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Rajiv Gulati @rajivxgulati
, 14 tweets, 8 min read Read on Twitter
SCAD case and new clinical and mechanistic data!
Strong work Tom Waterbury
38F presents with ACS due to SCAD of LM LAD. Intramural hematoma, no flap. Clinically stable without further pain 👇
How to manage?
4. While we wait for some votes here’s a different SCAD case. Treated with bypass but wow look at that left main after a year. Completely normal! #healed @SharonneHayes @marysia_tweet @DrMarthaGulati @DrSheilaSahni @ghoshhajra @heatherlgornik
5. Ok back to first case. Conservative therapy. Dismissed day 3. All good...
6. Until day 6. Acute anterior STEMI 👇
7. LM worse LAD occluded. Treated with emergency surgery and fortunately does ok. #sobering
8. So the question is what’s the early natural history of SCAD. Here’s the paper with the new data…
9. From N 240 conserv managed SCAD
- 1:6 risk of serious early clinical and angiographic worsening😱😱😱
- Highest risk day 1, burns out around d6
- Isolated Intramural hematoma carries higher risk. Ie intimal tear is protective 🤔🤔🤔
@saraceciliamtz @DocSavageTJU @docsaw m
10. In total there were 82 paired angios within 14 days (42 seriously worse per above, 40 not so). This allowed further insight into mechanism 👇👇
11. Isolated intramural hematoma at baseline carried a higher risk of
- prox and distal extension
- progression to occlusion
vs if intimal tear visible
Sorta makes sense?
@mmamas1973 @nolanjimradial @drandrewsharp @CardiacConsult @rwyeh @GreggWStone @djc795 @ShrillaB
12. And 20% of intramural hematoma developed intimal dissection on repeat study within 14 days. Suggesting SCAD in many begins in the media. And decompresses into the lumen in some
13. OCT substudy observations (N=17) lend support to the outside-in hypothesis of SCAD mechanism. You’ll have to read the paper for detail. Case example of prox IMH and mid lesion tear 👇
14. Obvious limitations to registry and observational analysis. But perhaps needle shifted a bit on understanding natural history and mechanism. Sorry for any errors above and thanks for reading all this way down 😀
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