1/ #ASPC2021 Day 2 continues!

@DrMarthaGulati presents on Ischemic Heart Disease Without Obstructive Coronary Arteries (INOCA)

Follow this🧵on INOCA:
♦️Outcomes
♦️Mechanisms of ischemia and diagnosis
♦️Guidelines

@ASPCardio @CardioNerds Image
2/ Definition of INOCA: symptoms of ischemia in the absence of obstructive CAD or flow-limited disease

Check out this great infographic by @najahakhan, @CardioNerds Academy Fellow, on INOCA

#ASPC2021 Image
3/ ✨Obstructive CAD is just one phenotype of IHD✨

INOCA – often normal LVEF, originally thought ischemia not present

But data shows elevated risk for cardiac events➡️poor outcomes

Guidelines haven’t caught up yet – focus on obstructive lesions

#ASPC2021 Image
4/ GUSTO trial – over 30% of women had non-obstructive lesions in UA group.

ACC CathPCI registry (stable ischemic heart disease & ACS)➡️women more likely to have non-obstructive disease. And worse outcomes in women. bit.ly/2UDoXb4

#ASPC2021 Image
5/ WISE study - INOCA pts more likely to have CV events irrespective of risk factors

🔥INOCA is not benign🔥

♂️ obstructive CAD
♀️ microvascular disease, endothelial dysfunction

No obstructive CAD➡️can be more diffuse atherosclerosis, vasospasm, etc

#ASPC2021 ImageImage
6/ Mechanisms of ischemia
Myocardial bridging, metabolic, systemic inflammation, metabolic abnormalities, coag abnormalities

If none above: consider INOCA, microvascular angina, vasospastic

Coronary circulation – not just epicardial arteries
pubmed.ncbi.nlm.nih.gov/29030424/

#ASPC2021 Image
7/ CorMicA trial – invasive coronary function testing➡️improvement in angina score & QOL

European guidelines: bit.ly/2UB3tM1

MINOCA Diagnosis
-AMI criteria
-non-obstructive coronaries on angiography, no stenosis >50%
-no clinically overt specific cause

#ASPC2021 ImageImage
8/ Important to consider INOCA/MINOCA (MI w/ no obstructive CAD) as syndromes, NOT diagnoses

-Coronary microvascular
-Plaque rupture/erosion
-In-situ thrombosis
-SCAD
-Vasospasm
-Non-ischemic: stress cardiomyopathy, myocarditis

AHA statement: bit.ly/3zB6XNj

#ASPC2021 Image
9/ Next steps – cardiac MRI to investigate subendocardial ischemia, PET, coronary functional testing, etc

ESC guidelines: academic.oup.com/eurheartj/arti…

#ASPC2021 Image
10/ HARP study – multi modality imaging (OCT + CMR) for diagnosis, underlying etiology found in 85% of women with MINOCA

MINOCA is not benign

❤️‍🔥Treatment❤️‍🔥
Swedeheart cohort:➕effect w/ GDMT (statin, ACE/ARB), trend towards ➕ w/ beta-blocker, neutral effect w/ DAPT

#ASPC2021 Image
11/ INOCA Summary

🔴Not all IHD is obstructive
🔴Syndrome, not a final diagnosis
🔴Not benign
🔴Diagnosis requires additional investigations, effective risk stratification (functional + anatomical)
🔴For treatment, need further research specific to disease process

#ASPC2021 Image

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More from @Gurleen_Kaur96

25 Jul
1/ Day 3 & last session of #ASPC2021 on special populations

Talk on MI & HF among people with HIV by Dr. Markella Zanni

Follow this🧵on:
🔹MI risk in people w/ HIV
🔹HF in PWH
🔹CVD preventive approaches tailored to people w/ HIV

@ASPCardio @CardioNerds Image
2/ Patients with HIV are now living longer ➡️increased risk of CVD

Global burden of atherosclerotic CVD in people living with HIV has tripled over past 2 decades

Relative risk of MI is 1.5-2 in high-income countries

pubmed.ncbi.nlm.nih.gov/23459863/

#ASPC2021 Image
3/ From US Partners database study – adjusted relative risk for MI was around 3 for women & 1.5 for men – regionally specific

Type 1 vs. type 2 MI: both ~50%
Women – more type 2 MI

pubmed.ncbi.nlm.nih.gov/17456578/

#ASPC2021 Image
Read 18 tweets
24 Jul
1/ #ASPC2021 talk for Honorary Fellowship Award by @NMHheartdoc on New Kind of Prevention – Reducing CV Health Disparities at Community and Individual Level

🧵from session

@ASPCardio @CardioNerds
2/ #ASPC2021
Covid-19 deaths by race and ethnicity in the US:
1 in 555 Black Americans has died

Populations w/ highest disease burden➡️ lowest vaccination rates
3/ Any discussion of prevention shouldn’t start at hypertension, dyslipidemia, but at the root cause of those inequities.

Need to address policy. All policy is health policy.

Stolen breaths nejm.org/doi/full/10.10…

#ASPC2021
Read 10 tweets
24 Jul
1/ Great #ASPC2021 session by @RonBlankstein on Chest Pain and Imaging

Follow this🧵for some takeaways on
🟣Stress Testing vs. Anatomical Testing
🟣Coronary CTA
🟣Guidelines

@ASPCardio @CardioNerds Image
2/ ‼️ Imaging tests alone do NOT change pt outcomes but how we act on them might

‼️ No one test is always the best test

‼️ Test selection influenced by multiple factors: local availability, prior training, guidelines, evidence

🔜AHA/ACC New Chest Pain Guidelines

#ASPC2021
3/ Stress testing vs. Anatomical

ETT: exercise capacity, not as great for ischemia

SPECT MPI: reversible perfusion deficits, underestimates extent of disease esp if multi-vessel

PET MPI: measure absolute blood flow, calculate myocardial blood flow reserve

#ASPC2021 ImageImage
Read 10 tweets
24 Jul
1/ Great #ASPC2021 session by @dramitkhera on ACS in Patients with COVID-19

Follow this🧵on pts w/ COVID
🔷Prevention of ACS events
🔷Identification of ACS
🔷Management of ACS

@ASPCardio @CardioNerds
2/ 8 fold📈in AMI w/ COVID even in pts with no ASCVD/FH

Absolute risk for AMI📈in pts with ASCVD. Even higher for FH +ASCVD bit.ly/3eJ2csW

Based on NHANES, 75% of US pop has risk factors (CKD, obesity, smoking, T2DM) for severe COVID
bit.ly/3xYxpQn

#ASPC2021
3/ 🌟Prevention of ACS🌟

🗝️Address barriers to medication adherence and access
🗝️Team-based approach
🗝️Regular physical activity and nutrition
🗝️Cardiac rehab
🗝️Utilize telehealth
🗝️Counsel on promptly reporting new symptoms

#ASPC2021
Read 12 tweets
17 May
Essentials of Stable Ischemic Heart Disease

♦️Plaque Characteristics & Progression
♦️Choosing From Imaging Toolbox
♦️Perils of Polypharmacy
♦️Who & When To Revascularize
♦️Overview of Guidelines

🧵on this great @ACCinTouch session from today #ACC21 #ACCMedStudent
1/Plaque Progression #ACC21

Non-atherosclerotic intimal lesions➡️progressive atheroscl. lesions (fibroatheroma)➡️lesions w/ acute thrombi

Plaque rupture = lesion growth
Lumen area maintained till 40% narrowing
Narrowing beyond 40% occurs w/ plaque rupture+intraplaque hemorrhage
2/Plaque Characteristics #ACC21

Coronary artery calcification begins as micro-calcification➡️fragment➡️sheet➡️nodular

Stable plaque?
🔸Associated with DM, HTN, smoking
🔸Most common is fibrocalcific plaque (mostly sheet Ca)

Unstable plaque is mostly fragmented Ca
Read 8 tweets
16 May
💥The Ultimate Guide to Lipids💥
🟢Lipid biology
🟢Physical exam clues for lipid disorders
🟢Lipid tests & interpretation
🟢CV risk assessment
🟢Fundamentals of lipid management
🟢Review of guidelines

🧵on this great @ACCinTouch session from today #ACC21 #ACCMedStudent #ACCPrev
1/ Lipid Biology #ACC21 #ACCMedStudent
Lipoprotein-central core of cholesterol ester/TG surrounded by apolipoprotein

Dietary fat➡️chylomicrons➡️TG metabolized in muscle & adipose by lipoprotein lipase➡️chylomicron remnants liver uptake➡️VLDL➡️FFA & IDL ➡️LDL➡️LDL receptor uptake
2/ Lipid Biology continued...#ACC21 #ACCMedStudent

HDL formed by liver/intestines - acquire cholesterol through reverse cholesterol transport

Lp(a) - modified LDL particle w/ additional apolipoprotein (a). Oxidation pro-inflammatory,⬆️atherosclerosis.
Read 10 tweets

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