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A 54-year-old female experienced short-term chest pains the day before admission. Two hours prior to admission, she reported severe chest pain radiating to her shoulders. She is hemodynamically stable with no significant arrhythmias.

Her vital signs include a blood pressure of 120/80 mmHg and a heart rate of 70 beats per minute.

Notable risk factors include hypertension, hypothyroidism, a history of smoking, menopause, and thyroid carcinoma surgery seven years ago. She has had no previous cardiovascular events. Additionally, it’s worth mentioning that her father passed away from pancreatic cancer.

 

ECG at admission:

TEE was preformed, EF 56%:

Lab values: Troponin 6.8, GFR 77 _ml/min/1.74m², K⁺  4.6, Gly 5.5, HOL 4.9, HDL 1.82, LDL 2.39, CRP 3.2

Initial therapy: ASA 300mg, Ticagrelor 180mg, Heparin 7000 i.v., Rosuvastatin 40mg

Coronary angiography:

Discharge therapy: ASA 75mg, Clopidogrel 75mg, Rosuvastatin 20mg, Bisoprolol 2.5mg , Ramipril 2.5mg, Euthyrox 100mcg

Control Coronary Angiography – 1 month after:

 

Initial and 1 month after

Six months following a previous episode of SCAD, the patient experienced severe chest pain radiating to both arms after strenuous activity. The patient remains hemodynamically stable with no significant arrhythmias observed.

Vital signs at the time of presentation show a blood pressure of 135/80 mmHg, a heart rate of 54 beats per minute, and a troponin level of 13.7.

ECG:

TEE was preformed, EF 61%:

Coronary angiography:

Discharge therapy: ASA 75mg, Clopidogrel 75mg -discontinued after a month, Rosuvastatin 20mg, Bisoprolol 2.5mg , Ramipril 2.5mg, Euthyrox 100mcg

What do you think is the reason for SCAD and ACS?
How long would you keep DAPT after the first and second events?

A 37-year-old female presented with a concerning episode of chest pain that radiated to her left arm, lasting approximately 10 minutes.

Notably, she has no known chronic diseases and does not possess any risk factors for cardiovascular disease.

Upon admission, her troponin level was measured at 2.27 ng/ml, prompting her admission to the Intensive Care Unit (ICU) for further evaluation and management.

ECG at admission:

An elective coronary angiography was done on the seventh day following her admission.

Coronary angiography:

RCA with 99% stenosis i medial segment and 80% in medio-distal segment.

PCI was preformed:

ECHO showed LV 4.72/3.28, EF:57%, hypokinesia of inferior wall.

One year later, a woman, 39 years old, presents with acute coronary syndrome (ACS), without risk factors for coronary heart disease (CHD), and without comorbidities.

She is the sister of a previous patient!

She is experiencing chest pain accompanied by nausea and vomiting. Symptoms started one day prior to admission. The pain is located behind the sternum and radiates to both arms down to the elbows.

Her troponin levels was measured at 0,00… 1,84… 12,55… 0,10 ng/ml

ECG at admission:

ECG during chest pain:

The patient was on medical therapy for 3 days, and subsequently, a coronary angiography was performed. In the meantime, there were multiple episodes of chest pain that responded to sublingual nitroglycerin (NTG) or NTG infusions.

Coronary angiography:

In the medial segment of LAD, there is SCAD type II with TIMI flow I-II.

It has been decided to continue with medical therapy.
Th: ASA 100mg, Clopidogrel 75mg, Nebivolol 5mg, Atorvastatin 60mg, PPI, NTG prn.

ECHO showed LV:5.15/3.22, EF:55% hypokinesia of apex and distal half of lateral wall

Coronary angiography after 3 months shows complete recovery:

Author: Prim Dr sc med Vladimir Mitov, FACC, KC Zaječar

Did the first sister had SCAD?

Would you treat the first sister conservatively if you had this knowledge about SCAD?

A 42 years old patient complains of chest pain on exertion for last 6 months. TEE shows normal LV with no wall motion abnormalities.
Fisk factors for CKD: obesity, positive family history for CKD.

After the positive stress test patient is referred for coronary angiography.

ECG:

Beginning of stress test

End of stress test

Coronary angiography:

Due to suspected SCAD patient was hospitalized. Repeated coronary angiography at 2 weeks showed no changes.

IVUS: dissection and intramural haematoma in LAD.

IVUS-guided PCI was done:

DES 3.50×30 mm @ 12atm.

False lumen covered with stent.

Stent optimisation with NC baloon.

 

ECHO: normal LV with no wall motion abnormalities.

After PCI patient is stable, no chest pain.

Therapy on discharge: ASA, Clopidogrel, b-blocker, ACEi.

Authors: dr Vlada Zdravković, dr Dušan Vulović, dr Đorđe Stevanović, UKC Kragujevac

Would You do PCI without intravascular imaging?

A 57 years-old female was admitted in regional hospital because of NSTEMI with OHCA due to the VF in October 2022.
Risk factors for cardiovascular diseases: hypertension, positive family history for CVD and smoker.

Three years ago Stanford B dissection was registered and conservatively treated.

After initial stabilisation patient was transferred to the tertiary center for coronary angiography and further diagnostic.
At the admission she was without any symptoms.
Status at the admission: alerted, oriented, hemodynamically and rhythmically stable, Killip I.

ECG on admission:

ECHO:

Coronary angiography:

Operators: Prof. Dr I. Ivanov, Doc. Dr M. Čanković, IKVBV Sremska Kamenica

Would you decide for PCI LAD?

             Part two

 

In the second act was planned PCI LAD with intravascular imaging ( OCT).

During the hospitalization, the patient had symptoms of COVID-19 infection and was transferred to COVID hospital Novi Sad.

Two weeks later OCT guided PCI LAD was performed.

OCT pullback before PCI

PCI LAD

OCT pullback after stent implantation

Stent postdilatation

Final result:

Female 62y. old hospitalized in a regional hospital as NSTEMI.

Presented on September 23. with chest pain. ECG showed SVT with ST-segment depression. Baseline troponin level 1.8 (ref. value <0.04).

Risk factors for CVD: hypertension, obesity (BMI 36), positive family history of CVD

Referred for elective coronarography on December 1.

ECG:

Coronarography:

ECHO:

 

Coronarography was presented to 8 interventional cardiologists for interpretation.

Answers:

SCAD: 5

Bridge: 1

SCAD+Bridge: 2

 

Due to the lack of an OCT catheter the patient was referred to CTA.

 

CTA: calcified plaque in proximal LAD with 25% stenosis 20mm from ostium.  Medial LAD is very thin with loss of opacification at 50mm from ostium.

 

Control coronarography was done on December 23, with a plan to do OCT.

After NTG administration.

Initially planned OCT was not done.

Questions:

Do you agree with the myocardial bridge as a diagnosis?

Would you do an OCT after the administration of NTG?

What are possible adverse events in OCT imaging of the coronary artery with a myocardial bride?

Coexistence of Spontaneous Coronary Artery Dissection, Takotsubo Cardiomyopathy, and Myocardial Bridge:

Female 41. years old presents to regional hospital Leskovac with chest pain that started 30 minutes ago with unprovoked, severe chest pain that propagated to the left arm a lower jaw and was accompanied by headache.

STEMI diagnosis was confirmed, and she was loaded with Aspirin and Clopidogrel and transported to the PCI center (KBC Niš). The patient complained of elevated blood pressure during her menstrual cycle which was accompanied by headaches.

Risk factors for CVD: arterial hypertension, obesity (BMI >40)

ECG on admission:

LAB: TnI 2.180; K 3.1; Hol 4.47; LDL 2.49; HDL 1.24; TRIG 1.6

In CICU she received LMWH (Clexane 100mg c.s) and was sent to the cath lab.

Angiography showed moderate lumen narrowing in mid-LAD with TIMI3 flow.

Angiogram SCAD; classified  as normal (without significant lesions)

After returning from a cath lab, the patient is asymptomatic.

During her stay in CICU she was on DAPT an LMWH (Clexane 100mg BID).

ECG after cath lab:

ECHO day one:

After a hearth team discussion and angiography review, SCAD was suspected.

On the fourth-day control angiography an OCT were performed confirming SCAT type 2 with intramural hematoma and no flap i mid-LAD.

LMWH was discontinued.

Patient discharged with 1 month DAPT and the Clopidogrel 75mg permanently.

ECG on discharge:

Coronary angiograpy after one month:

ECHO after one month:

 

1. Do you think that first angiographic results are misinterpreted often?
2. Would you do an OCT in the acute phase on a patient like this?
3. Since the patient didn’t undergo a PCI would you give DAPT up to one month?
4. Should a patient like this be sent to cardiac rehabilitation?

A 47-year-old female, 10 minutes before admission to the hospital, felt pain between her shoulder blades, then a sharp stabbing recurrent chest pain that lasted 2-3 minutes in each episode. The pain was accompanied by shortness of breath and nausea.
She is an administrative worker in a hospital, under lots of stress lately.
CVD risk factors: smoker (3 pack-years), positive family history of CVD.

During the exam she suddenly lost conscience; ECG showed VF, and she was defibrillated.

 

ECG after DC shock: ST elevation in inferior and lateral leads.

Premedication (Brilique 180mg, tbl. Aspirin 300mg, LMWH 0.6 s.c) and Cath lab was activated.

Angiography showed SCAD type 2 on mid-distal LAD with a lumen reduction of 99%.

 

After returning from a cath lab, the patient is asymptomatic, and ECG changes are in regression.

 

50 minutes after angiography she complains of chest pain again. ECG shows ST elevation in inferior and lateral leads.

 

Cath lab was activated a second time. Angiography showed SCAD type 4.

After multiple balloon pre-dilatations with Artimes 1.25x15mm stents, Resolute Onyx 2.5×18 at 12 atm, Resolute Onyx 2.75×18 at 14 atm, Resolute Onyx 2.75×15 at 18 atm were implanted in LAD. TIMI3 flow was restored.

After the PCI patient was asymptomatic with ECG changes resolution.

She received DAPT and Bisoprolol 5mg; LMWH was discontinued after 2 days.

ECHO:

Day one:

Day four:

Day 26:

Author: prof. dr Svetlana Apostolović, Klinika za KVB, UKC Niš

Operator: prof. dr Zoran Perišić, Klinika za KVB, UKC Niš

1. Do you think the fast progression of scad is due to intensive DAPT?
2. What do you think about the PCI technique used?
3. Would you continue LMHW after stent implantation?

Zašto sam počela da proučavam SCAD

Žena 38 godina, 7 dana nakon drugog porođaja se prezentuje u regionalni centar kao STEMI.

• Bez faktora rizika za KVB
• Lečila 2 godine sterilitet

2011 godina….malo se znalo o SCADu

Danas bi bilo sve drugačije……

Autor: prof. dr Svetlana Apostolović, Klinika za KVB, UKC Niš

Bolesnica 35 godina, 4.7.2020. primljena u ZC Zaječar iz bolnice u Negotinu zbog sumnje na AKS. Bol u grudima u toku noći koji je probudio iz sna i širi se u levu ruku.

Lična anamneza: leči se od steriliteta duži niz godina. Negira druge hronične bolesti.

U lab analizama: hs-Troponin T: 1487

Pulmo: normalan disajni šum. Cor: akcija ritmična, tonovi jasni, bez dodatnih tonova i šumova. TA:140/80 mmHg, Fr:80/min.

Pri prijemu bez bola u grudima.

EKG pri prijemu:

EHO srca: Ao: 2,8, LP: 3,8, LK: 5,6/3,5, EF: 63%, blago dilatirane šupljine sa EF:66%, bez segmentih ispada u kinetici, SPDK: 30mmHg. Perikard hiperehogen lako raslojen do 2,5mm ispred donjeg zida

Koronarografija:

U daljem toku hospitalizacije bolesnica bez bolova u grudima, hemodinamski stabilna.

U lab analizama se registruje peak hs-troponina T od 4000.

Elektrokardiografski evolucija anterolateralno:

 

Bolesnica je otpuštena na kućno lečenje sa terapijom: Cardiopirin 75mg, Vivace 5mg, Tensec 5mg, Rosuvas 20mg.

Otpusna dijagnoza Myocarditis acuta.

 

Autor: Prim Dr sc med Vladimir Mitov, FACC, KC Zaječar

Da li vidite neku promenu na angiogramu?
Šta mislite o faktorima rizika pacijentkinje?
Koja bi bila Vaša dopunska dijagnostika?
Da li biste je otpustili sa ovom terapijom?

             Drugi deo

 

Bolesnica je 24.06.2021. godine ponovno primjena iz bolnice u Negotinu u ZC Zaječar zbog sumnje na STEMI prednjeg zida. Bol u grudima koji traje poslednja 2h i širi se u levu ruku.
U Negotinu Troponin:12525 pg/ml
Pulmo: normalan disajni šum.
Cor: akcija ritmična, tonovi jasni, bez dodatnih tonova i šumova. TA:120/80 mmHg, Fr:80/min.

EKG:

EHO srca: Aorta 2,9, LP: 3,7, LK: 5,5/4,3, EF: 50%, hipokinezija vrha i apikalnog segmenta septuma, SPDK: 22mmHg. Perikard bez raslojavanja.

 

Koronarografija:

U daljem toku hospitalizacije bolesnica je bolova u grudima. Hemodinamski stabilna.

EKG na otpustu:

Terapija na otpustu: ASA 100mg, Clopidogrel 75mg, Bisoprolol 7,5mg, Amlodipin 5mg, Rosuvastatin 40mg

Dijagnoza na otpustu: MINOCA u čijoj osnovi je SCAD

Da li mislite da je ovo SCAD?
Da li biste ušli u proceduru sa cutting balonom?
Da li bi konzervativno lečenje podrazumevalo samo jedan antitrombocitni lek?

Dana 26.08.2021 urađena je rekoronarografija.

 

             Treći deo

 

Kontrolni EHO srca i ERGO test urađeni nakon dve godine.

EHO: Globalna i regionalna kontraktilna funkcija leve komore su očuvene

ERGO test:
U miru:

Tokom testa:

Oporavak:

 

Da li je bezbedno pacijentu sa istorijom SCAD raditi ERGO test?