CARDIOLOGY GRAND ROUNDS

Transcription

1 CARDIOLOGY GRAND ROUNDS Title: Acute Coronary Artery Failure Speaker: Alex R. Campbell, MD Cardiologist Minneapolis Heart Institute at Abbott Northwestern Hospital Scott W. Sharkey, MD, FACC Cardiologist Minneapolis Heart Institute at Abbott Northwestern Hospital Date: Monday, March 21, 2016 Time: 7:00 8:00 AM Location: ANW Education Building, Watson Room OBJECTIVES At the completion of this activity, the participants should be able to: 1. Differentiate causes of acute myocardial infarction due to non atherosclerotic coronary disease. 2. Distinguish options for advanced imaging of coronary arteries. 3. Recognize outcome of patients with unique coronary phenomenon. Physician: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Allina Health and Minneapolis Heart Institute Foundation. Allina Health is accredited by the ACCME to provide continuing medical education for physicians. Allina Health designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Nurse: This activity has been designed to meet the Minnesota Board of Nursing continuing education requirements for 1.2 hours of credit. However, the nurse is responsible for determining whether this activity meets the requirements for acceptable continuing education. DISCLOSURE STATEMENTS Speaker(s): Dr. Campbell and Dr. Sharkey have declared that they do not have any conflicts of interest to disclose. Planning Committee: Dr. Michael Miedema, Dr. Scott Sharkey and Jolene Bell Makowesky have declared that they do not have any conflicts of interest associated with the planning of this activity. Dr. Robert Schwartz declared the following relationship consultant: Boston Scientific. PLEASE SAVE A COPY OF THIS FLIER AS YOUR CERTIFICATE OF ATTENDANCE Signature: My signature verifies that I have attended the above stated number of hours of the CME activity. Allina Health - Learning & Development Chicago Ave - MR Minneapolis MN 55407

2 Minneapolis Heart Institute Grand Rounds Alex Campbell, MD Disclosures: None 57 year old male with chest pain No prior history CAD No risk factors Active, excellent functional capacity 8/14/14 Presents to ANW ER with 1 hour constant chest pain Started at rest Significant stress recently, otherwise feeling well 1

3 Tn 7.1 CBC, BMP, LFT s unremarkable 2

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6 Diffuse mid to distal stenosis No change with 100mcg IC NTG Findings most consistent with arteritis DDx Vasculitis Diffuse vasospasm Diffuse dissection Atherosclerotic CAD ASA / Plavix / Statin Nifedipine / Isosorbide Vasculitis panel Rheumatology / vascular medicine consults Further Hx from wife: severe stress, not sleeping Utox negative No symptoms suggestive of inflammatory disorder Negative ANA / ANCA CRP 5.1 (minimally elevated), ESR normal 5

7 Vascular surgery Likely vasculitis, not c/w spasm Rheumatology Not likely vasculitis CV Surgery Atherosclerotic CAD Cardiology Suspect vasospasm 6

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9 Multiple discrete scattered areas of edema Some confined to coronary territories Others to mid myocardial segments sparing endocardium Suggests non-coronary etiology such as myocarditis Normal thoracic / abdominal aorta and branch vessels 8

10 Repeat coronary angiogram 4 days later (on vasodilators) Coronary anatomy unchanged RV biopsied No evidence of myocarditis Discharged HD 5 Cardiology followup 10 days post discharge Clinically doing well, cardiac rehab On nifedipine, d/c d isosorbide for headache CCTA ordered 9

11 Contemporary Update Vasospastic Angina 10

12 Vasospasm as a culprit of ACS? Caucasian: 16% Da Costa A. Eur Heart J 2001;22: Taiwanese: 74% Wang A. Am Heart J. 2002;144: Europeans presenting w/ ACS and no culprit 488 = angiography 138 (28%) = no culprit 86 = no other cause identified (stress CM, PE, etc) Underwent graded IC ACH 42 (49%) = > 75% spasm (majority reproducing initial symptoms) Tn elevation 10% 3 year clinical event rate 0% death or non-fatal MI 4% repeat angiography High rate of vasodilator therapy 11

13 2100 pts with chest pain and non-obstructive CAD Positive : > 90% stenosis + EKG changes Intermediate : 50-90%, +/- EKG Negative : < 50% Positive: 21% 2 years: higher rates of adverse events (4% vs 1%) 94% on CCB or long acting Ntg Worse: multi-vessel spasm, current smoking, multiple episodes 139 patients with exertional angina 54 yo, 77% female 72% abnormal stress test Angiogram: Non-obstructive CAD (<50% stenosis) Comprehensive invasive assessment Epicardial vessels Functional evaluation w/ IC ACH (endothelial dysfunction = spasm > 20%) Physiologic evaluation with FFR of LAD Anatomic evaluation with IVUS of LAD Microvasculature Coronary flow reserve 12

14 Endothelial dysfunction: 44% Microvascular dysfunction: 21% FFR < 0.8: 5% Myocardial bridging: 58% Multiple findings: 54% The less than very good outcomes of these patients must be recognized so that a near-normal angiogram does not drive diagnostic and therapeutic complacency 13

15 Acute Coronary Artery Failure Cardiology Grand Rounds 22 March 2016 Campbell, Sharkey, Goessl I got a surprise on my 51 st birthday, but it wasn t a party it was a heart attack 1

16 I had taken a handful of vitamins, as was my bedtime routine when my neck and collarbone suddenly exploded with pain The achy pressure spread from shoulder to shoulder, about an 8 on a 10 point scale I lay down hoping the symptoms would pass 2

17 What happened next really scared me Both arms, from elbows to fingertips became weak like someone had turned off the blood supply It happened simultaneously in both arms, which made me think the problem was systemic 3

18 That s when it occurred to me I might be having a heart attack Husband drove her to ED. SL NTG with improvement Non smoker, No diabetes, No hypertension, No family history LDL 77, HDL 105 Runs 3X week 4

19 ED: 23:08 Day 2: 07:26 5

20 Serial Troponin I (URL ng/ml) # 1: ng/ml # 2: ng/ml delta = 19X 6

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22 Oct 15 discharged on aspirin 81mg Oct 17 recurrent chest pain 8

23 LAD ANGIO OCT 14 LAD ANGIO OCT 17 9

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26 Coronary artery intramural hematoma 12

27 Importance of Spatial Resolution for Imaging Coronary Arteries 13

28 Importance of Spatial Resolution Spatial Resolution Coronary Imaging Modalities Invasive angiography μm 14

29 Spatial Resolution Coronary Imaging Modalities Invasive angiography CTA μm μm Spatial Resolution Coronary Imaging Modalities Invasive angiography CTA Intra vascular ultrasound (IVUS) μm μm μm 15

30 Spatial Resolution Coronary Imaging Modalities Invasive angiography CTA Intra vascular ultrasound (IVUS) μm μm μm Optical Coherence Tomography (OCT) 15 μm Spatial Resolution Coronary Imaging Modalities Invasive angiography CTA Intra vascular ultrasound (IVUS) μm μm μm Optical Coherence Tomography (OCT) Micro CT 15 μm 0.5 μm 16

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33 Vasa Vasorum Anatomy Gössl et al, Anatomical Record 2003; 272A: Micro CT arterial vasa vasorum interna externa Gössl et al, Anatomical Record 2003; 272A:

34 Coronary artery Vasa vasorum density proximal distal Gössl et al, Atherosclerosis 2006 Human coronary vasa vasorum (VV) Micro CT Hypothesis: VV neovascularization >> fragile vessel >> VV rupture >> intra plaque hemorrhage >> plaque progression and rupture >>?? Dissection Gössl et al, JACC Imag

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36 ALL PATIENTS (RESEARCH FLG Y OR N) Total Patient Count (using unique MRN) 119 Female Count 71 Female Percentage 60% AVG Age for Female 53 AVG Age for both Male and Female 56 22