More about Spontaneous Coronary Artery Dissection (SCAD): Outpatient Management

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1 More about Spontaneous Coronary Artery Dissection (SCAD): Outpatient Management Matters of the Heart 7 th Annual Women s Heart Conference February 10, 2017 Marysia Tweet, MD, FACC 2016 MFMER

2 DISCLOSURE No relevant financial relationship(s) with industry 2016 MFMER

3 Spontaneous Coronary Artery Dissection (SCAD) Acute coronary syndrome without atherosclerosis Intramural hematoma +/- intimal dissection flap Diagnosed via: Coronary angio IVUS OCT * * 2016 MFMER

4 2016 MFMER

5 Spontaneous Coronary Artery Dissection (SCAD) Baseline Characteristics Mostly female Young (mean yrs) Minimal atherosclerotic risk factors Potential risk factors: fibromuscular dysplasia (FMD), postpartum/pregnancy, extreme emotion or exercise, connective tissue disease, coronary tortuosity, family history Tweet et al., Circulation 2012 Saw et al, Circ Cardiovasc Interv MFMER

6 2016 MFMER

7 Mayo Clinic SCAD Prospective Registry >700 enrolled (~60 in process ) Imaging, medical record review Questionnaires (retrospective, prospective) Personal SCAD narrative Prospective clinical/practice evaluations, imaging Planned serial/follow-up questionnaires Value of social media and patient-initiated research As of 1/ MFMER

8 Long-Term Survival SCAD vs Matched ACS Controls Survival (%) SCAD cases ACS controls Years after index event Tweet et al., Circulation MFMER

9 Long-Term Outcomes Major Adverse Cardiac Events Survival free of MACE (%) Years after index event Major Adverse Cardiac Events (MACE)= Death, Recurrent SCAD, MI, CHF No. at risk Tweet et al., Circulation MFMER

10 SCAD Long-Term Outcomes: MACE High burden, despite favorable predictors; EF, age, RF Vancouver Mayo Death, Recurrent SCAD, MI, CHF, CVA, Revasc Death, Recurrent SCAD, MI, CHF Years Italy Tweet, Circulation 2012; Tweet Circ CV Interv 2014; Lettieri, AJC 2015; Saw, Circ CV Interv 2014; Eleid, Circ Cardiovasc Interv MFMER

11 8 SCAD Outpatient Care Pearls 1. Cardiac Rehabilitation 2. Mental Health 3. Arteriopathies 4. Connective Tissue Disease 5. Familial SCAD 6. Pregnancy 7. Imaging Options 8. Medication Management 2016 MFMER

12 1. Cardiac Rehabilitation (CR) is Encouraged for SCAD Pts 2016 MFMER

13 CR in SCAD: Mayo Clinic SCAD Registry Data Reviewed 412 enrollees in the ongoing Mayo Clinic SCAD Registry ( ) 354 (86%) completed CR survey questions Mean age at time of SCAD 46 ± 10 yrs 95% female Krittanawong et al., Am J Cardiol, MFMER

14 v Number of SCAD Survivors outside the United States Krittanawong et al., Am J Cardiol, MFMER

15 CR in SCAD: Mayo Clinic SCAD Registry Data 76% participated in at least one CR session Those users averaged 18±12 sessions Krittanawong et al., Am J Cardiol, MFMER

16 Perceived CR Benefits Emotional benefits 75% Physical health benefits 82% Today I am still experiencing the benefits of participating in cardiac rehab 45% Krittanawong et al., Am J Cardiol, MFMER

17 Reasons for Not Participating in CR Too little energy to engage in a rehab program 2% Too ill to do any physical activities 2% My healthcare providers did not recommend rehab program 67% No insurance coverage for rehab program 8% Too expensive 2% Too far to travel or no way to get to rehab facility 12% Krittanawong et al., Am J Cardiol, MFMER

18 Regular Exercise CR n=269 No CR n=85 p Aerobic exercise >30 min (duration) Aerobic exercise at > 1/wk (frequency) 54% 40% % 66% <0.01 Krittanawong et al., Am J Cardiol, MFMER

19 Mayo Clinic SCAD CR Experience 9 SCAD pts in Mayo Clinic CR Average of 12.3 days (7-21) after SCAD Completed average of 28 CR sessions (5-39) Standard CR program: Supervised & independent flexibility, stretching, aerobic, strength training Counseling regarding nutrition, weight & stress management Silber et al., JCRP, MFMER

20 Mayo Clinic SCAD CR Experience CR was well received No cardiac symptoms or adverse events during exercise testing or training Peak O2 uptake 18% (n=4) 6-min walk distance 22% (n=4) Depression & stress scores improved Silber et al., JCRP, MFMER

21 Dedicated SCAD CR Program 70 women Mean age yrs Mean participation wks recurrent CP after CR (pre 63%, post 37%, p<0.001) Significantly improved STOP-D scores Chou et al., Can J Cardiol, MFMER

22 Baseline Functional Capacity in SCAD Treadmill stress testing for 18 female SCAD pts vs female all-comers controls <55 yrs Controls: Mean age 49 yrs Mean duration 6.2 min Mean METS 6.8 SCAD pts: Mean age 46 yrs (p=0.19) Mean duration 9.8 min Mean METs 10.6 (p value <0.001) Naderi et al., presented as poster at ACC, MFMER

23 2. Screen for Depression & Anxiety 158 SCAD pts 33% & 37% reported treatment for depression & anxiety, respectively Younger & pregnancy-related SCAD pts had mean PHQ-9 & GAD-7 scores Liang et al., J Cardiopulm Rehabil Prev, MFMER

24 3. Assess for Arteriopathies, Especially Fibromuscular Dysplasia (FMD), in SCAD FMD of external iliac artery on 8 of 16 femoral angiograms All female Tweet et al., Circulation MFMER

45% dysplasia Dissection Aneurysm Dilatation Tortuosity Undulating aorta

25 SCAD and Vascular Abnormalities 115 Mayo Clinic SCAD outpatients Overall Vascular Abnormalities 66% Vascular abnormalities: Overall Fibromuscular FMD 45% dysplasia Dissection Aneurysm Dilatation Tortuosity Undulating aorta Prasad et al., Am J Cardiol 2015 Tweet et al., JACC Imaging, MFMER

26 2016 MFMER

27 Tweet et al., JACC Imaging MFMER

28 Tweet et al., JACC Imaging MFMER

29 SCAD Coronary Tortuosity A. Intravessel symmetry B. Multivessel symmetry C. Corkscrew sign D. Coronary artery microaneurysm E. Coronary fibromuscular dysplasia Eleid et al., Circ Cardiovasc Interv MFMER

30 3. Connective Tissue Diseases (CTD) are Associated with SCAD Vascular Ehlers Danlos syndrome (Type IV) COL3A1 Marfan Syndrome FBN1 Loeys-Dietz Syndrome TGFBR1, TGFBR2, SMAD3, TGFB2?Pseudoxanthoma Elasticum (PXE) ABCC MFMER

31 Consider Genetic Evaluation 116 Mayo Clinic SCAD pts evaluated in Genetics Clinic 41% with FMD 59 underwent genetic testing 3 (5.1%) diagnosed with CTD Marfan and Vascular Ehlers-Danlos Henkin et al., Heart MFMER

5. SCAD Can Occur in Families 5 familial cases among 412 pt enrollees Mother-Daughter Identical twin sisters Sisters Aunt-niece First cousin pairs

32 5. SCAD Can Occur in Families 5 familial cases among 412 pt enrollees Mother-Daughter Identical twin sisters Sisters Aunt-niece First cousin pairs Implicates both recessive and dominant modes of inheritance Ongoing Mayo DNA biorepository Goel et al., JAMA Intern Med MFMER

33 Peripartum SCAD, N= Delivery = first week postpartum Number of SCAD patients < mos 7-12 mos Weeks Pregnant Weeks Postpartum Months following Pregnancy Tweet et al., AHA 2016 MFMER

34 Pregnancy after SCAD Of 363 women, 8 pregnant after SCAD Mean age at time of MI 36+3 yrs Elapsed time to pregnancy was 18+9 mos 3/8 initially given a diagnosis of coronary vasospasm Tweet et al., Ann Intern Med MFMER

35 Pregnancy after SCAD Follow-up median 36 mos 7 women without complications 1 woman with STEMI at 9 weeks postpartum Unsuccessful PCI->CABG for left main SCAD Tweet et al., Ann Intern Med MFMER

5 *TIA, SM G2P2 Pregnant 36 yo Elective C-section 28 mos 34 wks 4.

36 Initial SCAD 1 G2P2 Pregnant 35 yo Induced VD 22 mos To term 18 mos Last follow-up FMD 2 *MS G4P3 4 wks 4 mos Pregnant Miscarriage 42 yo 6.5 yrs Last follow-up Postpartum SCAD 3 G4P4 19 mos To term Pregnant 40 yo Elective C-section 2 yrs Last follow-up 4 G4P4 18 mos To term Pregnant 34 yo NSVD 2 mos 14 mos SCAD recurrence Last follow-up 5 *TIA, SM G2P2 Pregnant 36 yo Elective C-section 28 mos 34 wks 4.7 yrs Last follow-up 6 G4P4 Pregnant 36 yo Induced VD 26 mos To term 3 mos Last follow-up 7 G4P3 Pregnant 35 yo 9 mos To term Elective C-section 3 mos Last follow-up 8 *FT, MCT G3P1 23 mos Pregnant 39 yo 6 wks Miscarriage 3.6 yrs Last follow-up D&C = dilation and curettage; FMD = fibromuscular dysplasia; FT= fertility treatment history; G = Gravida; NSVD = normal spontaneous vaginal delivery; mos = months; MCT=mixed connective tissue disease; MS = multiple sclerosis; P = para; SCAD = spontaneous coronary artery dissection; SM=systemic mastocytosis; TIA=transient ischemic attack; VD = vaginal delivery Tweet et al., Ann Intern Med MFMER

37 6. Pregnancy after SCAD is not Advised Also advised to avoid systemic hormones Should a pt decide to pursue pregnancy, recommend care by cardiology & maternal fetal medicine team Tweet et al., Ann Intern Med MFMER

38 7. Multimodality Imaging is Helpful for Recurrent Symptoms Coronary Angiography OCT IVUS Echo CCTA CMR Stress Imaging Stress echo MPI Tweet et al., JACC Imaging MFMER

39 Cardiac CT 3 days after SCAD Tweet et al., JACC Imaging MFMER

40 Cardiac CT after SCAD 3 days post 10 days post Tweet et al., JACC Imaging MFMER

41 42 yo F with Medically Managed SCAD Tweet et al., JACC Imaging MFMER

42 Returned with Recurrent CP Assessed by CCTA Treated medically without CA Tweet et al., JACC Imaging MFMER

43 Uncertain Coronary Angiogram * 2016 MFMER

44 Delayed Enhancement in Corresponding Coronary Territory 2016 MFMER

45 8. Individualize Medications Minimal to no evidence Dual antiplatelets if PCI, baby asa otherwise May need to address menorrhagia Statins if hyperlipidemia ß-blockers/ACEI if LV dysfunction Avoid systemic hormones Nitrates or CCB for CP even if nonischemic (watch BP & HA) 2016 MFMER

46 Summary: SCAD Outpatient Care Pearls 1. Cardiac rehabilitation is encouraged 2. Screen for depression & anxiety 3. Assess for arteriopathies, especially FMD 4. CTDs are associated with SCAD Consider genetic evaluation 5. SCAD can occur in families 6. Pregnancy after SCAD is not advised But if pursued, cared for by a CV-MFM team 7. Multimodality imaging is helpful for recurrent symptom 8. Individualize medications 2016 MFMER

47 Thank you! MFMER

Pregnancy in Patients with a History of Spontaneous Coronary Artery Dissection (SCAD)

Pregnancy in Patients with a History of Spontaneous Coronary Artery Dissection (SCAD) Marysia Tweet, MD The 4 th International Congress on Cardiac Problems in Pregnancy February 29 th, 2016 2015 MFMER