Imperial College London

Dr Ricardo Petraco

Faculty of MedicineNational Heart & Lung Institute

Honorary Senior Lecturer
 
 
 
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Contact

 

+44 (0)20 7594 3386r.petraco

 
 
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Location

 

Block B Hammersmith HospitalHammersmith Campus

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Summary

 

Publications

Publication Type
Year
to

206 results found

Foley M, Rajkumar CA, Ahmed-Jushuf F, Nour D, Fung CH, Seligman H, Pathimagaraj RH, Petraco R, Sen S, Nijjer S, Howard JP, Ahmad Y, Allahwala U, Bhindi R, Chamie D, Doi S, Kuwata S, Kaihara T, Koga M, Ishibashi Y, Higuma T, Tanabe Y, Nakayama M, Kawase Y, Watanabe A, Funayama N, Horinaka R, Hijikata N, Takahashi T, Matsuo H, Hansen PS, Manica A, Weaver J, Alzuhairi K, Yong T-H, Warisawa T, Francis DP, Shun-Shin MJ, Al-Lamee RKet al., 2024, The ability of contemporary cardiologists to judge the ischemic impact of a coronary lesion visually., Cardiovasc Revasc Med, Vol: 59, Pages: 60-66

BACKGROUND: Landmark trials showed that invasive pressure measurement (Fractional Flow Reserve, FFR) was a better guide to coronary stenting than visual assessment. However, present-day interventionists have benefited from extensive research and personal experience of mapping anatomy to hemodynamics. AIMS: To determine if visual assessment of the angiogram performs as well as invasive measurement of coronary physiology. METHODS: 25 interventional cardiologists independently visually assessed the single vessel coronary disease of 200 randomized participants in The Objective Randomized Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina trial (ORBITA). They gave a visual prediction of the FFR and Instantaneous Wave-free Ratio (iFR), denoted vFFR and viFR respectively. Each judged each lesion on 2 occasions, so that every lesion had 50 vFFR, and 50 viFR assessments. The group consensus visual estimates (vFFR-group and viFR-group) and individual cardiologists' visual estimates (vFFR-individual and viFR-individual) were tested alongside invasively measured FFR and iFR for their ability to predict the placebo-controlled reduction in stress echo ischemia with stenting. RESULTS: Placebo-controlled ischemia improvement with stenting was predicted by vFFR-group (p < 0.0001) and viFR-group (p < 0.0001), vFFR-individual (p < 0.0001) and viFR-individual (p < 0.0001). There were no significant differences between the predictive performance of the group visual estimates and their invasive counterparts: p = 0.53 for vFFR vs FFR and p = 0.56 for viFR vs iFR. CONCLUSION: Visual assessment of the angiogram by contemporary experts, provides significant additional information on the amount of ischaemia which can be relieved by placebo-controlled stenting in single vessel coronary artery disease.

Journal article

Rajkumar CA, Foley MJ, Ahmed-Jushuf F, Nowbar AN, Simader FA, Davies JR, O'Kane PD, Haworth P, Routledge H, Kotecha T, Gamma R, Clesham G, Williams R, Din J, Nijjer SS, Curzen N, Ruparelia N, Sinha M, Dungu JN, Ganesananthan S, Khamis R, Mughal L, Kinnaird T, Petraco R, Spratt JC, Sen S, Sehmi J, Collier DJ, Sohaib A, Keeble TR, Cole GD, Howard JP, Francis DP, Shun-Shin MJ, Al-Lamee RK, ORBITA-2 Investigatorset al., 2023, A Placebo-Controlled Trial of Percutaneous Coronary Intervention for Stable Angina., N Engl J Med, Vol: 389, Pages: 2319-2330

BACKGROUND: Percutaneous coronary intervention (PCI) is frequently performed to reduce the symptoms of stable angina. Whether PCI relieves angina more than a placebo procedure in patients who are not receiving antianginal medication remains unknown. METHODS: We conducted a double-blind, randomized, placebo-controlled trial of PCI in patients with stable angina. Patients stopped all antianginal medications and underwent a 2-week symptom assessment phase before randomization. Patients were then randomly assigned in a 1:1 ratio to undergo PCI or a placebo procedure and were followed for 12 weeks. The primary end point was the angina symptom score, which was calculated daily on the basis of the number of angina episodes that occurred on a given day, the number of antianginal medications prescribed on that day, and clinical events, including the occurrence of unblinding owing to unacceptable angina or acute coronary syndrome or death. Scores range from 0 to 79, with higher scores indicating worse health status with respect to angina. RESULTS: A total of 301 patients underwent randomization: 151 to the PCI group and 150 to the placebo group. The mean (±SD) age was 64±9 years, and 79% were men. Ischemia was present in one cardiac territory in 242 patients (80%), in two territories in 52 patients (17%), and in three territories in 7 patients (2%). In the target vessels, the median fractional flow reserve was 0.63 (interquartile range, 0.49 to 0.75), and the median instantaneous wave-free ratio was 0.78 (interquartile range, 0.55 to 0.87). At the 12-week follow-up, the mean angina symptom score was 2.9 in the PCI group and 5.6 in the placebo group (odds ratio, 2.21; 95% confidence interval, 1.41 to 3.47; P<0.001). One patient in the placebo group had unacceptable angina leading to unblinding. Acute coronary syndromes occurred in 4 patients in the PCI group and in 6 patients in the placebo group. CONCLUSIONS: Among patients with stable angina who were receivi

Journal article

Petraco R, Bahl R, 2023, Physiology-Guided Deferral of Percutaneous Coronary Intervention in the Real World, Journal of the Society for Cardiovascular Angiography and Interventions, Vol: 2

Journal article

Stegehuis V, Boerhout C, Kikuta Y, Cambero-Madera M, van Royen N, Matsuo H, Nakayama M, de Waard G, Knaapen P, Nijjer S, Petraco R, Siebes M, Davies J, Escaned J, van de Hoef T, Piek Jet al., 2023, Impact of stenosis resistance and coronary flow capacity on fractional flow reserve and instantaneous wave-free ratio discordance: a combined analysis of DEFINE-FLOW and IDEAL, NETHERLANDS HEART JOURNAL, ISSN: 1568-5888

Journal article

Kanagaratnam P, Francis DP, Chamie D, Coyle C, Marynina A, Katritsis G, Paiva P, Szigeti M, Cole G, de Andrade Nunes D, Howard J, Esper R, Khan M, More R, Barreto G, Meneguz-Moreno R, Arnold A, Nowbar A, Kaura A, Mariveles M, March K, Shah J, Nijjer S, Lip GY, Mills N, Camm AJ, Cooke GS, Corbett SJ, Llewelyn MJ, Ghanima W, Toshner M, Peters N, Petraco R, Al-Lamee R, Boshoff ASM, Durkina M, Malik I, Ruparelia N, Cornelius V, Shun-Shin Met al., 2023, A randomised controlled trial to investigate the use of acute coronary syndrome therapy in patients hospitalised with COVID-19: the C19-ACS trial, Journal of Thrombosis and Haemostasis, Vol: 21, Pages: 2213-2222, ISSN: 1538-7836

BACKGROUND: Patients hospitalised with COVID-19 suffer thrombotic complications. Risk factors for poor outcomes are shared with coronary artery disease. OBJECTIVES: To investigate efficacy of an acute coronary syndrome regimen in patients hospitalised with COVID-19 and coronary disease risk factors. PATIENTS/METHODS: A randomised controlled open-label trial across acute hospitals (UK and Brazil) added aspirin, clopidogrel, low-dose rivaroxaban, atorvastatin, and omeprazole to standard care for 28-days. Primary efficacy and safety outcomes were 30-day mortality and bleeding. The key secondary outcome was a daily clinical status (at home, in hospital, on intensive therapy unit admission, death). RESULTS: 320 patients from 9 centres were randomised. The trial terminated early due to low recruitment. At 30 days there was no significant difference in mortality (intervention: 11.5% vs control: 15%, unadjusted OR 0.73, 95%CI 0.38 to 1.41, p=0.355). Significant bleeds were infrequent and not significantly different between the arms (intervention: 1.9% vs control 1.9%, p>0.999). Using a Bayesian Markov longitudinal ordinal model, it was 93% probable that intervention arm participants were more likely to transition to a better clinical state each day (OR 1.46, 95% CrI 0.88 to 2.37, Pr(Beta>0)=93%; adjusted OR 1.50, 95% CrI 0.91 to 2.45, Pr(Beta>0)=95%) and median time to discharge home was two days shorter (95% CrI -4 to 0, 2% probability that it was worse). CONCLUSIONS: Acute coronary syndrome treatment regimen was associated with a reduction in the length of hospital stay without an excess in major bleeding. A larger trial is needed to evaluate mortality.

Journal article

Seligman H, Patel SB, Alloula A, Howard JP, Cook CM, Ahmad Y, de Waard GA, Pinto ME, van de Hoef TP, Rahman H, Kelshiker MA, Rajkumar CA, Foley M, Nowbar AN, Mehta S, Toulemonde M, Tang M-X, Al-Lamee R, Sen S, Cole G, Nijjer S, Escaned J, Van Royen N, Francis DP, Shun-Shin MJ, Petraco Ret al., 2023, Development of artificial intelligence tools for invasive Doppler-based coronary microvascular assessment., Eur Heart J Digit Health, Vol: 4, Pages: 291-301

AIMS: Coronary flow reserve (CFR) assessment has proven clinical utility, but Doppler-based methods are sensitive to noise and operator bias, limiting their clinical applicability. The objective of the study is to expand the adoption of invasive Doppler CFR, through the development of artificial intelligence (AI) algorithms to automatically quantify coronary Doppler quality and track flow velocity. METHODS AND RESULTS: A neural network was trained on images extracted from coronary Doppler flow recordings to score signal quality and derive values for coronary flow velocity and CFR. The outputs were independently validated against expert consensus. Artificial intelligence successfully quantified Doppler signal quality, with high agreement with expert consensus (Spearman's rho: 0.94), and within individual experts. Artificial intelligence automatically tracked flow velocity with superior numerical agreement against experts, when compared with the current console algorithm [AI flow vs. expert flow bias -1.68 cm/s, 95% confidence interval (CI) -2.13 to -1.23 cm/s, P < 0.001 with limits of agreement (LOA) -4.03 to 0.68 cm/s; console flow vs. expert flow bias -2.63 cm/s, 95% CI -3.74 to -1.52, P < 0.001, 95% LOA -8.45 to -3.19 cm/s]. Artificial intelligence yielded more precise CFR values [median absolute difference (MAD) against expert CFR: 4.0% for AI and 7.4% for console]. Artificial intelligence tracked lower-quality Doppler signals with lower variability (MAD against expert CFR 8.3% for AI and 16.7% for console). CONCLUSION: An AI-based system, trained by experts and independently validated, could assign a quality score to Doppler traces and derive coronary flow velocity and CFR. By making Doppler CFR more automated, precise, and operator-independent, AI could expand the clinical applicability of coronary microvascular assessment.

Journal article

Buch AN, Alwair H, Cook CM, Petraco R, Efird JT, Gregory CP, Chagarlamudi AK, Davies JE, van de Hoef TP, Ferguson TBet al., 2022, Immediate impact of coronary artery bypass graft surgery on regional myocardial perfusion: Results from the Collaborative Pilot Study to Determine the Correlation Between Intraoperative Observations Using Spy Near-Infrared Imaging and Cardiac Catheterization Laboratory Physiological Assessment of Lesion Severity., JTCVS Open, Vol: 12, Pages: 158-176

OBJECTIVES: Coronary artery bypass grafting (CABG) is performed using anatomic guidance. Data connecting the physiologic significance of the coronary vessel stenosis to the acute physiologic response to grafting are lacking. The Collaborative Pilot Study to Determine the Correlation Between Intraoperative Observations Using Spy Near-Infrared Imaging and Cardiac Catheterization Laboratory Physiological Assessment of Lesion Severity study is the first to compare preintervention coronary physiology with the acute regional myocardial perfusion change (RMP-QC) at CABG in a per-graft analysis. METHODS: Non-emergent patients undergoing diagnostic catheterization suitable for multivessel CABG were enrolled. Synergy between Percutaneous Coronary Intervention with Taxus score, fractional flow reserve (FFR), instantaneous wave free ratio (iFR), and quantitative coronary angiography was documented in 75 epicardial coronary arteries, with 62 angiographically intermediate and 13 severe stenoses. At CABG, near-infrared fluorescence analysis quantified the relative change (post- vs pregrafting, termed RMP-QC) in the grafted vessel's perfusion territory. Scatter plots were constructed for RMP-QC versus quantitative coronary angiography and RMP-QC versus FFR/iFR. Exact quadrant randomization test for randomness was used. RESULTS: There was no relationship between RMP-QC and quantitative coronary angiography percent diameter stenosis, whether all study vessels were included (P = .949) or vessels with core-lab quantitative coronary angiography only (P = .922). A significant nonrandom association between RMP-QC and FFR (P = .025), as well as between RMP-QC and iFR (P = .008), was documented. These associations remained when excluding vessels with assigned FFR and iFR values (P = .0092 and P = .0006 for FFR and iFR, respectively). CONCLUSIONS: The Collaborative Pilot Study to Determine the Correlation Between Intraoperative Obse

Journal article

Ganesananthan S, Rajkumar C, Foley M, Thompson D, Nowbar A, Seligman H, Petraco R, Sen S, Nijjer S, Thom S, Wensel R, Davies J, Francis D, Shun-Shin M, Howard J, Al-Lamee Ret al., 2022, Cardiopulmonary exercise testing and efficacy of percutaneous coronary intervention: A substudy of the ORBITA trial, European Heart Journal, Vol: 43, Pages: 3132-3145, ISSN: 0195-668X

AimsOxygen-pulse morphology and gas exchange analysis measured during cardiopulmonary exercise testing (CPET) has been associated with myocardial ischaemia. We examine the relationship between CPET parameters, myocardial ischaemia and anginal symptoms in patients with chronic coronary syndrome. We also determine the ability of these parameters to predict the placebo-controlled response to percutaneous coronary intervention (PCI).Methods and resultsPatients with severe single vessel coronary artery disease were randomised 1:1 to PCI or placebo in the ORBITA trial. Subjects underwent pre-randomisation treadmill CPET, dobutamine stress-echocardiography (DSE) and symptom assessment. These assessments were repeated at the end of a 6-week blinded follow-up period. 195 patients with CPET data were randomised (102 PCI, 93 placebo). Patients in whom an oxygen-pulse plateau was observed during CPET had higher (more ischaemic) DSE score (+0.82 segments; 95%CI, 0.40 to 1.25, P=0.0068) and lower FFR (-0.07; -0.12 to -0.02, P=0.011) compared to those without. At lower (more abnormal) oxygen-pulse slopes, there was a larger improvement of the placebo-controlled effect of PCI on DSE score (oxygen-pulse plateau presence [Pinteraction=0.026] and oxygen-pulse gradient [Pinteraction=0.023]) and Seattle angina physical-limitation score (oxygen-pulse plateau presence [Pinteraction=0.037]). Impaired peak VO2, VE/VCO2 slope, peak oxygen-pulse and oxygen-uptake efficacy slope was significantly associated with higher symptom burden but did not relate to severity of ischaemia or predict response to PCI.ConclusionAlthough selected CPET parameters relate to severity of angina symptoms and quality of life, only an oxygen-pulse plateau detects the severity of myocardial ischaemia and predicts the placebo-controlled efficacy of PCI in patients with single-vessel coronary artery disease.

Journal article

Foley M, Hall K, Howard J, Ahmad Y, Gandhi M, Mahboobani S, Okafor J, Rahman H, Hadjiloizou N, Ruparelia N, Mikhail G, Malik I, Kanaganayagam G, Sutaria N, Rana B, Ariff B, Barden E, Anderson J, Afoke J, Petraco R, Al-Lamee R, Sen Set al., 2022, Aortic valve calcium score is associated with acute stroke in transcatheter aortic valve replacement patients, Journal of the Society for Cardiovascular Angiography & Interventions, Vol: 1, Pages: 1-6, ISSN: 2772-9303

BackgroundTranscatheter aortic valve replacement (TAVR) is the treatment of choice for patients with severe aortic stenosis who are at a moderate or higher surgical risk. Stroke is a recognised and serious complication of TAVR, and it is important to identify patients at higher stroke risk. This study aims to discover if aortic valve calcium score calculated from pre-TAVR computed tomography is associated with acute stroke in TAVR patients.MethodsWe conducted a retrospective, observational cohort study of 433 consecutive patients undergoing TAVR between January 2017 and December 2019 at the Hammersmith Hospital.ResultsThis cohort had a median age of 83 years (interquartile range, 78-87), and 52.7% were male. Fifty-two patients (12.0%) had a history of previous stroke or transient ischemic attack. Median aortic valve calcium score was 2145 (interquartile range, 1427-3247) Agatston units. Twenty-two patients had a stroke up to the time of discharge (5.1%). In a logistic regression model, aortic valve calcium score was significantly associated with acute stroke (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.01-1.53; P = .02). Acute stroke was also significantly associated with peripheral arterial disease (OR, 4.32; 95% CI, 1.65-10.65; P = .0018) and a longer procedure time (OR, 1.01; 95% CI, 1.00-1.02; P = .0006).ConclusionsAortic valve calcium score from pre-TAVR computed tomography is an independent risk factor for acute stroke in the TAVR population. This is an additional clinical value of the pre-TAVR aortic valve calcium score and should be considered when discussing periprocedural stroke risk.

Journal article

Kelshiker M, Seligman H, Howard JAMES, Rahman H, Foley M, Nowbar A, Rajkumar C, Shun-Shin M, Ahmad Y, Sen S, Al-Lamee R, Cole G, Hoole S, Morris P, Rigo F, Mayet J, Francis D, Petraco Ret al., 2022, Coronary flow reserve and cardiovascular outcomes: a systematic review and meta-analysis, European Heart Journal, Vol: 43, Pages: 1582-1593, ISSN: 0195-668X

Aims: This meta-analysis aims to quantify the association of reduced coronary flow with all3 cause mortality and major adverse cardiovascular events (MACE) across a broad range of patient groups and pathologies. Methods and Results: We systematically identified all studies between 1st January 2000 and1st August 2020, where coronary flow was measured and clinical outcomes were reported. The endpoints were all-cause mortality and MACE. Estimates of effect were calculated from published hazard ratios using a random-effects model. 79 studies, including 59,740 subjects were included. Abnormal coronary flow reserve (CFR) was associated with a higher incidence of all-cause mortality (HR 3.78, 95% CI 2.39-5.97) and a higher incidence of MACE (HR 3.42, 95% CI 2.92-3.99). Each 0.1-unit reduction in CFR was associated with a proportional increase in mortality (per 0.1 CFR unit HR 1.16, 95% CI 1.04-1.29) and MACE (per 0.1 CFR unit HR 1.08, 95% CI 1.04-1.11)). In patients with isolated coronary microvascular dysfunction, an abnormal CFR was associated with a higher incidence of mortality (HR 5.44, 95% CI 3.78-7.83) and MACE (HR 3.56, 95% CI 2.14-5.90). Abnormal CFR was also associated with a higher incidence of MACE in patients with acute coronary syndromes (HR 3.76, 95% CI 2.35-6.00), heart failure (HR 6.38, 95% CI 1.95-20.90), heart transplant (HR 3.32, 95% CI 2.34-4.71) and diabetes mellitus (HR 7.47, 95% CI 3.37-16.55). Conclusions: Reduced coronary flow is strongly associated with increased risk of all-cause mortality and MACE across a wide range of pathological processes. This finding supports recent recommendations that coronary flow should be measured more routinely in clinical practice to target aggressive vascular risk modification for individuals at higher risk

Journal article

Kelshiker M, Seligman H, Howard J, Petraco Ret al., 2022, The importance of time-to-event analysis in measuring the prognostic impact of coronary flow reserve, European Heart Journal, ISSN: 0195-668X

Journal article

Nowbar AN, Rajkumar C, Foley M, Ahmed-Jushuf F, Howard JP, Seligman H, Petraco R, Sen S, Nijjer SS, Shun-Shin MJ, Keeble TR, Sohaib A, Collier D, McVeigh P, Harrell FE, Francis DP, Al-Lamee RKet al., 2022, A double-blind randomised placebo-controlled trial of percutaneous coronary intervention for the relief of stable angina without antianginal medications: design and rationale of the ORBITA-2 trial, EUROINTERVENTION, Vol: 17, Pages: 1490-+, ISSN: 1774-024X

Journal article

Seligman H, Nijjer SS, van de Hoef TP, de Waard GA, Mejia-Renteria H, Echavarria-Pinto M, Shun-Shin MJ, Howard JP, Cook CM, Warisawa T, Ahmad Y, Androshchuk V, Rajkumar C, Nowbar A, Kelshiker MA, van Lavieren MA, Meuwissen M, Danad I, Knaapen P, Sen S, Al-Lamee R, Mayet J, Escaned J, Piek JJ, van Royen N, Davies JE, Francis DP, Petraco Ret al., 2022, Phasic flow patterns of right versus left coronary arteries in patients undergoing clinical physiological assessment, EUROINTERVENTION, Vol: 17, Pages: 1260-+, ISSN: 1774-024X

Journal article

Cook CM, Howard JP, Ahmad Y, Shun-Shin MJ, Sethi A, Clesham GJ, Tang KH, Nijjer SS, Kelly PA, Davies JR, Malik IS, Kaprielian R, Mikhail G, Petraco R, Warisawa T, Al-Janabi F, Karamasis G, Mohdnazri S, Gamma R, Stathogiannis KE, de Waard GA, Al-Lamee R, Keeble TR, Mayet J, Sen S, Francis DP, Davies JEet al., 2021, Comparing invasive hemodynamic responses in adenosine hyperemia versus physical exercise stress in chronic coronary syndromes, INTERNATIONAL JOURNAL OF CARDIOLOGY, Vol: 342, Pages: 7-14, ISSN: 0167-5273

Journal article

Seligman H, Zaman S, Pitcher DS, Shun-Shin MJ, Lloyd FH, Androshchuk V, Sen S, Al-Lamee R, Miller DM, Barnett HW, Haji GS, Howard LS, Nijjer S, Mayet J, Francis DP, Ces O, Linton NWF, Peters NS, Petraco Ret al., 2021, Correction: Reusable snorkel masks adapted as particulate respirators, PLoS One, Vol: 16, Pages: 1-1, ISSN: 1932-6203

Journal article

Naderi H, Robinson S, Swaans MJ, Bual N, Cheung W-S, Reid L, Shun-Shin M, Asaria P, Pabari P, Cole G, Kanaganayagam GS, Sutaria N, Bellamy M, Fox K, Nihoyannopoulos P, Petraco R, Al-Lamee R, Nijjer SS, Sen S, Ruparelia N, Baker C, Mikhail G, Malik I, Khamis R, Varnava A, Francis D, Mayet J, Rana Bet al., 2021, Adapting the role of handheld echocardiography during the COVID-19 pandemic: A practical guide, PERFUSION-UK, Vol: 36, Pages: 547-558, ISSN: 0267-6591

Journal article

Rajkumar C, Shun-Shin M, Seligman H, Ahmad Y, Warisawa T, Cook C, Howard J, Ganesananthan S, Amarin L, Khan C, Ahmed A, Nowbar A, Foley M, Assomull R, Keenan N, Sehmi J, Keeble T, davies J, Tang K, Gerber R, Cole G, O'Kane P, Sharp A, Khamis R, Kanaganayagam G, Petraco R, Ruparelia N, Malik I, Nijjer S, Sen S, Francis D, Al-Lamee Ret al., 2021, Placebo-controlled efficacy of percutaneous coronary intervention for focal and diffuse patterns of stable coronary artery disease, Circulation: Cardiovascular Interventions, Vol: 14, Pages: 809-818, ISSN: 1941-7640

Background Physiological assessment with pressure wire pullback can characterize coronary artery disease (CAD) with a focal or diffuse pattern. However, the clinical relevance of this distinction is unknown. We use data from ORBITA to test if the pattern of CAD predicts the placebo-controlled efficacy of percutaneous coronary intervention (PCI) on stress echocardiography ischemia and symptom endpoints.Methods164 patients in ORBITA underwent blinded instantaneous wave-free ratio (iFR) pullback assessment prior to randomization. Focal disease was defined as 0.03 iFR unit drop within 15mm, rather than over a longer distance. Analyses were performed using regression modelling. ResultsIn the PCI arm (n=85), 48 were focal and 37 were diffuse. In the placebo arm (n=79), 35 were focal and 44 were diffuse. Focal stenoses were associated with significantly lower fractional flow reserve (FFR) and iFR values than diffusely diseased vessels (focal mean FFR and iFR 0.600.15 and 0.650.24, diffuse 0.780.10 and 0.880.08 respectively, p<0.0001). With adjustment for this difference, PCI for focal stenoses resulted in significantly greater reduction in stress echo ischemia than PCI for diffuse disease (p<0.05). The effect of PCI on between-arm pre-randomization-adjusted exercise time was 9.32 seconds (95% CI, -17.1 to 35.7s; p=0.487). When stratified for pattern of disease, there was no detectable difference between focal and diffuse CAD (Pinteraction=0.700). PCI improved Seattle Angina Questionnaire angina frequency score and freedom from angina more than placebo (p=0.034; p=0.0035). However, there was no evidence of interaction between the physiological pattern of CAD and these effects (Pinteraction=0.436; Pinteraction=0.908).ConclusionPCI achieved significantly greater reduction of stress echocardiography ischemia in focal compared to diffuse CAD. However, for symptom endpoints, no such difference was observed.

Journal article

Chamie D, Petraco R, 2021, Stent type identification with optical coherence tomography: novelty in search of clinical application, EUROINTERVENTION, Vol: 17, Pages: 103-104, ISSN: 1774-024X

Journal article

Zaman S, Seligman H, Lloyd FH, Patel KT, Chappell D, O'Hare D, Cole GD, Francis DP, Petraco R, Linton NWFet al., 2021, Aerosolised fluorescein can quantify FFP mask faceseal leakage: a cost-effective adaptation to the existing point of care fit test, CLINICAL MEDICINE, Vol: 21, Pages: E263-E268, ISSN: 1470-2118

Journal article

Seligman H, Zaman S, Pitcher DS, Shun-Shin MJ, Hepworth Lloyd F, Androschuk V, Sen S, Al-Lamee R, Miller DM, Barnett HW, Haji GS, Howard LS, Nijjer S, Mayet J, Francis DP, Ces O, Linton NWF, Peters NS, Petraco Ret al., 2021, Reusable snorkel masks adapted as particulate respirators, PLoS One, Vol: 16, Pages: 1-11, ISSN: 1932-6203

ntroductionDuring viral pandemics, filtering facepiece (FFP) masks together with eye protection form the essential components of personal protective equipment (PPE) for healthcare workers. There remain concerns regarding insufficient global supply and imperfect protection offered by currently available PPE strategies. A range of full-face snorkel masks were adapted to accept high grade medical respiratory filters using bespoke-designed 3D-printed connectors. We compared the protection offered by the snorkel to that of standard PPE using a placebo-controlled respirator filtering test as well as a fluorescent droplet deposition experiment. Out of the 56 subjects tested, 42 (75%) passed filtering testing with the snorkel mask compared to 31 (55%) with a FFP3 respirator mask (p = 0.003). Amongst the 43 subjects who were not excluded following a placebo control, 85% passed filtering testing with the snorkel versus to 68% with a FFP3 mask (p = 0.008). Following front and lateral spray of fluorescence liquid particles, the snorkel mask also provided superior protection against droplet deposition within the subject’s face, when compared to a standard PPE combination of FFP3 masks and eye protection (3.19x108 versus 6.81x108 fluorescence units, p<0.001). The 3D printable adaptors are available for free download online at https://www.ImperialHackspace.com/COVID-19-Snorkel-Respirator-Project/.ConclusionFull-face snorkel masks adapted as particulate respirators performed better than a standard PPE combination of FFP3 mask and eye protection against aerosol inhalation and droplet deposition. This adaptation is therefore a promising PPE solution for healthcare workers during highly contagious viral outbreaks.

Journal article

Mikhail G, Khawaja SA, Mohan P, Jabbour R, Bampouri T, Bowsher G, Hassan AMM, Huq F, Baghdasaryan L, Wang B, Sethi A, Sen S, Petraco R, Ruparelia N, Nijjer S, Malik IS, Foale R, Bellamy M, Kooner J, Rana BS, Cole G, Sutaria N, Kanaganayagam G, Nihoyannopoulos P, Fox K, Plymen CM, Pabari P, Howard L, Davies R, Hajoi G, Lo Giudice F, Kanagaratnam P, Anderson J, Chukwuemeka A, Khamis R, Varnava A, Baker CSR, Francis D, Asaria P, Al-Lamee Ret al., 2021, COVID-19 and its impact on the cardiovascular system, Open Heart, Vol: 8, Pages: 1-9, ISSN: 2053-3624

Objectives: The clinical impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has varied across countries with varying cardiovascular manifestations. We review the cardiac presentations, in-hospital outcomes and development of cardiovascular complications in the initial cohort of SARS-CoV-2 positive patients at Imperial College Healthcare NHS Trust, United Kingdom.Methods: We retrospectively analysed 498 COVID-19 positive adult admissions to our institute from 7th March to 7th April 2020. Patient data was collected for baseline demographics, co-morbidities and in-hospital outcomes, especially relating to cardiovascular intervention.Results:Mean age was 67.4±16.1 years and 62.2%(n=310) were male. 64.1%(n=319) of our cohort had underlying cardiovascular disease (CVD) with 53.4%(n=266) having hypertension. 43.2%(n=215) developed acute myocardial injury. Mortality was significantly increased in those patients with myocardial injury (47.4% vs 18.4%,p<0.001). Only 4 COVID-19 patients had invasive coronary angiography,2 underwent percutaneous coronary intervention and 1 required a permanent pacemaker implantation. 7.0%(n=35) of patients had an inpatient echocardiogram. Acute myocardial injury (OR 2.39,1.31-4.40,p=0.005) and history of hypertension (OR 1.88 ,1.01-3.55,p=0.049) approximately doubled the odds of in-hospital mortality in patients admitted with COVID-19 after other variables had been controlled for.Conclusion:Hypertension, pre-existing CVD and acute myocardial injury were associated with increased in-hospital mortality in our cohort of COVID-19 patients. However, only a low number of patients required invasive cardiac intervention.

Journal article

Chamie D, Costa Jr JR, Damiani LP, Siqueira D, Braga S, Costa R, Seligman H, Brito F, Barreto G, Staico R, Feres F, Petraco R, Abizaid Aet al., 2021, Optical Coherence Tomography Versus Intravascular Ultrasound and Angiography to Guide Percutaneous Coronary Interventions The iSIGHT Randomized Trial, CIRCULATION-CARDIOVASCULAR INTERVENTIONS, Vol: 14, ISSN: 1941-7640

Journal article

Thompson D, Al-Lamee R, Foley M, Dehbi HM, Thom S, Davies JE, Francis DP, Patel P, Gupta P, ORBITA Investigatorset al., 2021, Achieving optimal adherence to medical therapy by telehealth: Findings from the ORBITA medication adherence sub-study, Pharmacology Research and Perspectives, Vol: 9, Pages: e00710-e00710, ISSN: 2052-1707

INTRODUCTION: The ORBITA trial of percutaneous coronary intervention (PCI) versus a placebo procedure for patients with stable angina was conducted across six sites in the United Kingdom via home monitoring and telephone consultations. Patients underwent detailed assessment of medication adherence which allowed us to measure the efficacy of the implementation of the optimization protocol and interpretation of the main trial endpoints. METHODS: Prescribing data were collected throughout the trial. Self-reported adherence was assessed, and urine samples collected at pre-randomization and at follow-up for direct assessment of adherence using high-performance liquid chromatography with tandem mass spectrometry (HPLC MS/MS). RESULTS: Self-reported adherence was >96% for all drugs in both treatment groups at both stages. The percentage of samples in which drug was detected at pre-randomization and at follow-up in the PCI versus placebo groups respectively was: clopidogrel, 96% versus 90% and 98% versus 94%; atorvastatin, 95% versus 92% and 92% versus 91%; perindopril, 95% versus 97% and 85% versus 100%; bisoprolol, 98% versus 99% and 96% versus 97%; amlodipine, 99% versus 99% and 94% versus 96%; nicorandil, 98% versus 96% and 94% versus 92%; ivabradine, 100% versus 100% and 100% versus 100%; and ranolazine, 100% versus 100% and 100% versus 100%. CONCLUSIONS: Adherence levels were high throughout the study when quantified by self-reporting methods and similarly high proportions of drug were detected by urinary assay. The results indicate successful implementation of the optimization protocol delivered by telephone, an approach that could serve as a model for treatment of chronic conditions, particularly as consultations are increasingly conducted online.

Journal article

Foley M, Rajkumar CA, Shun-Shin M, Ganesananthan S, Seligman H, Howard J, Nowbar AN, Keeble TR, Davies JR, Tang KH, Gerber R, O'Kane P, Sharp ASP, Petraco R, Malik IS, Nijjer S, Sen S, Francis DP, Al-Lamee Ret al., 2021, Achieving optimal medical therapy: insights from the ORBITA trial., Journal of the American Heart Association, Vol: 10, Pages: 1-20, ISSN: 2047-9980

Background In stable coronary artery disease, medications are used for 2 purposes: cardiovascular risk reduction and symptom improvement. In clinical trials and clinical practice, medication use is often not optimal. The ORBITA (Objective Randomised Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina) trial was the first placebo-controlled trial of percutaneous coronary intervention. A key component of the ORBITA trial design was the inclusion of a medical optimization phase, aimed at ensuring that all patients were treated with guideline-directed truly optimal medical therapy. In this study, we report the medical therapy that was achieved. Methods and Results After enrollment into the ORBITA trial, all 200 patients entered a 6-week period of intensive medical therapy optimization, with initiation and uptitration of risk reduction and antianginal therapy. At the prerandomization stage, the median number of antianginals established was 3 (interquartile range, 2-4). A total of 195 patients (97.5%) reached the prespecified target of ≥2 antianginals; 136 (68.0%) did not stop any antianginals because of adverse effects, and the median number of antianginals stopped for adverse effects per patient was 0 (interquartile range, 0-1). Amlodipine and bisoprolol were well tolerated (stopped for adverse effects in 4/175 [2.3%] and 9/167 [5.4%], respectively). Ranolazine and ivabradine were also well tolerated (stopped for adverse effects in 1/20 [5.0%] and 1/18 [5.6%], respectively). Isosorbide mononitrate and nicorandil were stopped for adverse effects in 36 of 172 (20.9%) and 32 of 141 (22.7%) of patients, respectively. Statins were well tolerated and taken by 191 of 200 (95.5%) patients. Conclusions In the 12-week ORBITA trial period, medical therapy was successfully optimized and well tolerated, with few drug adverse effects leading to therapy cessation. Truly optimal medical therapy can be achieved in clinical trials, and translating this i

Journal article

Manica JL, Duarte VO, Ribeiro M, Hartley A, Petraco R, Pedra C, Rossi Ret al., 2020, Standardizing Radiation Exposure during Cardiac Catheterization in Children with Congenital Heart Disease: Data from a Multicenter Brazilian Registry, ARQUIVOS BRASILEIROS DE CARDIOLOGIA, Vol: 115, Pages: 1154-1160, ISSN: 0066-782X

Journal article

Seligman H, Sen S, Nijjer S, Al-Lamee R, Clifford P, Sethi A, Hadjiloizou N, Kaprielian R, Ramrakha P, Bellamy M, Khan MA, Kooner J, Foale RA, Mikhail G, Baker CS, Mayet J, Malik I, Khamis R, Francis D, Petraco Ret al., 2020, Management of Acute Coronary Syndromes During the Coronavirus Disease 2019 Pandemic: Deviations from Guidelines and Pragmatic Considerations for Patients and Healthcare Workers, Interventional Cardiology Review, Vol: 15, Pages: e16-e16, ISSN: 1756-1477

Coronavirus disease 2019 (COVID-19) is forcing cardiology departments to rapidly adapt existing clinical guidelines to a new reality and this is especially the case for acute coronary syndrome pathways. In this focused review, the authors discuss how COVID-19 is affecting acute cardiology care and propose pragmatic guideline modifications for the diagnosis and management of acute coronary syndrome patients, particularly around the appropriateness of invasive strategies as well as length of hospital stay. The authors also discuss the use of personal protective equipment for healthcare workers in cardiology. Based on shared global experiences and growing peer-reviewed literature, it is possible to put in place modified acute coronary syndrome treatment pathways to offer safe pragmatic decisions to patients and staff.

Journal article

Nijjer SS, Petraco R, Sen S, 2020, Optimal management of acute coronary syndromes in the era of COVID-19, HEART, Vol: 106, Pages: 1609-1616, ISSN: 1355-6037

Journal article

Warisawa T, Cook CM, Rajkumar C, Howard JP, Seligman H, Ahmad Y, El Hajj S, Doi S, Nakajima A, Nakayama M, Goto S, Vera-Urquiza R, Sato T, Kikuta Y, Kawase Y, Nishina H, Petraco R, Al-Lamee R, Nijjer S, Sen S, Nakamura S, Lerman A, Matsuo H, Francis DP, Akashi YJ, Escaned J, Davies JEet al., 2020, Safety of Revascularization Deferral of Left Main Stenosis Based on Instantaneous Wave-Free Ratio Evaluation, JACC-CARDIOVASCULAR INTERVENTIONS, Vol: 13, Pages: 1655-1664, ISSN: 1936-8798

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