Thread by @rajivxgulati

SCAD case and new clinical and mechanistic data!
Strong work Tom Waterbury
@fischman_david
@chadialraies
@SVRaoMD
@CircIntv
@MayoClinicCV
1/n

38F presents with ACS due to SCAD of LM LAD. Intramural hematoma, no flap. Clinically stable without further pain 👇
2/n

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
ahajournals.org/doi/10.1161/CI…

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
#OutsideIn

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 😀