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

Transcription

1 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, MFMER slide-1

2 Overview Basics of spontaneous coronary artery dissection (SCAD) Postpartum SCAD Pregnancy following SCAD 2015 MFMER slide-2

3 Spontaneous coronary artery dissection (SCAD) Acute coronary syndrome without atherosclerosis Intramural hematoma +/- intimal disruption Diagnosed via: * Coronary angio IVUS OCT * * 2015 MFMER slide-3

4 2015 MFMER slide-4

5 39 yo G6P4 Woman 5 days postpartum Chest pain ECG negative at urgent care 8 days postpartum Recurrent CP ECG negative, CT PE negative 13 days postpartum Severe 10/10 CP EMS called, v fib arrest Resuscitated 2015 MFMER slide-5

6 2015 MFMER slide-6

7 2015 MFMER slide-8

8 Recurrent CP 2015 MFMER slide-9

9 2015 MFMER slide-10

10 2015 MFMER slide-11

11 2015 MFMER slide-12

12 * 2015 MFMER slide-13

13 Cardiac MRI 2015 MFMER slide-14

14 Case 2: 42 yo F with V. Fib Arrest 2015 MFMER slide-15

15 Optical coherence tomography (OCT) 2015 MFMER slide-16

16 Intramural hematoma on OCT * * 2015 MFMER slide-17

17 Conservatively managed, Healing on follow-up 2015 MFMER slide-18

18 SCAD Reported prevalence % Prevalence likely higher due to awareness and improved diagnostic techniques Cause of MI in 10-30% F <50 yo Likely most common etiology of MI during or shortly after pregnancy ~18% of SCAD is peripartum Tweet et al. Circ 2012 Vanzetto et al. Cardiothorac Surg 2009 Mortensen et al. Cardiovasc Interv 2009 Saw et al. Can Jour of Cardiol 2014 Elkayam et al. Circ MFMER slide-19

19 SCAD Baseline Characteristics Mostly female Young (mean yrs) Minimal CAD risk factors Potential risk factors: fibromuscular dysplasia, 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 slide-20

20 Survival free of MACE (%) Long-Term Outcomes Major Adverse Cardiac Events Major Adverse Cardiac Events (MACE)= Death, Recurrent SCAD, MI, CHF Years after index event No. at risk Tweet et al., Circulation MFMER slide-21

21 SCAD Angiographic Subtypes Type 1: Staining in the arterial wall Type 2: Diffuse narrowing Type 3: Mimics atherosclerosis Type 1 Saw, Catheter Cardiovasc Interv MFMER slide-22

22 Type 2 Type 3 * * * * * Saw, Catheter Cardiovasc Interv MFMER slide-23

23 2011 MFMER MFMER slide-25

24 Mayo Clinic SCAD Registry & DNA Biorepository North America 2015 MFMER slide-26

25 Mayo Clinic SCAD Registry & DNA Biorepository World >500 Confirmed SCAD Patients 2015 MFMER slide-27

26 MFMER slide-28

27 SCAD Acute Management Retrospective review (N = 189) Treated with balloon and/or stent(s): Failure 53% failure to cross lesion (7/23) Final 50% loss failure of flow in those (8/23) with preserved distal Residual coronary stenosis flow, 6 (13%) >30% (8/23) emergency CABG Conservative therapy: Uneventful hospital course 73% of 59 with repeat CA showed healing 9 (10%) early SCAD progression requiring stent or bypass surgery (mean 4 days, 2-7) Tweet et al., Circ Cardiovasc Interv MFMER slide-29

28 Free of recurrent SCAD (%) Free of recurrent SCAD (%) Free of target vessel revascularization (%) Free of target vessel revascularization (%) Comparison of Long-Term Outcomes According to Initial Treatment Strategy and Presenting Vessel Flow Revascularization vs Conservative Management 100 Conservative 80 Target Vessel Revascularization Target Vessel Revascularization PF-PCI vs PF-Con PF-Con 60 Revascularization 60 PF-PCI P= Years No. at risk P= Years No. at risk Revascularization vs Conservative Management 100 Revascularization 80 Recurrent SCAD Recurrent SCAD PF-PCI vs PF-Con PF-PCI Conservative PF-Con 20 P= P= Years Years No. at risk No. at risk Tweet et al., Circ Cardiovasc Interv, MFMER slide-30

29 Proposed Algorithm for Acute Management of Initial SCAD Acute SCAD on angiography No Yes OCT/IVUS: False lumen or intramural hematoma? Yes TIMI flow assessment TIMI 0-1 or clinically unstable TIMI 2-3 and clinically stable Revascularize with inpatient monitoring for 5-7 days, consider CABG in high volume surgical centers Conservative management with inpatient monitoring for 5-7 days Tweet et al., Circ Cardiovasc Interv, MFMER slide-33

30 SCAD Coronary Tortuosity SCAD Control 246 Mayo Clinic SCAD Registry patients vs 313 controls Mean age 45 yrs 96% women Eleid et al., Circ Cardiovasc Interv MFMER slide-34

31 Prevalence of SCAD Coronary Tortuosity 70% 60% P< for all 50% 40% 30% 20% SCAD (N=246) Controls (N=313) 10% 0% LAD tortuosity LCX tortuosity RCA tortuosity Eleid et al., Circ Cardiovasc Interv MFMER slide-35

32 SCAD Coronary Tortuosity Recurrent SCAD (n=40) occurred within segments of tortuosity in 80% High recurrence risk if severe tortuosity Arterial abnormalities and FMD associated with corkscrew and multivessel symmetrical tortuosity (P<0.05 for both) Eleid et al., Circ Cardiovasc Interv MFMER slide-36

33 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, MFMER slide-37

34 SCAD and Connective Tissue Disease (CTD) 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 slide-38

35 SCAD in the Family 5 familial cases among 412 patient enrollees Mother-Daughter Identical twin sisters Sisters Aunt-niece First cousin pairs False lumen Implicates both recessive and dominant modes of inheritance Ongoing Mayo DNA biorepository Goel et al., JAMA Intern Med, MFMER slide-39

36 Number of SCAD patients Peripartum SCAD, N= Delivery = first week postpartum < mos 7-12 mos Weeks Pregnant Weeks Postpartum Months following Pregnancy Tweet et al., AHA 2015 MFMER slide-40

37 Peripartum SCAD Tweet et al., AHA 2015 MFMER slide-41

38 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 slide-42

39 Pregnancy after SCAD 6 pregnancies resulted in live birth 3 vaginal deliveries 3 cesarean sections Placenta previa and antepartum hemorrhage 2 miscarriages at 9 and 15 wks Tweet et al., Ann Intern Med MFMER slide-43

40 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 slide-44

41 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 slide-45

42 Pregnancy after SCAD Advised to avoid pregnancy Advised against systemic hormonal contraception Should a patient decide to pursue pregnancy, recommend care by cardiology and maternal fetal medicine team Tweet et al., Ann Intern Med MFMER slide-46

43 Other Considerations Recommend cardiac rehab Assess for anxiety and depression 2015 MFMER slide-47

44 Thank you! Questions & Discussion 2015 MFMER slide-48