvasive FFRCT-based PCI planner tool more accurately predicts the true FFR contribution of each stenosis in serial coronary artery disease.
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Affiliation(s)
- Bhavik N. Modi
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London (B.N.M., H.E., R.R., D.P.)
| | | | - Hyun Jin Kim
- HeartFlow Inc, Redwood City, California (S.S., H.J.K., C.R., C.A.T.)
| | - Howard Ellis
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London (B.N.M., H.E., R.R., D.P.)
| | - Campbell Rogers
- HeartFlow Inc, Redwood City, California (S.S., H.J.K., C.R., C.A.T.)
| | - Charles A. Taylor
- HeartFlow Inc, Redwood City, California (S.S., H.J.K., C.R., C.A.T.)
| | - Ronak Rajani
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London (B.N.M., H.E., R.R., D.P.)
| | - Divaka Perera
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College London (B.N.M., H.E., R.R., D.P.)
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Modi BN, Ryan M, Chattersingh A, Eruslanova K, Ellis H, Gaddum N, Lee J, Clapp B, Chowienczyk P, Perera D. Optimal Application of Fractional Flow Reserve to Assess Serial Coronary Artery Disease: A 3D-Printed Experimental Study With Clinical Validation. J Am Heart Assoc 2018; 7:e010279. [PMID: 30371265 PMCID: PMC6474982 DOI: 10.1161/jaha.118.010279] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 08/20/2018] [Indexed: 01/10/2023]
Abstract
Background Assessing the physiological significance of stenoses with coexistent serial disease is prone to error. We aimed to use 3-dimensional-printing to characterize serial stenosis interplay and to derive and validate a mathematical solution to predict true stenosis significance in serial disease. Methods and Results Fifty-two 3-dimensional-printed serial disease phantoms were physiologically assessed by pressure-wire pullback (Δ FFR app) and compared with phantoms with the stenosis in isolation (Δ FFR true). Mathematical models to minimize error in predicting FFR true, the FFR in the vessel where the stenosis is present in isolation, were subsequently developed using 32 phantoms and validated in another 20 and also a clinical cohort of 30 patients with serial disease. Δ FFR app underestimated Δ FFR true in 88% of phantoms, with underestimation proportional to total FFR . Discrepancy as a proportion of Δ FFR true was 17.1% (absolute difference 0.036±0.048), which improved to 2.9% (0.006±0.023) using our model. In the clinical cohort, discrepancy was 38.5% (0.05±0.04) with 13.3% of stenoses misclassified (using FFR <0.8 threshold). Using mathematical correction, this improved to 15.4% (0.02±0.03), with the proportion of misclassified stenoses falling to 6.7%. Conclusions Individual stenoses are considerably underestimated in serial disease, proportional to total FFR . We have shown within in vitro and clinical cohorts that this error is significantly improved using a mathematical correction model, incorporating routinely available pressure-wire pullback data.
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Affiliation(s)
- Bhavik N. Modi
- NIHR Biomedical Research Centre and British Heart Foundation Centre of ExcellenceSchool of Cardiovascular Medicine and SciencesSt Thomas’ CampusKing's College LondonLondonUnited Kingdom
| | - Matthew Ryan
- NIHR Biomedical Research Centre and British Heart Foundation Centre of ExcellenceSchool of Cardiovascular Medicine and SciencesSt Thomas’ CampusKing's College LondonLondonUnited Kingdom
| | - Anjalee Chattersingh
- NIHR Biomedical Research Centre and British Heart Foundation Centre of ExcellenceSchool of Cardiovascular Medicine and SciencesSt Thomas’ CampusKing's College LondonLondonUnited Kingdom
| | - Kseniia Eruslanova
- NIHR Biomedical Research Centre and British Heart Foundation Centre of ExcellenceSchool of Cardiovascular Medicine and SciencesSt Thomas’ CampusKing's College LondonLondonUnited Kingdom
| | - Howard Ellis
- NIHR Biomedical Research Centre and British Heart Foundation Centre of ExcellenceSchool of Cardiovascular Medicine and SciencesSt Thomas’ CampusKing's College LondonLondonUnited Kingdom
| | - Nicholas Gaddum
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUnited Kingdom
| | - Jack Lee
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUnited Kingdom
| | - Brian Clapp
- NIHR Biomedical Research Centre and British Heart Foundation Centre of ExcellenceSchool of Cardiovascular Medicine and SciencesSt Thomas’ CampusKing's College LondonLondonUnited Kingdom
| | - Phil Chowienczyk
- NIHR Biomedical Research Centre and British Heart Foundation Centre of ExcellenceSchool of Cardiovascular Medicine and SciencesSt Thomas’ CampusKing's College LondonLondonUnited Kingdom
| | - Divaka Perera
- NIHR Biomedical Research Centre and British Heart Foundation Centre of ExcellenceSchool of Cardiovascular Medicine and SciencesSt Thomas’ CampusKing's College LondonLondonUnited Kingdom
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Williams RP, Asrress KN, Lumley M, Arri S, Patterson T, Ellis H, Manou‐Stathopoulou V, Macfarlane C, Chandran S, Moschonas K, Oakeshott P, Lockie T, Chiribiri A, Clapp B, Perera D, Plein S, Marber MS, Redwood SR. Deleterious Effects of Cold Air Inhalation on Coronary Physiological Indices in Patients With Obstructive Coronary Artery Disease. J Am Heart Assoc 2018; 7:e008837. [PMID: 30762468 PMCID: PMC6064824 DOI: 10.1161/jaha.118.008837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 04/11/2018] [Indexed: 01/09/2023]
Abstract
Background Cold air inhalation during exercise increases cardiac mortality, but the pathophysiology is unclear. During cold and exercise, dual-sensor intracoronary wires measured coronary microvascular resistance ( MVR ) and blood flow velocity ( CBF ), and cardiac magnetic resonance measured subendocardial perfusion. Methods and Results Forty-two patients (62±9 years) undergoing cardiac catheterization, 32 with obstructive coronary stenoses and 10 without, performed either (1) 5 minutes of cold air inhalation (5°F) or (2) two 5-minute supine-cycling periods: 1 at room temperature and 1 during cold air inhalation (5°F) (randomized order). We compared rest and peak stress MVR , CBF , and subendocardial perfusion measurements. In patients with unobstructed coronary arteries (n=10), cold air inhalation at rest decreased MVR by 6% ( P=0.41), increasing CBF by 20% ( P<0.01). However, in patients with obstructive stenoses (n=10), cold air inhalation at rest increased MVR by 17% ( P<0.01), reducing CBF by 3% ( P=0.85). Consequently, in patients with obstructive stenoses undergoing the cardiac magnetic resonance protocol (n=10), cold air inhalation reduced subendocardial perfusion ( P<0.05). Only patients with obstructive stenoses performed this protocol (n=12). Cycling at room temperature decreased MVR by 29% ( P<0.001) and increased CBF by 61% ( P<0.001). However, cold air inhalation during cycling blunted these adaptations in MVR ( P=0.12) and CBF ( P<0.05), an effect attributable to defective early diastolic CBF acceleration ( P<0.05) and associated with greater ST -segment depression ( P<0.05). Conclusions In patients with obstructive coronary stenoses, cold air inhalation causes deleterious changes in MVR and CBF . These diminish or abolish the normal adaptations during exertion that ordinarily match myocardial blood supply to demand.
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Affiliation(s)
- Rupert P. Williams
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Kaleab N. Asrress
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Matthew Lumley
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Satpal Arri
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Tiffany Patterson
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Howard Ellis
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | | | - Catherine Macfarlane
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Shruthi Chandran
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Kostantinos Moschonas
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Pippa Oakeshott
- Population Health Research InstituteSt George's University of LondonUnited Kingdom
| | - Timothy Lockie
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Amedeo Chiribiri
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Brian Clapp
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Divaka Perera
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Sven Plein
- Leeds UniversityLeeds Teaching Hospitals NHS TrustLeedsUnited Kingdom
| | - Michael S. Marber
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
| | - Simon R. Redwood
- Cardiovascular DivisionRayne InstituteSt Thomas’ HospitalKing's College LondonLondonUnited Kingdom
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Abstract
SummaryTwo patients with congenital factor-V deficiency and a third with a combined deficiency of factor V and factor VIII are described. Under cover of fresh frozen plasma, tooth extractions were performed on two of these patients and spontaneous bleeding arrested.It is concluded that the achievement of a blood level of factor V of 20 per cent once daily is sufficient to assure adequate haemostasis. A low recovery of factor V activity in the plasma following infusion was found. However, in spite of this, adequate blood levels were easily attained due to the excellent preservation of factor V activity in the stored fresh frozen plasma.
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Abstract
The surgical treatment of a group of 24 patients with hydradenitis suppurativa is described and the clinical features, aetiological factors and other methods of treatment are reviewed. An abnormally high incidence of atopy is noted within the group.
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Abstract
Recent work shows that a common pathway in adhesion production is a reduction in local plasminogen activator activity (PAA). This deficit permits deposited surface fibrin to become organized to fibrous adhesions. A rabbit model for adhesion formation was used to assess the effect of replacing the deficit with recombinant tissue plasminogen activator (rt-PA). Adhesions were produced by stripping peritoneum from corresponding parietal and visceral areas. One week later the adhesions were divided. Either rt-PA or placebo was applied to the divided adhesion. After a further week the animal was killed and the adhesions assessed. Sixty strips were performed. Fifty-five adhesions were produced (92%). Placebo gel was applied to 28 sides and rt-PA applied to 27. Twenty-two of the placebo group recurred (79%). Two of the rt-PA group reformed (7%, chi 2 = 20.883, P less than 0.001). Recombinant tissue plasminogen activator is an effective inhibitor of adhesion formation in the experimental animal.
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Affiliation(s)
- D Menzies
- Department of Surgery, Westminster Hospital, London
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Abstract
Two male homosexuals with carcinomata of the rectum with transitional cell changes are reported, and the possible aetiology of these lesions is discussed.
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Williams RP, de Waard GA, De Silva K, Lumley M, Asrress K, Arri S, Ellis H, Mir A, Clapp B, Chiribiri A, Plein S, Teunissen PF, Hollander MR, Marber M, Redwood S, van Royen N, Perera D. Doppler Versus Thermodilution-Derived Coronary Microvascular Resistance to Predict Coronary Microvascular Dysfunction in Patients With Acute Myocardial Infarction or Stable Angina Pectoris. Am J Cardiol 2018; 121:1-8. [PMID: 29132649 PMCID: PMC5746201 DOI: 10.1016/j.amjcard.2017.09.012] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/07/2017] [Accepted: 09/07/2017] [Indexed: 01/02/2023]
Abstract
Coronary microvascular resistance is increasingly measured as a predictor of clinical outcomes, but there is no accepted gold-standard measurement. We compared the diagnostic accuracy of 2 invasive indices of microvascular resistance, Doppler-derived hyperemic microvascular resistance (hMR) and thermodilution-derived index of microcirculatory resistance (IMR), at predicting microvascular dysfunction. A total of 54 patients (61 ± 10 years) who underwent cardiac catheterization for stable coronary artery disease (n = 10) or acute myocardial infarction (n = 44) had simultaneous intracoronary pressure, Doppler flow velocity and thermodilution flow data acquired from 74 unobstructed vessels, at rest and during hyperemia. Three independent measurements of microvascular function were assessed, using predefined dichotomous thresholds: (1) coronary flow reserve (CFR), the average value of Doppler- and thermodilution-derived CFR; (2) cardiovascular magnetic resonance (CMR) derived myocardial perfusion reserve index; and (3) CMR-derived microvascular obstruction. hMR correlated with IMR (rho = 0.41, p <0.0001). hMR had better diagnostic accuracy than IMR to predict CFR (area under curve [AUC] 0.82 vs 0.58, p <0.001, sensitivity and specificity 77% and 77% vs 51% and 71%) and myocardial perfusion reserve index (AUC 0.85 vs 0.72, p = 0.19, sensitivity and specificity 82% and 80% vs 64% and 75%). In patients with acute myocardial infarction, the AUCs of hMR and IMR at predicting extensive microvascular obstruction were 0.83 and 0.72, respectively (p = 0.22, sensitivity and specificity 78% and 74% vs 44% and 91%). We conclude that these 2 invasive indices of coronary microvascular resistance only correlate modestly and so cannot be considered equivalent. In our study, the correlation between independent invasive and noninvasive measurements of microvascular function was better with hMR than with IMR.
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Affiliation(s)
- Rupert P Williams
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Cardiovascular Division, Rayne Institute, St Thomas' Hospital, King's College London, London, United Kingdom
| | - Guus A de Waard
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Kalpa De Silva
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Cardiovascular Division, Rayne Institute, St Thomas' Hospital, King's College London, London, United Kingdom
| | - Matthew Lumley
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Cardiovascular Division, Rayne Institute, St Thomas' Hospital, King's College London, London, United Kingdom
| | - Kaleab Asrress
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Cardiovascular Division, Rayne Institute, St Thomas' Hospital, King's College London, London, United Kingdom
| | - Satpal Arri
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Cardiovascular Division, Rayne Institute, St Thomas' Hospital, King's College London, London, United Kingdom
| | - Howard Ellis
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Cardiovascular Division, Rayne Institute, St Thomas' Hospital, King's College London, London, United Kingdom
| | - Awais Mir
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Cardiovascular Division, Rayne Institute, St Thomas' Hospital, King's College London, London, United Kingdom
| | - Brian Clapp
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Cardiovascular Division, Rayne Institute, St Thomas' Hospital, King's College London, London, United Kingdom
| | - Amedeo Chiribiri
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Cardiovascular Division, Rayne Institute, St Thomas' Hospital, King's College London, London, United Kingdom
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre & Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Paul F Teunissen
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Maurits R Hollander
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Michael Marber
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Cardiovascular Division, Rayne Institute, St Thomas' Hospital, King's College London, London, United Kingdom
| | - Simon Redwood
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Cardiovascular Division, Rayne Institute, St Thomas' Hospital, King's College London, London, United Kingdom
| | - Niels van Royen
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Divaka Perera
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, Cardiovascular Division, Rayne Institute, St Thomas' Hospital, King's College London, London, United Kingdom.
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Affiliation(s)
- B Modarai
- Department of Anatomy, Guy's, King's and St Thomas' School of Medicine, Guy's Campus, London, UK.
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Mulder C, Mgode GF, Ellis H, Valverde E, Beyene N, Cox C, Reid SE, van't Hoog AH, Edwards TL. Accuracy of giant African pouched rats for diagnosing tuberculosis: comparison with culture and Xpert® MTB/RIF. Int J Tuberc Lung Dis 2017; 21:1127-1133. [DOI: 10.5588/ijtld.17.0139] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- C. Mulder
- Anti-Persoonsmijnen Ontmijnende Product Ontwikkeling, Sokoine University of Agriculture, Morogoro, Tanzania, Department of Global Health, Academic Medical Centre, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam,
The Netherlands
| | - G. F. Mgode
- Anti-Persoonsmijnen Ontmijnende Product Ontwikkeling, Sokoine University of Agriculture, Morogoro, Tanzania
| | - H. Ellis
- Anti-Persoonsmijnen Ontmijnende Product Ontwikkeling, Sokoine University of Agriculture, Morogoro, Tanzania, Waikato University, Hamilton, New Zealand
| | - E. Valverde
- Anti-Persoonsmijnen Ontmijnende Product Ontwikkeling, Sokoine University of Agriculture, Morogoro, Tanzania, Vanderbilt University Medical School, Nashville, Tennessee
| | - N. Beyene
- Anti-Persoonsmijnen Ontmijnende Product Ontwikkeling, Sokoine University of Agriculture, Morogoro, Tanzania
| | - C. Cox
- Anti-Persoonsmijnen Ontmijnende Product Ontwikkeling, Sokoine University of Agriculture, Morogoro, Tanzania
| | - S. E. Reid
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA, Tuberculosis Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - A. H. van't Hoog
- Department of Global Health, Academic Medical Centre, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, The Netherlands
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Affiliation(s)
- Haseeb Rahman
- From King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St Thomas' Hospital, United Kingdom (H.R., B.M., H.E, D.P.); and Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (S.A.)
| | - Bhavik Modi
- From King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St Thomas' Hospital, United Kingdom (H.R., B.M., H.E, D.P.); and Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (S.A.)
| | - Howard Ellis
- From King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St Thomas' Hospital, United Kingdom (H.R., B.M., H.E, D.P.); and Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (S.A.)
| | - Satpal Arri
- From King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St Thomas' Hospital, United Kingdom (H.R., B.M., H.E, D.P.); and Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (S.A.)
| | - Divaka Perera
- From King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St Thomas' Hospital, United Kingdom (H.R., B.M., H.E, D.P.); and Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (S.A.).
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Modi B, Chattersingh A, Ryan M, Ellis H, Lee J, Gaddum N, Chowienczyk P, Perera D. P3322Optimising physiological assessment of serial coronary artery lesions using an in vitro model of tandem stenoses. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx504.p3322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Asrress KN, Williams R, Lockie T, Khawaja MZ, De Silva K, Lumley M, Patterson T, Arri S, Ihsan S, Ellis H, Guilcher A, Clapp B, Chowienczyk PJ, Plein S, Perera D, Marber MS, Redwood SR. Physiology of Angina and Its Alleviation With Nitroglycerin: Insights From Invasive Catheter Laboratory Measurements During Exercise. Circulation 2017; 136:24-34. [PMID: 28468975 PMCID: PMC5491223 DOI: 10.1161/circulationaha.116.025856] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 04/26/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND The mechanisms governing exercise-induced angina and its alleviation by the most commonly used antianginal drug, nitroglycerin, are incompletely understood. The purpose of this study was to develop a method by which the effects of antianginal drugs could be evaluated invasively during physiological exercise to gain further understanding of the clinical impact of angina and nitroglycerin. METHODS Forty patients (mean age, 65.2±7.6 years) with exertional angina and coronary artery disease underwent cardiac catheterization via radial access and performed incremental exercise using a supine cycle ergometer. As they developed limiting angina, sublingual nitroglycerin was administered to half the patients, and all patients continued to exercise for 2 minutes at the same workload. Throughout exercise, distal coronary pressure and flow velocity and central aortic pressure were recorded with sensor wires. RESULTS Patients continued to exercise after nitroglycerin administration with less ST-segment depression (P=0.003) and therefore myocardial ischemia. Significant reductions in afterload (aortic pressure, P=0.030) and myocardial oxygen demand were seen (tension-time index, P=0.024; rate-pressure product, P=0.046), as well as an increase in myocardial oxygen supply (Buckberg index, P=0.017). Exercise reduced peripheral arterial wave reflection (P<0.05), which was not further augmented by the administration of nitroglycerin (P=0.648). The observed increases in coronary pressure gradient, stenosis resistance, and flow velocity did not reach statistical significance; however, the diastolic velocity-pressure gradient relation was consistent with a significant increase in relative stenosis severity (k coefficient, P<0.0001), in keeping with exercise-induced vasoconstriction of stenosed epicardial segments and dilatation of normal segments, with trends toward reversal with nitroglycerin. CONCLUSIONS The catheterization laboratory protocol provides a model to study myocardial ischemia and the actions of novel and established antianginal drugs. Administration of nitroglycerin causes changes in the systemic and coronary circulation that combine to reduce myocardial oxygen demand and to increase supply, thereby attenuating exercise-induced ischemia. Designing antianginal therapies that exploit these mechanisms may provide new therapeutic strategies.
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Affiliation(s)
- Kaleab N Asrress
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.).
| | - Rupert Williams
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Timothy Lockie
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Muhammed Z Khawaja
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Kalpa De Silva
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Matthew Lumley
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Tiffany Patterson
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Satpal Arri
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Sana Ihsan
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Howard Ellis
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Antoine Guilcher
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Brian Clapp
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Philip J Chowienczyk
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Sven Plein
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Divaka Perera
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Michael S Marber
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
| | - Simon R Redwood
- From King's College London British Heart Foundation Centre of Excellence, Rayne Institute, St. Thomas' Hospital, London, United Kingdom (K.N.A., R.W., T.L., M.Z.K., K.D.S., M.L., T.P., S.A., H.E., D.P., M.S.M., S.R.R.); National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (K.N.A., M.S.M., S.R.R.); Department of Cardiology, Royal North Shore Hospital, Sydney, Australia (K.N.A., K.D.S.); Kolling Institute, Northern Clinical School, University of Sydney, Australia (K.N.A.); Department of Clinical Pharmacology (A.G., P.J.C.) and Division of Imaging Sciences and Biomedical Engineering, Rayne Institute (S.I., S.P.), St Thomas' Hospital, King's College London, London, United Kingdom; Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom (B.C.); and Division of Cardiovascular and Neuronal Remodelling, University of Leeds, United Kingdom (S.P.)
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Briceno N, Silva KD, Lumley M, Kailey B, Ellis H, Redwood S, Perera D. 21 A comparison of coronary haemodynamics in 40cc versus 50cc intra-aortic balloon pumps. Heart 2017. [DOI: 10.1136/heartjnl-2017-311726.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Arri S, Williams R, Asrress K, Lumley M, Ellis H, Patterson T, Khawaja M, Perera D, Clapp B, Marber M, Redwood S. UNRAVELLING THE MECHANISMS OF MENTAL STRESS INDUCED MYOCARDIAL ISCHAEMIA: NOVEL INSIGHTS FROM INTRACORONARY MEASUREMENTS DURING CARDIAC CATHETERISATION. J Am Coll Cardiol 2017. [DOI: 10.1016/s0735-1097(17)33402-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Murchison A, Asher A, Manen AV, Ellis H. P25 Retrospective analysis of patients presenting with acute pulmonary embolism (pe) as the first manifestation of malignancy. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Ellis H. Book Review: The Acute Abdomen, An Approach to Diagnosis and Management. Proc R Soc Med 2016. [DOI: 10.1177/003591577707001117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- H Ellis
- Professor of Surgery Westminister Hospital Medical School Section Editor Section of Proctology
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Affiliation(s)
| | - H. Ellis
- Surgical Unit, Westminster Hospital, London SW1
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Lumley M, Williams R, Asrress KN, Arri S, Briceno N, Ellis H, Rajani R, Siebes M, Piek JJ, Clapp B, Redwood SR, Marber MS, Chambers JB, Perera D. Coronary Physiology During Exercise and Vasodilation in the Healthy Heart and in Severe Aortic Stenosis. J Am Coll Cardiol 2016; 68:688-97. [DOI: 10.1016/j.jacc.2016.05.071] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/05/2016] [Accepted: 05/10/2016] [Indexed: 01/10/2023]
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