Cause Of Acute Coronary Syndrome Research Articles

Uncovering a hidden danger: a case report of diffuse coronary spasm concealing spontaneous coronary artery dissection

BackgroundOver recent years, spontaneous coronary artery dissection (SCAD) has emerged as a no longer rare cause of acute coronary syndrome (ACS). On the other hand, coronary artery spasm (CAS) is the main cause of ischemic heart disease with non-obstructive coronary lesions. Clinical manifestations of both vary from stable angina to ACS or, rarely, sudden cardiac death. These entities may be underdiagnosed on a coronary angiography.Case presentationWe report the case of a young woman presenting with acute chest pain and no coronary risk factors. Angiography revealed a focal subcritical stenosis of the right coronary artery. Coronary wiring resulted in diffuse and critical spasm. However, optical coherence tomography (OCT) and intravascular ultrasound (IVUS) showed extensive SCAD. She was therefore treated conservatively. On the fourth day, cardiac computed tomography angiography (CCTA) excluded disease progression, and then she was discharged on medical therapy.ConclusionsCombined IVI plays a vital role in providing accurate and detailed visualization of the coronary anatomy and thus allowing for more precise diagnosis, risk stratification, and treatment planning. CCTA can be considered a valuable tool in the noninvasive follow-up of SCAD.

Spontaneous coronary artery dissection in patients with prior psychophysical stress: a systematic review of case reports and case series

BackgroundSpontaneous coronary artery dissection (SCAD) is an underdiagnosed cause of acute coronary syndrome, particularly in younger women. Due to limited information about SCAD, case reports and case series can provide valuable insights into its features and management. This study aimed to comprehensively evaluate the features of SCAD patients who experienced psychophysical stress before the SCAD event.MethodsWe conducted an electronic search of PubMed, Scopus, and Web of Science from inception until January 7, 2023. We included case reports or series that described patients with SCAD who had experienced psychophysical stress before SCAD. Patients with pregnancy-associated SCAD were excluded from our analysis.ResultsIn total, we included 93 case reports or series describing 105 patients with SCAD. The average patient age was 44.29 ± 13.05 years and a total of 44 (41.9%) of patients were male. Among the included SCAD patients the most prevalent comorbidities were fibromuscular dysplasia (FMD) and hypertension with the prevalence of 36.4 and 21.9%, respectively. Preceding physical stress was more frequently reported in men than in women; 38 out of 44 (86.4%) men reported physical stress, while 36 out of 61 (59.1%) females reported physical stress (p value = 0.009). On the other hand, the opposite was true for emotional stress (men: 6 (13.6%)), women: 29 (47.6%), p value < 0.001). Coronary angiography was the main diagnostic tool. The most frequently involved artery was the left anterior descending (LAD) (62.9%). In our study, recurrence of SCAD due to either the progression of a previous lesion or new SCAD in another coronary location occurred more frequently in those treated conservatively, however the observed difference was not statistically significant (p value = 0.138).ConclusionWhile physical stress seems to precede SCAD in most cases, emotional stress is implicated in females more than males.

Two case reports of spontaneous coronary dissection

Spontaneous coronary artery dissection (SCAD) has nowadays been described as a non-negligible etiology of acute coronary syndromes (ACS). Its prevalence approximates 3% in most cohorts. It mainly affects women in the young to middle-aged range. Individuals with SCAD typically exhibit fewer conventional cardiovascular risk factors associated with ischemic heart disease compared to those with atherosclerotic coronary artery disease. Nevertheless, some SCAD patients may present with risk factors such as hypertension, smoking, and dyslipidemia, although their direct contribution to SCAD risk remains uncertain. We present two cases of spontaneous coronary dissection to explore its pathogenesis, diagnosis, and treatment options. Learning objectives · Recognize spontaneous coronary artery dissection as the possible cause of ACS in females even with cardiovascular risk factors. Learn the importance of angiographic control after a conservative therapy that may lead to a more invasive approach.

The role of C-reactive protein:albumin ratio and Neutrophil:lymphocyte ratio in predicting coronary artery disease.

Acute coronary syndrome (ACS), one of the most common causes of death worldwide, is a condition characterised by ischaemia and/or infarction due to reduced coronary blood flow. The most prevalent cause of ACS is coronary artery disease. In this study, we aimed to investigate the relationship between blood parameters that we commonly use in the laboratory [C-reactive protein (CRP), albumin, neutrophils and lymphocytes] and coronary artery disease (CAD). This retrospective, single-centre study included 100 patients who underwent coronary angiography, with the diagnosis of acute coronary syndrome between January and June 2023, and 106 patients with high clinical suspicion and normal coronary arteries as a control group. The NLR was obtained from the ratio of neutrophils to lymphocytes and the CAR was obtained from the ratio of CRP to albumin. We analysed the relationship between CAD and NLR and CAR according to laboratory findings and demographic characteristics of the patients. The average age of the study group was 59 ± 10 years. NLR and CAR values were higher in the patient group than the control group (5.2 ± 3.3 vs 2.27 ± 1.2, p = 0.004 and 0.5 ± 0.1 vs 0.097 ± 0.095, respectively, p < 0.001). Albumin ratios were found to be statistically significantly lower in the patient group than the patient group (42.4 ± 4 vs 44 ± 3.3, respectively, p = 0.01). In addition, CAR and NLR showed a significant diagnostic value for CAD in receiver operating characteristic curve analysis (area under the curve: 0.68 ± 0.07, p = 0.003; 0.66 ± 0.09 p ≤ 0.001). NLR and CAR values, which are important indicators of inflammation, were found to be higher in the patient group. We believe it may be important to monitor these patients more frequently and follow them closely in terms of CAD, especially if the rate is higher in individuals without CAD who come for out-patient clinic check-ups.

Acute Coronary Syndrome in Women: An Update.

The goal of this manuscript is to provide a concise summary of recent developments in the approach to and treatment of women with acute coronary syndrome (ACS). This review covers terminology updates relating to ACS and myocardial injury and infarction. Updates on disparities in recognition, treatments, and outcomes of women with ACS due to atherosclerotic coronary artery disease are covered. Other causes of ACS, including spontaneous coronary artery dissection and myocardial infarction with non-obstructive coronary artery disease are discussed, given the increased frequency in women compared with men. The review summarizes the latest on the unique circumstance of ACS in women who are pregnant or post-partum, including etiologies, diagnostic approaches, medication safety, and revascularization considerations. Compared with men, women with ACS have unique risk factors, presentations, and pathophysiology. Treatments known to be effective for men with atherosclerosis-related ACS are also effective for women; further work remains on reducing the disparities in diagnosis and treatment. Implementation of multimodality imaging will improve diagnostic accuracy and allow for targeted medical therapy in the setting of myocardial infarction with non-obstructive coronary artery disease.

Spontaneous Coronary Artery Dissection: An Updated Comprehensive Review.

Spontaneous coronary artery dissection (SCAD) is defined as a non-iatrogenic, non-traumatic separation of the coronary artery wall, which has gained considerable recognition as an important cause of acute coronary syndrome. Despite the emerging evidence, it is still frequently missed and requires a high index of suspicion, as failure to accurately identify SCAD promptly could prove fatal. SCAD is most prevalent among middle-aged women, although it can also be found in men and postmenopausal women. Risk factors of SCAD include exogenous hormone use, physical and emotional stressors, pregnancy, and several inflammatory and connective tissue disorders. COVID-19 also contributes to the prevalence of SCAD. SCAD is classified into four main types based on the angiographic findings - type 1, type 2, type 3, and type 4. The gold standard for diagnosis is coronary angiography; however, intracardiac imaging is useful if diagnostic doubts persist. Despite the increasing recognition of this disease, there is a paucity in the guidelines on the management of SCAD. Management may be conservative, medical, or interventional. Cardiac rehabilitation is also necessary in the management of patients with SCAD.In light of the gaps in evidence, the authors aim to provide a comprehensive review of the existing literature, outlining the pathophysiology, classification, and, most importantly, the evidence and pitfalls circulating diagnosis, acute, and long-term management of SCAD.

Chest Pain: Wellens Syndrome Due to Spontaneous Dissection of the Left Anterior Descending Coronary Artery - A Case Report and Literature Review.

Wellens syndrome is an abnormal electrocardiographic pattern characterized by biphasic (type A) or deeply inverted (type B) T waves in leads V2-V3. It is typically caused by temporary obstruction of the left anterior descending (LAD) coronary artery due to the rupture of an atherosclerotic plaque leading to occlusion. Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and even a rarer cause of Wellens Syndrome. It occurs when an intramural hematoma forms, leading to the separation of the tunica intima from the outer layers and creating a false lumen that protrudes into the real lumen, ultimately reducing blood flow and thus resulting in myocardial infarction. Here we report a case of SCAD presenting as an acute coronary syndrome with self-resolving chest pain, slightly elevated myocardial necrosis markers and electrocardiographic changes consistent with Wellens pattern type A first, and type B afterwards, that were not present upon arrival to the emergency department.

Polygenic Risk in Families With Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a poorly understood cause of acute coronary syndrome that predominantly affects women. Evidence to date suggests a complex genetic architecture, while a family history is reported for a minority of cases. To determine the contribution of rare and common genetic variants to SCAD risk in familial cases, the latter via the comparison of a polygenic risk score (PRS) with those with sporadic SCAD and healthy controls. This genetic association study analyzed families with SCAD, individuals with sporadic SCAD, and healthy controls. Genotyping was undertaken for all participants. Participants were recruited between 2017 and 2021. A PRS for SCAD was calculated for all participants. The presence of rare variants in genes associated with connective tissue disorders (CTD) was also assessed. Individuals with SCAD were recruited via social media or from a single medical center. A previously published control database of older healthy individuals was used. Data were analyzed from January 2022 to October 2023. PRS for SCAD comprised of 7 single-nucleotide variants. Disease status (familial SCAD, sporadic SCAD, or healthy control) associated with PRS. A total of 13 families with SCAD (27 affected and 12 unaffected individuals), 173 individuals with sporadic SCAD, and 1127 healthy controls were included. A total of 188 individuals with SCAD (94.0%) were female, including 25 of 27 with familial SCAD and 163 of 173 with sporadic SCAD; of 12 unaffected individuals from families with SCAD, 6 (50%) were female; and of 1127 healthy controls, 672 (59.6%) were female. Compared with healthy controls, the odds of being an affected family member or having sporadic SCAD was significantly associated with a SCAD PRS (where the odds ratio [OR] represents an increase in odds per 1-SD increase in PRS) (affected family member: OR, 2.14; 95% CI, 1.78-2.50; adjusted P = 1.96 × 10-4; sporadic SCAD: OR, 1.63; 95% CI, 1.37-1.89; adjusted P = 5.69 × 10-4). This association was not seen for unaffected family members (OR, 1.03; 95% CI, 0.46-1.61; adjusted P = .91) compared with controls. Further, those with familial SCAD were overrepresented in the top quintile of the control PRS distribution (OR, 3.70; 95% CI, 2.93-4.47; adjusted P = .001); those with sporadic SCAD showed a similar pattern (OR, 2.51; 95% CI, 1.98-3.04; adjusted P = .001). Affected individuals within a family did not share any rare deleterious variants in CTD-associated genes. Extreme aggregation of common genetic risk appears to play a significant role in familial clustering of SCAD as well as in sporadic case predisposition, although further study is required.

Spontaneous Coronary Artery Dissection Presenting as Electrical Storm: A Case Report.

Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction in patients of younger age without typical atherosclerotic risk factors and can present with ventricular arrhythmia such as ventricular tachycardia (VT) or ventricular fibrillation (VF). Electrical storm (ES) is defined as greater than or equal to 3 episodes of VT or VF occurring within 24 hours. A healthy 38-year-old-male developed chest pain while exercising at the gym and presented to the emergency department unresponsive in a ventricular arrhythmia defined as ES. The patient's cardiac arrest was initially refractory to standard defibrillation and Advanced Cardiac Life Support medications. He was ultimately diagnosed with SCAD of the left anterior descending artery, which was stented. The patient survived neurologically intact after a 13-day hospital stay. Spontaneous coronary artery dissection is a significant cause of acute coronary syndrome and occurs in healthier patients without cardiac risk factors. Electrical storm represents a unique manifestation of SCAD. Emergency physicians should maintain a heightened suspicion for SCAD for accurate diagnosis and treatment.

Spontaneous Coronary Artery Dissection (SCAD) from an Interventionalist Perspective.

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome (ACS), particularly among women < 50years of age. Here, we aim to review the pathogenesis of SCAD, discuss SCAD as an initial manifestation of systemic arterial disease, and highlight invasive strategies as well as unique challenges in the care of women with SCAD. A paradigm shift has occurred in the care of SCAD patients in the past decade as recommendations for conservative management have become widespread. Invasive interventions are reserved for patients with hemodynamic compromise or active ischemia due to increased periprocedural complications and failure rates. Certain patient populations have been identified for larger territory infarcts and proximal disease including patients with known connective tissue disease, premenopausal women, and patients with pregnancy-associated SCAD (P-SCAD). Current recommended management of SCAD is conservative. Despite a growing awareness of SCAD and its known association with systemic arteriopathies in women, evidence-based data remains scarce. Future studies focused on identifying genetic factors, optimal medical therapy after SCAD, and techniques to minimize interventional complications are needed.

Early Effects of the COVID-19 Pandemic on Patients in a Virtual Multicenter Spontaneous Coronary Artery Dissection (SCAD) Registry

BackgroundThe COVID-19 pandemic effects among patients with a history of spontaneous coronary artery dissection (SCAD), a cause of acute coronary syndrome associated with emotional and physical stress, are unknown. MethodsFor this cross-sectional cohort study, participants of the Mayo Clinic “Virtual” Multicenter SCAD Registry were surveyed about the COVID-19 pandemic. ResultsAmong 1352 participants, 727 (53.8%) completed surveys between June 2, 2021 and September 29, 2021. The majority of respondents (96.7%) were female, with a mean age of 54.9 ± 9.4 years. At the time of completing the survey, which was early in the pandemic, 91 respondents (12.6%) reported having prior COVID-19 symptoms, with < 1% experiencing hospitalization (n = 4) or cardiac complications (n = 6). A total of 14% had ≥ moderate anxiety symptoms, per the General Anxiety Disorder-7 item survey, and 11.8% had ≥ moderate depressive symptoms, per the Patient Health Questionnaire-9 item. Higher stress scores on the Likert scale were correlated with pandemic-related reduction in work hours and/or pay and/or unemployment (P = 0.013), remote work and/or change of job (P < 0.001), and loss of insurance and/or medical coverage (P = 0.025). A higher anxiety level, as measured on the Likert scale, was correlated with pandemic-related remote work and/or change of job (P = 0.007) and loss of insurance and/or medical coverage (P = 0.008). Since the start of the pandemic, 54% of respondents reported having at least monthly chest pain. Chest pain and COVID symptoms were each associated with higher scores on the General Anxiety Disorder-7 item survey and the Patient Health Questionnaire-9 item. ConclusionsEarly in the pandemic, COVID-19 symptoms, hospitalization, and cardiac complications were uncommon among SCAD patients. The burden of anxiety and depressive symptoms was minimal to mild, similar to that in prior reports. Likert-scale measures of stress and anxiety were higher among persons with work and/or pay reduction and/or unemployment, remote work and/or change of job, and loss of insurance and/or medical coverage. Over half of respondents reported experiencing chest pain, which was correlated with depressive and anxiety symptoms, highlighting an overarching clinical need.

Kounis syndrome as a cause of acute coronary syndrome

Introduction. Kounis syndrome (KS) represents an acute coronary syndrome (ACS) induced by a hypersensitivity reaction. First described by Kounis and Zavras in 1991, KS today represents an infrequently diagnosed clinical syndrome. Three different KS variants have been defined: type I vasospastic allergic angina, type II allergic myocardial infarction, and type III stent thrombosis. Outlines of cases. This paper presents three cases of type II KS causing anaphylactic ACS. In the first case, a 66-year-old female presented with dyspnea, dizziness, and electrocardiography findings suggesting ACS after she was stung by a bee. In the second case, we present a 64-year-old female admitted to the Emergency Department with chest pain after an anaphylactic reaction due to an iodine contrast injection used for a thoracic computed tomography scan. In the third case, an 80-year-old female presented with chest pain, palpitation, and skin rash shortly after administration of the intravenous anesthetic propofol during elective malignant colon tumor surgical intervention. All patients were treated at the Cardiology Clinic, University Clinical Center of Serbia. Conclusion. The primary mechanism of KS corresponds to the release of inflammatory mediators during a hypersensitivity reaction triggered by different sources. Although well known, constant reminders of this cause of ACS are needed.

Characterizing atherosclerotic tissues: in silico analysis of mechanical properties using intravascular ultrasound and inverse finite element methods.

Atherosclerosis is a prevalent cause of acute coronary syndromes that consists of lipid deposition inside the artery wall, creating an atherosclerotic plaque. Early detection may prevent the risk of plaque rupture. Nowadays, intravascular ultrasound (IVUS) is the most common medical imaging technology for atherosclerotic plaque detection. It provides an image of the section of the coronary wall and, in combination with new techniques, can estimate the displacement or strain fields. From these magnitudes and by inverse analysis, it is possible to estimate the mechanical properties of the plaque tissues and their stress distribution. In this paper, we presented a methodology based on two approaches to characterize the mechanical properties of atherosclerotic tissues. The first approach estimated the linear behavior under particular pressure. In contrast, the second technique yielded the non-linear hyperelastic material curves for the fibrotic tissues across the complete physiological pressure range. To establish and validate this method, the theoretical framework employed in silico models to simulate atherosclerotic plaques and their IVUS data. We analyzed different materials and real geometries with finite element (FE) models. After the segmentation of the fibrotic, calcification, and lipid tissues, an inverse FE analysis was performed to estimate the mechanical response of the tissues. Both approaches employed an optimization process to obtain the mechanical properties by minimizing the error between the radial strains obtained from the simulated IVUS and those achieved in each iteration. The second methodology was successfully applied to five distinct real geometries and four different fibrotic tissues, getting median R 2 of 0.97 and 0.92, respectively, when comparing the real and estimated behavior curves. In addition, the last technique reduced errors in the estimated plaque strain field by more than 20% during the optimization process, compared to the former approach. The findings enabled the estimation of the stress field over the hyperelastic plaque tissues, providing valuable insights into its risk of rupture.

Contemporary review on spontaneous coronary artery dissection: insights into the angiographic finding and differential diagnosis

Spontaneous coronary artery dissection (SCAD), although in the majority of cases presents as an acute coronary syndrome (ACS), has different pathophysiology from atherosclerosis that influences specific angiography findings and enables most patients to be solved by optimal medical therapy rather than percutaneous coronary intervention (PCI). Therefore, accurate diagnosis is essential for adequate treatment of each patient as management of SCAD differs from that of ACS of atherosclerotic aetiology. So far, invasive coronary angiography remains the most important diagnostic tool in suspected SCAD. However, there are ambiguous cases that can mimic SCAD. In this review, the authors summarize current knowledge about the diagnostic algorithms, particularly angiographic features of SCAD, pitfalls of angiography, and the role of intracoronary imaging in the context of SCAD diagnosis. Finally, apart from the pathognomonic angiographic features of SCAD that are thoroughly discussed in this review, the authors focus on obscure angiography findings and findings that can mimic SCAD as well. Differential diagnosis and the timely recognition of SCAD are crucial as there are differences in the acute and long-term management of SCAD and other causes of ACS.

Hemophagocytic syndrome and coronary artery aneurysms in a child with Kawasaki disease

Mucocutaneous lymph node syndrome (Kawasaki syndrome/disease) is an acute systemic disease characterized by a predominant lesion of medium and small arteries (arteriitis), the development of destructive proliferative vasculitis. The most serious manifestations of Kawasaki disease are coronaritis and the formation of aneurysms of the coronary arteries, which can be a potential cause of acute coronary syndrome in children. The article presents our own clinical observation of a 7-month-old child with a complete form of Kawasaki disease with the formation of aneurysms of the coronary arteries, complicated by acute coronary and hemophagocytic syndromes. Kawasaki syndrome should be considered in all children with persistent fever ≥ 5 days, and the combination of persistent fever with 2–3 typical features of Kawasaki syndrome should be an absolute indication for echocardiography with mandatory visualization of the coronary arteries.

Case Report: Concomitant spontaneous dissection of the coronary artery and internal carotid artery in a young man

Introduction Spontaneous coronary artery dissection (SCAD) is a relatively rare cause of acute coronary syndrome (ACS), generally affecting young or middle-aged women and people with few conventional atherosclerosis risk factors. Its association with dissection of the internal carotid artery is exceptional. Through our observation of a concomitant spontaneous coronary and carotid dissection, we discuss its clinical presentation, therapeutic management, pathogenesis and factors favouring its occurrence. Case We report the case of a 34-year-old man admitted to emergency with a segment elevation myocardial infarction (STEMI). The patient developed right hemiplegia and aphasia. Cerebral CT revealed a left ischaemic stroke in the anterior junctional territory, and CT angiography of the supra-aortic arteries revealed a dissection of the left internal carotid artery. However, CT angiography of the aorta revealed no abnormalities. Coronary angiography performed after 48 hours showed a dissection of the anterior inter-ventricular artery. Conclusions Concurrent dissection of the coronary and internal carotid arteries with an uninjured aorta is a rare entity. This association suggests a congenital pathology of the vessels such as Marfan’s disease or Ehlers-Danlos syndrome.

Drugs for spontaneous coronary dissection: a few untrusted options.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome that is often overlooked, misdiagnosed, and maltreated. Medical treatment poses a significant challenge because of the lack of randomized studies to guide treatment. The initial clinical presentation should guide medical and interventional management. Fibrinolytic agents and anticoagulants should be avoided because they could favor hematoma propagation. In patients with SCAD, antiplatelet therapy should be prescribed especially dual antiplatelet therapy (DAPT) consisting of aspirin and clopidogrel, whereas potent P2Y12 inhibitors, e.g., ticagrelor and prasugrel, should be avoided. If a stent was used, DAPT should be continued for 12 months. Aspirin only can be an option for patients without "high-risk" angiographic features-thrombus burden, critical stenosis, and decreased coronary flow. Beta-blocking (BB) agents should be used to prevent recurrence of SCAD. There is a general agreement that angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, mineralocorticoid antagonists, and loop diuretics should be used in patients with SCAD experiencing the symptoms of heart failure and a decrease in left ventricular ejection fraction below 50%. Although without firm evidence, statins can be used in SCAD due to their pleiotropic properties. The results of a randomized trial on the use of BB and statins are awaited. Aggregation of data from national registries might point out truly beneficial medications for patients with SCAD.

Poor prognosis of patients with acute coronary syndrome presenting optical coherence tomography-defined calcified nodule at culprit lesions after emergent percutaneous coronary intervention

Abstract Background Optical coherence tomography (OCT) enables the diagnosis of underlying causes of acute coronary syndrome (ACS). Calcified nodule (CN) is reported to be a rare but important cause of ACS, although its prognostic impact on clinical outcomes after emergent percutaneous coronary intervention (EPCI) remains undetermined. TACTICS registry is an investigator-initiated, prospective, multicenter, observational study to be conducted at 22 hospitals in Japan to clarify the prevalence of underlying causes of ACS defined by OCT (plaque rupture [PR], plaque erosion [PE] and CN) and its impact on clinical outcomes, and assess the feasibility of OCT-guided emergent PCI (UMIN-CTR, ID 000039050). Purpose This study aimed to clarify the prevalence of CN at the culprit lesions in ACS patients and its prognostication after EPCI in a large prospective registry. Methods We assessed 702 patients enrolled in TACTICS registry who underwent OCT assessment of the culprit lesion during EPCI. Advanced chronic kidney disease (CKD) was defined as those with creatinine clearance &amp;lt;30 ml/min/1.73m2. The prevalence of OCT-defined CN and occurrence of MACE, defined as a composite of cardiovascular death, myocardial infarction, heart failure, or ischemia-driven unplanned revascularization at 1 year were compared between patients with and without advanced CKD. Result Patients with advanced CKD was found in 5.4% of a total cohort. The prevalence of CN was 3.0% in patients with non-advanced CKD and 21.1% in those with advanced CKD (p&amp;lt;0.001). In advanced CKD, MACE occurred most frequently in patients with CN (87.5%), followed by plaque rupture (11.8%) and plaque erosion (10.0%) (p&amp;lt;0.001). In Cox hazard analysis, CN was a significant predictor for MACE in advanced CKD (hazard ratio [HR], 12.94 (3.31-50.67), p&amp;lt;0.001). In contrast, CN was not significant predictor for MACE in non-advanced CKD (HR1.931 (0.706-5.281), p=0.200). Conclusion CN is significantly more frequently found at the culprit lesions of ACS in advanced CKD patients. CN was associated with poor outcome in advanced CKD patients.

Breaking the silence: uncovering the underdiagnosis of SCAD in young women with acute coronary syndromes

Abstract Background Spontaneous Coronary Artery Dissection(SCAD) is a recognized cause of Acute Coronary Syndrome (ACS), particularly in young women. Despite increasing awareness, underdiagnosis of SCAD remains common. Given the distinct differences in management and potential outcomes, a prompt and accurate diagnosis of SCAD is crucial for appropriate treatment and follow-up. Purpose To assess the prevalence and implications of SCAD underdiagnosis in young women with ACS and to identify potential indicators of SCAD. Methods We included consecutive women aged ≤55 years with an ACS referred for coronary angiography (CAG) to a tertiary center from 2012 to 2021. All index CAG’s and when available intracoronary imaging recordings were retrospectively reviewed to identify angiographic signs of SCAD according to the Yip-Saw criteria. Known cardiovascular risk factors, predisposing conditions for SCAD, and major adverse cardiovascular events (hospital visits, recurrent ACS, target vessel revascularization, stroke) were collected during hospitalization and follow-up. SCAD patients were compared to ACS patients without SCAD (atherosclerotic coronary artery disease, coronary spasm, no abnormalities). Subsequentially, the initially recognized SCAD patients were compared to the reclassified SCAD patients. Results 293 patients (mean age 48±5 years) were included, 217 (74%) presenting as STEMI and 64 (22%) as NSTEMI. Based on retrospective analysis of the (intra)coronary images SCAD was the underlying cause of the ACS in 17% of all patients (n=50/293) while only recognized at initial diagnosis in 26% (n=13/50) of these cases. SCAD type 2a was most frequently missed (30%). Compared to ACS patients without SCAD, SCAD patients were younger (47±6 vs. 49±5 years, p&amp;lt;0.05), had lower rates of smoking (28% vs. 60%, p&amp;lt;0.05) and less often a history of dyslipidemia (10% vs. 24%, p&amp;lt;0.05) and diabetes (2% vs. 16%, p&amp;lt;0.05). Furthermore, the coronary tortuosity score was higher (4.7±2.0 vs. 3.0 ±1.5, p&amp;lt;0.05). Invasively treated SCAD patients often received ≥3 coronary stents when compared to ACS patients without SCAD (28% vs. 15%, p=0.02) mostly due to hematoma extension. Follow-up showed ACS based on atherosclerosis occurred less often in SCAD patients compared to non-SCAD patients (resp. 9% vs. 14%, p&amp;lt;0.05), and recurrent SCAD was only recorded in reclassified SCAD patients (5% vs. 0%, p&amp;lt;0.05). On multi-variate analysis, the coronary tortuosity score (1.58 [1.3-1.88]) was associated with SCAD. Conclusion This study reveals that underdiagnosis of SCAD is common in young women with ACS leading to incorrect treatment with specific medication and excessive coronary stenting. Healthcare providers should be cautious for SCAD in young ACS patients with few cardiovascular risk factors and high coronary tortuosity scores. This study emphasizes the need for greater awareness and improved diagnostic methods for SCAD in young women with ACS.

Abstract 18940: Can the Religious Observation of Fasting Cause Prinzmetal’s Angina?

CASE DESCRIPTION: A 73-year-old male with HTN, HLD, CAD/MI status post PCI to the RCA and LAD (2021), and former tobacco use presented with acute, severe, left-sided chest pain with nausea, diaphoresis and dizziness. He started fasting and adjusted his sleep schedule 3 days prior for Ramadan, but did not miss any of his medications including isosorbide and ranolazine. He was chest pain free on arrival, but subsequently developed severe chest pain becoming bradycardic, hypotensive and hypoxic. At that time the EKG (Figure 1) showed ST elevation (STEMI) in leads II, III and aVF with high degree atrioventricular block. He was started on intravenous fluids and a vasopressor but had spontaneous resolution of symptoms within 10 minutes. Emergent coronary angiography revealed stable 70% stenosis of an ostial left circumflex (LCx) artery and non-obstructive CAD of the RCA. Labs revealed normal blood glucose, negative urine toxicology and mild elevation of troponin (trended serially). Echocardiogram was normal with no regional wall motion abnormalities. He was treated as vasospastic angina with addition of a calcium channel blocker without recurrence of his symptoms. DISCUSSION: Vasospastic angina is an important cause of acute coronary syndrome. Our patient had severe vasospastic angina while being treated for CAD for over 10 years. No prior studies have linked fasting to vasospasm. We hypothesize that fasting and a diurnal sleep schedule may contribute to worsened episodes in susceptible individuals due to hormonal changes including glucose shifts and an increase in catecholamines and cortisol. Increased catecholamine levels may induce spasm by stimulation of alpha receptors in the coronary arteries, and cortisol can induce vascular inflammation, potentiating negative effects. We highlight the importance of keeping high clinical suspicion for a diagnosis of vasospasm, as well as the need to further understand the complex pathophysiology to counsel patients in the future.