Eve Aymong

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.

Gender Differences in Outcomes After Primary Angioplasty Versus Primary Stenting With and Without Abciximab for Acute Myocardial Infarction Results of the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) Trial

Background—Women with acute myocardial infarction (AMI) undergoing primary angioplasty have higher rates of morbidity and mortality than do men. Whether contemporary interventional treatment strategies have improved outcomes for women compared with men is unknown. Methods and Results—In the CADILLAC trial, 2082 patients (27% women) with AMI within 12 hours of symptom onset were randomized to balloon angioplasty (PTCA; n=518), PTCA+abciximab (n=528), stenting (n=512), and stenting+abciximab (n=524). As compared with men, women had a lower body surface area; had a greater prevalence of diabetes, hypertension, and hyperlipidemia; experienced significant delays to treatment; and had better baseline and final TIMI grade 3 flows. Unadjusted 1-year event rates were higher for women, including death (7.6% versus 3.0%, P<0.001), ischemic target-vessel revascularization (TVR; 16.7% versus 12.1%, P=0.006), and major adverse cardiac events (MACE; 23.9% versus 15.3%, P<0.001). Female gender was an independent predictor of MACE and bleeding complications, although comorbid risk factors and body surface area but not gender predicted 1-year death. For women, primary stenting resulted in a reduction in 1-year MACE from 28.1% to 19.1% (P=0.01) and in ischemic TVR from 20.4% to 10.8% (P=0.002) compared with PTCA. The addition of abciximab to primary stenting significantly reduced the 30-day ischemic TVR without increasing bleeding or stroke rates. Conclusions—The higher mortality rate in women compared with men after interventional treatment for AMI may be explained by differences in body size and clinical risk factors, although female gender remains an important independent determinant of overall adverse outcomes. For women in the CADILLAC trial, the addition of abciximab reduced 30-day TVR without increasing bleeding risk, and primary stenting reduced 1-year TVR and MACE rates compared with PTCA.

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).

Safety of an Aspirin-Alone Regimen After Intracoronary Stenting With a Heparin-Coated Stent Final Results of the HOPE (HEPACOAT and an Antithrombotic Regimen of Aspirin Alone) Study

Background—Stent thrombosis is an infrequent complication of intracoronary stenting that often has devastating clinical consequences. This study assesses the additional benefit of heparin coating with the BX VELOCITY Balloon-Expandable Stent with HEPACOAT, Carmeda end-point attached heparin (HEPACOAT) in patients with de novo or restenotic native coronary artery lesions treated with aspirin monotherapy after optimal stenting. Methods and Results—This was a multicenter, prospective, nonrandomized, pilot study. Two hundred patients (69% men; mean age, 64.1±11.2 years) meeting the eligibility criteria were treated with the HEPACOAT stent and aspirin alone after stenting. Any other antiplatelet or anticoagulation therapy was not permitted. Procedural success was achieved in all patients. There were 3 postprocedural non–Q-wave myocardial infarctions. The primary end point of stent thrombosis at 30 days occurred in 2 of 200 patients (1%): in one after blunt chest trauma and in the other in the setting of essential thrombocytosis. Major adverse cardiac events (death, myocardial infarction, target lesion revascularization, and coronary artery bypass grafting) were observed at 30 days in 5 of 200 (2.5%) patients. Conclusions—The BX VELOCITY stent with HEPACOAT and aspirin alone after the procedure was safe in select patients with de novo or restenotic lesions in native coronary arteries. Heparin coating provides additional protection against stent thrombosis.

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.

Impact of Symptomatic Peripheral Arterial Disease on 1-Year Mortality in Patients Undergoing Percutaneous Coronary Interventions

Purpose: To determine the impact of symptomatic peripheral arterial disease (PAD) on clinical outcomes in patients treated with percutaneous coronary interventions (PCI). Methods and Results: Symptomatic PAD was identified in 1969 (18.9%) of 10440 consecutive patients undergoing PCI. Patients with PAD were older, more frequently female, and had smaller body surface area and more atherosclerotic risk factors, chronic renal insufficiency, and heart failure. Patients with PAD had lower rates of procedural success (94.2% versus 96.2%, p<0.0001) and higher rates of in-hospital complications, including all-cause mortality (2.1% versus 1.1%, p=0.0002), cardiac death (1.5% versus 0.7%, p=0.0009), urgent coronary artery bypass grafting (1.9% versus 1.2%, p=0.01), recurrent ischemia (5.6% versus 2.8%, p<0.0001), re-PCI to the target lesion (2.4% versus 1.1%, p<0.0001), stroke (0.6% versus 0.3%, p=0.0344), transient ischemic attack (0.4% versus 0.1%, p=0.01), femoral hematoma (10.3% versus 8.5%, p=0.01), retroperitoneal hematoma (0.8% versus 0.3%, p=0.009), limb ischemia (3.0% versus 0.7%, p<0.0001), gastrointestinal bleeding (1.9% versus 0.9%, p<0.0001), and blood transfusion (10.1% versus 5.2%, p<0.0001). At 1-year follow-up, patients with PAD had a higher mortality rate (13.6% versus 5.2%, p<0.0001), a higher rate of myocardial infarction (8.3% versus 6.5%, p=0.008), and also more target lesion (21.2% versus 19.8%, p=0.02) or target vessel revascularization (24.6% versus 21.2%, p=0.002). By multivariate analysis, PAD was an independent predictor of 1-year mortality (odds ratio 1.71, 95% confidence interval 1.42 to 2.07, p<0.0001). Conclusions: Nearly a fifth of patients undergoing PCI have symptomatic PAD. The presence of PAD is associated with lower rates of procedural success, higher rates of in-hospital and 1-year adverse events, and is independently associated with increased 1-year mortality.

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.

Outcomes in Young South Asian Canadians After Acute Myocardial Infarction

BACKGROUND South Asians have a high prevalence of ischemic heart disease and experience high incident acute myocardial infarction (AMI) rates at younger ages than their white counterparts. The aim of this study was to compare outcomes after AMI in a Canadian population of South Asian and white patients, aged 20 to 55 years. METHODS Using hospital discharge abstract administrative data, we included patients with incident AMI, residing in British Columbia and the Calgary Health Region, between April 1, 1995 and March 31, 2002. The cohort was followed for up to 8 years (mean 4.2 years) to determine outcomes of mortality, recurrent AMI, and congestive heart failure (CHF) requiring hospitalization. South Asian ethnicity was determined using validated surname analysis. Baseline demographic characteristics and comorbidities were adjusted using Cox proportional hazard models. RESULTS Of 7135 young patients with AMI, 487 were of South Asian ancestry. Compared with white patients, South Asian patients were more likely to have diabetes (25% vs. 12%) and hypertension (24% vs. 20%). After adjustment for sociodemographic and comorbidity variables, there were no significant differences in rates of 30-day mortality (risk adjusted hazard ratio [aHR] 0.90; 95% confidence interval [CI], 0.38-2.10), long-term mortality (aHR 0.81; 95% CI, 0.53-1.26), recurrent AMI (aHR 1.07; 95% CI, 0.89-1.29), or CHF (aHR 0.90; 95% CI, 0.51-1.59) between the 2 groups. CONCLUSIONS Despite the recognition of increased cardiovascular mortality among young South Asian patients, our Canadian sample demonstrated similar rates of fatal and nonfatal outcomes among young South Asian and white patients with AMI.

Long-term outcomes following drug-eluting stents versus bare metal stents for primary percutaneous coronary intervention: A real-world analysis of 11,181 patients from the british columbia cardiac registry.

Drug eluting stents (DES) are associated with reduced risk of restenosis when compared with bare metal stents (BMS). Their use in ST‐elevation myocardial infarction (STEMI) is debated, owing to concerns about stent thrombosis. There are limited real‐world data comparing DES versus BMS in STEMI. We conducted an observational analysis in this setting and rigorously adjusted for treatment selection bias.

Clinical presentation of patients with spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is an infrequent but important cause of myocardial infarction (MI) especially in younger women. However, the clinical presentation and the acuity of symptoms prompting invasive management in SCAD patients have not been described. Understanding these presenting features may improve SCAD diagnosis and management.