Andrew Starovoytov

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

OBJECTIVES We sought to evaluate the prevalence of fibromuscular dysplasia (FMD) and other predisposing conditions among spontaneous coronary artery dissection (SCAD) patients. BACKGROUND Spontaneous coronary artery dissection is considered rare. However, we observed many young women with SCAD and concomitant FMD. METHODS Spontaneous 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. RESULTS We 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. CONCLUSIONS Nonatherosclerotic 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.

Spontaneous Coronary Artery Dissection Association With Predisposing Arteriopathies and Precipitating Stressors and Cardiovascular Outcomes

Background—Nonatherosclerotic spontaneous coronary artery dissection (NA-SCAD) is underdiagnosed and an important cause of myocardial infarction in young women. The frequency of predisposing and precipitating conditions and cardiovascular outcomes remains poorly described. Methods and Results—Patients with NA-SCAD prospectively evaluated (retrospectively or prospectively identified) at Vancouver General Hospital were included. Angiographic SCAD diagnosis was confirmed by 2 experienced interventional cardiologists and categorized as type 1 (multiple lumen), 2 (diffuse stenosis), or 3 (mimic atherosclerosis). Fibromuscular dysplasia screening of renal, iliac, and cerebrovascular arteries were performed with angiography or computed tomographic angiography/MR angiography. Baseline, predisposing and precipitating conditions, angiographic, revascularization, in-hospital, and long-term events were recorded. We prospectively evaluated 168 patients with NA-SCAD. Average age was 52.1±9.2 years, 92.3% were women (62.3% postmenopausal). All presented with myocardial infarction. ECG showed ST-segment elevation in 26.1%, and 3.6% had ventricular tachycardia/ventricular fibrillation arrest. Fibromuscular dysplasia was diagnosed in 72.0%. Precipitating emotional or physical stress was reported in 56.5%. Majority had type 2 angiographic SCAD (67.0%), only 29.1% had type 1, and 3.9% had type 3. The majority (134/168) were initially treated conservatively. Overall, 6 of 168 patients had coronary artery bypass surgery and 33 of 168 had percutaneous coronary intervention in-hospital. Of those treated conservatively (n=134), 3 required revascularization for SCAD extension, and all 79 who had repeat angiogram ≥26 days later had spontaneous healing. Two-year major adverse cardiac events were 16.9% (retrospectively identified group) and 10.4% (prospectively identified group). Recurrent SCAD occurred in 13.1%. Conclusions—Majority of patients with NA-SCAD had fibromuscular dysplasia and type 2 angiographic SCAD. Conservative therapy was associated with spontaneous healing. NA-SCAD survivors are at risk for recurrent cardiovascular events, including recurrent SCAD.

Abbreviated Infusion of Eptifibatide After Successful Coronary Intervention : The BRIEF-PCI (Brief Infusion of Eptifibatide Following Percutaneous Coronary Intervention) Randomized Trial

OBJECTIVES The purpose of this study was to assess whether the early discontinuation of eptifibatide infusion in nonemergent percutaneous coronary intervention (PCI) is associated with a higher frequency of periprocedural ischemic myonecrosis. BACKGROUND The recommended regimen for eptifibatide is a double bolus followed by an infusion for 18 h. It is not known whether the infusion can be shortened if the PCI is uncomplicated. METHODS We enrolled 624 patients with stable angina, acute coronary syndrome, or recent ST-segment elevation myocardial infarction (>48 h) who underwent successful coronary stenting and received eptifibatide. Patients were randomly assigned to receive either an 18-h infusion or an abbreviated infusion of <2 h. The primary end point was the incidence of periprocedural myonecrosis defined as troponin-I elevation >0.26 microg/l. Secondary end points included death, myocardial infarction, urgent target vessel revascularization at 30 days, and in-hospital major bleeding using the REPLACE-2 (Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events) trial criteria. RESULTS The incidence of periprocedural myonecrosis was 30.1% in the <2-h group versus 28.3% in the 18-h group (mean difference: 1.8%; upper bound of 95% confidence interval: 7.8%; p < 0.012 for noninferiority). The 30-day incidence of myocardial infarction, death, and target vessel revascularization was similar in both groups (p = NS). Major bleeding was less frequent in the <2-h group (1.0% vs. 4.2%, p = 0.02). CONCLUSIONS After uncomplicated PCI, eptifibatide infusion can be abbreviated safely to <2 h. It is not inferior to the standard 18-h infusion in preventing ischemic outcome, and it may be associated with less major bleeding. (Brief Infusion of Eptifibatide Following Percutaneous Coronary Intervention [BRIEF PCI]; NCT00111566).

Angiographic appearance of spontaneous coronary artery dissection with intramural hematoma proven on intracoronary imaging

The pathognomonic appearance of multiple radiolucent lumen on angiography is used to diagnose spontaneous coronary artery dissection (SCAD). However, this finding is absent in >70% of SCAD, in which case optical coherence tomography (OCT) or intravascular ultrasound (IVUS) is useful to assess arterial wall integrity.

The First Dedicated Cardiac Rehabilitation Program for Patients With Spontaneous Coronary Artery Dissection: Description and Initial Results

BACKGROUND Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction in women, but the role of rehabilitation after SCAD is unclear. METHODS We designed a dedicated SCAD cardiac rehabilitation (SCAD-CR) program for our SCAD survivors at Vancouver General Hospital. This program encompasses a multidisciplinary approach including exercise rehabilitation, psychosocial counselling, dietary and cardiovascular disease education, and peer group support. Exercise and educational classes were scheduled weekly with a targeted participation of 6 months. Psychosocial counselling, mindful living sessions, social worker and psychiatry evaluations, and peer-group support were offered. RESULTS We report our first consecutive cohort of 70 SCAD women who joined SCAD-CR from November 2011 to April 2015. The average age was 52.3 ± 8.4 years. Mean participation duration was 12.4 ± 10.5 weeks; 28 completed 6 months, 48 completed ≥ 1 month. At entry, 44 (62.9%) had recurrent chest pains and average metabolic equivalents on exercise treadmill test was 10.1 ± 3.3. At program exit, the proportion with recurrent chest pains was lower (37.1%) and average metabolic equivalents was higher 11.5 ± 3.5 (both P < 0.001). There was a significant improvement in the STOP-D depression questionnaire, with mean scores of 13.0 ± 1.4 before and 8.0 ± 1.7 after the SCAD-CR (P = 0.046). Twenty (28.6%) social worker referrals and 19 (27.1%) psychiatry referrals were made. Mean follow-up was 3.8 ± 2.9 years from the presenting SCAD event, and the major cardiac adverse event rate was 4.3%, lower than our non-SCAD-CR cohort (n = 145; 26.2%; P < 0.001). CONCLUSIONS This is the first dedicated SCAD-CR program to address the unique exercise and psychosocial needs of SCAD survivors. Our program appears safe and beneficial in improving chest pain, exercise capacity, psychosocial well-being and cardiovascular events.

Spontaneous Coronary Artery Dissection Misdiagnosed as Takotsubo Cardiomyopathy: A Case Series

Spontaneous coronary artery dissection (SCAD) and Takotsubo cardiomyopathy (TTC) can both cause myocardial infarction with subsequent normalization of wall motion abnormality. Angiograms of patients with TTC at Vancouver General Hospital were reviewed for SCAD. Clinical and investigational characteristics were recorded. Nine women with nonatherosclerotic SCAD were misdiagnosed as having TTC. Their average age was 55 years. Five patients had hypertension and 4 had emotional or physical stress. Fibromuscular dysplasia was present in 4 women. Wall motion abnormalities corresponded to dissected artery location and subsequently resolved. SCAD should be included in the differential diagnosis of patients suspected of having TTC and coronary angiograms scrutinized for subtle SCAD.

Catheter-Induced Iatrogenic Coronary Artery Dissection in Patients With Spontaneous Coronary Artery Dissection

Iatrogenic coronary artery dissection (ICAD) during coronary angiography is a rare (<0.2%) [(1,2)][1] but potentially fatal complication. ICAD may be particularly problematic in patients with spontaneous coronary artery dissection (SCAD). A high prevalence of predisposing arteropathies, particularly

Pre-Disposing and Precipitating Factors in Men With Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is an infrequent but important cause of myocardial infarction (MI) in younger women. The underlying cause, presentation, and natural history of SCAD in women are increasingly being described because >90% of cases affect women. However, SCAD in men is

Incidental atherosclerotic renal artery stenosis diagnosed at cardiac catheterization: no difference in kidney function with or without stenting.

BACKGROUND The long-term kidney function of patients with atherosclerotic renal artery stenosis (ARAS) diagnosed incidentally at the time of cardiac catheterization is not well described despite the increasingly common practice of assessing these vessels at the time of cardiac investigation. METHODS This is a retrospective analysis of a cohort identified prospectively at the time of non-emergent coronary angiography. Those with >or=50% ARAS were managed medically and underwent stenting if recommended by their nephrologist and/or cardiologist. Longitudinal regression analysis was used to compare the annualized change in estimated glomerular filtration rate (GFR) in stented and unstented patients. Cox regression analysis was used to determine the predictors of a decline in GFR by >or=25%. RESULTS Of 140 patients, 67 (48%) were stented, mostly for preservation of kidney function (70.1%) and/or resistant hypertension (53.7%). Median follow-up time was 943 days. Stented patients were younger, had higher systolic blood pressure and more severe ARAS. The adjusted rate of change in GFR was -1.49 (95% CI -2.33 to -0.65) ml/min/1.73 m(2)/year in the unstented group, and -1.48 (95% CI -2.34 to -0.62) ml/min/1.73 m(2)/year in the stented group (p = 0.99). A decline of GFR >or=25% occurred in 42 (30%) patients; no patient required dialysis. Only the presence of cereberovascular disease was associated with this outcome (hazard ratio 2.52, 95% CI 1.56-5.41). CONCLUSION We were unable to demonstrate a benefit or harm of renal artery stenting for ARAS, thus further increasing the uncertainty of the significance of these lesions and how they are best managed.

Ticagrelor and aspirin for the prevention of cardiovascular events after coronary artery bypass graft surgery

Background Ticagrelor was shown to reduce mortality in patients who underwent coronary artery bypass grafting (CABG), but its effect on graft patency is unknown. Methods We performed a prospective, randomised, double-blind, placebo-controlled trial, comparing ticagrelor 90 mg twice daily versus placebo for 3 months added to aspirin 81 mg/day, following isolated CABG. Aspirin was started within 12 h, and study medication within 72 h after CABG. Primary outcome was graft occlusion on CT angiography (CTA) performed 3 months post CABG. Patients were followed to 12 months for death, myocardial infarction, stroke, repeat revascularisation and bleeding. Results The study was terminated prematurely after randomising 70 patients between September 2011 and August 2014 because of slow recruitment. CTA was performed in 56 patients who completed >1 month of study drug. Graft occlusion occurred in 7/25 (28.0%) patients on ticagrelor and 17/31 (48.3%) on placebo, p=0.044. Of 207 analysable grafts, graft occlusion occurred in 9/87 (10.3%) with ticagrelor and 22/120 (18.3%) with placebo, p=0.112. Graft occlusion or stenosis ≥50% occurred in 10/87 (11.5%) ticagrelor vs 32/120 (26.7%) placebo, p=0.007. There was no major bleeding, but minor bleeding was higher with ticagrelor (31.4% vs 2.9%, p=0.003). In univariate analysis, ticagrelor use reduced graft occlusion (OR 0.32, 95% CI 0.10 to 0.97, p=0.047), which remained significant on multivariable analysis (OR 0.25, 95% CI 0.073 to 0.873, p=0.03). Conclusions Ticagrelor added to aspirin after CABG reduced the proportion of patients with graft occlusion, and was a significant univariate and multivariable predictor of graft occlusion. These results are hypothesis-generating and should be confirmed in larger studies. Trial registration number NCT01373411: Results.