Spontaneous coronary artery dissection: a focus on post-dissection care for the vascular medicine clinician

Spontaneous coronary artery dissection (SCAD) is an uncommon condition which is increasingly recognized as a cause of significant morbidity. SCAD can cause acute coronary syndrome and myocardial infarction (MI), as well as sudden cardiac death. It presents similarly to atherosclerotic MI although typically in patients with few or no atherosclerotic risk factors, and particularly in women. As more patients are recognized to have this condition, there is a great need for clinician familiarity with diagnostic criteria, as well as with contemporary treatment approaches, and with appropriate patient-centered counseling, including genetic testing, exercise recommendations, and psychological care. The standard of care for patients with SCAD is rapidly evolving. This review therefore summarizes the diagnosis of SCAD, epidemiology, modern treatment, cardiac rehabilitation and preconception counseling, and the current approach to genetic testing, exercise recommendations, and psychological care, all of which are crucial to the vascular medicine specialist.

A novel operator-independent noninvasive device for assessing arterial reactivity

Background

Endothelial dysfunction is associated with increased risk of cardiovascular disease (CVD). Currently available noninvasive methods of measuring endothelial function have limitations. We tested a novel device that provides an automated measurement of the difference between baseline and post-ischemic, hyperemia-induced, brachial arterial compliance, a phenomenon known to be endothelium-dependent. The association between the calculated index, Flow-mediated Compliance Response (FCR), and established CVD risk indices was determined.

Methods

Adults with CVD risk factors or known coronary artery disease (CAD) were enrolled. Framingham Risk Score (FRS) was calculated and presence of metabolic syndrome (MetSyn) was assessed. Carotid artery plaques were identified by ultrasound. Cardiorespiratory fitness was assessed by 6-minute walk test (6MWT). FCR was measured using the device.

Results

Among 135 participants, mean age 49.3 +/- 17.9 years, characteristics included: 48% female, 7% smokers, 7% CAD, 10% type 2 diabetes, 34% MetSyn, and 38% with carotid plaque. Those with MetSyn had 24% lower FCR than those without (p < 0.001). Lower FCR was associated with higher FRS percentile (r = -0.29, p < 0.001), more MetSyn factors (r = -0.30, p < 0.001), more carotid plaques (r = -0.22, p = 0.01), and lower 6MWT (r = 0.34, p < 0.0001).

Conclusion

FCR, an index of arterial reactivity obtained automatically using a novel, operator-independent device, was inversely associated with established CVD risk indices, increased number of carotid plaques, and lower cardiorespiratory fitness. Whether measuring FCR could play a role in screening for CVD risk and assessing whether endothelial function changes in response to treatments aimed at CVD risk reduction, warrants further study.

Supervised exercise therapy for patients with peripheral artery disease: Clinical update and pathways forward

Peripheral artery disease (PAD) is an atherosclerotic vascular disease resulting in widespread morbidity and mortality, particularly among older adults. One first-line therapy to improve symptoms, function, and clinical outcomes in PAD is supervised exercise therapy (SET), which is based primarily on a structured, start-and-stop walking protocol and is implemented in cardiac rehabilitation programs. SET is supported by a Class IA guideline for patients with symptomatic PAD; however, despite the effectiveness of SET and the 2017 CMS decision to cover SET for PAD, challenges of awareness, access, and implementation of SET persist. Recent efforts to address these challenges include digital health and hybrid approaches to SET that may minimize barriers to care by delivering SET in more innovative, flexible formats. Further study is needed to understand barriers, improve awareness, and implement SET in more equitable and accessible ways.

Coronary Calcium Scanning and Cardiovascular Risk Assessment Among Firefighters

INTRODUCTION

Sudden cardiac death is the main cause of death among firefighters. The goal of this study is to identify firefighters at risk for cardiovascular disease using coronary artery calcium screening.

METHODS

Asymptomatic firefighters aged ≥40 years without known cardiovascular disease or diabetes (N=487) were recruited from fire departments in 3 Maryland counties from 2016 to 2018, with data analysis from 2018 to 2019. The cardiovascular disease prevention program included an evaluation of blood pressure, cholesterol, BMI, fasting glucose, medications, and a coronary calcium scan. A subset (n=100) was evaluated in more detail, including family history, metabolic syndrome, diet, exercise, smoking, and atherosclerotic cardiovascular disease risk score.

RESULTS

Results indicated that 191 (39%) firefighters had a coronary artery calcium score >0, of which 91% were above the average for age, sex, and ethnicity. On univariable logistic regression, older age, male sex, hypertension, BMI, and glucose were significantly (p<0.05) associated with a higher likelihood of having any coronary artery calcium. Multiple logistic regression found that older age; male sex; taking lipid-lowering or antihypertensive medications; and higher low-density lipoprotein cholesterol, BMI, and fasting blood glucose were significantly associated with a higher likelihood of having coronary artery calcium. Of those with coronary artery calcium, 141 (74%) were not on lipid-lowering medication. In addition, 47 (94%) of those on lipid-lowering medication had a low-density lipoprotein cholesterol >70 mg/dL. In the detailed subset, 30 (30%) had coronary artery calcium. Among these, 28 (93%) had an atherosclerotic cardiovascular disease risk score <7.5%. Thus, if atherosclerotic cardiovascular disease scores alone were used to assess risk in this subset, an opportunity would have been missed to identify and treat firefighters who may have benefited from more aggressive treatment.

CONCLUSIONS

A coronary artery calcium scan may identify the firefighters at increased risk for cardiovascular disease. A comprehensive cardiovascular disease prevention program implemented early in a firefighter's career may help reduce cardiovascular disease risk and thus death and disability in this high-risk population.

A randomized, placebo-controlled trial of canakinumab in patients with peripheral artery disease

Extensive atherosclerotic plaque burden in the lower extremities often leads to symptomatic peripheral artery disease (PAD) including impaired walking performance and claudication. Interleukin-1β (IL-1β) may play an important pro-inflammatory role in the pathogenesis of this disease. Interruption of IL-1β signaling was hypothesized to decrease plaque progression in the leg macrovasculature and improve the mobility of patients with PAD with intermittent claudication. Thirty-eight patients (mean age 65 years; 71% male) with symptomatic PAD (confirmed by ankle-brachial index) were randomized 1:1 to receive canakinumab (150 mg subcutaneously) or placebo monthly for up to 12 months. The mean vessel wall area (by 3.0 T black-blood magnetic resonance imaging (MRI)) of the superficial femoral artery (SFA) was used to measure plaque volume. Mobility was assessed using the 6-minute walk test. Canakinumab was safe and well tolerated. Markers of systemic inflammation (interleukin-6 and high-sensitivity C-reactive protein) fell as early as 1 month after treatment. MRI (32 patients at 3 months; 21 patients at 12 months) showed no evidence of plaque progression in the SFA in either placebo-treated or canakinumab-treated patients. Although an exploratory endpoint, placebo-adjusted maximum and pain-free walking distance (58 m) improved as early as 3 months after treatment with canakinumab when compared with placebo. Although canakinumab did not alter plaque progression in the SFA, there is an early signal that it may improve maximum and pain-free walking distance in patients with symptomatic PAD. Larger studies aimed at this endpoint will be required to definitively demonstrate this. ClinicalTrials.gov Identifier: NCT01731990.

Impact of the modified Atkins diet on cardiovascular health in adults with epilepsy

AIM

The current study investigated biochemical and vascular markers of cardiovascular health in adult patients with epilepsy treated with long-term (greater than 1year) ketogenic diet therapy compared with controls.

METHOD

Anthropometric measures, serum fasting lipid panel, apolipoproteins A-1 and B, lipoprotein sub-fractions as well as common carotid intima-media thickness (cIMT), and plaque presence were assessed in 20 adult patients with epilepsy on a modified Atkins diet (MAD) for >1year started as an adult compared with 21 adult patients with epilepsy naïve to diet therapy.

RESULTS

Patients treated with MAD had significantly lower weight, body mass index, waist and hip circumference, percent body fat, and serum triglyceride levels when compared with control patients. In contrast, they had significantly higher serum levels of small low-density-lipoprotein (LDL) particles and were significantly more likely to have LDL pattern B in which small LDL particles predominate when compared with controls. However, there was no significant difference in cIMT or plaque presence between groups.

CONCLUSION

Our results provide clinical evidence demonstrating the cardiovascular safety of a high-fat, low-carbohydrate diet used in adults with epilepsy for at least 12months. It also highlights potential markers of cardiovascular risk - small dense LDL particles - that should be closely monitored in adults treated with diet therapy long-term.

Medical management of claudication

Peripheral artery disease (PAD) is common and associated with significant morbidity and mortality. Optimal medical management of PAD is required for each patient, irrespective of the decision regarding lower extremity revascularization. The goals include reducing cardiovascular morbidity and mortality and improving quality of life. The approach should consist of aggressive and individualized risk factor modification including smoking cessation, antiplatelet therapy, a statin, and an angiotensin-converting enzyme inhibitor. Exercise is critical for cardiovascular health and highly effective for improving claudication symptoms. Cilostazol may be considered for symptomatic treatment in certain patients.

Abstract 11: Effects of Canakinumab in Patients With Peripheral Artery Disease

Background: Peripheral artery disease (PAD) affects 8.5 million people in the US. PAD patients are at high risk for cardiovascular events, and their quality of life is often significantly impaired by decreased mobility. Interleukin-1β (IL-1β) may play an important role in this disease by promoting inflammatory responses that drive atherosclerotic plaque progression and impair vascular function. We sought to test whether interruption of IL-1β signaling would improve patient mobility and decrease plaque progression in the lower extremities.

Methods: 38 patients (mean age 65; 71% male) with symptomatic PAD (confirmed by ankle-brachial index) were randomized 1:1 to receive Canakinumab (150 mg subcutaneously) or placebo monthly for up to 12 months. Plaque volume in the superficial femoral artery (SFA) was assessed serially using 3.0T MRI. Mobility was assessed serially using the 6-minute walk test (maximum and pain-free walking distance).

Results: Canakinumab was safe and well-tolerated. 12 patients discontinued (8 placebo, 4 Canakinumab). MRI data (from 31 patients at 3 months; 21 patients at 12 months) showed no evidence of plaque progression in the SFA at either time point in placebo-treated patients; nor was there a change in plaque volume in the Canakinumab-treated group. There was a serial and significant improvement in placebo-adjusted maximum and pain-free walking distance observed as early as 3 months after treatment with Canakinumab (58-meter improvement over placebo in pain-free distance at 3 months, P=0.01). Two placebo-treated patients required peripheral vascular interventions due to progression of disease; however, no Canakinumab-treated patients required revascularization during the study. Canakinumab decreased markers of systemic inflammation (IL-6 and hsCRP).

Conclusions: Treatment with Canakinumab may improve maximum and pain-free walk distance in patients with symptomatic PAD. In conjunction with results soon to be reported for the CANTOS trial of Canakinumab for secondary prevention of cardiovascular events, additional studies may provide support that inhibition of IL-1β signaling can improve symptoms and function in this patient population with high unmet need.

Aortoenteric Fistula: A Late Complication of Endovascular Repair of an Inflammatory Abdominal Aortic Aneurysm

Endovascular repair provides a reasonable alternative to open repair for the treatment of abdominal aortic aneurysms in select cases. Although the endovascular approach may be preferable for inflammatory aneurysms, aggressive surveillance is needed to monitor for long-term complications. A 61-year-old man underwent endovascular exclusion of a symptomatic inflammatory abdominal aortic aneurysm with an AneuRx bifurcated aortic prosthesis. He presented with gastrointestinal bleeding 51/2 months later and was found to have an aortoenteric fistula involving the third portion of the duodenum. The aneurysm had expanded significantly at the proximal neck. The patient underwent successful removal of the device, aortic ligation, and extraanatomic bypass. Aortoenteric fistula is a rare but now established complication of endovascular aneurysm repair. The pathophysiology in these cases remains unclear. The presence of inflammation and endoleak may predispose to further aneurysmal degeneration.

Diagnosis and treatment of uncomplicated type B aortic dissection

A type B dissection involves the aorta distal to the subclavian artery, and accounts for 25–40% of aortic dissections. Approximately 75% of these are uncomplicated with no malperfusion or ischemia. Multiple consensus statements recommend thoracic endovascular aortic repair (TEVAR) as the treatment of choice for acute complicated type B aortic dissections, while uncomplicated type B dissections are traditionally treated with medical management alone, including strict blood pressure control, as open repairs have a prohibitively high morbidity of up to 31%. However, with medical treatment alone, the morbidity, including aneurysm degeneration of the affected segment, is 30%, and mortality is 10% over 5 years. For both chronic and acute uncomplicated type B aortic dissections, emerging evidence supports the use of both best medical therapy and TEVAR. This paper reviews the current diagnosis and treatment of uncomplicated type B aortic dissections.

Malperfusion syndromes in aortic dissections

Aortic dissection remains a challenging clinical scenario, especially when complicated by peripheral malperfusion. Improvements in medical imaging have furthered understanding of the pathophysiology of malperfusion events in association with aortic dissection, including the elucidation of different mechanisms of branch vessel obstruction. Despite these advances, malperfusion syndrome remains a deadly entity with significant mortality. This review presents the latest knowledge regarding the pathogenesis of aortic dissection complicated by malperfusion syndrome, and discusses the diagnostic and therapeutic guidelines for management of this vicious entity.

mActive: A Randomized Clinical Trial of an Automated mHealth Intervention for Physical Activity Promotion

Background

We hypothesized that a fully automated mobile health (mHealth) intervention with tracking and texting components would increase physical activity.

Methods and Results

mActive enrolled smartphone users aged 18 to 69 years at an ambulatory cardiology center in Baltimore, Maryland. We used sequential randomization to evaluate the intervention's 2 core components. After establishing baseline activity during a blinded run‐in (week 1), in phase I (weeks 2 to 3), we randomized 2:1 to unblinded versus blinded tracking. Unblinding allowed continuous access to activity data through a smartphone interface. In phase II (weeks 4 to 5), we randomized unblinded participants 1:1 to smart texts versus no texts. Smart texts provided smartphone‐delivered coaching 3 times/day aimed at individual encouragement and fostering feedback loops by a fully automated, physician‐written, theory‐based algorithm using real‐time activity data and 16 personal factors with a 10 000 steps/day goal. Forty‐eight outpatients (46% women, 21% nonwhite) enrolled with a mean±SD age of 58±8 years, body mass index of 31±6 kg/m², and baseline activity of 9670±4350 steps/day. Daily activity data capture was 97.4%. The phase I change in activity was nonsignificantly higher in unblinded participants versus blinded controls by 1024 daily steps (95% confidence interval [CI], −580 to 2628; P=0.21). In phase II, participants receiving texts increased their daily steps over those not receiving texts by 2534 (95% CI, 1318 to 3750; P<0.001) and over blinded controls by 3376 (95% CI, 1951 to 4801; P<0.001).

Conclusions

An automated tracking‐texting intervention increased physical activity with, but not without, the texting component. These results support new mHealth tracking technologies as facilitators in need of behavior change drivers.

Clinical Trial Registration

URL: http://ClinicalTrials.gov/. Unique identifier: NCT01917812.

Vascular disease patient information page. Inferior vena cava (IVC) filters

IVC filters are medical devices that are placed in the large vein of the abdomen to prevent blood clots from traveling from the veins of the legs to the lungs. They are most commonly used when a patient cannot receive blood thinners to treat leg blood clots (DVT). IVC filter insertion can be done as an outpatient under local anesthesia, with only a puncture to a vein in the leg or neck. Most IVC filters are designed to be removed when no longer necessary. IVC filter complications are uncommon.