Annie Y. Chou

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.

Basis for Sex-Specific Expression of Takotsubo Cardiomyopathy, Cardiac Syndrome X, and Spontaneous Coronary Artery Dissection

Takotsubo cardiomyopathy, cardiac syndrome X, and spontaneous coronary artery dissection are cardiovascular syndromes with a predilection for women. A complex interplay between neurohormonal factors, genetic influences, anatomic alterations, and other factors together affect cardiovascular function. Specifically, a high, variable, or deficient estrogen state leads to vasomotor instability with propensity toward vasoconstriction and endothelial dysfunction that predispose women to myocardial impairment, microvascular dysfunction, and coronary arterial wall instability. As the predominant sex hormone in women, fluctuating estrogen levels lead to a sex disparity in the expression of these cardiac entities. This review explores the research on sex-based differences of the neurohormonal, genetic, and mechanical factors in the normal cardiovascular system and in the pathophysiology of these 3 conditions. The understanding of their prevalence, pathogenesis, and sex disparity allows improved recognition, management, and support of female patients inflicted with these syndromes.

Warfarin Monotherapy in Atrial Fibrillation Patients With Stable Coronary Disease One Year After Myocardial Infarction/Stent: Two Birds With One Stone?

Patients with atrial fibrillation and stable coronary artery disease remain a therapeutic challenge because of the different antithrombotic therapies for the 2 conditions and the increase in bleeding with concomitant antiplatelet and anticoagulant medications. Current guidelines extrapolated data from studies of antithrombotic regimens of each condition separately but there is limited evidence for the optimal regimen in patients with atrial fibrillation and stable coronary artery disease beyond the first year after an acute coronary syndrome or stent implantation. In this review we suggest that warfarin monotherapy is sufficient for this patient population beyond 1 year.

IS FIBRINOLYSIS STILL A VIABLE ALTERNATIVE FOR PATIENTS WITH ST ELEVATION MYOCARDIAL INFARCTION: Results FROM A MIXED-REPERFUSION MODEL OF ST ELEVATION MYOCARDIAL INFARCTION CARE

fibrinolysis differs based on smoking status. METHODS: The TRANSFER-AMI study randomized patients with STEMI to a routine early invasive (pharmacoinvasive) versus a standard (delayed coronary angiography, with early transfer only for rescue PCI) strategy after fibrinolysis. In this post-hoc subgroup analysis, we compared the efficacy of these strategies among 1,051 patients based on their smoking status, and performed multivariable analysis to evaluate for interaction between smoking status and treatment strategy after adjusting for baseline GRACE risk score. For the purpose of this analysis, ex-smokers were considered non-smokers. RESULTS: Ofthe1,051patients (medianage57years; 79.5%male), 448 (42.6%) were current smokers. Smokers were younger, had fewer cardiovascular risk factors, and lower GRACE risk scores than non-smokers. Smokers had a lower unadjusted rate of the primary composite endpoint of 30-day mortality, re-infarction (re-MI), recurrent ischemia, heart failure, or cardiogenic shock, and fewer deaths or re-infarctions at 30 days, 6 months and 1 year (Table).