Cause Of Acute Coronary Syndrome Research Articles

Treatment strategy for spontaneous coronary artery dissection based on anatomical characteristics

ObjectivesTo compare the clinical and angiographic characteristics of high-risk and low-risk spontaneous coronary artery dissection (SCAD) patients to determine the optimal treatment strategy.BackgroundSCAD is a rare and emerging cause of acute coronary syndrome and sudden cardiac death, especially in young female patients. However, the indication of percutaneous coronary intervention (PCI) in patients with SCAD remains elusive.MethodsWe evaluated the clinical and angiographic characteristics of all SCAD patients admitted to our center from 2012 to 2020. The outcomes of the high-risk and low-risk SCAD patients according to the location of the lesion segment with dissection or intramural hematoma were compared. Further analyses were performed to evaluate the vessel healing or residual dissection in the patients receiving the follow-up angiography.ResultsA total of 81 SCAD patients were enrolled in the present study, in which 38 patients were categorized as high-risk group, defined as involvement of the left main artery or proximal segment of any main coronary artery. PCI was the more common treatment approach in the high-risk group (68.4%), while conservative treatment was more common in the low-risk group (62.8%). The incidence of major adverse cardiac events, defined as cardiac death, myocardial infarction, unstable angina pectoris, severe arrhythmias, or heat failure, within 1 year follow-up was similar between the two groups. 57 patients (70.4%) received the follow-up angiography after 1 year. The high- and low-risk groups had a similar rate of vessel healing among the PCI treatment patients. However, more patients achieved spontaneous healing in the low-risk group than the high-risk group among the conservative treatment patients (86.4% vs. 33.3%, p < 0.05).ConclusionsConservative management remains the recommended treatment strategy for the low-risk SCAD patients. PCI could be considered in high-risk SCAD patients with favorable clinical outcomes and vessel healing. Characterization of lesion anatomy may be an important indicator for treatment decision.

Essential Thrombocytosis in Patients

In patients under <40 years, traditional cardiovascular (CV)-risk factors are a less likely cause of acute coronary syndromes (ACS) compared to older counterparts. To estimate the prevalence of essential thrombocytosis (ET), a hematological disorder and less-prevalent risk factor, in young patients presenting with ACS. We constructed a retrospective database of all patients <40 years (n=271) that had consecutively undergone coronary angiography (CAG) after theirfirstACS within our hospital within the last ten years (2010-2020) and had known thrombocyte counts (n=241). Patients with thrombocytes >450x10*9/L were screened for this hematological disorder. In our database, we identified 15 subjects with thrombocytosis. One was previously known as ET. Of the remaining 14 patients, five were considered reactive/secondary thrombocytosis, and four were lost to follow-up, four were eventually diagnosed with ET, one remains uncertain. The diagnosis was newly established before the initiation of this study in two patients (average delay: six years). Two patients were identified as a result of this study. Conclusion: With a prevalence of at least 2.1%, ET appears not uncommon in patients <40 years with ACS. Moreover, screening patients with ACSandelevated thrombocytes yielded a novel diagnosis of ET in 27% of patients. The diagnosis was initially missed in all cases. Since the timing of revascularization should be adjusted to thrombocyte count/initiation of ET therapy to prevent thrombotic complications, cardiologists should know, recognize and screen for this pathology in ACS-patients, notably in those with absent traditional CV-risk factors: an 'ACS-protocol' aimed at less-prevalent risk factors could support this.

585 SPONTANEOUS CORONARY ARTERY DISSECTION: THE ROLE OF CORONARY CT ANGIOGRAPHY IN THE FOLLOW-UP MANAGEMENT

Abstract Background Spontaneous coronary artery dissection (SCAD) is one of the causes of acute coronary syndrome (ACS) and sudden death (SD). This condition predominantly affects young women with a few or no conventional risk factors for CAD. Diagnosis is traditionally made with invasive coronary angiography (ICA); nevertheless, coronary computed tomography angiography (CCTA) is going to be a new useful tool in the acute diagnosis and at follow-up in these patients. Conventional treatment could involve a conservative approach with medical therapy or an invasive approach with percutaneous coronary intervention (PCI). Methods We retrospectively analyzed data of 57 SCAD patients followed up with Coronary CT angiography (CCTA) at our centre. Clinical and angiographic (invasive and non invasive) data were collected at baseline and at the follow-up. The primary outcome was a composite of all cause mortality and hospitalization for cardiovascular cause evaluated at 1690,7±1082,3 days; the secondary outcome was the evaluation of the vessels with CCTA at 777,9 ± 271,6 days. Results 57 patients were divided in 2 groups: 46 patients underwent a conservative treatment (80,7%) and 11 patients a PCI treatment (19,3%). The first group is composed of 15,2% male and the second of 27,3% male (p=0,387), mean age is 52,8±11,1 years vs 48,0±10,7 years (p=0,201). Patients treated with PCI has a significative higher incidence of smoking habits (45,5% vs 15,2%; p=0,042), peripheral arteriopathy (18,2% vs 0%; p=0,034), higher troponin peak (40425,8 vs 13436; p=0,011) and lower ejection fraction (51,4±11,0 vs 57,1±7,6; p=0,050). Moreover the PCI population has a more common involvement of 2 vessels (72,7% vs 6,5%; p&amp;lt;0,001), of the left main coronary artery (45,4% vs 0%; p&amp;lt;0,001) and of the circumflex coronary artery (45,4% vs 2,2%; p=0,001). At the follow up, there were no statistical differences for the primary and secondary outcomes between the 2 groups (p&amp;gt;0,05). Among patients treated with conservative therapy, there were a more frequent recurrence of SCAD in those treated with DAPT than in those treated with SAPT (33,3% vs 5,9%; p=0,033). Conclusions in patients with SCAD, conservative management is comparable to PCI treatment in terms of clinical and angiographic outcomes. Among patients treated with conservative therapy, DAPT at discharge was independently associated with a higher rate of SCAD recurrence at follow-up.

The Australian New Zealand Spontaneous Coronary Artery Dissection (ANZ-SCAD) Registry - A Multi-Centre Cohort Study: Protocol, Background and Significance.

Spontaneous coronary artery dissection (SCAD) is an under-recognised cause of acute coronary syndrome (ACS) with a strong female predominance. There are currently limited prospective studies and no randomised controlled trials that inform on SCAD's best clinical care. Little is also known about predictors of acute SCAD deterioration or recurrence. We describe the study design of a multi-centre prospective and historical cohort study recruiting patients with SCAD across 15-20 sites in Australia/New Zealand (NZ). The primary aim is to describe the clinical presentation, management and outcomes along with predictors of acute deterioration and recurrence in a large Australian/NZ SCAD cohort, with international data pooling. Consented patients diagnosed with SCAD during a hospital admission for an ACS will be prospectively followed at 30 days then yearly, for up to 5 years. Each recruiting site will also retrospectively identify historical cases of SCAD from the proceeding 10 years, with a waiver of consent. For historical cases, data will be collected in a de-identified manner with date of last follow-up or death obtained from the medical records. All cases undergo core laboratory adjudication of coronary angiography and any accompanying imaging to confirm SCAD diagnosis. The primary endpoint will be occurrence of major adverse cardiovascular events; a composite of all-cause mortality, recurrent myocardial infarction (including SCAD recurrence), stroke/transient ischaemic attack, heart failure, cardiogenic shock, cardiac arrest/ventricular arrhythmia, heart transplantation and, repeat/unplanned revascularisation. Secondary endpoints will include each individual primary outcome as well as acute SCAD extension and quality of life/Seattle Angina Score in prospectively recruited participants. Endpoints will be assessed at the end of the hospital admission and at 30-days, 1 year, and median long-term follow-up. Multicentre ethics approval has been granted from the Western Sydney Local Health District Human Research Ethics Committee (2021/ETH00040). The analysed results will be published in peer-reviewed journals on completion of the historical data collection and then on completion of the prospective data collection. The ANZ-SCAD registry has been prospectively registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12621000824864).

Multivessel spontaneous coronary artery dissection: Clinical features, angiographic findings, management, and outcomes

BackgroundSpontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. Multivessel (MV) SCAD is a challenging clinical presentation that might be associated to a worse prognosis compared with patients with single-vessel (SV) involvement. MethodsThe Spanish multicentre nationwide prospective SCAD registry included 389 consecutive patients. Patients were classified, according to the number of affected vessels, in SV or MV SCAD. Major adverse events (MAE) were analyzed during hospital stay and major cardiac or cerebrovascular adverse events (MACCE) at long-term clinical follow-up. ResultsA total of 41 patients (10.5%) presented MV SCAD. These patients had more frequently a previous history of hypothyroidism (22% vs 11%, p = 0.04) and anxiety disorder (32% vs 16%, p = 0.01). MV SCAD patients presented more often as non-ST segment elevation myocardial infarction (73% vs 52%, p = 0.01) and showed less frequently type 1 angiographic lesions (12% vs 21%, p = 0.04). An impaired initial Thrombolysis In Myocardial Infarction (TIMI) flow 0–1 was less frequent (14% vs 29%, p < 0.01) in MV SCAD. In both groups, most patients were treated conservatively (71% vs 79%, p = NS). No differences were found regarding in-hospital MAE or MACCE at late follow-up (median 29 ± 11 months). However, the rate of stroke was higher in MV SCAD patients, both in-hospital (2.4% vs 0%, p < 0.01) and at follow-up (5.1% vs 0.6%, p = 0.01). ConclusionsPatients with MV SCAD have some distinctive clinical and angiographic features. Although composite clinical outcomes, in-hospital and at long-term follow-up, were similar to those seen in patients with SV SCAD, stroke rate was significantly higher in patients with MV SCAD.

Abstract 11578: A Case of Spontaneous Coronary Artery Dissection Masking as Acute Myopericarditis

Introduction: Chest pain is a common reason for emergency room visits. Acute coronary syndrome (ACS) remains a high mortality etiology of chest pain. Spontaneous coronary artery dissection (SCAD) is a rare cause of ACS in the general population, but a relatively common cause of ACS in young women. Case: Patient is a 29-year-old female with history of anxiety and fibroids that presented with chest pain. She described the chest pain as sharp, substernal, non-radiating that lasted for 10 minutes after eating dinner. The pain improved with leaning forward and resolved when lying on her stomach. She had a second episode of chest pain after 2 hours with similar characteristics which lasted 10 minutes. She was 4 months post-partum. She reported having a sore throat 4 days prior to the presentation. Troponin peaked at 0.173. ECG showed diffuse ST-elevation and PR depression in V3-V6 I II III aVF. TTE showed LVEF 65% and no wall motion abnormalities. CTA coronary showed 50-60% narrowing of mid LAD. Cardiac MR showed mild hypokinesis of mid-anteroseptal wall with associated subendocardial to midmyocardial delayed enhancement with focal elevations in myocardial native T1 and T2, and LVEF 53%. Coronary catheterization showed 50-60% stenosis in the mid-LAD distal to the first diagonal artery, there was no improvement in the stenosis after administration of intra-coronary nitroglycerin, there were no septals noted to arise from this area, consistent with diagnosis of SCAD (figure 1). Diagnosis: On initial evaluation, the etiology of her chest pain appeared to be myopericarditis. However, using CTA coronary, cardiac MR and coronary catheterization findings, the pain was more consistent with type 1 NSTEMI in the setting of SCAD. Patient was started on IV heparin, metoprolol tartrate, and aspirin. Conclusions: SCAD is a life-threating and often missed etiology of ACS. It requires a high index of suspicion and should be in the differential diagnosis in young women presenting with chest pain.

Abstract 11699: In Hospital Outcomes of Acute Coronary Artery Dissection and Obesity

Introduction: Coronary artery dissection is an emergency condition due to a tear in the coronary arterial wall, and it’s an uncommon cause of acute coronary syndrome. The Effect of Obesity on the outcome of acute coronary artery dissection is poorly documented. Hence, our study sought to estimate the impact of Obesity on clinical outcomes of hospitalizations of patients with acute Coronary artery dissection using the national database. Methods: We queried the National Inpatient Sample (NIS) database from 2016 to 2019. The NIS is the largest inpatient hospitalization database in the United States. The NIS was searched for hospitalization of adult patients with acute Coronary artery dissection as a principal diagnosis with and without Obesity as a secondary diagnosis using ICD-10 codes. The primary outcome was inpatient mortality. The secondary results were Acute kidney injury (AKI), Cardiogenic shock (CS), Cardiac arrest (CA), Total hospital charge (THC), and length of stay (LOS). Multivariate logistic and linear regression analyses were used accordingly to adjust for confounders. Results: About 2440 patients were admitted for acute Coronary artery dissection; 17.4% (425) had underlying obesity. Cohorts with obesity vs No obesity had a mean age of 52.9 years [CI 50.4 - 55.5] vs 55.9 years [CI 54.5 - 57.4]; male (20% vs 25.8%), female (80% vs 74.2%); white (71.3% vs 73.3%), black (21.3% vs 12.0%), and Hispanic (6.3% vs 7.8%). Compared to patients without obesity, patients admitted with coexisting obesity had similar inpatient mortality (7.1% vs 3.2%, AOR 3.22, 95% CI 0.74 - 13.88, P=0.118), AKI (15.3% vs 9.9%, P 0.357), CS (9.4% vs 11.2% P=0.098), CA (5.9% vs 5.0% P=0.530), THC (IRR 0.94, 95% CI 0.64 - 1.37, P=0.738), and LOS (IRR 0.79, 95% CI 0.59 - 1.05, P=0.107). Conclusions: Patients admitted primarily for acute Coronary artery dissection with co-existing Obesity had similar inpatient mortality, AKI, CS, CA, THC, and LOS compared to patients without Obesity.

Abstract 13011: A Rare Case of Spontaneous Coronary Artery Dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is a rare condition; an intimal tear or bleeding of vasa vasorum leads to the creation of a false lumen filled with intramural hematoma. The hematoma causes coronary stenosis, leading to subsequent myocardial ischemia. SCAD is the cause of Acute Coronary Syndrome (ACS) in 0.1 to 4% of cases. Men account for less than 10% of cases, with a mean age of 48.6. Case Study: A 19-year-old male with prior medical history of morbid obesity and marijuana use was transferred from another hospital to our service after presenting with non-ST elevation MI. He was admitted following 30 minutes of a throbbing/pressure-like sensation in his throat, one episode of vomiting, and paresthesia in his left arm that spontaneously resolved. Initial EKG showed sinus rhythm with early repolarization changes. His troponin rose from 0.2 to 18 ng/mL. Upon admission, his high sensitivity troponin peaked at 15,000 pg/mL. Repeat EKG showed dynamic changes with T wave inversions in the inferolateral leads. The patient underwent an angiogram showing a diffuse, mid-LAD 40% de novo spontaneous dissection and a diffuse, distal-LAD 20% de novo spontaneous dissection with TIMI grade 3 and 2 flow, respectively. A repeat angiogram two days later showed improved coronary artery flow and deemed a low-risk lesion with stable patient hemodynamics; no intervention followed. The patient was treated conservatively with DAPT and discharged home with an outpatient Cardiology follow-up. A plan to have further imaging in 4 weeks to assess hematoma resolution was made. Conclusions: This case demonstrates an atypical presentation of SCAD in a very low-risk patient, given his sex, age, and clinical presentation of nonspecific chest pain. This case highlights the importance of high clinical suspicion for SCAD regardless of ACS risk profile in a patient presenting with chest pain.

Abstract 10420: Spontaneous Coronary Artery Dissection in a Young Man Taking Sumatriptan

Introduction: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. There is an approximate 9:1 female predominance, and commonly cited risk factors include fibromuscular dysplasia, pregnancy, and cocaine use. We present a case of SCAD in a young man with migraines and triptan use, initially misdiagnosed as panic disorder. Case: A 25-year-old man with a history of migraines treated with sumatriptan presented with several months of intermittent chest pain and syncopal episodes. He had been evaluated in an emergency department at the onset of symptoms and diagnosed with panic disorder. His EKG now showed Q waves in leads V1-V2 and T wave inversions in leads I and AVL. Serial troponins were stable at 0.04 ng/mL. An echocardiogram showed left ventricular apical ballooning and large thrombus. Left heart catheterization revealed significant stenosis of the proximal LAD and 50% stenosis of the mid LAD (Fig. 1A). A follow-up CT angiogram showed intimal thickening and perivascular fat stranding in the proximal and mid LAD, confirming a diagnosis of SCAD (Fig. 1B). A full-body CTA showed no additional aneurysm or dissection. Inflammatory markers and autoimmune serologies were negative. Urine toxicology was negative for cocaine or amphetamines. Given an otherwise unrevealing workup, migraines and triptan use were identified as the significant risk factors for SCAD. He was discharged with clopidogrel, warfarin, and metoprolol and counseled against further use of triptans Discussion: Multiple studies have reported increased prevalence of SCAD in patients with migraines, particularly those using triptans. This phenomenon likely relates to stimulation of 5-HT1B and 5-HT1D receptors in the coronary vasculature. Greater recognition of SCAD and its risk factors is essential for timely diagnosis and treatment, particularly in young patients whose chest pain may be falsely attributed to non-cardiac causes.

Abstract 15281: Patient and System-Related Delays in Presentation and Invasive Coronary Angiography in Patients Presenting With Acute Myocardial Infarction Secondary to Spontaneous Coronary Artery Dissection: A Report of the ISCAD Registry

Introduction: Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome especially in young patients. Factors associated with delays in presentation and care delivery are not well understood. Methods: We used data from the iSCAD Registry which is a prospective multicenter US registry of patients with SCAD. Early vs. delayed hospital presentation (&lt; 24 vs. ≥ 24 hours), and early vs. delayed coronary angiography (time from hospital presentation to coronary angiography &lt; 24 vs. ≥ 24 hours) for SCAD patients with AMI were assessed. Patient characteristics, and in-hospital events were compared between the two groups. Factors associated with delayed presentation and angiography were explored using multivariable logistic regression. Results: A total of 346 SCAD (294 white, 52 non-white) patients presented with STEMI (34%) or NSTEMI; 57 had a delayed presentation to the hospital after symptoms onset. No significant factors were identified for delays in seeking care. However, white race was less likely to have delayed invasive coronary angiography (multivariable OR=0.38; 95% CI 0.19 to 0.76; p=0.0059). Patients undergoing delayed angiography were also more likely to be medically managed (91.7% vs. 69.8%, p=0.0008), but less likely to receive dual antiplatelet therapy (57.0% vs. 73.1%, p=0.007). In-hospital outcomes were similar between the two groups. Conclusion: In this study, no patient-related variables were identified that predicted a delay in presentation with AMI secondary to SCAD. On the other hand, non-white race was associated with delays in performing invasive coronary angiography. Further investigation is required to determine the factors contributing to this potential disparity.

Abstract 13836: Factors Associated With a Complicated Hospital Course in Patients With Spontaneous Coronary Artery Dissection: A Report of the iSCAD Registry

Introduction: Spontaneous coronary artery dissection (SCAD) is a cause of acute coronary syndrome in younger patients. Though associated with lower short and long-term mortality, there is still a need to identify the subset of patients who are at a higher risk of adverse events or a more complex hospital course. Methods: Using data from the iSCAD Registry, a multicenter registry of patients with SCAD, univariate and multivariable logistic regression models were created to assess the association between factors related to the index admission and a complicated hospital course. A complicated hospital course was defined as the occurrence of either a recurrent myocardial infarction (MI), cerebrovascular accident (CVA), a new arrhythmia, heart failure requiring diuretics, ≥ 2 angiograms performed, or a hospital admission of more than 5 days. The multivariable logistic regression model was developed using a backward selection approach with exit criteria set at p &gt;0.2. Patients presenting with cardiac arrest were excluded. Results: Of the 414 patients included, 159 patients (38.4%) had a complicated hospital course: 76 patients had a prolonged admission, 27 had a recurrent MI, 1 had a CVA, 39 had an arrhythmia, 13 had heart failure requiring diuretics and 72 had ≥ 2 angiograms in the index admission. The final model showed that patients who had structural complications related to MI, fibromuscular dysplasia (FMD), or a history of cardiomyopathy were more likely to experience a complicated hospital course (Table). Finally, patients on anticoagulation were at a higher risk of having the composite outcome but this may be secondary to the indication for anticoagulation. Conclusions: The presence of structural complications related to MI, a diagnosis of FMD, or a history of cardiomyopathy were associated with an increased risk of a complicated hospital course related to SCAD. Identification of risk factors for a complex inpatient stay may help to tailor the acute care of SCAD patients.

Abstract 15639: Infected Thrombus - An Unusual Etiology of Acute Coronary Syndrome in a Patient With New Onset Atrial Fibrillation

Background: Coronary embolism (CE) is an uncommon (3%) cause of acute coronary syndromes (ACS) and is often missed. Case Presentation: A 68-year-old woman with a h/o hypertension &amp; breast cancer post lumpectomy 10 yrs ago, presented with generalized weakness, fever (101F), &amp; vomiting without chest pain, dyspnea, or palpitations. She was afebrile, tachycardic (158 beats/min), tachypneic (26 breaths/min) with BP of 98/64 mmHg. Cardiac exam revealed irregularly irregular rhythm, 5 cm jugular venous distension &amp; 3+ bilateral pretibial edema. Labs revealed thrombocytopenia, lactic acidosis, &amp; hyponatremia. High sensitivity-Troponin was 1023 &amp; NT-pro-BNP 19854. EKG showed atrial fibrillation (AF), diffuse ST elevations in the precordial leads &amp; aVR, poor R wave progression &amp; inferior Q waves. Her cardiac cath revealed a large thrombus from mid-left main extending into the LAD with minimal atherosclerotic burden. Intraoperative transesophageal echocardiogram for emergent surgical resection of the thrombus revealed a highly mobile thrombus 2.32x0.6 cm on the aortic aspect originating between L and R coronary cusps and a left atrial appendage thrombus (1.1 cm) with marked spontaneous contrast in LA appendage &amp; LA which was surgically resected. Blood cultures &amp; of coronary thrombus grew Methicillin sensitive Staphylococcus Aureus (MSSA) . Anticoagulation &amp; appropriate antibiotics were initiated. but after a protracted, complicated ICU stay, patient was made comfort care. Discussion/Conclusion: CE should be considered in cases of recurrent coronary thrombus or in the setting of heavy thrombus burden despite a relatively normal coronary vessel. AF is the most common underlying cause of CE causing ACS. Aspiration or surgical thrombectomy should be performed with a high thrombus burden. Thrombus should be sent for pathology to further delineate the source of thrombus.

Positive Association of Plasma Trimethylamine-N-Oxide and Atherosclerosis in Patient with Acute Coronary Syndrome.

Atherosclerosis is the major cause of acute coronary syndrome (ACS) which is a significant contributor to both morbidity and mortality in the world. The microbiome-derived metabolite trimethylamine-N-oxide (TMAO) has aroused great interest and controversy as a risk factor of atherosclerosis. Therefore, in this study, we aimed at investigating whether plasma TMAO can be a risk factor of atherosclerosis in coronary artery of patients with ACS and how this relates to lipids and proinflammatory cytokines in plasma. We enrolled consecutive patients with ACS who underwent percutaneous coronary intervention (PCI). Gensini scoring was used to evaluate angiographic atherosclerosis in the coronary artery of the patients. 13 patients were divided into low (Gensini score < 25), 33 into intermediate (Gensini score 25-50), and 81 into severe atherosclerosis (Gensini score ≥50). Plasma TMAO, vasculitis factors, and cardiovascular biomarkers were measured by clinical biochemistry, intima-media thickness (IMT) of carotid artery was determined by the Color Doppler ultrasound, and the atherosclerotic lesion in coronary artery was assessed in PCI. Plasma TMAO concentrations were positively associated with Gensini score (OR = 0.629, p < 0.001) and Gensini subgroup (R = 0.604, p < 0.001). Plasma TMAO concentrations in patients with severe coronary atherosclerosis were higher than those of patients with moderate coronary atherosclerosis, and the plasma TMAO concentrations of patients with moderate coronary atherosclerosis were higher than those of patients with mild coronary atherosclerosis, the difference was statistically significant [4.73 (3.13, 4.62) versus 1.13 (0.63, 3.34) versus 0.79 (0.20, 1.29), p < 0.001], respectively. Furthermore, ROC analysis showed that plasma TMAO could identify the severity of atherosclerosis (p < 0.001). The AUC of TMAO for severe atherosclerosis was 0.852 (95%CI = 0.779 - 0.925). The sensitivity and specificity of TMAO for identifying severe atherosclerosis are 96.3% and 63.0% when the cut-off value of TMAO was set at 1.2715 pg/ml. Furthermore, logistic regression analysis showed plasma TMAO concentrations were positively associated with severity of atherosclerosis in coronary artery (OR = 1.934, 95%CI = 1.522 - 2.459, p < 0.001). For all that, negatively association was observed between TMAO and age (OR = -0.224, p < 0.05), B-type natriuretic peptide (BNP) (OR = -0.175, p < 0.05), and interleukin-8 (IL-8) (OR = -0.324, p < 0.001), while positive association was observed between TMAO and nitric oxide (NO) (OR = 0.234, p < 0.01). However, there is no obvious association was observed between Gensini score and cardiovascular biomarkers, vasculitis factors, and carotid IMT, respectively. Our cross-sectional observation suggested that plasma TMAO concentrations positively associated with coronary atherosclerosis in ACS patients and serve as a risk factor for severe atherosclerosis. Plasma TMAO also correlated with age, BNP, IL-8, and NO. However, no obvious association was found between atherosclerosis with vasculitis factors and cardiovascular biomarkers in this study, and there was no conclusive evidence showing TMAO enhance atherosclerosis via regulation of inflammation or lipid.

ODP148 GENDER AFFIRMING HORMONE THERAPY AND SPONTANEOUS CORONARY ARTERY DISSECTION

Abstract Introduction Spontaneous coronary artery dissection (SCAD) is an important and underreported cause of acute coronary syndrome in women. SCAD has been linked to arteriopathy, pregnancy, as well as hormone replacement therapy in cisgender patients. There is a scarcity of data on the long-term cardiovascular effects of gender affirming hormonal therapy (GAHT) with estrogen. Observational studies have shown increased thromboembolic disease and cardiovascular events in transwomen on estrogen, with oral synthetic or oral combined equine estrogens showing a higher association versus transdermal formulations, however there had been no reports of SCAD in transgender patients on GAHT. Clinical Case A 37-year old transwoman with a history of gender affirming orchiectomy on GAHT with sublingual estradiol 2 mg BID presented with typical symptoms of acute coronary syndrome. No prior history of chest pain. No personal history or family history of cardiovascular disease or risk factors. Initial Troponin I was 9.52 ng/dl (&amp;lt;0. 04 ng/dl), ECG with non-specific ST-changes. A transthoracic echocardiogram showed hypokinesis of the mid anterior and lateral wall. She underwent urgent cardiac catheterization, found to have SCAD of her ramus intermedius. Given the size of the lesion and wall motion abnormalities, a cutting balloon was used to inflate the lesion, and she remained chest pain free during the hospitalization. She was started on Aspirin, Clopidogrel, and Metoprolol. Sublingual estradiol was determined to be her only predisposing risk factor and therefore it was held during her hospitalization and during the lesion healing period, with plans to change to a constant transdermal estrogen patch in the primary care setting. Discussion This is the first case report showing an association of estrogen GAHT and SCAD in a transwoman. SCAD has been observed to occur more often in cisgender women during the late luteal phase and post-partum period, raising the hypothesis that estrogen level fluctuations could potentially play a role. Sublingual estradiol has been shown to have higher peak and trough serum concentration compared to oral estradiol. Research is needed in this area and on the potential adverse cardiovascular effects of GAHT and whether route of estrogen administration plays a role. We support transdermal estradiol in transwomen with or at risk of cardiovascular disease, and close monitoring of serum levels, as well as aggressive treatment of cardiovascular risk factors. Presentation: No date and time listed

Multivessel spontaneous coronary artery dissection as a cause of acute coronary syndrome: An oft-forgotten differential diagnosis.

Multivessel spontaneous coronary artery dissection as a cause of acute coronary syndrome: An oft-forgotten differential diagnosis.

Spontaneous coronary artery dissection: A review of diagnostic methods and management strategies.

Spontaneous coronary artery dissection (SCAD) is a rare non-atherosclerotic cause of acute coronary syndromes defined as non-iatrogenic, non-traumatic separation of the coronary artery wall. The most common profile is a middle-aged woman between 44 and 53 years with few cardiovascular risk factors. SCAD is frequently linked with predisposing factors, such as postpartum, fibromuscular dysplasia or other vasculopathies, connective tissue disease and hormonal therapy, and it is often triggered by intense physical or emotional stress, sympathomimetic drugs, childbirth and activities increasing shear stress of the coronary artery walls. Patients with SCAD usually present at the emergency department with chest discomfort, chest pain, and rapid heartbeat or fluttery. During the last decades, the most common problem of SCAD was the lack of awareness about this condition which has led to significant underdiagnosis and misdiagnosis. However, modern imaging techniques such as optical coherence tomography, intravascular ultrasound, coronary angiography or magnetic resonance imaging have contributed to the early diagnosis of the disease. Treatment of SCAD remains controversial, especially during the last years, where invasive techniques are being used more often and in more emergent cardiac syndromes. Although conservative treatment combining aspirin and beta-blocker remains the recommended strategy in most cases, revascularization could also be suggested as a method of treatment in specific indications, but with a higher risk of complications. The prognosis of SCAD is usually good and long-term mortality seems to be low in these patients. Follow-up should be performed on a regular basis.

Spontaneous Coronary Artery Dissection: Review of Possible Pathophysiological Risk Factors.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS) that typically affects the younger and healthier female population without the typical ACS risk factors such as hypertension, diabetes, or hyperlipidemia. The clinical presentation of SCAD can be diverse and the diagnosis is typically by coronary angiography but also can require advanced imaging such as intravascular ultrasound or optical coherence tomography. Past studies have shown the atypical patient characteristics of SCAD patients among ACS patients. The main challenge is that the exact pathophysiology of SCAD is unknown. Potential pathophysiological risk factors are discussed including fibromuscular dysplasia, other arteriopathies, pregnancy and female sex hormone changes, migraines, inflammatory conditions, and stress. The current understanding of these risk factors along with potential pathophysiological mechanisms are discussed. There still remain many areas of additional investigation in understanding this rare cause of ACS.

Clinical features and lipid profiles of plaque erosion over lipid rich plaque versus fibrous plaque

Abstract Backgrounds and aims Plaque erosion (PE) which is one of the most common causes of acute coronary syndrome (ACS) can occur over fibrous plaque or lipid-rich plaque (LRP) according to pathological reports. Whereas in plaque rupture (PR) the main cause of ACS, underlying plaque is basically LRP with thin fibrous cap. We aimed to investigate the clinical features and lipid profiles of PE with or without LRP in comparison to PR. Methods A total of 165 statin-naïve patients with ACS who underwent percutaneous coronary intervention using optical coherence tomography and met the criteria for PR or PE were included. LRP was defined as a plaque with lipid having the maximal lipid arc (&amp;gt;180°). Culprit lesions were categorized into the PR, PE with/without LRP [PE(LRP), PE(Fibrous), respectively). Results The prevalence of PR, PE(LRP), and PE(Fibrous) was 104 (63.0%), 42 (25.5%), and 19 (11.5%), respectively. Patients with PR and PE(LRP) had significantly higher peak creatine kinase (1338, 1733, 214 U/L, respectively, P&amp;lt;0.01) and more prevalence of ST-elevation myocardial infarction (71.2, 78.6, 21.1%, respectively, P&amp;lt;0.01) than PE(Fibrous). Overall, the levels of the various lipid profiles were mostly comparable between PE(Lipid) and PR but different in PE(Fibrous). The levels of small-dense low-density lipoprotein cholesterol was significantly greater in PR and PE(LRP) than in PE(Fibrous) (39.0, 36.6, 25.7 mg/dL, respectively, P=0.02). Conclusion PE(LRP) had substantially different clinical features and lipid profiles compared to PE(Fibrous) showing some similarity to those of PR. Funding Acknowledgement Type of funding sources: None.

Different clinical and pathological profiles of sudden cardiac death victims caused by coronary artery dissection or myocardial infarction with non-obstructed coronary arteries

Abstract Background Spontaneous coronary artery dissection (SCAD) is a potential cause of acute coronary syndrome and sudden cardiac death (SCD). Coronary fibromuscolar dysplasia (FMD) has been correlated to SCAD occurrence.The prevalence of SCAD and FMD among SCD victims are unclear. Myocardial infarction with non-obstructed coronary arteries (MINOCA) could represent a cause of SCD. Since SCAD could clinically manifest as acute myocardial infarction, expert consensus documents have often considered SCAD as a subtype of MINOCA (1,2), but studies which address direct comparison between these two conditions are lacking. Purpose To assess characteristics of decedents with SCAD and/or FMD found at autopsy, and to compare their clinical and pathological profile with MINOCA SCD victims. Methods We reviewed a database of 5325 consecutive cases of SCDs referred to our cardiac pathology center between 1994 and July 2017. Results We identified 21 (0.4%) with SCAD and 37 (0.7%) victims with MINOCA (3), whereas FMD was found only in 2 (0.04%). SCAD decedents were females in 81%, versus 38% of MINOCA (p=0.02). No signs of coronary FMD were found among SCAD and MINOCA victims. Necrotic myocardium was identified in the totality of MINOCA and only in 8 (38%) of SCAD decedents (p&amp;lt;0.001). Pre-mortem cardiac symptoms were present in 100% of SCAD and 49% of MINOCA victims (p&amp;lt;0.001); illicit drug use was reported in none of SCAD versus 46% of MINOCA decedents (p=0.001). Conclusions SCAD is a rare cause of SCD. Compared to MINOCA, SCAD victims are more frequently females, always experienced pre-mortem cardiac symptoms and have no habit of substances abuse. At autopsy coronary FMD is not present among SCAD victims. SCAD and MINOCA shows different clinical and pathological profile. SCAD should not be considered a subtype of MINOCA. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Cardiac Risk in the Young (CRY) and the Charles Wolfson Charitable Trust.

Multivessel spontaneous coronary artery dissection: clinical features, angiographic findings, management, and outcomes

Abstract Background Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. The rate of SCAD patients with multivessel (MV) involvement varies between series (6–13%)1,2. MV SCAD might be potentially associated to a worse prognosis due to a higher ischemic burden compared with patients with single-vessel (SV) involvement. However, comparative data between patients with MV versus SV SCAD is lacking. Methods The Spanish multicentre nationwide SCAD registry prospectively included 389 consecutive patients from 34 university hospitals. Patients were classified according to the number of affected vessels in two groups: SV or MV SCAD. In-hospital major adverse event (MAE) was defined as a composite of death, myocardial reinfarction, unplanned revascularization, cardiogenic shock, ventricular arrhythmia or stroke. A major cardiac or cerebrovascular adverse event (MACCE) was defined as a composite of death, myocardial reinfarction, unplanned revascularization, SCAD recurrence or stroke. Results A total of 41 patients (10.5%) presented MV SCAD (Table 1). There were no significant differences between groups regarding age, sex and distribution of most cardiovascular risk factors, with a non-significant trend towards more hypertension in the MV group (49% vs 34%, p=0.06). MV SCAD patients had more often previous history of hypothyroidism (22% vs 11%, p=0.04) and anxiety disorder (32% vs 16%, p=0.01), with a trend towards more fibromuscular dysplasia (50% vs 29%, p=0.12) among those patients screened. MV SCAD patients presented more often with NSTEMI (73% vs 52%, p=0.01). Regarding angiographic findings, MV SCAD patients presented more frequently focal type 3 lesions (19% vs 6%, p&amp;lt;0.01) and fewer type 1 double-lumen lesions (12% vs 21%, p=0.04). The rate of lesions with an impaired initial Thrombolysis In Myocardial Infarction (TIMI) flow 0–1 was lower (14% vs 29%, p&amp;lt;0.01) in MV SCAD. In both groups, most patients were treated conservatively (71% vs 79%, p=NS). We found no significant differences between groups in MAE during admission. At long-term follow-up (median 29 months), there were no significant differences in MACCE between groups (18% vs 12%, p=0.28). However, the rate of stroke was higher in patients with MV SCAD, both in-hospital (2.4% vs 0%, p&amp;lt;0.01) and at follow-up (5.1% vs 0.6%, p=0.01). This finding could be explained by the basal differences found in hypertension and fibromuscular dysplasia between MV and SV SCAD patients. Conclusions Patients with MV SCAD have some distinctive clinical and angiographic features. We found no significant differences in our primary composite outcomes, both in-hospital and at long-term follow-up, between patients with SV and MV SCAD. Rate of stroke was significantly higher in patients with MV SCAD. Funding Acknowledgement Type of funding sources: None.