Thread by @jholtzman3

🚨How do you get a STEMI without atherosclerotic coronary artery disease?? 📟

✏️ Drawing a blank? 📃

Join me to learn more about the world of non-atherosclerotic coronary artery disease and coronary artery vasculitis!

🎣 In this tweetorial, we'll tackle how to -

🚨 Implement an approach to ⬆️ troponin

🚨 Classify non-atherosclerotic coronary artery disease

🚨 Recognize causes of coronary artery vasculitis

So, how do you feel answering the following question:

"I feel comfortable identifying a patient with coronary artery vasculitis."

Let's start with a case!

Recently on @cardionerds, the @um_cardiology fellowship (@ManuMysore2, @smuktas, @azviman, & Scott Butler) presented the case of:

👱🏾‍♀️ a young woman with postpartum angina, troponin elevation, and cardiac arrest.

cardionerds.com/103-case-repor…

How do you think about the Ddx for a young woman with chest pain and elevated trop?

First, evaluate if trop ⬆️ ≠ obstructive atherosclerotic disease (role for #yesCCT – discussed more below).

But what else causes ⬆️ trop? 🤷🏽‍♀️

I think about ⬆️ troponin in 3 buckets mapped 🗺 onto the 4th Universal Def of MI. Remember this is on a spectrum!

First: is there clinical evidence of ischemia?

Next:

🔎 Supply Issue Primarily - think acute plaque rupture, SCAD, vasospasm, embolism, aneurysm, vasculitis

🔎 Demand Issue Primarily - think tachycardia, CHF, PE, aortic stenosis, HTN

🔎 Non-isch Myocardial Injury - think ESRD, infiltrative dx, myocarditis, or Takotsubo

🕑 to delve into the primarily *supply* issue bucket

Let's say our patient has 🚫 or few ASCVD risk factors. What else causes coronary disease?

Well – anything that leads to luminal narrowing

In terms of large buckets, this includes:

🔎 Fixed luminal obstruction (e.g. anomalous coronary)

🔎 External compression of lumen or nearby tissues (see @HussainMKCards tweetorial on myocardial bridges!)

🔎 Dynamic changes (e.g. spasm)

These may not be as rare as we think!

Some specific non-ASCVD entities include

🚨 anomalous coronary arteries
🚨 dissection
🚨 coronary vasculitis
🚨 coronary spasm
🚨 fibromuscular dysplasia
🚨 lipoma
🚨 emboli

Together, these non-ASCVD entities are responsible for ~3% of sudden cardiac death.

Let's 🔎 in on coronary vasculitis

Can be seen w/ systemic vasculitis or isolated coronary dx

Include this in your Ddx when -

- ⬆️ inflamm markers
- constitutional sxs
- Absent/asymmetric pulse or bruit
- Visceral infarcts
- Young age w/o traditional cardiac Risk Factors

Specific types of vasculitis that affect the coronary arteries include

🛑Large vessel: Takayasu and GCA
🛑 Medium vessel: PAN, Kawasaki
🛑 Variable vessel: IgG4 related, Behcet
🛑 Small vessel: ANCA vasc

Check out this 💯 graphic from @karanpdesai and @RichardAFerraro

Morphology of lesions can vary. For Takayasu's arteritis, one classification system organizes into 3 main types of lesions:

- Type 1: ostial stenosis or occlusion (most common)
- Type 2: diffuse multifocal disease
- Type 3: aneurysms (rare)

pubmed.ncbi.nlm.nih.gov/1360966/

How can imaging help us dx cor vasculitis?

- Med/large vessel vasculitis: think non-invasive angiography of the chest/abd/pelvis and #yesCCT

- Small vessel vasculitis: think CT chest (looking for pulm parenchymal changes) + cardiac MRI (looking for non-coronary abnormalities)

Cardiac MRI can help distinguish between causes of chest pain in inflammatory conditions (like SLE), including pericarditis, myocarditis, + atherosclerotic CAD and visualize lumen and vessel wall with high resolution!

FDG-PET can also help identify areas of increased metabolism/inflammation in the cardiovascular system

Specifically, circumferential regions of increased metabolic activity can indicate active disease and be used to monitor treatment!

So back to our young patient -- what are complications of coronary vasculitis? 🚑 🏩

Highly variable but can include severe coronary ischemia, arrhythmia, and cardiac arrest, all of which we saw in the patient presented in @cardionerds ep #103

For more details of this humbling case, make sure to check out here:

cardionerds.com/103-case-repor…

Let's summarize!

🚨 Think about trop elevation as supply, demand, or non-isch injury
🚨 There are many types of non-athero CAD including dissection, vasculitis, spasm, + more
🚨 Recognize that cor vasculitis has variable presentations, some of which can be life threatening

So, back to our first question - how many of you feel comfortable answering the following:

"I feel comfortable identifying a patient with coronary artery vasculitis."

"I learned something in this Tweetorial that may change my clinical practice."

@CardioNerds, what has been your experience with coronary artery vasculitis? What treatment modalities have you seen be the most effective?

#MedTwitter #MedStudentTwitter #MedEd

As always, thank you to the @cardionerds leadership for support and feedback – particularly super🌟@ThomasMDas! 🙌 🙌 🙌

@amitgoyalmd @dr_danmd @carinehamo @karanpdesai
@justinberk @EuniceDuganMD @RichardAFerraro @CBlumenthal2 @EvelynSongMD