SimplePhysiology is co-ordinated by a team of Cardiologists at Imperial College London and the Hammersmith Hospital. Combining skills in medicine, research, engineering and computing, the team are the cutting edge of invasive coronary research. Working together with the IDEAL Collaborators (Iberian-Dutch-English), the team have international reputation and great experience in delving deep into the field of coronary physiology.
Meet the team
Iqbal Malik is an Honorary Senior lecturer at Imperial College London, and Consultant Interventional Cardiologist at Hammersmith and St Mary’s Hospitals. His research interests are in complex coronary disease and structural heart disease.
He qualified from Cambridge University with a 1st Class degree, and then moved to Guys Hospital, London, winning the Golding Bird Medal as an undergraduate. He trained in Medicine and then Cardiology, before completing a PhD at Imperial College London, looking at the role of Inflammation in Coronary Artery Disease. He was awarded a BHF junior research fellowship for 3 years.
He was appointed as a Consultant in 2003, having completed sabbaticals in Italy and Germany to hone his skills in Structural Heart Disease. He is clinical lead for the care of acute coronary syndromes and Structural Heart Disease at Imperial College Healthcare NHS trust, including the Transcatheter Valve (TAVI) and Septal Defect Closure programs.
He has been involved with Simplephysiology since the inception of the concept of iFR as a way to simplify the use of coronary physiological assessment. His meticulous verification of data with the more complex technique of coronary flow measurement, has allowed validation of the science behind iFR. Starting from normal arteries, simple and complex native coronary lesions, and bypass grafts, the group has now studied the effects of hemodynamic support device such as balloon pumps and Impella devices on coronary physiology. Next is the unique opportunity to assess the effect of immediate removal of aortic stenosis using TAVI!
He enjoys teaching both his juniors and his peers, via lectures, recorded sessions, and live cases. See him again “Live at the Hammersmith”.
Rasha Al-Lamee is an Interventional Cardiologist and Clinical Research Fellow working at Imperial College Healthcare NHS Trust in London (UK) and the National Heart and Lung Institute, Imperial College London.
Rasha studied Medicine at Oxford University and University College London and graduated in 2002 with Honours. She completed the Barts and the London general medical rotation and went onto to be appointed as a Cardiology Specialist Registrar on the North West London training rotation.
She was trained in Interventional Cardiology at the Hammersmith Hospital and completed an international fellowship at San Rafaelle Scientific Institute and Columbus Hospital, Milan, under the mentorship of Professor Antonio Colombo from 2009 to 2010. She obtained the Certificate of Completion of Training in cardiology in 2013.
Her interests are complex coronary intervention and the percutaneous treatment of structural heart disease. She is trained in intravascular imaging and physiology and has a number of peer-reviewed publications in Interventional Cardiology.
For her PhD at Imperial College London, Rasha is leading the ground breaking ORBITA study. This is the first double-blinded randomised sham-controlled trial of stable angina. ORBITA will answer one of the most important unanswered questions in Interventional Cardiology: does coronary angioplasty improve the functional capacity of patients with stable angina?
Dr Sayan Sen is a Cardiologist and NIHR Clinical Lecturer at Imperial College London.
His research interests are dedicated to improving patient care. As such, they include the development and validation of new diagnostic tools, determining how the design of comparative efficacy studies can affect clinical use of competing therapies and the development and application of tools that permit a more patient centered approach to therapy.
He studied Medicine at University College London (UCL), achieving a First Class (Honours) Bachelor of Science degree in Medical Sciences & Neuroscience in 2000 and graduated with distinction (Surgery) in his final MBBS Examinations in 2003. He trained as a junior doctor on the Hammersmith and UCL medical rotations prior to being appointed as a Cardiology Specialist Registrar in the North West London region in April 2006 and a NIHR clinical Lecturer in 2013.
In 2009, he was awarded the prestigious MRC Clinical Research Training Fellowship to study the haemodynamic changes in coronary artery bypass grafts, diseased coronary arteries and the haemodynamic changes associated with percutaneous aortic valve insertion. His work involves close collaboration with the bioengineering department at Imperial College and the MRC Clinical Sciences Centre. His research has been presented at the leading cardiology conferences around the world.
One of the themes of his research is to determine the need for potent vasodilators when assessing coronary stenosis severity. Working with Dr Justin Davies, Dr Sen’s PhD introduced and developed a new technique of stenosis evaluation (the instantaneous wave-free ratio, iFR). He is the first author of ADVISE and CLARIFY – two investigator lead studies that demonstrate the potential of iFR and challenge current concepts of coronary physiology.
Currently, in addition to being the Principal Investigator of several first in man physiological studies, he is also the Medical Director of the FLAIR trial – a global multi-centre randomized study comparing iFR to existing techniques.
Dr Sen’s most recent academic awards include the Royal Society of Medicine Investigator of the Year Award (All Sections, 2013), the Royal Society of Medicine President’s Gold Medal (Cardiology section, 2013), the prestigious Imperial College Armstrong Medal and Prize (2012), the Young Investigator Award at the British Cardiac Intervention Society Advanced Coronary Intervention meeting (2012), and the Young Investigator Prize at the Translating Coronary Physiology and Biophysics to Clinical Applications Symposium, Amsterdam (2010). He was shortlisted as a Young Investigator Finalist at the British Hypertension Society and Artery meetings (2010).
Dr Ricardo Petraco is a Cardiology Specialist Registrar and a Research Fellow at the International Centre for Circulatory Health and National Heart and Lung Institute at Imperial College London.
Dr Petraco graduated from The Federal Faculty of Medical Sciences (FFFCMPA) and undertook his junior General Medical Training at the Santa Casa University Hospital in Porto Alegre, Brazil. He came to the UK in 2006 to start his higher specialist training in Cardiology.
Throughout his career, Dr Petraco has been a high achiever on clinical and academic grounds. As an undergraduate, he was awarded two Scientific Initiation Scholarships by the National Research and Technology Council (CNPq, Brazil). In the UK, he worked as a junior Research Fellow at the Royal Brompton Hospital, in the Adult Congenital Heart Unit under Professor Gatzoulis. He helped to identify markers of poor prognosis in adult patients with congenital heart disease. After passing his membership examination (MRCP UK), he started clinical work as a Specialist Registrar in Cardiology at the Royal Brompton and St Mary’s Hospitals.
He has completed his PhD in the pathophysiology of coronary artery disease, coronary haemodynamics and myocardial ischaemia.
Dr Sukhjinder Nijjer is an Interventional Cardiology Registrar and NIHR Academic Clinical Fellow at the Hammersmith Hospital. He has completed his PhD with the support of the highly prestigious Medical Research Council Clinical Research Fellowship at the National Heart and Lung Institute, Imperial College.
He graduated from University of Bristol with 15 distinctions, two scholarships and many prizes including the Romeo Vecht Prize in Cardiology and the Hans Heller Memorial Prize for his intercalated BSc. He is the author of many peer-reviewed publications and text books and has presented at major international conferences, winning prizes at TCT-AP. Most recently he has been runner-up for Young Investigator of the Year competitions held by the Academy of Medical Sciences, Royal Society of Medicine and the British Cardiovascular Intervention Society.
His particular interest in coronary physiology has been how it can help guide coronary intervention, not only identifying ischaemia but also specifying the value of treating an individual stenosis. Sukhjinder has used a combination of pressure and flow velocity data to describe the changes in both flow and pressure after stenting. Together with the results of largest human coronary pressure-flow library and with the application of computer flow dynamics from highly detailed 3D OCT reconstructions of of coronary vessels, Sukhjinder has worked to develop models that can predict the haemodynamic effects of stenting. His work on iFR, iFR-Pullback and Virtual-PCI represents a tangible result, and this simple approach to pressure wire assessment enables the prediction of the physiological results of stenting and trialling different stenting approaches before they are performed in the real world. Such an advance has potential in changing the way coronary intervention is performed.
Dr Justin Davies is a leading clinical academic in the field of interventional cardiology. Based as a consultant interventional cardiologist at Hammersmith Hospital, part of Imperial College Healthcare NHS Trust London, he has pioneered the development of several new clinical techniques from bench top to the clinical catheter laboratory. Most recently these technological breakthroughs include iFR (instant wave-free ratio) and iFR SCOUT both of which make use of a better understanding of coronary haemodynamics. Together with improved sensor and microprocessor technology, iFR allow for the first time the evaluation of the severity of a coronary stenosis without the need for administration of powerful vasodilator drugs.
Although currently a practicing interventional consultant cardiologist, Justin’s science training was a doctorate in fluid dynamics and computational programming. This led to the development of analysis techniques such as coronary wave intensity analysis and the wave-reservoir theory both of which are increasingly used in research studies. In his post-doctoral days he has continued to work on the development of mathematical algorithms to aid understanding of large artery physiology and to develop new tools to assess arterial disease.
The holder of 15 patents, he has published widely in the field of hypertension, coronary and large artery physiology and is the winner of many national and international awards. He has several international collaborations, and is the developer of iFR and the co-principal investigator of the ADVISE studies, the DEFINE-FLAIR, and ORBITA studies. Justin has an interest in renal denervation, and has lead first-in-man studies to evaluate the safety of this technique to patients with chronic systolic heart failure (REACH studies) and hypertension.
In these pages, we reflect on the latest evidence supporting the use of the resting physiology to interrogate coronary stenoses and determine if they will benefit from revascularisation.
Measuring functional gain after PCI
Advise in Practice
Using iFR in Clinical Practice
Calculation of iFR and the Wave-free Period
Why is basal flow so ideal for coronary stenosis assessment?
Why do we measure pressure instead of flow?
Glossary and Definitions of Physiological Indices
Measuring iFR – Pitfalls and Techniques
Using iFR and FFR together in a Hybrid approach
Prospective data from South Korea
New-novel non-hyperaemic indices Basal Stenosis Resistance (BSR) and Instant wave-free ratio (iFR)
Pressure gradient assessment: an historical perspective
Regulation of Coronary Blood Flow
Background of coronary flow
Significant advances are being made with detailed pressure and flow studies to explain why indices may differ. Furthermore there have been advances in both pressure wire techniques and computation that allow new approaches such as iFR Pullback.
The JUSTIFY Family of studies assesses the relationship between pressure and flow velocity in patients undergoing physiological assessment in the cath lab. In the JUSTIFY-CFR paper, we assess which pressure index, iFR or FFR is most closely related to flow in humans.
The development of iFR-Pullback with Virtual PCI is potentially a huge boost for physiology in the catheter lab. Not only can stenoses be specifically assessed and quantified, but it is possible to predict the result of PCI.
The iFR Pullback paper is available here.
The following clinical trials are underway to assess the role of resting physiology using parameters such as iFR in modern practice.
SYNTAX II embraces the Hybrid iFR-FFR approach to offer revascularisation to physiologically significant stenoses. Patients in equipoise between surgery (CABG) and PCI according to the SYNTAX-II Score and a Heart Team decision, will undergo complete revascularisation to all ischaemia causing lesions. By using the Hybrid approach, unto 60% of patients will be spared adenosine. Stents will be optimised by IVUS according to the MUSIC criteria.
This study will enroll 900 patients with acute coronary syndrome from over 20 hospitals in Sweden, Denmark and Norway as part of the SCAAR program. Patients will have IVUS and NIRS performed in the culprit vessel and successful PCI will be deemed physiologically, using iFR or FFR. Patients will then be enrolled into the study and have IVUS and blinded NIRS of all three vessels with an aim to detect vessels and plaque that may rupture and drive future events.
Join us and an International Faculty to discuss the evidence and share experience in the use of coronary physiology for improving patient outcomes. We discuss FFR, iFR, CFR and the other flow based parameters, how they relate and how you can use them in your practice.
To view the latest dates and scheduled programmes please Register with the SimplePhysiology website to view the details.
Click here to see the courses available in the UK and the USA.
For more information please use the contact form HERE.
Course Dates for 2015 – United States of America
13th January 2015With an international faculty of experts, join us in the United States to learn about the impact coronary physiology can have on your practice.
Course Dates for 2015 – Great Britain
13th January 2015With an international faculty, including the IDEAL investigators and specialists in Intervention and Coronary Physiology, we aim to cover a wide-range of physiological concepts including new developin...
We regularly perform live case presentations with transmissions from the
Hammersmith Hospital Catheter Laboratories.
Choose to view some recent cases by clicking below.
Introducing iFR-Scout to Japan
Broadcast to Japan with guest faculty, Hitoshi Matsuo MD from the GIFU Heart Centre, we look the newly available iFR-Scout system, which utilises iFR-Pullback technology. Use it to estimate the functional gain from treating a specific stenosis and plan intervention in diffuse and tandem disease.
iFR physiological mapping with iFR Scout
We frequently perform live case transmissions which are available by online streaming. Here is a recent transmission of a typical physiological case which utilises iFR Scout, a clinical application of the iFR-Pullback technology.
SYNTAX II Case with Dr David Kandzari
Watch Dr Justin Davies, Dr Iqbal Malik and Dr David Kandzari from the Piedmont Heart Institute perform three vessel assessment as part of the SYNTAX II study. This case involves the use of both iFR and IVUS co-registration in complex disease.
Live from the Hammersmith
In this live case, recorded as part of the Live from the Hammersmith programme co-ordinated with Radcliffe Cardiology, Dr Justin Davies and Dr Sayan Sen tackle physiological assessment in three vessel disease using Fractional Flow Reserve. Dr Davies covers both didactic core material as well as demonstrating how to practically perform physiological measurements.
We encounter challenging cases every day and live cases are no different! The advantage of smaller meetings is that we can have an open forum to discuss these challenges and gain real insight into what the experts really think. Dr Sukhjinder Nijjer and Dr Javier Escaned talk directly to the audience to discuss the findings of an interesting physiological case in which no treatment option was going to be easy.
Cath lab team directly interact with the audience
Every course has a live case transmission with direct communication between the audience and the operators. Take part in the debate on how to assess and treat whilst observing cutting edge new technology.
Live case transmissions during the course
The course is open for any question and active debate is encouraged. Open debate leads to an improvement in knowledge and greater understanding in complex areas. Dr Javier Escaned discusses the merits of pressure only technology while Professor Jan Piek explains the discrepancy between pressure and flow.
Expect debates and reassessment of established dogma
Dr Javier Escaned has huge international reputation in the field of coronary physiology. An author of the FAME studies, Javier has combined angiographic assessment with pressure based physiological assessment as well as thermodilution CFR and microvascular resistance. Understand how hyperaemia increases flow in predominantly non-significant stenoses. Using multimedia presentations, didactic materials and the old fashioned flip chart, nothing is off-limits.
Javier Escaned talks about first principles in physiology
Professor Jan Piek is an expert in the measurement of coronary flow and was involved the development of HSR and BSR, key indices for assessing stenosis severity. He has pioneered the field of coronary physiology and is a greater speaker, providing a historical perspective of how we moved from the measurement of flow, to pressure and back again.
Jan Piek gives a masterclass in understanding coronary flow
News in Physiology
In this section we will provide a forum to discuss the latest news and developments in coronary physiology. We will discuss recent papers and trials and provide view points and practical perspectives.
DEFINE-FLAIR now HALF-WAY through enrolment
17th February 2015UPDATED 17-2-15: DEFINE-FLAIR has now reached 50% of patient enrolment! Recruitment rates accelerating . This is a great achievement, and together with the global nature of patient enrolment we hope t...
DEFINE-FLAIR a truly global study
17th February 2015The DEFINE-FLAIR study has over 5o enrolling centres from all over the world, including England, main-land Europe, the United States, Japan, Korea and Australia. We also welcome the addition of Saudi...
DEFINE FLAIR reaches over 1000 patients recruited
9th February 2015Recruitment for the DEFINE FLAIR Study is continuing at a high pace. With over 50 recruiting centres world wide, we have now over 1000 patients recruited into the study. This is already larger than ...