In this interview, Penn cardiologist Monika Sanghavi, MD, discusses myocardial infarction in non-obstructed coronary arteries (MINOCA), a syndrome linked to spontaneous coronary artery dissection, or SCAD, in young women.
Dr. Sanghavi's Profile Welcome to the podcast, Siri's from the specialists at Penn Medicine. I'm Melanie Coal, and we're speaking today with Penn Medicine Cardiologists Dr Monica Sung Gavi, about myocardial infarction and non obstructed coronary arteries. Orman Oka ah syndrome that appears in up to 14% of patients having acute myocardial infarction. Dr. Sung Gavi We know from the man nervous study and others that little is known about the clinical profile or the functional and psychosocial status of patients with men. Oka Do we know who the typical patient is? Do we know who's at risk? So if we think about men Oka we have to compare it to your typical coronary artery disease patient because the only way that Monica is diagnosed is when you're in the cath lab. So the typical M, my patient and, um, Anoke, a patient present the same way they have chest pain. E k g changes biomarkers suggestive of an m. I. But the difference is when they're taken to the cath lab. Minidoka patients did not have obstructive coronary arteries, and that's the diagnosis of Manaka. When we look at the epidemiology of Monica, we can see that these patients, they're usually younger. They're usually female and often ethnic minorities. Could you elaborate on any cause that we know of? So when you have a diagnosis of men Oka. It's absolutely important for, ah, physician to look into this a little bit further. And the reason being is that for many years men aka patients were sent home thinking that they don't have obstructive coronary arteries. They're fine. However, what we've seen is thes. Patients actually are at higher risk for persistent chest pain. They're at higher risk for recurrent hospitalizations. For chest pain, there are more likely to have a recurrent Am I and actually even more likely to die than someone who did not have the myocardial infarction in the first place? And so if we think about this, it's really important to get to the underlying cause for these patients so that we can understand how to treat them. Studies have shown that there is a wide variety of causes of Manaka spanning from coronary vases spasm, which is basically when the coronary artery spasms enough that it causes obstruction of flow to the myocardial. Um, there is scad spontaneous coronary artery dissection, which is much more common in young women microvascular disease, which is a problem with, or a dysfunction of the small blood vessels of the heart. There's so many smaller blood vessels that provide and regulate blood flow to the heart that we don't see an angiogram. And when these air dysfunctional, they are also thought to be able to cause a myocardial infarction. Other things include plaque erosion, as opposed to plaque rupture and plaque. Erosion is thought to be more common in women, and so there are so many possible causes there. Also, some people who have shown that sometimes it isn't even a myocardial infarction at all. And it's actually myocarditis, or Takasu bow, which is a stress induced cardiomyopathy. And that's why it's so important for your physician to really look into the underlying cause and try to understand what caused the damage to the myocardial infarction. Well, I'm glad you mentioned spontaneous coronary artery dissection, or scad. It's a condition that seems to affect a similar population as Manaka. Is there a link between the two and as a cardiologists? Is this event a different entity compared toa one due to after sclerosis? Oh, most definitely. Scad is spontaneous coronary artery dissection, and it's one of the most common causes off heart attacks in women under the age of 50. So it actually makes up about 35% of all heart attacks in women under the age of 15. And so, if someone has a minnow CA event, it becomes really important toe look for scad. It takes, ah, high level of suspicion to really be able to see it sometimes, and it takes some training of the eye to be able to see it. So if you suspect scad, which you should if especially if it's a ah young woman, you see tortuous coronary arteries. You know if there is a recent pregnancy, because those women are even more likely to have scad. So scad was thought to be a very rare disease. It now makes up about 1 to 4% off all acute coronary syndrome cases as an ISA mentioned about 35% off all M eyes in women under the age of 15, and about 45% of pregnancy related M eyes. Scat is very different than your typical Afro sclerotic coronary artery disease. The people who are affected by scad look completely different than your typical of my patients. One. They usually don't have a lot of the risk factors that you have with coronary artery disease. They're not usually diabetic. They don't necessarily have high cholesterol. They're not necessarily smokers. They're actually very healthy, active young women who are having these events. And the problem with this is that because they look so different than what we typically think of when we think of a patient having a myocardial infarction that they're often overlooked. Hello. Oftentimes these women are sent home from the ER with chest pain because they don't look like a typical person with chest pain. So it's important for these women to be advocates for themselves in terms of the underlying ideology of scad. I think we're kind of still beginning to understand it. The pathology is there is basically a blood pocket or a hematoma in the lining of the blood vessels that causes obstruction to the Lumen, preventing blood flow. Some people think that the inciting factor is a rip in the blood vessel lining itself. Others think that it's actually the blood pocket that causes the terror or the dissection flat, but they've even seen patients who have this blood pocket in the blood vessel but don't have the tear. So that's why it's unclear whether the actual underlying pathology is that human tomer that blood pocket or if it's Thea underlying dissection. One other thing that I want to point out is that FMD or fiber muscular dysplasia? Um, underlying vascular apathy is very common in these patients. And so the recommendation is that all women with a history of SCAD be screened for underlying arterial path ease, and that includes basically ahead to pelvis scan to make sure that there's no aneurysms or evidence of fiber muscular dysplasia. Dr. Sung Gavi I'd like to talk about image ing now. Do you think it's important that providers have this in their mind at the Cath lab or even before they enter it and tell us a little bit about what you're doing? US. Faras coronary angiography is first line image ing and some of the risks that come with that when you are looking for men Oka or scad, right? So it's imperative that any patient with suspected scad or Madoka event get angiogram because if you're having a mid oak event or you're having an M I. You can't distinguish Afro sclerotic coronary artery disease from a Manaka event unless you do an angiogram. The same is true for a patient with SCAD. It's essential to do an angiogram because other image ing modalities such a CT coronary angio grand. They're not as good in terms of diagnosing scad, and so it's really essential that these women undergo angiogram to establish the diagnosis. It's really important to have AH high index of suspicion because these aren't your typical coronary artery disease lesions, and so they can be missed, overlooked if you don't know what to look for. The other thing to think about is that there sometimes these women are increased risk for catheter induced injury to the blood vessels. And so I think physicians, interventional cardiologists try to take a lot of care to try to prevent any kind of I a tra genic damage from the catheters. Let's talk about treatment for a minute. So his treatment of men Oka dependent upon the underlying cause, which you may or may not know. Please tell the listeners what you take into mind regarding duration of hospital stay and what you determine As far as treatment options available. When we think of a man Oka event for a long time, we just treated this as in in mind. But we know now that this is not always the case. If you're able to determine the cause of the men Oka event, then you would treat the underlying cause. But if you don't know what the underlying causes, the treatment is actually controversial. They're very limited studies to look at the treatment options. This is in contrast to SCAD if you determine that the SCAD is the cause of the men. Okay, events. The treatment is also controversial because we don't have any randomized controlled trials toe look. But in general, we usually treat with beta blockers and then aspirin and Plavix. So do anti platelet therapy. Although the duration of adapt or do anti platelet therapy is controversial, we're not sure how long people should be on it. And so there is a wide variation in practices across the country and how long people treat with taps therapy. Statens are another area of controversy some people started, but the current guidelines or recommendations say you should only start statin therapy if there is another indication. So let's say the patient does have high cholesterol or they do have significant plaque buildup in the blood vessels of their heart. Then you would treat with status. But don't use the scat event as an indication for the Staten treatment. As we're talking about treatment, what are some other supportive therapies? What do you want other providers to know about this picture? So I want to first address of length of stay. So for a Minidoka event, we usually just keep patients in the hospital, maybe for a day or two days, depending on the underlying clause. If the underlying cause is thought to be scad, the recommendation is usually to keep the patients in longer because there is concern that that hematoma that blood pocket can expand and cause further obstruction. That would require intervention because it's cad. Usually we don't stent unless we absolutely have thio. In terms of additional treatment options. A very, very important one is cardiac rehabilitation. So I'm a strong believer in cardiac rehab, and I do recommend that toe all of my m my patients, including my scad patients. SCAD patients have to be careful because we believe that extremes of exercise or emotion can be triggers for scad. There are a good percentage of women who present after significant exertion with their first scat event. And so there is not only an underlying fear but this true risk that if they significantly exerted themselves again, that could they have a recurrent event. The recommendation this is more of an expert opinion is that women with a history of scats should try to avoid anything extreme extreme exercise, extreme weather when they're exercising, really hot weather or really cold weather. And there is a board scale of exertion perceived exertion, So trying to stay in really the middle portion of that scale. And like I mentioned that extreme exertion can be a trigger for scad. Extreme stress can also be a trigger for scad. So when we're looking at women on were counseling them in clinic after their scat event, I always take into account what they're triggering. Event waas. Was it after pregnancy? Was it after a significant stressful event? Was it during extreme exercise and then I counsel accordingly, in order to help try to prevent a future event. Although I still recommend cardiac, we have for all these patients, but with thes parameters in mind. Dr Sung Gavi tell other providers what you would like them to know about what you're doing at Penn Medicine and when they should refer patients at Penn. We are part of the icecap, registering to help accumulate data from patients with a history of scat still considered a relatively rare disease. And so the more patients we have collectively, the more information we have collectively, the more information we can glean and the better results we can glean from cumulative data. I would say that any physician who has any suspicion for a prior SCAD event or a Manaka event where they just want a little bit of help trying to tease out you know what the cause is, Definitely Call us or you can refer to us. This is something wet. We see often in our clinic and with Manaka Patient. It's really time is important because some of the image ING studies, such as cardiac emery that we'd want to get after Monica event are kind of time sensitive in the sense that it requires us to get the Emory quicker in order to be able to make the underlying diagnosis. The farther out we are from the event, the more likely that we might never know what the underlying caused for the Manaka event is. But we're happy to see any patient that has a history of it. And if physicians have any questions about the diagnosis, Thank you so much, Dr Sung Gavi. What a very fascinating topic. Thank you again for joining us, and that concludes this episode from the experts at Penn Medicine to refer your patient to a specialist at Penn Medicine, you can please visit our website at penn medicine dot org's slash Refer or you can call 877937 pen for more information and to get connected with one of our providers. Please remember to subscribe rate and review this podcast and all the other pen medicine podcasts. I'm Melanie Coal