Esther S Kim’s research while affiliated with Vanderbilt University and other places

Introduction: Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of myocardial infarction. Migraine headache has been reported to be common among patients with SCAD, but the degree of migraine-related disability has not been quantified. Methods: Clinical data and headache variables were obtained from the baseline assessment of the prospective, multicenter iSCAD Registry. Migraine-related disability was quantified using the self-reported Migraine Disability Assessment (MIDAS). Demographic, clinical, psychosocial, and medical characteristics from data entry forms were compared between patients with and without migraine. Results: Of the 773 patients with available data, 46% reported previous or current migraines. Those with migraines were more likely to be women (96.9% vs 90.3%, p = 0.0003). The presence of underlying carotid fibromuscular dysplasia was associated with migraine (35% vs 27%, p = 0.0175). There was not a significant association with carotid artery dissection and migraine. Current migraine frequency was less than monthly (58%), monthly (24%), weekly (16%), and daily (3%). Triptan use was reported in 32.5% of patients, and 17.5% used daily migraine prophylactic medications. Using the MIDAS to quantify disability related to migraine, 60.2% reported little or no disability, 14.4% mild, 12.7% moderate, and 12.7% severe. The mean MIDAS score was 9.9 (mild to moderate disability). Patients with SCAD had higher rates of depression and anxiety (28.2% vs 17.7% [p = 0.0004] and 35.3% vs 26.7% [p = 0.0099], respectively). Conclusions: Migraines are common, frequent, and a source of disability in patients with SCAD. The association between female sex, anxiety, and depression may provide some insight for potential treatment modalities.

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 >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.

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 (< 24 vs. ≥ 24 hours), and early vs. delayed coronary angiography (time from hospital presentation to coronary angiography < 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.

Introduction: Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of myocardial infarction. The demographics and clinical differences based on race in patients with SCAD are not well understood. Methods: Demographics and clinical variables were obtained from the prospective, multicenter iSCAD Registry. Characteristics of study participants (including demographics, past medical history, timeline, imaging studies, follow-up visits, SCAD presentation, and treatment) were compared between white and non-white patients. Race and ethnicity was self-reported by a patient questionnaire. Results: A total of 505 patients were included in the analysis. Among them, 427 (84.6%) were characterized as white and 78 (15.4%) were characterized as non-white. White patients were 49.5 years and non-white patients were 46.8 years at the time of the initial SCAD presentation (p=0.0435). White patients were more likely to be married (77% vs 51%, p<0.0001) and were more likely to have a college degree (42 vs 28%, p<0.0001). White patients were more likely to present to the hospital in less than 24 hours (85% vs 75%, p=0.07) and have an angiogram in less than 24 hours (78% vs 58%, p=0.004). White patients were more likely to present with STEMI (30% vs 11%, p=0.004) and were more likely to receive revascularization (25% vs 11%, p=0.0147). A multivariable analysis explored the variables associated with angiography greater than 24 hours. STEMI vs NSTEMI [OR 0.090 (0.035 to 0.231), p<0.0001] and white vs non-white [OR 0.376 (0.188 to 0.755), p=0.0059] remained significant. White patients were more likely to have fibromuscular dysplasia (FMD), (43% vs 30%, p=0.0336). There was no significant difference in the number of non-coronary vascular imaging studies between the two groups. Conclusions: The number of non-white patients enrolled in the iSCAD registry is low. White patients with SCAD were more likely to present with STEMI and were more likely to have a diagnosis of FMD. Further research is needed to study associations between race and differences in presentation, comorbidities, and treatment in patients with SCAD.

Introduction: Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction in young women; however, SCAD has also been described in older patients. Differences in SCAD presentation, cardiovascular risk factors, presence of extracoronary vascular abnormalities (EVAs), and management across the lifespan have been understudied. Methods: Single-center cohort study of consecutive patients seen in a dedicated SCAD clinic. Medical history, radiographic, and angiographic data were collected. All patients underwent brain to pelvis CTA imaging to evaluate for EVAs. Patients were stratified into three age groups: 20-40, 40-60, and ≥60 years. Differences among age groups were evaluated using Kruskal-Wallis tests for continuous variables and Pearson Chi-squared tests or Fisher’s exact tests for categorical variables. Results: 193 patients met inclusion criteria, 94.3% women. Prevalence of hypertension (14.8%, 42.6%, and 60%, p<0.001) and dyslipidemia (11.1%, 37.4%, and 53.3%, p<0.001) increased with age. Precipitating factors were significantly different among age groups (p<0.001) with usual exertion more commonly seen in the older cohort (25.5%, 39%, 73.3%). Peripartum SCAD (40%, 2.5%, 0%) and female sex (94.5%, 95.9%, 80%) were more commonly seen in the younger cohort (p<0.001). Younger patients were more frequently discharged on anticoagulation (10.9%, 0.8%, 0%, p<0.004). There were no significant differences in SCAD presentation, vessel involvement, SCAD management, and EVA prevalence. Procedural complications were not different. Conclusions: Older women who develop SCAD have more typical risk factors for ACS including hypertension, and dyslipidemia. Clinical presentation, vessel distribution, and management of SCAD do not vary across age groups. The prevalence of arteriopathies is high and similar across age groups, underscoring the importance of the evaluation for EVAs following SCAD in patients of all ages.

Introduction: Dual antiplatelet therapy (DAPT) is standard for patients (pts.) with acute coronary syndrome due to atherosclerosis. Evidence to support DAPT vs single antiplatelet therapy (SAPT) for spontaneous coronary artery dissection (SCAD) is limited. Hypothesis: Prescription of DAPT vs SAPT varies among specialized centers for SCAD. Methods: Analysis of 505 pts. with complete patient questionnaire, case report form, and angiography review enrolled in the iSCAD Registry from 9 sites with > 20 pts. enrolled. Data are presented for 442 pts. with complete medication data who received DAPT or SAPT during index hospitalization (HOSP) and continued at discharge (DC). Results: Patient age 49.6 + 10.2 years, 83% were female. Presentation of SCAD: NSTEMI (55.9%), STEMI (26.9%), unstable angina (13.8%), cardiac arrest (4.3%), cardiogenic shock (0.2%). Most common SCAD location was the LAD (60.9%); 20.8% had multivessel SCAD. Management was: medical therapy (75.2%), PCI (22.5%), CABG (1.4%), or PCI + CABG (0.92%). During HOSP 70.1% (317/452) were treated with DAPT vs 29.9% SAPT (135/452). At DC, 74.7% were prescribed DAPT (339/442) vs 25.3% SAPT (112/452). In multivariable analyses, only PCI as SCAD treatment was associated with DAPT during HOSP (OR 3.57, 95% CI 1.90-6.70) or DC (OR 4.9, 95% CI 2.28-10.53). There was significant heterogeneity of antiplatelet regimen across sites ranging from 34.0%-87% DAPT during HOSP (p<0.0001) and 53.8%-83.6% DAPT at DC (p=0.0011) (Figure). There was a trend of recurrent MI among pts. treated with DAPT vs SAPT during HOSP that did not achieve statistical significance (7.1% vs 3.0%, P=0.09). Conclusion: In the iSCAD Registry, most pts. with SCAD were treated with DAPT during index HOSP and DC with significant heterogeneity across sites. PCI during index HOSP was associated with DAPT (vs SAPT) prescription. Further study of outcomes, including recurrent MI, with DAPT (vs SAPT) during hospitalization and subsequent follow-up is needed.

Introduction: Association of takotsubo syndrome (TTS) with spontaneous coronary artery dissection (SCAD) has been described previously. Characteristics and in-hospital prognosis of SCAD patients with concomitant TTS remain unclear. Methods: Patients with angiography-confirmed SCAD were selected from the iSCAD Registry and underwent core lab adjudication of left ventriculography (LVG) and coronary angiography including assessment of SCAD lesion characteristics, TIMI Flow Grade (TFG), and TIMI Myocardial Perfusion Grade (TMPG). Classic TTS was defined as wall motion abnormality (WMA) presenting as apical ballooning. TTS variants were defined as non-apical WMA discordant to dissected coronary territory with apical sparing. In-hospital event was defined as composite of recurrent myocardial infarction (MI), cerebrovascular accident, heart failure requiring diuretics, or new arrhythmia. Results: On blinded review of LVG from 216 patients, TTS was identified in 38 (17.6%) patients (classic, midventricular, and focal pattern: 86.8%, 2.6%, and 10.5%, respectively). There was no significant difference in age, cardiovascular risk factors, history of anxiety or depression, recreational substance use, emotional or physical stressors, extracoronary vascular abnormalities, peak troponin levels, or TFG of dissected arteries between TTS and non-TTS groups. TTS patients were more likely to present with ST-segment elevation MI (47.4% vs 27.5%; p=0.02), left anterior descending artery (LAD) involvement (89.5% vs 59.0%; p=0.0004), and TMPG < 3 (68.4% vs 48.3%; p=0.02) compared to non-TTS patients. TTS patients had a greater risk of in-hospital events (32.4% vs 15.1%; p=0.01), mainly attributed to new arrhythmia (27.0% vs 6.5%; p=0.0009) and heart failure (11.4% vs 3.0%; p=0.03). Conclusion: Coexistence of TTS and SCAD was associated with ST-elevation MI, LAD involvement, impaired microvascular myocardial perfusion, and adverse in-hospital outcomes.