Multimodality Imaging in Spontaneous Coronary Artery Dissection in the Peripartum Period Marysia Tweet, MD NASCI Annual Meeting October 18 th, 2016 2016 MFMER slide-1
DISCLOSURE No relevant financial relationship(s) with industry Off Label Usage: None 2016 MFMER slide-2
Overview Basics of spontaneous coronary artery dissection (SCAD) Pregnancy-related SCAD Multimodality imaging for SCAD 2016 MFMER slide-3
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 2016 MFMER slide-4
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Recurrent CP 2016 MFMER slide-8
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Cardiac MRI 2016 MFMER slide-13
Spontaneous Coronary Artery Dissection (SCAD) Acute coronary syndrome without atherosclerosis Intramural hematoma +/- intimal dissection flap Diagnosed via: Coronary angio IVUS OCT * * * 2016 MFMER slide-14
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Optical Coherence Tomography (OCT) 2016 MFMER slide-16
Intramural Hematoma on OCT * * 2016 MFMER slide-17
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 2014 2016 MFMER slide-18
SCAD Baseline Characteristics Mostly female Young (mean 42-52 yrs) Minimal CAD risk factors Potential risk factors: coronary tortuosity, fibromuscular dysplasia (FMD), postpartum/pregnancy, extreme emotion or exercise, connective tissue disease (CTD), family history Tweet et al., Circulation 2012 Saw et al., Circ Cardiovasc Interv 2014 2016 MFMER slide-19
SCAD Prevalence Reported as 0.07-1.1% Likely higher ~18% (perhaps less) associated with pregnancy Cause of MI in 10-30% of women <50 yo Most common etiology of peripartum MI 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 2014 2016 MFMER slide-20
Number of SCAD patients Peripartum SCAD, N=41 30 25 Delivery = first week postpartum 20 15 10 5 0 <28 28-32 33-36 37-40 1-4 5-8 9-12 3-6 mos 7-12 mos Weeks Pregnant Weeks Postpartum Months following Pregnancy Tweet et al., AHA 2016 MFMER slide-21
Peripartum SCAD Tweet et al., AHA 2016 MFMER slide-22
All-Comers SCAD Presentation (n = 87) STEMI n=43 Single-vessel (34) Multi-vessel (9) V fib/tach (10) NSTEMI n=38 Single-vessel (29) Multi-vessel (9) V fib/tach (2) UA n=6 Single-vessel (4) Multi-vessel (2) Tweet et al., Circulation 2012 2016 MFMER slide-24
Survival free of MACE (%) SCAD Major Adverse Cardiac Events (MACE) 100 80 MACE=Death, Recurrent SCAD, MI, CHF 60 40 20 0 0 2 4 6 8 10 Years after index event No. at risk 87 64 56 48 39 32 27 26 18 14 11 Tweet et al., Circulation 2012 2016 MFMER slide-25
Recurrence of SCAD Recurrence in 15/71 females, 0/16 males (p = 0.023) Median 2.8 yrs (3 days - 12 yrs) 3rd episode SCAD (n = 2) at 1 and 11 mos after prior event Tweet et al., Circulation 2012 2016 MFMER slide-26
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 2014 2016 MFMER slide-27
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 2014 2016 MFMER slide-28
Imaging for SCAD Coronary Angiography OCT IVUS Echo CCTA CMR Stress Imaging Stress echo MPI Tweet et al., JACC Imaging 2016 2016 MFMER slide-29
Role of Echocardiography Demonstrates regional wall motion abnormalities Expect to be consistent with involved SCAD territory Can be a clue for reviewing a normal angiogram more carefully Do not be misled by a takotsubo appearance 2016 MFMER slide-30
32 yo F with postpartum STEMI 2016 MFMER slide-31
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Cardiac CT 3 days after SCAD Tweet et al., JACC Imaging 2016 2016 MFMER slide-34
Cardiac CT after SCAD 3 days post 10 days post Tweet et al., JACC Imaging 2016 2016 MFMER slide-35
CCTA Can show coronary dissection Myocardial hypoperfusion Limitations include motion and vessel size Not first line diagnostic tool 2016 MFMER slide-36
SCAD pt with recurrent CP assessed by CCTA Treated medically without invasive angio Tweet et al., JACC Imaging, 2016 2016 MFMER slide-37
SCAD and Vascular Abnormalities on CT 115 Mayo Clinic SCAD outpatients Overall Vascular Abnormalities 66% Vascular abnormalities: Overall Fibromuscular FMD 45% dysplasia Dissection Aneurysm Dilatation Tortuosity Undulating aorta Prasad, Tweet et al., Am J Cardiol 2015 2016 MFMER slide-38
SCAD & 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 2016 2016 MFMER slide-39
Cardiac Magnetic Resonance Imaging Assess for regional wall motion abnormalities Assess extent of myocardial injury or recovery Sequences to assess for edema Delayed gadolinium enhancement 2016 MFMER slide-40
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SCAD Take Home Points SCAD affects young women without CAD Presentation is heart attack, unstable angina, cardiac arrest Associated conditions: coronary tortuosity, FMD, pregnancyassociated (postpartum), extreme emotion or exercise, CTD, family history Not always obvious on the coronary angiogram OCT or IVUS can confirm Echo, CCTA and CMR are integral for diagnosis and followup Important to diagnose because management is different than guidelines Will see more awareness, diagnostic techniques, ongoing Mayo Clinic SCAD Registries 2016 MFMER slide-45
Mayo Clinic SCAD Registry World >600 Confirmed SCAD Patients >500 SCAD probands and >350 parents 2016 MFMER slide-46
Questions & Discussion www.mayo.edu/research/scad tweet.marysia@mayo.edu 2016 MFMER slide-47