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The iSCAD Registry and Predictors of Persistent Left Ventricular Dysfunction After Spontaneous Coronary Artery Dissection
Listen in as Dr. Malissa Wood, Co-Director of the Corrigan Women's Heart Health Program at Massachusetts General Hospital, talks about the iSCAD registry and predictors of persistent left ventricular dysfunction after spontaneous coronary artery dissection.
What is spontaneous coronary artery dissection?
Spontaneous coronary artery dissection (SCAD)1 is defined as the non-traumatic, non-iatrogenic separation of the coronary arterial wall by intramural hemorrhage creating a false lumen, with or without an intimal tear. SCAD nearly always presents as an acute myocardial infarction. The prevalence of SCAD varies depending on the population studied. A goal of iSCAD Registry is to expand diversity of race, ethnicity, and sex of study participants. The mean age of SCAD presentation is 45-53 years of age, and appears to primarily affect women.
Reference
1. Study Population. International Spontaneous Coronary Artery Dissection (SCAD) "iSCAD" Registry. https://clinicaltrials.gov/ct2/show/NCT04496687
The transcript below has been lightly edited for clarity.
Rebecca Kapur:
Welcome to Cath Lab Conversations. I'm Cath Lab Digest managing editor Rebecca Kapur. Today we talk with Dr. Malissa Wood, Co-Director of the Corrigan Women's Heart Health Program at Massachusetts General Hospital, about the iSCAD registry and predictors of persistent left ventricular dysfunction after spontaneous coronary artery dissection. Thank you for joining us.
Dr. Malissa Wood:
I am fortunate to be on the steering committee of the iSCAD Registry, which stands for the international Spontaneous Coronary Artery Dissection Registry. We created this registry in order to really try to diversify the recruiting sites where patients with SCAD are seen throughout the United States, and also internationally as well, so that we could minimize the bias that may in fact be present in patients that join the registries.
We are so appreciative of all of the work that's been done to study SCAD, but when you only have one location studying it, we understand that there could potentially be bias, particularly when you're looking at only a subset of patients that perhaps are seen in that geographic location. We're basically including patients that are seen in person at a number of different geographic locations. We have representation throughout the West, the Northwest, Northeast, Midwest, Southwest and Southeast in the United States, and we're in the process of enrolling patients from the Australia-New Zealand area.
So number one, that's why we did it, to create a more diverse set of patients to study. Number two, we incorporated the voice of patients when creating the tools in this prospective, observational registry. We talked to patients about the things that are concerning to them and the experiences they've had. We really try to incorporate their experiences into the data that we collect so that we can understand the journey of SCAD patients better. Number three, we wanted to, again, look at observationally how patients do when they're followed by the current standardized approach.
We don't have guidelines to manage SCAD. There have not been randomized placebo-controlled trials to look at different management strategies, but there are some general recommendations in the way that we manage patients, published in the 2018 Scientific Statement. Following the publication of that, this approach has become much more widespread, and so the majority of people who see a lot of SCAD patients will follow that same approach.
Next, we wanted to answer some unanswered clinical questions with robust statistical power. And those key, burning questions for patients include, why did I have this? We are looking at predisposing clinical history, situations, and then underlying conditions. And then, patients want to know, what is my risk for having a recurrence? That's certainly something patients want to know about. Are there any situations that might make me more likely to have a recurrence? And also, is it safe or what are the risks associated with having a baby after someone has had SCAD? Either before they've ever had children or associated with a pregnancy, or SCAD not associated with pregnancy, but someone wants to go ahead and have another pregnancy after experiencing SCAD.
So those are some of the key questions. We want to look at the imaging data that's associated with SCAD that's collected as part of routine care to see if any clues that could help us understand a little bit more about SCAD and how it should be treated. Because I think that's another big question. Can medications prevent recurrences or can medications help patients get better, faster? And so we really want to be able to take a contemporary look at the current management and be able to draw some nice conclusions about best practices, and then to have a large enough body of patients that we can actually potentially do some clinical trials and ask some questions with robust statistical power.
Rebecca Kapur:
How did you evaluate for predictors of left ventricular dysfunction?
Dr. Malissa Wood:
We took a subset of patients from our SCAD registry, and looked at 370 patients that did not have a prior history of any abnormal heart function and we looked at those who had abnormal heart function, meaning systolic function or ejection fraction below 50% at baseline. We found that about a quarter did have reduced systolic function at baseline. Then we looked at the patients who had follow-up data. And of those patients, 17% of them had persistent decreased LV function with a mean ejection fraction of 43%.
The predictors of that really were patients who were younger. The mean age of those who had recovery was higher than those who did not have normalization of their systolic function. Peripartum SCAD or SCAD either during or following pregnancy also predicted persistent left ventricular (LV) dysfunction. Also, patients with myocardial infarction involving the front of the heart, the anterior wall, were more likely to have LV systolic dysfunction. But I will also mention that the most common artery involved in SCAD is the left anterior descending (LAD) coronary artery, or the artery that runs down the front of the heart. In this group of patients, it was the most common area of the heart that was involved when there was persistent decreased function of the heart.
The good news is that the majority of patients who have abnormal systolic function normalize their function. Also, that it is the minority of patients at the outset who have abnormal systolic function. Overwhelmingly, close to 75% have normal function when they present. Of those who have abnormal function, the majority recover. So it's only a small subset of patients that have persistent LV dysfunction. We will be looking at other variables such as total duration of pain. But of the things that we did look at, like whether or not they had a angioplasty or stent or revascularization, these things were not associated with recovery of systolic function.
Younger age, peripartum, and anterior wall area were the factors that were associated with persistent LV dysfunction.
Rebecca Kapur:
Thank you for joining us. And our thanks to Dr. Wood.
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