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Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI). However, the role of revascularization for SCAD according to presentation remains unclear.We analyzed patients with SCAD who presented acutely and were participating in the Canadian SCAD Cohort Study. We compared revascularization strategy and clinical outcomes (in-hospital major adverse events and major adverse cardiovascular event [MACE] including recurrent MI at 1-year) in patients with SCAD presenting with ST-elevation MI (STEMI) vs unstable angina or non-STEMI (UA-NSTEMI).Among 750 patients with SCAD (mean 51.7 ± 10.5years; 88.5% were women; median follow-up was 373 days), 234 (31.2%) presented with STEMI. More patients with SCAD-STEMI (27.8%) were treated with revascularization (98.5% percutaneous coronary intervention [PCI]) compared with 8.7% of patients with UA-NSTEMI (93.3% PCI). For patients with SCAD and STEMI, 93.9% were planned procedures vs 71.1% for UA-NSTEMI. Successful or partially successful PCI was 65.5% for STEMI and 76.9% for UA-NSTEMI (P0.001). In revascularized patients, 1-year MACE was not different between STEMI and UA-NSTEMI. Revascularization was associated with higher in-hospital major adverse events and its association was more prominent in UA-NSTEMI (STEMI: 26.2% vs 10.7%, P0.001; UA-NSTEMI: 37.8% vs 3.6%, P0.001). The difference in adverse events according to revascularization diminished over time and was not evident at 1 year.Despite higher in-hospital events with revascularization in patients with SCAD, and higher revascularization with SCAD-STEMI, 1-year MACE was not different compared with UA-NSTEMI. This is reassuring, as revascularization may be required for ongoing ischemia at the time of initial presentation in STEMI-SCAD, and emphasizes the need for careful patient selection for revascularization in UA-NSTEMI.

BACKGROUND The coronavirus 2019 (COVID-19) pandemic has caused unparalleled public health crisis worldwide. Myocardial injury in acutely ill hospitalized COVID-19 patients was associated with higher mortality and worse clinical outcomes. However, Canadian data on COVID-19 and myocardial injury is not available, and this is paramount to inform quality of care and direct efficient resource allocation. METHODS AND RESULTS We conducted a retrospective study of patients with COVID-19 with myocardial injury admitted to two quaternary hospitals in British Columbia; Vancouver General Hospital between March 2020 – February, 2021 and St. Paul's Hospital between April – December, 2020. Myocardial injury was defined as troponin elevation greater than 99% upper limit of normal (normal troponin-I < 0.05 ng/L, troponin-T < 9 ng/L in female, < 14 ng/L in male) on admission or during hospitalization. Baseline demographics, laboratory results, and in-hospital outcomes were collected. The study was approved by our institutional research board. We included 494 COVID-19 patients in the study. The mean age was 63.4 years, and 58.9% were men. The prevalence of myocardial injury was 37.2%. Sixty-five patients (13.2%) died during hospitalization, of which 49 (9.9%) had myocardial injury. Patients with myocardial injury were more likely to require mechanical ventilation (31.1% vs. 12.1%, p < 0.001) and inotropic support (2.7% vs. 0.0%, p < 0.01). They had higher mortality (26.8% vs. 5.2%, p < 0.001), shock (11.5% vs. 1.0%, p < 0.00), cardiac arrest (15.3% vs. 2.9%, p < 0.001), heart failure (7.1% vs. 0.3%, p < 0.001), stroke (2.7% vs. 0.3%, p=0.019), and significantly longer length of hospitalization (23.7 vs. 13.6 days, p < 0.001) than patients without myocardial injury. Four myocardial injury patients were diagnosed with ST-elevation or non-ST elevation MI. CONCLUSION Myocardial injury was frequent amongst hospitalized COVID-19 patients in British Columbia, and was associated with worse clinical outcomes and increased length of hospital stay.

Fibromuscular dysplasia (FMD) is widely recognized as an important predisposing condition for spontaneous coronary artery dissection (SCAD). However, it remains unclear in SCAD patients with coexistent extracoronary FMD whether SCAD can be attributed to coronary FMD.We retrospectively analyzed consecutive patients enrolled in our Vancouver SCAD registries between September 2009 and October 2019 who were screened for extracoronary FMD. We reviewed coronary angiograms for manifestations of coronary FMD that were previously described (ie, irregular stenosis, smooth stenosis, dilatation/ectasia, and severe tortuosity). Outcome of interest was major adverse cardiovascular event (MACE).We included 346 SCAD patients, of these, 250 (72.3%) had extracoronary FMD. Patients with FMD were older (54.6 ± 9.5 vs 51.7 ± 9.8 years) and more likely to have prior history of myocardial infarction (7.2% vs 1.0%, P = 0.047) and stroke (4.4% vs 0%, P = 0.081) compared with non-FMD patients. On coronary angiography, severe tortuosity was more prevalent in patients with extracoronary FMD (58.4% vs 36.5%, P0.001). Rates of irregular stenosis, smooth stenosis, and dilatation/ectasia were numerically higher in patients with extracoronary FMD, but differences were not significantly different. The rate of MACE at median follow-up of 807 (interquartile range, 392-1096) days was not different between groups (19.6% vs 15.6%; non-FMD as a reference: hazard ratio 1.44; 95% confidence interval, 0.76-2.71, P = 0.261).SCAD patients with extracoronary FMD were more likely to have coronary FMD manifestations on angiogram, especially severely tortuous vessels, compared with those without extracoronary FMD, with similar clinical outcomes. This may suggest that SCAD can occur at sites of pre-existent subclinical coronary FMD.

Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction in women, but the role of rehabilitation after SCAD is unclear.We designed a dedicated SCAD cardiac rehabilitation (SCAD-CR) program for our SCAD survivors at Vancouver General Hospital. This program encompasses a multidisciplinary approach including exercise rehabilitation, psychosocial counselling, dietary and cardiovascular disease education, and peer group support. Exercise and educational classes were scheduled weekly with a targeted participation of 6 months. Psychosocial counselling, mindful living sessions, social worker and psychiatry evaluations, and peer-group support were offered.We report our first consecutive cohort of 70 SCAD women who joined SCAD-CR from November 2011 to April 2015. The average age was 52.3 ± 8.4 years. Mean participation duration was 12.4 ± 10.5 weeks; 28 completed 6 months, 48 completed ≥ 1 month. At entry, 44 (62.9%) had recurrent chest pains and average metabolic equivalents on exercise treadmill test was 10.1 ± 3.3. At program exit, the proportion with recurrent chest pains was lower (37.1%) and average metabolic equivalents was higher 11.5 ± 3.5 (both P0.001). There was a significant improvement in the STOP-D depression questionnaire, with mean scores of 13.0 ± 1.4 before and 8.0 ± 1.7 after the SCAD-CR (P = 0.046). Twenty (28.6%) social worker referrals and 19 (27.1%) psychiatry referrals were made. Mean follow-up was 3.8 ± 2.9 years from the presenting SCAD event, and the major cardiac adverse event rate was 4.3%, lower than our non-SCAD-CR cohort (n = 145; 26.2%; P0.001).This is the first dedicated SCAD-CR program to address the unique exercise and psychosocial needs of SCAD survivors. Our program appears safe and beneficial in improving chest pain, exercise capacity, psychosocial well-being and cardiovascular events.

Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome predominantly affecting younger women. SCAD is often associated with predisposing arterial abnormalities and precipitating emotional, physical, and hormonal stressors. We previously showed that fibromuscular dysplasia is strongly associated with SCAD and may be a causative factor. Hormonal changes related to pregnancy and sex hormones have also been shown to be an important cause of SCAD. We describe the first case report, to our knowledge, of SCAD associated with β-human growth hormone injections in a patient with concomitant FMD.

Takotsubo cardiomyopathy, cardiac syndrome X, and spontaneous coronary artery dissection are cardiovascular syndromes with a predilection for women. A complex interplay between neurohormonal factors, genetic influences, anatomic alterations, and other factors together affect cardiovascular function. Specifically, a high, variable, or deficient estrogen state leads to vasomotor instability with propensity toward vasoconstriction and endothelial dysfunction that predispose women to myocardial impairment, microvascular dysfunction, and coronary arterial wall instability. As the predominant sex hormone in women, fluctuating estrogen levels lead to a sex disparity in the expression of these cardiac entities. This review explores the research on sex-based differences of the neurohormonal, genetic, and mechanical factors in the normal cardiovascular system and in the pathophysiology of these 3 conditions. The understanding of their prevalence, pathogenesis, and sex disparity allows improved recognition, management, and support of female patients inflicted with these syndromes.

Spontaneous coronary artery dissection (SCAD) is an infrequent condition that is underdiagnosed. There is a predilection for young women without traditional cardiovascular risk factors, and it is increasingly diagnosed in women who are not peripartum. We discovered an association between SCAD and fibromuscular dysplasia (FMD), in which most women with nonatherosclerotic SCAD were found to have FMD in another vascular territory. We suspect that these seemingly healthy patients have underlying coronary FMD that predisposed them to coronary dissection. Medical treatment of SCAD includes antiplatelet therapy and β-blockade. Revascularization of SCAD patients might be challenging, and the recommendation for stenting or surgery depends on their clinical status and the dissected coronary anatomy. The long-term outcome of patients who survived their SCAD event is generally good, however, they are at risk for recurrent dissection and major cardiovascular events, and thus should be closely monitored by cardiovascular specialists. This review summarizes the epidemiology, associated etiology, diagnosis, management, and outcome of patients with SCAD.

Fibromuscular dysplasia (FMD) is increasingly recognized as a nonatherosclerotic pathology in young women presenting with acute coronary syndromes. The angiographic appearance of these lesions may mimic typical atherosclerosis, and a high index of suspicion is needed. The pathophysiological changes in the intima and media alter the vessel's elasticity and may adversely affect the lesion's response to balloon dilatation and stenting. Intracoronary imaging is therefore useful when planning percutaneous intervention. We present a case of stent implantation in a coronary FMD lesion complicated by perforation with intravascular ultrasound images demonstrating the typical changes of FMD.

Functional exclusion of the left atrial appendage using transcatheter devices has been developed as an alternative therapy for atrial fibrillation in patients for whom formal anticoagulation is contraindicated. Noninvasive follow-up imaging of these devices is desirable. Transthoracic echocardiography has limitations due to field of view, limited available imaging windows, and metallic shadowing. Cardiac computed tomography has superior image resolution for determining device position and has the added capacity to noninvasively assess when exclusion of the appendage has occurred. This imaging technique is demonstrated in 2 cases of left atrial appendage closure using the Amplatzer Cardiac Plug (AGA Medical Corp, Plymouth, MN).

Interventional cardiology is a subspecialty of adult cardiology dedicated to the use and application of imaging-based diagnostic techniques and minimally invasive modalities for the treatment of cardiovascular disease. Currently, interventional cardiologists must demonstrate expert knowledge of cardiac imaging, along with cardiovascular anatomy and the pathophysiology of cardiovascular disease. In addition, they must possess the technical skills required for the practice of interventional cardiology and be knowledgeable about new antiplatelet and antithrombotic drugs mandated for optimal patient care. The 2010 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiologists Guidelines for Training and Maintenance of Competency in Adult Interventional Cardiology are the first such guidelines to be published in Canada. These guidelines should allow for more-fluid provision of high-quality interventional cardiology education, along with less geographic variation, resulting in more-widespread high-level services to the population.

This Consensus Conference has been supported by the Canadian Cardiovascular Society. The process is dynamic, with intentional structure that requires peer review and feedback from cardiovascular specialists across Canada. The writing and review panel encompassed a broad range of specialists caring for the patient with peripheral arterial disease (PAD). PAD is an often asymptomatic, underdiagnosed, under-recognized and undertreated condition. It is associated with significant morbidity and cardiac mortality. Until recently, little attention has focused on the evaluation and treatment of the disease process itself. The goal of the present paper is to ensure better treatment, to reduce both morbidity and mortality in the patient with vascular disease and, importantly, to serve as a guide to the busy clinician. Although the focus is PAD, there are chapters on thoracic and abdominal aortic disease, renal arterial disease and the evidence supporting management. Screening and diagnostic techniques including history and physical examination as well as noninvasive imaging techniques are reviewed. Medical management for patients with vascular disease including prevention and risk reduction is graded based on evidence, including both pharmacological and nonpharmacological management strategies, followed by an introduction to newer percutaneous techniques. Finally, surgical treatment for claudication including new concepts on the perioperative risk assessment for patients undergoing major vascular surgery is discussed.

The prevalence of chronic kidney disease (CKD) is increasing in North America, with an attendant increase in cardiovascular complications. The bulk of the mortality and morbidity in CKD patients can be attributed to coronary artery disease (CAD), especially in the presence of diabetes mellitus. Thus, screening and diagnosis of CAD is particularly important in the management of these patients, especially during evaluation for renal transplantation. However, numerous limitations exist with noninvasive tests that cloud the ideal strategy for diagnosis. In addition, the optimal revascularization strategy (surgery versus percutaneous intervention) for CAD is controversial for these patients. Randomized trials are clearly needed; unfortunately, major cardiovascular trials usually exclude patients with significant renal dysfunction. The current diagnostic and revascularization strategy for CAD in CKD patients is discussed, highlighting current controversies that warrant further investigation.