Samer Arnous - Academia.edu (original) (raw)

Papers by Samer Arnous

PubMed, Mar 16, 2022

Aim We hypothesised that pre-hospital ticagrelor loading would result in a higher proportion of S... more Aim We hypothesised that pre-hospital ticagrelor loading would result in a higher proportion of STEMI patients presenting with pre percutaneous coronary intervention TIMI flow grade (ppTFG) 3 than had previously been reported in the clopidogrel era. Methods Retrospective observational analysis of all STEMI patients attending our centre from 01/01/2016 to 31/12/2019. Patients presenting with STEMI were required to have received pre-hospital load-ing with 180 mg ticagrelor. The coronary angiography images were assessed for each patient to determine the ppTFG in the infarct related artery. Results 590 patients met the inclusion criteria. 125 patients (21.2%) presented with ppTFG 3 on pre-PCI angiography with the remaining 465 patients (78.8%) presenting with ppTFG ≤ 2. In-hospital mor-tality was comparable between the two groups (4% vs 5.6%, p=0.48). Conclusion In STEMI patients loaded with ticagrelor in the field, over one-fifth present with ppTFG 3 on angi-ography pre-PCI. This data is comparable to data from the clopidogrel era.

Journal of the American College of Cardiology, May 1, 2021

American Journal of Cardiology, Aug 1, 2023

Journal of Cardiovascular Computed Tomography, Jul 1, 2023

Clinical Medicine, Mar 1, 2023

Expert Review of Cardiovascular Therapy, Jan 2, 2018

Patent foramen ovale has been suggested to be a risk factor for cryptogenic stroke by means of pa... more Patent foramen ovale has been suggested to be a risk factor for cryptogenic stroke by means of paradoxical embolism. The data, however, are complex, conflicting and largely unavailable. In this review, we attempt to summarize the existing data separately for the questions of whether patent foramen ovale is associated with cryptogenic stroke and whether it is a risk factor for a first ischemic stroke and for recurrent strokes. Treatment options will be discussed, and the different viewpoints from the two specialists mainly involved in the care of those complex patients (neurologists and cardiologists) will be provided.

Journal of the American College of Cardiology, Mar 1, 2023

Authorea (Authorea), Jan 10, 2023

Aim Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) remains the s... more Aim Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) remains the standard of care. CYP2C19 genetic polymorphisms results in variable Clopidogrel bioactivation. Increased function (CYP2C19*17) allele carriers (rapid metabolizers (RM) or ultrarapid metabolizers (UM)), are Clopidogrel hyper-responders and hence more susceptible to Clopi

30% within the not negative groups (excluding SADS where it was 100%). Factors contributing to lo... more 30% within the not negative groups (excluding SADS where it was 100%). Factors contributing to low rates of genetic testing and phenotypic predictors of positive genotype warrant further investigation.

Journal of the American College of Cardiology

presenting with NSTEMI (1). We sought to ascertain adherence to current guidelines and compare ou... more presenting with NSTEMI (1). We sought to ascertain adherence to current guidelines and compare outcomes with the use of different antithrombotic regimes in our institution. Methods 388 patients underwent urgent coronary artery bypass grafting (CABG) in our institution between 2016 and 2018. The national electronic healthcare record was used to retrospectively collect data. Patients meeting the ESC universal definition of myocardial infarction at presentation were included. The primary safety outcome was defined as any Bleeding Academic Research Consortium Bleeding (BARC) Type 2-5 event on therapy at 1 year. The primary efficacy outcome was defined as a composite of non-fatal MI, CV death, unplanned revascularisation and documented graft failure at 1 year. The net clinical composite end point was a combination of both ischaemic and bleeding end points at 1 year. Results 181 patients met our inclusion criteria (table 1). Mean age=67.8 ±9.4. Male sex=80.6%. Mean follow-up dura-tion=710 ±177 days. 60.2% were managed with SAPT (aspirin 300 mg OD), 27.1% with DAPT (90% aspirin 75 mg OD plus clopidogrel 75 mg OD) and 12.7% with oral anticoagulation (OAC) plus SAPT. OAC regimes were warfarin plus aspirin (60.9%), NOAC plus aspirin (34.8%) and NOAC plus clopidogrel (4.3%). The primary safety end point was observed in 6.1% in the DAPT group, 9.2% in the SAPT group (HR 0.74; 95% CI 0.20-2.72; p 0.65) and 21.7% in

Expert Review of Cardiovascular Therapy, Aug 3, 2019

Introduction: Atherosclerotic coronary artery disease, in particular acute myocardial infarction ... more Introduction: Atherosclerotic coronary artery disease, in particular acute myocardial infarction (AMI) is a leading cause of morbidity and mortality globally. Percutaneous coronary intervention (PCI) is the mainstay of treatment for obstructive coronary artery disease and AMI through the restoration of TIMI III flow. Despite good macrovascular flow, the myocardium can remain hypoperfusion due to poor microvascular perfusion, and this is referred to as "no-reflow". Various treatments have been studied with variable success in both prevention and treatment of no reflow. Areas covered: This review outlines the cutting-edge diagnostic investigations which have been explored in no reflow, allowing a deeper understanding of mechanism and microvascular pathological processes involved in its genesis. These include utility of novel MRI techniques and perfusion echo in conjunction with traditional approaches. Detailed review has been undertaken of both pharmacological and non-pharmacological techniques to prevent and manage microvascular dysfunction associated with no reflow. Particular attention was payed to the evolution and successes of various mechanical protection devices. Expert review: Most promising innovations in the diagnosis and management of no reflow are evaluated, and future outlook is explored. Emerging advances in acute coronary syndrome have their findings applied a role in modifying the pathophysiology of no reflow.

Aim The objective of this study was to define the patient demographics, periprocedural characteri... more Aim The objective of this study was to define the patient demographics, periprocedural characteristics and mid to long term outcomes associated with rotational atherectomy in modern clinical practice in Ireland. Methods We performed a retrospective analysis of all patients who underwent rotational atherectomy in two Irish centres. Data on all patients was collected from the electronic patient records system. Baseline characteristics were collected for all patients. This included demographic and procedural characteristics. Demographic characteristics included age, co-morbidities, medications and presentation. Long term follow up was obtained at 3 and 12 months to assess clinical response. NYHA functional class and CCS angina scores were evaluated at 3 months and 12 months post procedure. 66 cases were identified over the study period and a database of patients was produced. Results 66% of patients were male. Mean age was 72±8.12 years (Range 54–86 years). 90.6% of our patients were hypertensive, 32.3% were diabetic. 28.33% had CKD and 96.88% had hypercholesterolaemia. 44% were current smokers, 35.6% never smokers and 20.33% ex-smokers. Mean weight was 79.66±17.67 kg (Range 42.6–124 kg) and mean creatinine was 104.77±70.03 (Range 56–398). 40.6% of patients had previous PCI, 31.25% had previous failed attempts at PCI and 15.625% had previously had coronary artery bypass grafting. 98.5% of patients were on Aspirin and 92.3% were on a second antiplatelet agent. Periprocedural complications were detailed for all procedures based on pre-specified criteria. The most common complications reported were coronary artery dissection (9.09%) and bleeding (9.2%). 2 patients required dialysis post procedure (3.03%), 1 patient required emergency CABG (1.5%) and 1 patient suffered cardiac death (1.5%). Coronary artery rupture and cardiac tamponade did not occur in any cases. We also analysed for any association between outcomes and categorical variables. These included burr size, femoral vs radial access and age (Over/Under 75). We found no statistically significant difference between complication rates between cases with burr size 1.25 mm and cases using burr size of over 1.25 mm (18.4% vs 10%, p=0.33). Similarly complication rates were not significantly different for radial versus femoral access (23.5% vs 23.9%, p=0.974) and age over/under 75 (17.8% vs 28%, p=0.900919) Patients were assessed at 3 months and 12 months to assess clinical status post rotational atherectomy. Canadian cardiovascular society grading of angina pectoris and New York heart association functional scores were utilised. Mean CCS score at 3 months was 0.26±0.77 (Range 0–3) and this persisted out until 12 months (0.25±0.657). NYHA score at 3 months was 0.5±0.993 and again, this persisted until 12 months (0.457±0.816), indicating that the clinical benefit of rotational atherectomy is maintained until 1 year post procedure. Conclusions Whilst less commonly used in modern day intervention, rotational atherectomy still has a role in the drug eluting stent era to modify heavily calcified plaque. The risk of MACEs remains higher than conventional PCI, reflecting the complexity of the disease and increased procedural technical difficulty.

Interventional Cardiology Review, 2018

Transcatheter aortic valve implantation (TAVI) is the treatment of choice in patients with sympto... more Transcatheter aortic valve implantation (TAVI) is the treatment of choice in patients with symptomatic severe aortic stenosis who are either inoperable or at high risk for conventional surgical aortic valve replacement. Recent data have also shown favourable outcomes in patients deemed to be at intermediate operative risk, which expands the application of this novel technology. Despite its success, TAVI has been associated with rare life-threatening complications. Of these, aortic annular rupture is considered to be the most devastating. Advances in pre-procedural screening and patient selection have reduced the incidence of annular rupture. When this complication occurs, early recognition and prompt management are essential. This article is intended to provide a comprehensive review of the predictors, management and clinical outcomes of aortic annular rupture.

Open heart, May 1, 2022

⇒ We suggest that this justifies performing troponin T sampling at 24-48 hours post-admission as ... more ⇒ We suggest that this justifies performing troponin T sampling at 24-48 hours post-admission as an effective non-invasive method for stratifying patients' risk of mortality and ventricular dysfunction.

$Research paper thumbnail of SGLT2i uptake among heart failure patients with reduced ejection fraction: ongoing prescriber hesitancy and how to address this$

European Heart Journal, Oct 1, 2022

Background: The evidence of mortality benefit from sodium-glucose transport protein 2 inhibitors ... more Background: The evidence of mortality benefit from sodium-glucose transport protein 2 inhibitors (SGLT2i) in the management of heart failure with reduced ejection fraction (HFrEF) has been observed since 2019. Its first-line use in HFrEF, regardless of diabetes status, has been recommended by The European Society of Cardiology (ESC) since September 2021. Yet prescriber hesitancy surrounding SGLT2i use is still an under investigated issue resulting in centres falling short of gold-standard care. A simple review of pharmacotherapy pattern can alert clinicians to under prescribing of SGLT2i inhibitors and respond by improving adherence to guidelines. Purpose: To describe the pharmacotherapy pattern of HFrEF patients attending an outpatient (Heart Failure Support Unit) HFSU in Ireland. Methods: A retrospective analysis was performed in HFrEF patients actively attending the HFSU. Active attendance was considered a single engagement with the service between 1st January 2021 and 31st December 2021, and patients who have not died, been transferred to another service, or loss to follow-up. Information collected from digital records included patient demographic, comorbidities, baseline investigations, and pharmacotherapy pattern. Sensitivity analysis was performed for patients with type 2 diabetes (T2DM). Results: 156 HFrEF patients were actively attending the HFSU. The mean age was 72.1 (±12.5) years and majority were male 114 (73.1%). The following pharmacotherapy pattern was revealed: angiotensin-converting enzyme inhibitors/ angiotensin II receptor blockers (ACEi/ARBs) 80 (51.3%), ARNi 55 (35.3%), β-blockers 142 (91.0%), mineralocorticoid receptor antagonist (MRA) 58 (37.2%), SGLT2i 9 (5.8%) and Ivabradine 9 (5.8%). Sensitivity analysis for T2DM patients (n=45) reveals a pattern of ACEi/ARBs 46.7%, ARNi 37.8%, β-blockers 95.6%, MRA 42.2%, SGLT2i 20.0% and Ivabradine 8.9%. All 9 instances of SGLT2i use were in T2DM patients. Since identification of SGLT2i under-prescribing, an interim review on 28th February 2022 revealed that total SGLT2i prescription had increased by 19 (211.1%), all of which were outside the T2DM population. Conclusions: SGLT2i is still under prescribed for HFrEF management and prescriptions have the tendency to be restricted to T2DM patients. Identification of pharmacotherapy pattern can alert clinicians to prescriber hesitancy and increase new SGLT2i prescriptions outside the T2DM population.

Ireland benefits from a highly functioning primary percutaneous coronary intervention (PPCI) prog... more Ireland benefits from a highly functioning primary percutaneous coronary intervention (PPCI) programmes, but despite this STEMI is still associated with significant morbidity and mortality. The European Society of Cardiology updated the STEMI guidelines in 2017, and with them introduced a novel metric relating to STEMI patients: ‘total ischaemic time’. This time-period starts at the onset of chest pain and ends at wire cross, and it is thought to accurately reflect burden of myocardial destruction. The guidelines also introduce striker guidance on timelines, in order to minimise systemic delay. This study aimed to assess the total ischaemic time of patients presenting with STEMI in an Irish tertiary referral centre and the factors influencing delays in presentation and treatment. Methods Prospective cohort analysis was conducted on all patients presenting to University Hospital Limerick with STEMI from October 2017 to January 2019. Patients were included if they had a culprit lesion that was successfully revascularized. Baseline demographics were recorded at time of presentation. Bayesian statistics were employed to conduct the analysis. Results 158 patients were recruited. Mean age was 61(range29–96). Male:female ratio 5:1 in this cohort. Average total ischaemic time was 409.4 mins±501.4. The average time from chest pain to ‘call for help’ (i.e. patient delay) was 208.3 mins±397.8, which represented 50.89% of the total ischaemic time (See figure 1). The average time from ‘call for help’ to first medical contact (FMC) was 18.4 mins±30.07. Average time from FMC to ECG was 44.9 mins±151.16, and was dependent upon type of FMC (Primary care 127 mins vs paramedic 25 mins p=0.030932). After FMC, 48.7% of patients had an ECG performed in under 10 mins as per guidelines. After ECG was performed, 46.4% of patients had ECG to ‘wire cross’ time under 90 mins as per guidelines; 65.8% were within 120 mins and 91.4% were within 180 mins. Those presenting to their general practitioner as FMC were significantly less likely to have both an ECG in <10 mins (NNH 2.84 95%CI 1.79–6.91) and ECG to wire time of <90 mins (NNH 6.13 95%CI 2.88–48.70). As age increased, so too did total ischaemic time (Pearson R=0.164, p=0.043), which was dependent on increasing patient delay with age (Pearson R=0.2181, p=0.0066). Women had a higher total ischaemic time than men (546 vs 382 mins p=0.0233). This was determined to be as a result of: a numerically higher patient delay (220 vs 206 mins, p=0.214) and women having a longer time from FMC to ECG (104 mins vs 34 mins, p=0.0021).Abstract 29 Figure 1 Ischaemic time and delays Ischaemic time and delays Conclusion Over 50% of the total ischaemic time was before patients called for help, suggesting a role for cardiovascular awareness programmes. Increasing age was associated with longer patient delay, indicating a need for directed awareness in this demographic. Women had a higher total ischaemic time, and waited a significantly longer time for ECG following FMC; highlighting the need for awareness amongst healthcare professionals of atypical clinical features associated with STEMI in women. Patients who attended their GP waited longer for an ECG and, once performed, were less likely to be revascularised within 90 mins.

Mesentery and Peritoneum

Background: Basic cardiac echocardiography (ECHO) has become a core skill for intensive care medi... more Background: Basic cardiac echocardiography (ECHO) has become a core skill for intensive care medicine (ICM) trainees. The Joint Faculty of Intensive Care Medicine in Ireland (JFICMI) recognizes the Focused UltraSound in Intensive Care (FUSIC) programme of the Intensive Care Society (ICS) and the British Society of Echocardiography (BSE) as a framework for basic cardiac ECHO training. At present, the FUSIC programme is offered in a number of Irish ICM training centres including, University Hospital Limerick (UHL). Cardiologists and cardiac physiologists are central to the running of our basic cardiac ECHO programme. This is supported by the 2021 University of Limerick Hospitals Group ICU JFICMI Inspection report which made a 0.5 working time equivalent (WTE) cardiac physiologist recommendation to support ongoing FUSIC Heart training. Currently, this role in UHL is present in an informal capacity only. Methods: Underscoring the FUSIC Heart programme is deliberate practice of image acquisition techniques with expert feedback. In UHL, supervised scans are undertaken in fortnightly group sessions, run by approved FUSIC mentors with a 1-2 learners per mentor ratio. These group sessions involve both ICM and cardiology trainees, mentors and a supervisor when available. De-identified unsupervised scans are self-directed by the trainee and sent to mentors for appraisal. Both ICM & cardiology trainees informally team up for unsupervised scans to assist in highlighting suitable candidates & good learning opportunities. Several different models of ECHO machines exist UHL and consequently different scan formats. Thus, management of these images provides many challenges. Results: The integration of cardiology & ICM trainees, mentors and supervisors has several benefits. Firstly, cardiology supervision provides high level expertise for the acquisition and management of basic cardia ECHO images. Group learning sessions foster good working relationships and an appreciation for the perspective of other specialities. Conclusions: Cardiologist and cardiac physiologist support, supervision & input in basic ECHO training is invaluable and benefits both ICM and cardiology trainees. We recommend formalization of these roles in UHL.