Rationale and design of the BA-SCAD (Beta-blockers and Antiplatelet agents in patients with Spontaneous Coronary Artery Dissection) randomized clinical trial.

INTRODUCTION Y OBJECTIVES: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. Most patients are empirically treated with beta-blockers and antiplatelet drugs. The Beta-blockers and Antiplatelet agents in patients with Spontaneous Coronary Artery Dissection (BA-SCAD) is an academic, pragmatic, prospective, randomized, open-label, blinded-endpoint clinical trial, performed under the auspices of the Spanish Society of Cardiology, to assess the efficacy of pharmacological therapy in patients with SCAD. METHODS: Using a 2 x 2 factorial design, 600 patients will be randomized (1:1/1:1) to: a) beta-blockers (yes/no) and b) "short" (1 month) vs "prolonged" (12 months) antiplatelet therapy. Only patients with preserved left ventricular ejection fraction will be randomized to beta-blockers (yes/no) because patients with reduced left ventricular ejection fraction will receive beta-blockers according to current guidelines. Similarly, only conservatively managed patients (ie, no coronary intervention) will be randomized to the antiplatelet stratum, as patients requiring coronary interventions will receive 1-year dual antiplatelet therapy. The primary efficacy endpoint includes a composite of death, myocardial infarction, stroke, coronary revascularization, recurrent SCAD, and unplanned hospitalization for acute coronary syndrome or heart failure at 1 year. The primary safety endpoint will be bleeding. All patients will be clinically followed up yearly. A comprehensive set of additional substudies (clinical, imaging, revascularization, biomarkers, inflammatory, immunologic, pharmacogenetics, and genetic) will be conducted to ensure a holistic view of this unique and challenging clinical entity. CONCLUSIONS: The results of the BA-SCAD randomized clinical trial will advance our knowledge in the treatment of patients with SCAD. The study was registered at ClinicalTrials.gov (Identifier: NCT04850417).

Long-Term Follow-Up of Pediatric Patients After Congenital Coronary Artery Fistula Closure.

The surgical closure of congenital coronary artery fistulas (CAF) is associated with excellent immediate outcomes. Few studies have investigated the long-term prognosis in patients who have undergone surgery for the closure of CAF or differentiated among types of CAF or types of surgical procedures. In this study, we performed clinical examinations and computed tomography angiography (CTA) to characterize outcomes after CAF closure in pediatric patients. The medical records of 79 pediatric patients who underwent surgical closure of CAF were retrospectively reviewed. The median age of the patients included in the study at the time of surgery was 3.4 years (range 0.2 to 15.3 years). The patients had been followed up for 11 years (range 1 to 17 years) with electrocardiography, echocardiography, and coronary CTA. There were 67 medium-to-large CAF and 12 small CAF. Twenty-six (32.9%) CAF arose from the branch coronary artery (proximal type); the others arose from the parent coronary artery (distal type). The surgical procedure included endocardial closure in 16 cases, epicardial distal ligation in 51 cases, epicardial proximal and distal ligation in 12 cases. There was no instance of perioperative death among the cases included in the study. Twenty-eight patients were treated with antiplatelet medication postoperatively. No patient required re-operation during the follow-up period. Coronary thrombi were detected in 27 patients (34.2%). There was no instance of myocardial ischemia related to thrombosis. Among the patients with thrombosis, 26 had medium-to-large CAF (96.3%), and 23 had distal-type CAF (85.2%). Average age at surgery was higher among the patients with thrombosis than among the patients without thrombosis (7.4 years vs. 3.3 years, t = 5.509, P = 0.000). Among the patients with distal-type CAF, thrombosis was more common among the patients treated with ligation than treated with endocardial closure (41.5% vs. 16.7%, χ2 = 3.742, P = 0.043). There was no difference in risk for thrombosis between the patients who did vs. did not receive antiplatelet therapy (P = 0.436). The most common complication after CAF closure was thrombosis. Increased risk for thrombosis was associated with large fistulae, distal-type CAF, and older age at presentation. Antiplatelet treatment did not appear to decrease the risk of thrombosis. Among patients with distal-type CAF, risk for thrombosis was lower among patients treated with endocardial closure, compared with patients treated with epicardial ligation.

Unduly long left main (79 mm) coronary artery arising from right coronary sinus in a 64-year-old diabetic man.

Coronary artery anomalies are usually an incidental finding on coronary angiogram. Most of them are benign, although few of them are malignant which may cause sudden cardiac death. A 64-year-old diabetic, hypertensive man underwent coronary angiography for evaluation of exertional dyspnoea, and angina which revealed an anomalous left main coronary artery (LMCA) arising from right coronary sinus which was unduly long (79 mm) but free from any disease. To the best of our knowledge after extensive search in literature, this is the longest LMCA to be ever reported. The patient was managed conservatively.

Multiple recurrences of spontaneous coronary artery dissection in a woman with fibromuscular dysplasia.

A 54-year-old woman with no prior coronary artery disease or cardiac risk factors was diagnosed with spontaneous coronary artery dissection (SCAD) after presenting with an acute coronary syndrome. Over the next 5 years, she experienced four more episodes of SCAD, involving different coronary artery distributions, with evidence of complete angiographic healing following conservative management with antiplatelet therapy and beta-blockade.

Spontaneous Coronary Artery Dissection in the Postoperative Period: A Case Report.

Spontaneous coronary artery disease is an uncommon and likely underdiagnosed cause of sudden cardiac death affecting typically young and middle-aged women. We report a case of spontaneous coronary artery disease in the postoperative period in a female patient who developed an acute coronary event after gynecologic surgery. The patient was clinically asymptomatic except for mild hemodynamic instability and ST-segment-elevation myocardial infarction seen on electrocardiogram. Spontaneous coronary artery disease was diagnosed with coronary angiography, and a pharmacological therapy was instituted with favorable results.

Spontaneous coronary artery dissection in a young woman with polycystic ovarian syndrome.

Polycystic ovarian syndrome (PCOS) affects 4% to 12% of women in reproductive age, representing a clinical condition that could predispose to cardiovascular diseases. We report a case of a 34-year-old woman with PCOS, presenting with chest pain, onset two days before, and ST segment-elevation myocardial infarction. She was not pregnant or in a postpartum state. Subsequent cardiac angiography revealed spontaneous left anterior descending coronary artery dissections, managed by conservative approach. The patient was discharged in medical therapy after 5days. This is the first observation of spontaneous coronary artery dissection occurring in a PCOS patient.

Spontaneous Distal Right Coronary Artery Dissection in a Patient With Massive Pulmonary Embolism: Thrombolyze or Not?

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial ischemia, myocardial infarction, and sudden cardiac death. We report a case with SCAD of distal right coronary secondary to pulmonary thromboembolism. Reported treatment options for SCAD include medical therapy, thrombolysis, balloon angioplasty, and coronary artery bypass surgery. The decision as to which one depends on the clinical and angiographic factors. The benefit of thrombolysis in these patients is controversial. The prognosis in patients surviving the initial event is generally believed to be favorable. In patients who remain stable, conservative management seems to be safe and is compatible with a good long-term outcome.

[Spontaneous coronary artery dissection and ST-segment elevation myocardial infarction (STEMI)]. / Un cas, une revue : hématome et dissection coronaire spontanés dans le SCA ST.

Spontaneous coronary artery dissection (SCAD) is a poorly understood and under-diagnosed entity of acute coronary syndrome, affecting predominantly young women. On coronary angiography, the diagnosis remains challenging, particularly in case of intramural hematoma without intimal rupture. Intracoronary imaging, especially by optical coherence tomography (OCT), provides an incremental value in terms of diagnosis and management. We report the case of a 49-year-old woman admitted for STEMI caused by an intramural hematoma. In the discussion part, we aim to review the epidemiology, physiopathology, diagnosis, management and long-term prognosis of SCAD.

Spontaneous coronary artery dissection: the management dilemma continues.

Spontaneous coronary artery dissection (SCAD) is an increasingly recognised cause of acute coronary syndrome, particularly in women. A 36-year-old Caucasian woman presented to our hospital with sudden onset chest pain and was diagnosed with a non-ST elevation myocardial infarction. Coronary angiography revealed mid and distal left anterior descending artery (LAD) dissection with distal LAD occlusion. A short segment of apical LAD filled late with incomplete opacification (Thrombolysis In Myocardial Infarction (TIMI) 1 flow). A decision was made to treat the patient conservatively, with subsequent resolution of dissection over the next 3 months. Our patient made a good clinical recovery with healing of her affected coronary vasculature on subsequent angiogram. The case illustrates that SCAD can be managed conservatively with antiplatelet agents, ß-blockers, heparin and statins, if the patient is haemodynamically stable and coronary flow is adequate.

Recurrent spontaneous coronary artery dissection in a woman with fibromuscular dysplasia.

We report a case of five recurrent myocardial infarctions due to repeat spontaneous coronary artery dissection (SCAD) in a woman with underlying fibromuscular dysplasia. Her angiographic SCADs were missed on two occasions. Patients with a history of SCAD are at risk for recurrent dissections. This case also highlights the angiographic variants of SCAD, and the utility of intracoronary imaging in diagnosing suspected SCAD.

Spontaneous coronary artery dissection associated with fibromuscular dysplasia.

This case presentation concerns a woman known to have fibromuscular dysplasia (FMD) who presented with an acute coronary syndrome (ACS). The coronary angiogram was considered to be normal. However, as spontaneous coronary artery dissection (SCAD) has a close association with FMD, subsequent meticulous review of the angiogram revealed a dissection within the circumflex coronary artery. SCAD causes 10% of ACS seen in women under 55 years of age. Both FMD and SCAD are underdiagnosed and SCAD may be overlooked or misdiagnosed on coronary angiography. The recommended management of SCAD differs from that of the usual presentations of ACS. For this reason, one should be alert to the possibility of SCAD when confronted by ACS in a younger woman, especially when she is known to have FMD.

Outcomes following conservative management of spontaneous coronary artery dissection.

Spontaneous coronary artery dissection (SCAD) is a rare but a serious cause of myocardial ischaemia and infarction that occurs most frequently in younger female patients. The management of this rare condition remains controversial. In this case series we describe the spectrum of outcomes observed following conservative management.

Estatinas para el síndrome coronario agudo: medicina basada en evidencia sobre la administración temprana con dosis de carga / Stations in acute coronary syndrome: use of an early loading dose

Objetivo: En algunos Servicios de Emergencias de la CCSS, a los pacientes con infarto agudo de miocardio se les administra una dosis alta aunque variables de lovastatina en las primeras horas de evolución de los síndromes coronarios agudos, con la expectativa de lograr efectos pleiotrópicos, un resultado positivo sobre el endotelio y la disminución de mediadores inflamatorios. Analizar la evidencia científica que sustenta el beneficio de esta intervención farmacológica y clarificar la posible dosis oral y el potencial intervalo idóneo. Búsqueda vías electrónicas en sistemas secundarios de información científica y análisis de fuentes primarias, con énfasis en ensayos clínicos aleatorizados que evalúen la eficacia de las estatinas en los eventos coronarios agudos; también de fuentes terciarias , específicamente revisiones sistemáticas y guías de consenso para prácticas clínicas basadas en evidencia y revisiones por instancias evaluadoras de tecnología con reconocimiento internacional. Resultados: Cuatro ensayos clínicos aleatorizados controlados con placebo, no demostraron diferencias significativas ni clínicamente relevantes en la variable primaria combinada: evento cardiaco mayor, muerte, IAM recurrente fatal, AVC fatal u otra causa de muerte cardiovascular, ninguno usó dosis de carga, ni se inició la administración en las 24hs del inicio de la sintomatología. Conclusión: Ante la falta de evidencia que permita proyectar con claridad un papel beneficioso para las estatinas en el manejo inicial del síndrome coronario agudo, esta práctica desequilibra la relación beneficio/riesgo y se aleja de los principios del uso racional de medicamentos y la aplicación del paradigma de la medicina basada en evidencia.

Solitary coronary artery nourishing the entire heart.

Coronary artery anomalies are being more frequently diagnosed these days both because increasing numbers of patients are undergoing diagnostic studies and because advanced radiographic imaging methods are now commonly available. An isolated single coronary artery giving rise to the main coronary branches is a rare congenital anomaly. In this report we present a patient with a solitary coronary ostium, with both the left and right coronary artery systems arising from it, and then following their usual courses. This case was diagnosed incidentally during conventional angiography.

Anomalous origin of left coronary artery from the pulmonary artery does the management in the adult differ from that of the infant? Four cases of the Bland-White-Garland Syndrome.

We report four adult patients with anomalous origin of left main coronary artery from the pulmonary artery that presented to us from 1995 to 2006. One died suddenly at the age of 21 years before undergoing surgery, two patients had ligation and left internal mammary artery (LIMA) grafting to the left anterior descending artery, and one had aortic implantation of the left main coronary artery. All three patients who had surgical treatment are doing well.

Ponte miocárdica multiarterial: apresentações clínica e anatômica incomuns / Multi-arterial myocardial bridge: uncommon clinical and anatomical presentations

Homem de 42 anos, sem fatores de risco para doença arterial coronariana, internado com precordialgia atípica. Eletrocardiograma após a introdução de nitrato endovenoso evidenciou supradesnivelamento do segmento ST de V1 a V4. Cineangiocoronariografia demonstrou ponte miocárdica nas três artérias coronárias além de extensão incomum na descendente anterior (80 mm). A evolução foi satisfatória com a suspensão do nitrato e instituição de betabloqueador e antagonista de canais de cálcio.

We report the case of a 42-year-old man with no risk factors for coronary artery disease admitted with atypical chest pain. The electrocardiogram performed after intravenous injection of nitrate revealed ST-segment elevation in leads V1 to V4. The coronary angiography showed myocardial bridges in the three coronary arteries, besides an unusual length of the left anterior descending artery (80 mm). The patient progressed well following the discontinuation of nitrate use and introduction of beta-blockers and calcium channel antagonists.

Management of anomalous coronary arteries from the contralateral sinus.

Anomalous origin of the coronary artery from the contralateral sinus of Valsalva, coursing between the aorta and pulmonary artery, has garnered much attention because of its association with sudden death. Current medical opinion is heavily skewed toward "successful" intervention. However, two key issues have not been critically analyzed: what is the true risk of sudden death from an anomalous coronary artery, and how does this risk balance against the risk of surgical intervention? Common misconceptions about risk derive from citations of autopsy data. In fact, the scant available data suggest a far lower absolute risk than commonly cited. The risks of surgical intervention, while likely quite low, remain real, and include aortic valve damage and neurological sequelae. The lack of long-term outcomes data precludes any definite recommendations in most patients. The decision to intervene is thus not straightforward, and should be approached cautiously and only after appropriate counseling of the patient.

Multiple congenital coronary artery fistulae draining into the left ventricle.

Coronary artery fistula between a coronary artery and a cardiac chamber is a rare condition, especially when multiple fistulas communicate with the left ventricle. Herein we report a case of an elderly woman with multiple diffuse coronary artery-left ventricular fistulas diagnosed by angiography. Since the coronary artery-cardiac chamber communications were multiple and diffuse neither surgery nor transcatheter coil occlusion was considered in this case.

Multiple congenital coronary artery fistulae draining into the left ventrice / Físulas coronariias congénitas múltiples drenando el ventrículo izquierdo

Coronary artery fistula between a coronary artery and a cardiac chamber is a rare condition, especially when multiple fistulas communicate with the left ventricle. Herein we report a case of an elderly woman with multiple diffuse coronary artery-left ventricular fistulas diagnosed by angiography. Since the coronary artery-cardiac chamber communications were multiple and diffuse neither surgery nor transcatheter coil occlusion was considered in this case.

Las fístulas de las arterias coronarias que drenan a las cavidades cardíacas son una anomalía infrecuente, especialmente cuando son múltiples y drenan hacia el ventrículo izquierdo. Presentamos el caso de una mujer octogenaria con múltiples fístulas difusas que se originan de la coronaria izquierda y que drenan al ventrículo izquierdo. El hecho de que fuesen múltiples y difusas imposibilitó una intervención quirúrgica o percutánea como se recomienda en estos casos. (Arch Cardiol Mex 2004; 74:45-48).