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Dive into the research topics where Satpal Arri is active.

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Featured researches published by Satpal Arri.


Heart | 2016

Mental stress-induced myocardial ischaemia

Satpal Arri; Matthew Ryan; Simon Redwood; Michael Marber

### Learning objectives The management of angina is determined by symptoms and cardiovascular risk, together guiding further assessment in order to detect significant underlying coronary artery disease (CAD). The current National Institute for Health and Care Excellence guidelines require that symptoms are precipitated by physical exertion to be defined as typical angina.1 There are, however, a number of other stressors that may induce myocardial ischaemia, including cold exposure2 and mental stress. In the first detailed description of angina pectoris in the medical literature in 1772, William Heberden noted “it is increased by disturbance of the mind”.3 Mental stress-induced myocardial ischaemia (MSIMI) is a recognised phenomenon, but in the absence of an evidence base it is not routinely explored during either the clinical consultation or subsequent investigations. Significant uncertainties remain; in particular, how does MSIMI differ from exercise-induced myocardial ischaemia, and does it hold any particular significance for patients with ischaemic heart disease? Numerous observational studies have suggested that exposure to both acute and chronic mental stress is associated with an increased incidence of adverse cardiac events. Natural disasters, including earthquakes4–7 and hurricanes,8 have been linked with increases in cardiac mortality immediately after the event. There was a 71% increase in cardiac deaths on the day of the Northridge earthquake and a 35% increase in hospital admissions for myocardial infarction over the ensuing week.5 Similar findings are reported with unnatural events including in civilian communities under threat of imminent missile attack9 and with major sporting competitions.10–13 During the 2006 FIFA World Cup in Germany, the incidence of acute cardiac events was 2.7 times higher on match days involving the German national team.14 In those known to have …


Circulation | 2017

Physiology of Angina and its Alleviation with Nitroglycerine- Insights from Invasive Catheter Laboratory Measurements During Exercise

Kaleab N. Asrress; Rupert Williams; Timothy Lockie; Muhammed Z. Khawaja; Kalpa De Silva; Matthew Lumley; Tiffany Patterson; Satpal Arri; Sana Ihsan; Howard Ellis; Antoine Yves Marie Guilcher; Brian Clapp; Philip Chowienczyk; Sven Plein; Divaka Perera; Michael Marber; Simon Redwood

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.


Heart Failure Clinics | 2016

Current Concepts in the Pathogenesis of Takotsubo Syndrome

Rupert Williams; Satpal Arri; Abhiram Prasad

Takotsubo syndrome is typically characterized by acute reversible impairment of apical and mid -left ventricular systolic function. The pathophysiology is complex and remains to be completely understood. A catecholamine surge appears to be a central feature. Patients with prior history of psychiatric disorders have a predisposition. The putative role of a switch in b-adrenoceptor signalling resulting in negative inotropy remains uncertain. Downregulation of noncritical cellular functions may offer some protection in preventing irreversible cellular necrosis. Microvascular function is a common occurrence in these patients.


American Journal of Cardiology | 2018

Doppler Versus Thermodilution-Derived Coronary Microvascular Resistance to Predict Coronary Microvascular Dysfunction in Patients With Acute Myocardial Infarction or Stable Angina Pectoris

Rupert Williams; Guus de Waard; Kalpa De Silva; Matthew Lumley; Kaleab N. Asrress; Satpal Arri; Howard Ellis; Awais Mir; Brian Clapp; Amedeo Chiribiri; Sven Plein; Paul F. Teunissen; Maurits R. Hollander; Michael Marber; Simon Redwood; Niels van Royen; Divaka Perera

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.


Circulation | 2017

A lead to the culprit

Haseeb Rahman; Bhavik Modi; Howard Ellis; Satpal Arri; Divaka Perera

A 45-year-old woman presented with persistent chest pain. She had no past medical history and was otherwise fit and well. A 12-lead ECG (Figure 1) recorded by the ambulance team triggered the primary percutaneous intervention pathway. On transit to the primary percutaneous intervention center, the patient suffered a ventricular fibrillation arrest, and sinus rhythm was successfully restored after 3 minutes of resuscitation protocol. What is the likely angiographic finding that would explain the 12-lead ECG pattern? Please turn the page to read the diagnosis. Haseeb Rahman, BMBCh Bhavik Modi, MBBS Howard Ellis, BSc Satpal Arri, MBBS Divaka Perera, MD A Lead to the Culprit


Journal of the American College of Cardiology | 2015

DOPPLER INDICES OF RESISTANCE ARE SUPERIOR TO THERMODILUTION INDICES AT PREDICTING CORONARY MICROVASCULAR DYSFUNCTION

Rupert Williams; Kalpa De Silva; Matthew Lumley; Kaleab N. Asrress; Satpal Arri; Howard Ellis; Awais Mir; Brian Clapp; Michael Marber; Amedeo Chiribiri; Sven Plein; Simon Redwood; Divaka Perera

methods: 27-patients (64±11 yrs) were recruited, 48% following an acute coronary syndrome. Simultaneous pressure, Doppler flow velocity and cold-bolus transit time were measured in 40 unobstructed coronary arteries, using a Volcano Combowire and St Jude Pressure Wire, at rest and during intravenous adenosine hyperemia. The following were calculated using standard definitions: coronary flow reserve (CFR) by thermodilution and Doppler, hMR and IMR. 3T cardiac MRI scans were carried out and Myocardial Perfusion Reserve Index (MPRI) calculated in the corresponding segments as previously described.


Heart | 2016

18 Baseline coronary flow varies with normal cardiac catheter laboratory stimuli

Bhavik Modi; Howard Ellis; Satpal Arri; Matthew Lumley; Natalia Briceno; Rupert Williams; Brian Clapp; Simon Redwood; Michael Marber; Divaka Perera

Introduction Fractional Flow Reserve (FFR) is a pressure-derived estimate of coronary flow impairment during maximal and constant hyperaemia provided by an adenosine infusion, when flow and pressure approximate linearly. The need for adenosine-induced hyperaemia has led to development of a stenosis severity index measured at rest, Instantaneous Wave Free Ratio (iFR). Its use and proposed applicability to serial/diffuse disease has relied on assumptions that coronary flow at rest is maintained at constant levels. This study aimed to assess variability of resting coronary flow with normal Catheter laboratory stimuli. Methods Forty-Seven elective patients were recruited with a variety of coronary artery disease severity (mean FFR: 0.883; SD: 0.938). Simultaneous intracoronary pressure (Pd) and Doppler Average Peak Flow Velocity, APV(U), recordings were made. These were made both at rest and just prior to supine bicycle exercise or intravenous adenosine infusion. Results Average peak flow velocity varied significantly between measurements at rest and just prior to commencement of adenosine or supine bicycle exercise (18.1765cm/s vs. 19.4689cm/s, p 0.002). This was without significant change in haemodynamics (Table 1). Conclusion Resting coronary flow appears to vary significantly with normal Catheter Laboratory stimuli, such as simple warnings, irrespective of haemodynamic status. Abstract 18 Table 1 Table illustrating changes in Heart Rate, Systolic Blood Pressure (SBP), Ratio of distal coronary pressure to proximal aortic pressure (Pd/Pa) and Average Peak Coronary Flow Velocity (APV) Mean Std. Deviation Resting HR 80.149 14.7780 Pre Stress HR 82.468 (p: 0.227) 15.9208 Resting SBP 128.23 20.6944 Pre Stress SBP 128.88 (p: 0577) 22.9778 Resting Pd/Pa 0.9307 0.1106 Pre Stress Pd/Pa 0.9370 (p: 0.089) 0.1120 Resting APV (U) 18.1765 7.4892 Pre Stress APV (U) 19.4689 (p: 0.002) 7.7007


Archive | 2018

Left Heart Catheterization

Satpal Arri; Brian Clapp

The selective injection of contrast media into the right coronary artery of a middle-aged male by Mason Sones on October 30, 1958, introduced a new era in cardiovascular medicine that was to revolutionize our understanding and management of coronary disease. Two radiologists, Judkins and Amplatz, later used the Seldinger technique to gain access to the femoral artery. Independently, they designed pre-formed catheters, allowing easier intubation of the left and right coronary arteries as well as facilitating access to the left ventricle. This subsequently enabled the widespread dispersion of angiography as a diagnostic technique throughout the cardiology and radiology communities.


Journal of the American College of Cardiology | 2018

TCT-189 Extending Application of Intravascular Lithotripsy to a High Risk Real World Population

Julian Yeoh; Nilesh Pareek; Satpal Arri; Rajiv Rampat; Rafal Dworakowski; Jonathan Byrne; Philip MacCarthy; Jonathan Hill

Coronary arterial calcification increases procedural complexity in percutaneous coronary intervention (PCI) with a higher risk of major adverse cardiac events. The Disrupt-CAD I study suggested benefit with the use of intravascular lithotripsy (IVL) in selected cases. We present outcomes for IVL-


Circulation | 2018

Response by Asrress et al to Letter Regarding Article, “Physiology of Angina and Its Alleviation With Nitroglycerin: Insights From Invasive Catheter Laboratory Measurements During Exercise”

Kaleab N. Asrress; Rupert Williams; Timothy Lockie; Muhammed Z. Khawaja; Tiffany Patterson; Satpal Arri; Kalpa De Silva; Divaka Perera; Michael Marber; Simon Redwood

We are grateful to Jin-shan and Xue-bin for their interest in our work, where we described the physiology of angina and its alleviation with nitroglycerin during physiological exercise in the catheter laboratory while simultaneously measuring intracoronary and aortic hemodynamics.1 It was also the subject of an insightful editorial.2 We agree entirely that understanding the physiological mechanisms by which other commonly used drugs alleviate angina is …

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