Spontaneous Coronary Artery Dissection Prevalence of Predisposing Conditions Including Fibromuscular Dysplasia in a Tertiary Center Cohort

ObjectivesWe sought to evaluate the prevalence of fibromuscular dysplasia (FMD) and other predisposing conditions among spontaneous coronary artery dissection (SCAD) patients.BackgroundSpontaneous coronary artery dissection is considered rare. However, we observed many young women with SCAD and concomitant FMD.MethodsSpontaneous coronary artery dissection patients were identified prospectively and retrospectively at Vancouver General Hospital over the past 6 years. Coronary angiograms were meticulously reviewed by 2 senior interventional cardiologists. Identified patients were contacted for prospective evaluation at our SCAD clinic, and screening for FMD of renal, iliac, and cerebrovascular arteries was performed with computed tomography angiography or magnetic resonance angiography, if not already screened during the index angiogram. Potential predisposing and precipitating conditions for SCAD were extracted from clinical history.ResultsWe identified 50 patients with nonatherosclerotic SCAD from April 2006 to March 2012. Average age was 51.0 years, and almost all were women (98.0%). All presented with myocardial infarction (MI), 30.0% had ST-segment elevation, and 70.0% had non–ST-segment elevation MI. Only 1 was postpartum, and 2 were involved in intense isometric exercises. Emotional stress was reported in 26.0% before the MI. Twelve percent had >1 dissected coronary artery. Most SCAD patients had FMD of ≥1 noncoronary territory (86.0%): 25 of 43 (58.1%) renal, 21 of 43 (48.8%) iliac, and 20 of 43 (46.5%) cerebrovascular (6 of 43, 14.0% had intracranial aneurysm). Five had incomplete FMD screening.ConclusionsNonatherosclerotic SCAD predominantly affects women, and most have concomitant FMD. We suspect these patients have underlying coronary FMD that predisposed them to SCAD, but this requires proof from histology or intracoronary imaging of the affected coronary arteries

Cardiac CT angiography after percutaneous left atrial appendage closure: early versus delayed scanning after contrast administration

PURPOSECardiac computed tomography angiography (CCTA) is increasingly used for device surveillance after left atrial appendage closure (LAAC). While CT protocols with delayed scans are useful to diagnose thrombus in the LAA, an optimal protocol for post-procedural CCTA has not been established. Therefore, we assessed the role of delayed versus early scans for device surveillance.METHODSWe retrospectively reviewed patients who underwent LAAC at Vancouver General Hospital who had follow-up CCTAs using standard (early) and delayed scans. Scans were performed on Toshiba 320-detector (Aquilion ONE). Image quality was interpreted by 2 independent observers for anatomy, LAA contrast patency, and device-related thrombus (DRT) using VitreaWorkstationTM. A Likert scale of 1–5 was used (1= poor quality, 5= excellent) for assessment.RESULTSWe included 27 consecutive LAAC patients (9 Amplatzer, 18 WATCHMAN) with mean age 76.0±7.7 years, mean CHADS2 score 2.8±1.3, CHA2DS2-VASc score 4.4±1.6 and HAS-BLED score 3.4±1.0. Subjective quality assessments by both reviewers favored early scans for assessment of anatomy (reviewer 1: 4.63±0.63 [early] vs. 1.74±0.71 [delayed]; reviewer 2: 4.63±0.63 [early] vs. 1.89±0.64 [delayed]) and DRT (reviewer 1: 4.78±0.42 [early] vs. 3.11±1.16 [delayed]; reviewer 2: 4.70±0.47 [early] vs. 3.04±1.29 [delayed]). Inter-rater variability showed good correlation between reviewers (intraclass correlation 0.61–0.95). Mean LAA/LA attenuation ratios were significantly different between scans, with larger mean percent reduction of contrast opacification from LA to LAA in the early scans (57.0±36.6% reduction for early vs. 29.1±30.8% for delayed; p < 0.001)CONCLUSIONFor CT device surveillance post-LAAC early phase imaging provides superior image quality objectively and subjectively compared with delayed scanning

TCT-48: Medical therapy and clinical outcomes with spontaneous coronary artery dissection

Background Conservative management is currently the preferred therapy for patients with spontaneous coronary artery dissection (SCAD). However, the optimal medical regime remains controversial. Our objective is to evaluate the use of cardiac medications in contemporary clinical management of SCAD, and their potential association with clinical outcomes. Methods We reviewed non-atherosclerotic SCAD patients who were prospectively followed at the Vancouver General Hospital SCAD clinic, and enrolled in our SCAD registries. Baseline characteristics, medications on admission, discharge, and follow-up were examined. Major adverse cardiac events (MACE) at follow-up were recorded and included repeat MI, death, stroke/TIA. Results We prospectively followed 286 consecutive SCAD patients. Mean age was 52.5±9.4 years, and most were women (90.2%). All presented with myocardial infarction (MI). After an acute event, patients were discharged on aspirin (93.7%), P2Y12 inhibitor (64.5%, predominantly clopidogrel), beta-blocker (BB) (82.8%), angiotensin-converting-enzyme inhibitors or angiotensin-II-receptor blocker (RAAS) (53.5%), calcium channel blocker (CCB) (15.7%), and statin (52.9%). There were 195 patients followed for at least 1 year. At 1 year, the majority remained on aspirin (92.8%) and BB (75.4%), but there were lower usage of RAAS (47.7%), statin (40.0%), P2Y12 inhibitor (26.7%), and CCB (19%). The overall median follow-up was 3.1 (IQR 2.0-5.7yr) and MACE was 20.5%. The use of CCB at last follow-up was associated with higher incidence of repeat MI (29.7% vs. 15.2%, p=0.038), and the use of BB at last follow-up was associated with a trend to lower incidence of repeat MI (15.0% vs. 27.1%, p=0.058). Conclusion Our observational data showed that aspirin and BB were commonly used for SCAD management. Patients on CCB appeared to have higher repeat MI at long-term follow-up. Whereas, BB was associated with a trend in reduction of repeat MI. Future studies are warranted to assess the relationship between medications and outcomes in SCAD patients

Outcomes of Percutaneous Coronary Intervention in Patients with Spontaneous Coronary Artery Dissection

Objectives. To compare outcomes of percutaneous coronary intervention (PCI) in spontaneous coronary artery dissection (SCAD) patients versus conservative therapy. Background. SCAD is an important cause of myocardial infarction (MI) in young-to-middle-aged women. Percutaneous coronary intervention (PCI) is often pursued, but outcomes compared to conservative therapy are unclear. Methods. 403 nonatherosclerotic SCAD patients were enrolled between 2011 and 2017 and prospectively followed up in our Vancouver General Hospital registries. Detailed baseline, hospital, PCI, and outcomes were recorded. We explored the outcomes of SCAD patients who underwent PCI during their initial presentation. Results. PCI was performed in 75 patients, the average age was 48.9 ± 10.1 yrs, and 94.7% were women. All presented with MI; 50.7% STEMI, 49.3% NSTEMI, and 13.3% had VT/VF. PCI was successful in 34.7%, partially successful in 37.3%, and unsuccessful in 28.0%. Stents were deployed in 73.3%, 16.0% had balloon angioplasty alone, 10.7% had wiring attempts only, and 5.3% required bailout surgery. Major adverse cardiovascular event rates (MACE) were significantly higher with the PCI group in hospital (29.3% versus 2.8%, p<0.001), and at median follow-up of 3.7 yrs (58.7% versus 22.6% (p<0.001) compared to the non-PCI group. Conclusion. PCI in SCAD patients was associated with high failure rate and MACE in hospital and at long-term follow-up. These findings support the recommendation of conservative therapy as first-line management unless high-risk features are present