Case Presentation: STEMI. Jennifer A. Tremmel, MD, MS Stanford University Medical Center SCAI Fall Fellow s Course 2015

Transcription

1 Case Presentation: STEMI Jennifer A. Tremmel, MD, MS Stanford University Medical Center SCAI Fall Fellow s Course 2015

2 STEMI 42 yo woman with no cardiac risk factors presents with chest pain radiating down her bilateral arms associated with diaphoresis

3 RCA

4 LCA

5 What is diagnosis? 45 yo woman who presented to an OSH with a STEMI Given IC nitro and verapamil "intense pruning of the distal vessel, suggestive of spasm

6 Not all coronary lesions are atherosclerosis!! Patients are usually young women who commonly lack most traditional cardiac risk factors The top two diagnoses to consider in these patients: Coronary dissection Coronary spasm If it doesn t go away with IC nitro, it s not spasm

7 Interventionalists often unsure of what they re looking at Reports often read abrupt taper, unusually small vessel distally, diffuse narrowing with reconstitution, but slow flow distally, small caliber vessel, normal appearing Diagnosis is often atherosclerosis, thrombotic/embolic, spasm (but put on b- blocker), and frequently no etiology is attempted

8 LAD called normal

9 2 years later, develops chest, arm, and jaw pain. EKG shows lateral ST elevation. Interventionalists note that the LCx is a small caliber vessel whereas before it was sizable

10 Tried wiring dissection aborted

11 CK reached 1000 Started on Norvasc for possible spasm Came to me the following month for a 2 nd opinion had never heard of coronary dissection

12 Perception of rarity due to being underdiagnosed Considered to be rare (0.1%-4% of all ACS), but up to one-quarter of young women (age <50) undergoing angiography with MI have SCAD Predominately affects women (>90% of cases), particularly young women Most have few or no traditional cardiac risk factors Nishiguchi et al. Eur Heart J, Acute Cardiovasc Care 2013 Saw et al. J Am Coll Cardiol 2011;58:B113 Tweet et al. Circulation 2012;126:

13 Still, can be older and have risk factors Saw et al. Circ Cardiovasc Interv 2014;7:

14 Proposed Patterns of SCAD Type 1: Initiated by an intimal tear propagating medial dissection Appears as mutiple lumens (true and false), intimal flap, or slow clearing of contrast Type 2: Medial dissection, perhaps initiated by rupture of the vaso vasorum Appears as a luminal narrowing or occlusion by intramural hematoma compression Saw et al. J Am Coll Cardiol 2014;64: Saw. Canadian J Card 2013;29:

15 IVUS and OCT can be helpful IVUS: more complete vessel visualization OCT: better for showing intimal tears Paulo et al. J Am Coll Cardiol Intv 2013;6:830-2

16 Heterogeneous Presentation Can involve any coronary artery in any location, sometimes multiple arteries at once Stability can wax and wane, as can angiographic appearance, particularly in the first few days after presentation

17 Possible etiologies/associations Hormonal shifts Peri-partum state, oral contraceptives, etc. Collagen vascular disorders/connective tissue disorders Fibromuscular dysplasia (70%-80% with SCAD have FMD) Systemic inflammatory conditions Coronary artery tortuosity,?spasm,?myocardial bridging Cocaine/methamphetamines Intense exercise/emotional stress Saw et al. J Am Coll Cardiol Intv 2013;6:44-52 Eleid et al. Circ Cardiovasc Interv 2014;7: Saw et al. Circ Cardiovasc Interv 2014;7:

18 Management Conservative management generally best most heal spontaneously?beta-blockers and aspirin/clopidogrel PCI (Often poor technical success compared with atherosclerotic disease) CABG (Can be difficult to find true lumen, dissections often distal) If survive initial event, prognosis relatively good, although recurrence rate ~30% over subsequent 10 years Psychological trauma often significant and should be addressed Alfonso et al. J Am Coll Cardiol Intv 2012;5:

19 40 yo woman with no cardiac risk factors

20 Difficulty wiring, no reflow after ballooning attributed to spasm (although no change with nitro, adenosine, and verapamil)

21 Stented, no reflow persisted, apical akinesis

22 SCAD Can Be Scary--36 yo woman with no cardiac risk factors, 16 days post-partum

23 Dissections Appear to Worsen

24 2.5 x 28 mm DES, ballooned branch

25

26 Ongoing CP with EKG changes-returns to cath lab

27 Stent placed

28 2 nd stent placed

29 POBA, final result

30 Take-Home Points Not all coronary lesions are atherosclerosis SCAD should be top of your differential in a young woman with no/few risk factors SCAD does not act like athero, approach it with a healthy amount of fear and respect Take care of these patients afterward Explain SCAD and that we don t know a lot Don t overmedicate them Be alert for recurrence, but don t sit around waiting for it Help with psychological trauma