January 3, 2024 • 34 mins
Join our host, Ohio-ACC President Dr. Kanny Grewal, and guests Drs. Ellen Sabik and Heather Gornik, both from University Hospitals of Cleveland, as they discuss the diagnosis and practical management of fibromuscular dysplasia (FMD) - including clinical assessment, classification, screening and the role of imaging. They then review spontaneous coronary artery dissection (SCAD), including clinical assessment, diagnosis, and therapy.
For more information, see:
Spontaneous Coronary Artery Dissection: JACC State-of-the-Art Review from the ACC.
2019 FMD International Consensus: https://journals.sagepub.com/doi/10.1177/1358863X18821816?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
AHA SCAD Scientific Statement
https://www.ahajournals.org/doi/10.1161/CIR.0000000000000564
Interesting case of identical twins with FMD
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Kanny (00:10):
So welcome back to the cardio podcast.
Thanks for joining us today.
We are going to have a veryexciting discussion today about
vascular medicine as aspecialty, but also specifically
about fibromuscular dysplasia.
And spontaneous coronarydissection and as we often get
to do on our podcast, we have acouple of experts from right
(00:33):
here in Ohio joining us.
I want to start at you byintroducing Ellen Savick.
She's currently a senior staffcardiologist at University
Hospital in Cleveland.
As many of you know.
But we're also excited thatshe's the president elect for
the Ohio chapter of the ACC.
And in fact, she'll be startingher term, I believe, around
(00:55):
early April, April 4th now.
And not that I'm counting downthe days specifically, but so
first of all, Ellen, welcome.
And can you just take a fewminutes to let those who maybe
don't already know you a littlebit about your clinical
interests up at and kind of thepath that led you there?
Heather (01:12):
Wonderful.
Thank
Ellen (01:13):
you, Kenny, for the introduction.
So I'm a noninvasivecardiologist here at University
Hospitals, Cleveland MedicalCenter.
I do spend some time clinicallyat Ahuja Medical Center as well,
and I, I enjoy doing a lot ofteaching as well as clinical
work in the echocardiographylab.
as well as taking care ofgeneral cardiology patients, as
(01:35):
well as patients whospecifically have valvular heart
disease.
So I'm actually really lookingforward to my time as president
upcoming in the future yearsand, and looking to build on a
lot of what you haveaccomplished over your, your
three year tenure.
So I'm very excited to introduceDr.
(01:56):
Heather Gornick.
Heather and I have known eachother for years, first at
Cleveland Clinic, but now atUniversity
Heather (02:03):
Hospitals.
Ellen (02:04):
Heather is a one of the co directors of our vascular
center here at the HarringtonHeart and Vascular Institute, as
well as a professor of medicineat Case Western Reserve
University.
In addition to that, she is oneof the past presidents of the
Society for Vascular Medicineand is a world leading expert on
fibromuscular dysplasia.
(02:25):
So, welcome, Heather.
We're so looking forward tospeaking
Heather (02:28):
with you tonight.
Well, thank you, Ellen and Kani,and hello, Ohio ACC.
Kanny (02:35):
Yeah, hello, Heather.
Thanks again for taking timewith us.
You know, I think many of us doknow you from your time here in
Ohio as a clinician.
I know there's some excellentvascular specialists here in
Columbus, actually, that trainedunder you and other leaders in
the field here as well.
Can you just say a little bitabout, you know, your path?
(02:55):
Because I know you were a bit ofa trendsetter into the field of
vascular medicine with abackground in cardiology and how
that led to your clinical, focusand then ultimately what led to
your interest in FMD as asubspecialty.
Heather (03:12):
Sure.
Thank you.
Well, it was a real journey.
When I started my internalmedicine residency, I trained at
Brigham and Women's Hospital inBoston.
I thought I was going to be anoncologist.
And actually then I fell in lovewith critical care.
I loved physiology.
I was doing a, a cardiologyrotation and I met Dr.
(03:35):
Mark Krieger, who's a pastpresident of the American Heart
Association and was the head ofthe vascular medicine group at
the Brigham.
And he really just inspired me.
He was a, he is an amazingbedside clinician.
He is a translational andphysiology researcher.
So I had this great sense ofphysiology and he introduced me
(03:56):
to the field of vascularmedicine where there is lots of.
Physiology and a real chance touse clinical skills coupled with
physiology, imaging to diagnoseand treat patients.
So I became interested incardio, cardiovascular medicine.
I did training in cardiology,and then I did two additional
(04:20):
years of training with MarkKrieger's group with people I
think well known to ACC memberslike Josh Beckman and Marie
Gerhard Hermann and SamGoldhaber.
and I trained in vascularmedicine.
I finished my training in 2005and was looking for my first job
(04:40):
and I had a sense I wanted to,to leave the Brigham.
I had been there for eight yearsat that point and was looking
around the country and Came uponthe program at Cleveland Clinic,
and they had one of the largestvascular medicine programs in
the United States, actually thesecond program in the United
(05:01):
States.
It was founded after the MayoClinic program, and I was very
impressed with their clinicalprogram, their training program,
their academic program, and Ijoined the staff of the
Cleveland Clinic, and I guessthe rest is history.
I was there for 13 years.
I had a chance to run thevascular lab there for, oh,
(05:21):
about 11 or 12 of them, and itwas there that I really
developed an interest in FMD,and I saw a few patients who
were actually A Patientspreviously cared for by Dr.
Jeff Olin, who, for those whoknow the field of FMD, knows
he's another person who's veryactive in the field, and he had
(05:42):
been at the Cleveland Clinic andleft a few years prior to my
arrival, and some of his formerpatients were put on my schedule
because people knew I was Inaddition to being a vascular
medicine specialist, I'm acardiologist and was very
interested in arterial disease.
So I started following thesepatients and a couple patients
(06:02):
made comments to me with thingslike, gosh, it's so nice to meet
a doctor who.
has seen one of me before.
Or, you know, Dr.
Gornick, you didn't have to pullout a textbook to know what to
do about me.
And I just realized that the barwas so low in this disease
state.
You know, I'm used to acardiology background where we
(06:23):
have randomized trials ofthousands of patients.
And here patients with a seriouscondition are talking about
doctors relying on a A textbook.
So I realized that it was achance to have a real impact.
So in 2008, after I had comeback from maternity leave from
my second child, my son, who'snow going to be 16, I started
(06:47):
the first dedicated FMD clinic,kind of hung out a shingle and
said I was going to see patientswith FMD once a month.
And eventually it became acouple times a month and then
once a week and really grew fromthere.
Subsequently, as we'll talkabout, I became very involved in
FMD related research andnational collaborations,
(07:08):
including with the FMD Societyof America, a wonderful patient
advocacy organization.
And then in 2018, I had theopportunity to really grow
professionally and cross town toUniversity Hospitals, Harrington
Heart and Vascular Institute tocontinue my work in FMD and also
(07:32):
to take on some new roles.
I help run the vascular serviceline across all of the
hospitals.
And so I'm able to do somedifferent things, but my passion
for FMD has continued.
We now have FMD.
It's gone from once a month in2008 to now up to three or four
times a week in 2023 and havealso, as the years have gone by
(07:56):
taken on an interest inspontaneous coronary artery
dissection, SCAD, other arterialdissections aortopathies and the
like.
So it's been, it's been a realjourney.
And like, All of us who havecareers in cardiology the path
is really interesting andcontinues to evolve.
Kanny (08:16):
It sure does.
That sounds like a veryinteresting path so thanks for
sharing that with us.
So just to kind of frame adiscussion about FMD before we
eventually, get into more aboutcoronary dissection for our
general cardiology audience, Ithink back to when I was a
trainee in the 1990s and we hadsuch a, cursory exposure to Non
(08:37):
coronary arterial diseasesmainly just an occasional case
of vasculitis or suspected,vasculitis, for example.
how, how do you frame ourcurrent perspective on FMD now
that there's been, a little bitmore research and understanding
about the epidemiology?
how do you approach it inrelation to other Very, very
(08:57):
common atheroscleroticcardiovascular disease in terms
of your, how you classify it,and then eventually when, what
clinical scenarios should we asclinicians suspected.
Heather (09:07):
Well, I think it starts with the fundamentals and
recognizing that all of us ascardiovascular physicians and
APPS are attentive to thevascular system as well as the
heart.
So I think it just starts withthe fundamentals and being in
practice and recognizing thatour patients with heart disease
may well have.
peripheral vascular disease aswell, so it's including that
(09:30):
review of systems for symptomslike claudication, limb
swelling, for FMD, we thinkabout pulsatile tinnitus and
headaches.
It's doing a really thoroughphysical exam, blood pressures
in both arms, auscultating forbreweries throughout the body.
palpating the pulses.
So first it's like recognizingthe peripheral vascular disease
(09:51):
beyond the heart disease.
And then once we determine thispatient has vascular disease and
that it seems to be arterialdisease, it's figuring out if
it's the horse or the zebra.
And I would say the horse isatherosclerosis.
As you said, Kenny, I mean,that's like 90 percent of
arterial disease that we seethroughout the body is
(10:12):
atherosclerotic.
But then we have the zebras.
And I think among the zebraconditions, fibromuscular
dysplasia is probably one of themore common.
And just for the, for thelisteners, as a reminder, FMD is
a disease that affects thearteries.
It's generally the medium sizedor branch arteries.
(10:33):
It can affect arteriesthroughout the body, most
commonly the renal arteries, thecarotid and vertebral arteries,
but can also affect theintracranial arteries.
the coronary arteries manifestwith SCAD the intestinal
visceral arteries, and the iliacand brachial arteries.
So it's really a total bodyprocess.
(10:54):
About 90 percent of patients,perhaps more in some series, are
women, generally diagnosed atmidlife.
Say our average patient is inthe early fifties, but can
present in children.
Then it's generally a type ofFMD called the focal type.
In the adult type it's generallycalled the multifocal type.
(11:15):
It looks like a string of beads,and again, more commonly in more
of a middle aged adultpopulation.
But we do have patients who arediagnosed in their sixties,
seventies.
I even have a few patients whoare in, in their late eighties
with FMD.
So I think the general approachis to recognize there is
peripheral vascular disease aswell as heart disease.
(11:37):
Determine that it seems to be anarterial problem, and then try
to address whether it's thehorse, the atherosclerosis, or
the zebra.
And of course, if you have anolder patient with diabetes,
hyperlipidemia, all of thoserisk factors more likely to be
athero.
But think of FMD when you haveyounger patients who don't have
a lot of atherosclerotic riskfactors and who have disease in
(12:00):
the, in the typical locations.
So, Heather,
Ellen (12:04):
I guess just to, to focus that a little bit further is
what patient population wouldyou say, or what features would
you say you need to startthinking about FMD, and what is
the role of imaging in makingthat diagnosis once you have the
question of is there possiblyFMD or not?
Heather (12:21):
Yeah, I, I think patients with FMD have three
broad classic clinicalpresentations.
One is the hypertensive patient.
So early onset hypertension,drug resistant hypertension,
hypertension in a, a.
thin middle aged woman whoreally you're surprised has
(12:43):
hypertension.
So that's the hypertensivephenotype we'll say.
The other bucket is people whomanifest with symptoms related
to the cerebrovascular disease.
So these are patients who havecarotid bruise.
have migraine headaches, havepulsatile tinnitus.
I never thought I'd be spendingmy career when I started asking
(13:05):
people about ear noises, butit's a classic symptom of FMD, a
pulsatile sound that times withthe heartbeat, and most patients
describe it as a swooshing, likea whoosh, whoosh, whoosh.
So that's another group ofpatients.
And then the third category isthe manifestations of dissection
and aneurysm.
So these are patients who have.
(13:26):
coronary dissection, carotid orvertebral dissection, renal
dissection with infarct, andthat's how they're diagnosed
with FMD.
So those are the three generalclinical categories where we
most commonly see patientspresent.
I think Absolutely, as youalluded to, we have to move
quickly to imaging.
(13:47):
I think duplex is a good startto evaluate the carotid and
renal arteries and just screenfor FMD, but to definitively
rule out or in FMD anddefinitely to screen all of the
vasculature for aneurysms anddissections, we generally need
CTA or MRA.
And these patients with FMD, werecommend they get a head to
(14:10):
pelvis cross sectional imaging.
Kanny (14:15):
Yeah, thanks, Heather.
As Ellen was mentioning andobviously we're both imagers, so
we have a big interest in thisas well.
For for us, generalcardiologists who do a lot of
consoles many times, the entrypoint is, you know, a patient
was suspected or confirmed, youknow, coronary dissection I
assume in those patients, we dowant to screen for other
(14:36):
manifestations of F.
M.
D.
With the image and you alludedto
Heather (14:40):
absolutely.
And the story of of recognizingthe link between coronary
dissection and FMD is just sointeresting.
And it really starts in WesternCanada.
And there was an interventionalcardiologist, Chris Buehler, and
his subsequent and his partnerJacqueline saw.
who did a lot of the early work.
(15:02):
This was really in the 1990s andearly 2000s.
What they did was they hadcatheter angiograms on their
patients who had acute coronarysyndrome and they would do kind
of drive by renal angiography asI, as, as some may remember, was
kind of in vogue in the 1990s.
And they reported on this seriesof patients, younger women with
(15:26):
acute coronary syndromes andquote atypical coronaries who
when they did these renalangiograms had string of beads
multifocal FMD and they sort ofpostulated could this be
coronary dissection and thatinitial publication I remember
reading it as someone takingcare of patients with FMD and
(15:47):
being very skeptical I didn'tknow what this was about what is
coronary FMD.
But now we really know that thisis SCAD, and Jacqueline Saw at
Vancouver General Hospital, thegroup at Mayo Sharon Hayes,
Marisha Tweet, many otherinvestigators have now done a
lot of work that has reallylinked these atypical
(16:09):
coronaries, determining thatthey're actually coronary
dissections, and then withimaging of the coronaries.
Extracoronary vasculature,identifying that probably about
half, it's more or lessdepending on the case series and
how the patients are imaged ofpatients with SCAD have FMD, if
(16:29):
you image them comprehensively.
So there was a really niceconsensus statement from the
American Heart Association thatI love.
I was not a part of it.
I love, I love reading in it.
It's very informative that cameout in 2019.
If any of the listeners want todownload it and it recommends
(16:49):
that patients who have acoronary artery dissection have
comprehensive imaging, which isdefined as head to pelvis CT
angiography or contrast enhancedMR angiography to look for FMD
as well as a colt.
Aneurysms or dissections.
Wow, that's
Ellen (17:07):
wonderful.
Heather, I have a question foryou regarding when should we be
referring patients tospecialists like yourself?
You know, whether, like I had apatient who we found out that
she had FMD because withhypertension that was
uncontrolled, I was looking forrenal artery stenosis and we
found the classic beatingpattern.
That person was referred.
(17:28):
if they had a spontaneousdissection, that's another
person.
But when do we send them to thespecialist and we let you all
pick up the head to pelvis CTAor, you know, at what point is
it appropriate to send?
Heather (17:42):
Well, I think I would say really at, at any time, I
think for patients with a raredisease to see a physician who,
for them, it's just another dayin clinic versus for.
For some specialists, it may bepulling out the textbook, I
think makes a big difference inthe patient's experience.
I think the opportunity to see aspecialist who's participating
(18:05):
in research.
There's a national FMD actuallynow it's North American registry
for FMD.
That other 20 centers in theUnited States which are
participating for patients tohave a chance to see an expert
who sees FMD routinely, who hasa multi specialty care team they
work with to help out withthings like brain aneurysms,
(18:27):
visceral aneurysms, pulsatiletinnitus, severe headaches, and
to participate in research Ithink has value.
I think that may not always beavailable, but I think if you
have a specialist In your areawho's interested in FMD and I'm
just up the road in inCleveland.
But there's others throughoutthe country.
(18:48):
I think, I think there's valuefor patients with a rare disease
like FMD.
Yeah, thanks,
Kanny (18:53):
Heather.
One quick question is obviouslyI know the image, it can have a
very classic appearance,especially like in the renal
bed, for example.
Is that plus a clinical eventenough to make a diagnosis?
Do we have any, have there beenany advances, for example, in
genetic testing?
Or are there any times youreally have to rely on histology
to really understand that apatient actually has FMD?
Heather (19:18):
Well, in the early days of this disease state, it was
described in the 1930s, actuallyin a pediatric patient at Johns
Hopkins who had an aphrectomy.
It was an early days ofdiagnosis was by histopathology.
In the modern era, however, it'sAlmost exclusively by imaging.
So even in my center, which is ahigh volume FMD center It's
(19:41):
maybe once a year that weactually get histopathology.
So we are really relying onimaging Similarly as of this
time, there's no biomarkers forFMD And although there have been
advances in terms ofunderstanding the genetics and
genetic markers for FMD, andthere's a large international
(20:02):
consortium of investigatorsworking on this, we do not yet
have a genetic test or a bloodtest.
So we're really relying onimaging.
I will say as we talk aboutimaging, FMD overlaps with many
other conditions on imagingstudies.
So Every woman who has a carotiddissection is not a patient with
(20:25):
FMD.
I mean, you can just havedissections without FMD.
Dissection is on thedifferential.
Atherosclerosis sometimes canmimic FMD.
Vasculitis can mimic FMD.
There's other Arterial syndromeslike Loeys Dietz syndrome,
vascular Ehlers Danlos that canmimic FMD.
There's some imaging artifactsactually with reformatting or or
(20:49):
beam hearting artifact fromdental work that can mimic
beating of FMD.
So it's imaging and then aknowledgeable person reviewing
the imaging to confirm thediagnosis and avoiding some of
the pitfalls of things thatoverlap with FMD on imaging.
So Heather, one other
Ellen (21:07):
question is, is once you make that diagnosis in that
individual patient, you said wedon't really have great genetic
markers or genetic testing.
What kind of screening do familymembers, if any, need?
And, and at what point do youstart screening
Heather (21:20):
people for this?
It's a great question.
It's one that, I think we're isevolving.
There was an internationalconsensus.
Actually, it's if anyone'sinterested.
There's an internationalconsensus on FMD led by myself
and Alexander pursue of Belgium,which was published in 2019 and
(21:41):
is available for free downloadon the journal vascular medicine
and At the time of publication,that group looked at the
literature and really felt likewe cannot broadly recommend
screening of family members forpatients with FMD.
Because if you look at the data,such as in the United States, or
now I should say North AmericanFMD registry, among the people
(22:04):
in the registry with FMD, lessthan 10 percent have an affected
family member with FMD.
What's interesting is a quarterof patients with FMD in the
registry have a family memberwith an aneurysm.
So there may be, there clearlyare genetic mechanisms and
(22:26):
familial mechanisms.
I actually published a few yearsago a set of ladies I just saw.
Within the past week who areidentical twins who have FMD and
they actually have FMD in thesame spots, carotid and renal,
although one has brain aneurysmsand one has splenic aneurysms.
(22:47):
So clearly there are familialFMD cases and families.
But it's complicated and in, inmost cases, family members are
not affected.
So what this consensusrecommends is not screening all
family members for FMD, butfocusing on history and physical
(23:07):
exam really.
So if the family members havesymptoms, they have pulsatile
tinnitus, they have migraineheadaches, they have
hypertension at an early age,those folks should be screened.
I think the one caveat I'llthrow in there is if I meet a
patient with FMD who hasaneurysms, and especially if
(23:27):
they have a family member withaneurysms, I would recommend
other family members bescreened.
That's
Kanny (23:35):
fascinating.
Fascinating case you mentioned.
Just 1 very quick questionbefore we spend the last 5
minutes talking about scadsspecifically is about serial
imaging.
You know, like a lot ofcardiologists, I have a panel of
patients who have gone through acoronary dissection had a good
recovery and we see them andthey.
You know, as you know, do verywell clinically over time.
(23:57):
Generally if they've had anegative initial screen, I
assume at some point it's worthre imaging them as well as your
established FMD patients aswell.
And would you basically stick toC.
T.
A.
Combined with occasional duplexstudies for that?
Heather (24:14):
Yeah, I say, Kenny, I would say the guidelines really
do not address this or thescientific statements.
But I like you do for mypatients with scad.
Where there's no otherexplanation and they have
initial imaging that's negativefor a number of those patients.
I've obtained repeat imaging atthe 5 to 7 year mark or so.
(24:38):
And similarly, for patients withFMD, let's say they have carotid
FMD.
and they don't have any diseaseelsewhere on that negative
imaging initially.
I have had patients where again,like five to seven years later,
I've done a repeat CTA and Ihave anecdotally very few, but
(25:00):
occasionally have picked up likean incidental Incident new
aneurysm in those patients, butcurrent scientific statements
and guidelines don't reallyaddress that.
And in general, we don't dofrequent serial CTAs on people
who've had SCAD.
Kanny (25:17):
So, Ellen, I have a question for you.
I know you're have a biginterest in heart disease in
women and in your clinic there.
As we kind of spend our last fewminutes talking more
specifically about coronarydissection, do you mind
reminding our listeners, as acardiology consultant, when
should bells be going off in ourhead that this may not be a
typical, ischemic event and maybe more likely to be a coronary
(25:40):
dissection?
Well,
Ellen (25:44):
certainly we do see scattered or, or spontaneous
coronary dissections morecommonly, I think, in women.
And oftentimes we have toremember that if we have our
postpartum or peripartumpatients at times who have chest
pain, they may have any acoronary dissection as well.
So I think, you know, as peopleget older.
(26:07):
You start thinking usual things,common things are common.
You think of atheroscleroticdisease, but certainly in
patients who you are surprisedthat they're coming in with an
acute coronary event, you lookat the cath films and you have
to look very carefully for thedissections at times, but, but,
but having a high suspicion issomething that's really
important in those people whoyou're, you're pretty surprised
(26:29):
that they're coming in,particularly in women coming in
with these syndromes.
Is that
Heather (26:34):
your experience, Heather?
Yeah.
Yeah, for sure.
I think you have to have thesuspicion.
You have to really scrutinizethose calf films.
I think, as mentioned, I wouldparticularly give a shout out to
Jacqueline saw at VancouverGeneral Hospital, who's done a
lot of work on the angiographicclassification of scad and
(26:56):
raising awareness of scad in thecalf lab.
And the scads have these verydistinctive patterns.
They're actually divided intothree groups.
And I think, With rate giving aclassification system and
raising awareness in the, in theinterventional community,
there's a lot more awareness ofSCAD.
It's actually, it's interesting.
I've actually had a few patientswho were labeled as having
(27:20):
Takotsubo or myocarditis, butwhen you get the cath films and
you really scrutinize, there'sthat type two SCAD of the LAD.
There's that branch OM SCAD.
So I think you really have tohave a high index of suspicion
and really scrutinize those calffilms.
(27:40):
And I, I'm not an interventionalcardiologist, but I have great
relationships with my colleaguesand we'll, my, my
interventionalists, and we'llshare films back and forth.
And really, do you think thiscould be SCAD and really look
for these classic types of SCADon the imaging?
So, Heather
Kanny (27:57):
My understanding as well, is that for more recent series.
FMD and SCAD that, the age rangeis a bit wider than maybe we
thought in the past and that,this can occur in in middle age
or elderly patients.
Has that been your experiencewith the more patients that you
see as well?
For sure.
Heather (28:15):
I think for SCAD, I think, I think when we start
seeing really SCAD, sometimesthere's dissections that are
related to an atheroscleroticlesion, but We absolutely are
seeing a wider range of ages forboth FMD
Kanny (28:31):
And Ellen, with you, you as an imager you know, my
understanding in reading CCTA isthat it just is much more
challenging to distinguish adissection from other types of
occlusion.
Has that been your experience,too, so that we still have to
kind of rely on angiography toreally.
kind of confirm that adissection is occurring versus,
say, a CCTA?
Ellen (28:52):
I think for the most part, we do rely on the invasive
angiography and looking at thosefilms very carefully.
I think maybe over time, wemight be able, as imaging with
CCTA gets better over time andeven more and more granularity,
it might be something we canuse.
But I think for the most part,at the current time, it's with
invasive angiography that we'llmake that
Heather (29:14):
diagnosis.
And I will just add on that, ifI may, that I think coronary CTA
in my own experience has been,has been able to detect major
SCAD.
I mean main LAD SCAD, main RCASCAD.
I think it is really challengingwith the smaller branches.
(29:34):
Yeah, I
Kanny (29:35):
agree as well.
So maybe in the last coupleminutes Heather, we can just
talk a little bit aboutmanagement of.
Yeah, scared.
I think I think most of usclinicians who are now kind of
familiar with the condition whosee it as a consultant
understand that, patients dovery, very well with
conservative management.
I think our interventionalcolleagues have also learned
over the years that interveningcan be problematic.
(29:56):
And that most patients do well,is that still kind of the
current framework when we makethis diagnosis to focus on
conservative management?
And then what medical therapyspecifically has has some
evidence base, and improvingoutcomes here?
Heather (30:10):
Well, I, I.
I do think there's stillopportunity for recognition of
SCAD in the cath lab andappropriate management.
As a referral center for SCADand participating in, we have,
there's actually aninternational SCAD registry for
which we're a site.
We see a number of patients andI have seen even recently
(30:31):
patients who had a SCAD for whomthe lesion was not recognized as
SCAD and there was actually goodflow you know, TIMI 3 flow.
But there was an attempt atintervention that led to
propagation of dissection, verylong segment stenting and a
suboptimal outcome.
(30:53):
So, I, I think not everyone haslearned that.
We need to recognize SCAD andthat the majority of patients
with SCAD, especially if they'renot having ongoing chest pain.
If there's to me good to methree or maybe to me to flow can
be managed conservatively.
That being said, there arepatients who having.
(31:13):
STEMIs who have occluded LADs,who are having ventricular
tachycardia, who are criticallyill, who need revascularization.
It's, it's beyond my strike zoneto address techniques, but there
is a subset of patients who doneed revascularization.
We've had a few patients who'vehad very severe SCAD, very high
(31:36):
risk SCAD, left main SCAD whoneeded even emergency coronary
artery bypass grafting.
So a subset of patients We'llneed intervention, but you're I
completely agree.
The large majority can bemanaged medically generally with
anti platelet therapy betablockers blood pressure control.
(31:56):
There's a lot of interest inongoing research in terms of the
optimal anti platelet regimenfor patients with scab.
There's a study that.
We did with the iSCAD registrythat showed there's a lot of
heterogeneity in terms of whatregimens are being prescribed,
even among the SCAD registrysites dual versus single, what
(32:19):
combinations of dual, andthere's really no clear data.
There's been.
Some data that has suggestedthat perhaps a dual antiplatelet
therapy may not be the besttherapy for patients who have
SCADs, especially the types, themost common type of the type 2
(32:39):
SCAD, which is that taperedlesion due to a mural hematoma,
and maybe single antiplatelettherapy is better.
But I think there are people inthe international FMD research
community who are hopefullydesigning and implementing and
getting funded some researchstudies to address this.
But for now, it's antiplatelettherapy, definitely beta blocker
(33:02):
and blood pressure control.
Kanny (33:03):
Awesome.
Well I'd love to talk about somany other aspects of this
because I think it's been agreat discussion.
I think we're kind of up againstour time.
I do want to remind ourlisteners.
I will put, you know, thereferences that you alluded to
Heather in our show notes with acouple of review articles as
well.
For a further reference, I guessI just want to thank you both.
(33:27):
I think it's been a greatdiscussion.
I think it's great to have youas a resource here in Northeast
Ohio and for Ohio in general.
And we look forward to followingprogress as we learn more about
this condition.
Thanks to questions like you.
So thanks Ellen.
And thanks Heather.
Both for joining us today.
Thank you.
Kenny.
Heather (33:49):
Thank you.
Thank you for joining today'spodcast.
For more information about thespeakers or the topics, please
go to Ohio acc.org,
So welcome back to the cardio podcast.
Thanks for joining us today.
We are going to have a veryexciting discussion today about
vascular medicine as aspecialty, but also specifically
about fibromuscular dysplasia.
And spontaneous coronarydissection and as we often get
to do on our podcast, we have acouple of experts from right
(00:33):
here in Ohio joining us.
I want to start at you byintroducing Ellen Savick.
She's currently a senior staffcardiologist at University
Hospital in Cleveland.
As many of you know.
But we're also excited thatshe's the president elect for
the Ohio chapter of the ACC.
And in fact, she'll be startingher term, I believe, around
(00:55):
early April, April 4th now.
And not that I'm counting downthe days specifically, but so
first of all, Ellen, welcome.
And can you just take a fewminutes to let those who maybe
don't already know you a littlebit about your clinical
interests up at and kind of thepath that led you there?
Heather (01:12):
Wonderful.
Thank
Ellen (01:13):
you, Kenny, for the introduction.
So I'm a noninvasivecardiologist here at University
Hospitals, Cleveland MedicalCenter.
I do spend some time clinicallyat Ahuja Medical Center as well,
and I, I enjoy doing a lot ofteaching as well as clinical
work in the echocardiographylab.
as well as taking care ofgeneral cardiology patients, as
(01:35):
well as patients whospecifically have valvular heart
disease.
So I'm actually really lookingforward to my time as president
upcoming in the future yearsand, and looking to build on a
lot of what you haveaccomplished over your, your
three year tenure.
So I'm very excited to introduceDr.
(01:56):
Heather Gornick.
Heather and I have known eachother for years, first at
Cleveland Clinic, but now atUniversity
Heather (02:03):
Hospitals.
Ellen (02:04):
Heather is a one of the co directors of our vascular
center here at the HarringtonHeart and Vascular Institute, as
well as a professor of medicineat Case Western Reserve
University.
In addition to that, she is oneof the past presidents of the
Society for Vascular Medicineand is a world leading expert on
fibromuscular dysplasia.
(02:25):
So, welcome, Heather.
We're so looking forward tospeaking
Heather (02:28):
with you tonight.
Well, thank you, Ellen and Kani,and hello, Ohio ACC.
Kanny (02:35):
Yeah, hello, Heather.
Thanks again for taking timewith us.
You know, I think many of us doknow you from your time here in
Ohio as a clinician.
I know there's some excellentvascular specialists here in
Columbus, actually, that trainedunder you and other leaders in
the field here as well.
Can you just say a little bitabout, you know, your path?
(02:55):
Because I know you were a bit ofa trendsetter into the field of
vascular medicine with abackground in cardiology and how
that led to your clinical, focusand then ultimately what led to
your interest in FMD as asubspecialty.
Heather (03:12):
Sure.
Thank you.
Well, it was a real journey.
When I started my internalmedicine residency, I trained at
Brigham and Women's Hospital inBoston.
I thought I was going to be anoncologist.
And actually then I fell in lovewith critical care.
I loved physiology.
I was doing a, a cardiologyrotation and I met Dr.
(03:35):
Mark Krieger, who's a pastpresident of the American Heart
Association and was the head ofthe vascular medicine group at
the Brigham.
And he really just inspired me.
He was a, he is an amazingbedside clinician.
He is a translational andphysiology researcher.
So I had this great sense ofphysiology and he introduced me
(03:56):
to the field of vascularmedicine where there is lots of.
Physiology and a real chance touse clinical skills coupled with
physiology, imaging to diagnoseand treat patients.
So I became interested incardio, cardiovascular medicine.
I did training in cardiology,and then I did two additional
(04:20):
years of training with MarkKrieger's group with people I
think well known to ACC memberslike Josh Beckman and Marie
Gerhard Hermann and SamGoldhaber.
and I trained in vascularmedicine.
I finished my training in 2005and was looking for my first job
(04:40):
and I had a sense I wanted to,to leave the Brigham.
I had been there for eight yearsat that point and was looking
around the country and Came uponthe program at Cleveland Clinic,
and they had one of the largestvascular medicine programs in
the United States, actually thesecond program in the United
(05:01):
States.
It was founded after the MayoClinic program, and I was very
impressed with their clinicalprogram, their training program,
their academic program, and Ijoined the staff of the
Cleveland Clinic, and I guessthe rest is history.
I was there for 13 years.
I had a chance to run thevascular lab there for, oh,
(05:21):
about 11 or 12 of them, and itwas there that I really
developed an interest in FMD,and I saw a few patients who
were actually A Patientspreviously cared for by Dr.
Jeff Olin, who, for those whoknow the field of FMD, knows
he's another person who's veryactive in the field, and he had
(05:42):
been at the Cleveland Clinic andleft a few years prior to my
arrival, and some of his formerpatients were put on my schedule
because people knew I was Inaddition to being a vascular
medicine specialist, I'm acardiologist and was very
interested in arterial disease.
So I started following thesepatients and a couple patients
(06:02):
made comments to me with thingslike, gosh, it's so nice to meet
a doctor who.
has seen one of me before.
Or, you know, Dr.
Gornick, you didn't have to pullout a textbook to know what to
do about me.
And I just realized that the barwas so low in this disease
state.
You know, I'm used to acardiology background where we
(06:23):
have randomized trials ofthousands of patients.
And here patients with a seriouscondition are talking about
doctors relying on a A textbook.
So I realized that it was achance to have a real impact.
So in 2008, after I had comeback from maternity leave from
my second child, my son, who'snow going to be 16, I started
(06:47):
the first dedicated FMD clinic,kind of hung out a shingle and
said I was going to see patientswith FMD once a month.
And eventually it became acouple times a month and then
once a week and really grew fromthere.
Subsequently, as we'll talkabout, I became very involved in
FMD related research andnational collaborations,
(07:08):
including with the FMD Societyof America, a wonderful patient
advocacy organization.
And then in 2018, I had theopportunity to really grow
professionally and cross town toUniversity Hospitals, Harrington
Heart and Vascular Institute tocontinue my work in FMD and also
(07:32):
to take on some new roles.
I help run the vascular serviceline across all of the
hospitals.
And so I'm able to do somedifferent things, but my passion
for FMD has continued.
We now have FMD.
It's gone from once a month in2008 to now up to three or four
times a week in 2023 and havealso, as the years have gone by
(07:56):
taken on an interest inspontaneous coronary artery
dissection, SCAD, other arterialdissections aortopathies and the
like.
So it's been, it's been a realjourney.
And like, All of us who havecareers in cardiology the path
is really interesting andcontinues to evolve.
Kanny (08:16):
It sure does.
That sounds like a veryinteresting path so thanks for
sharing that with us.
So just to kind of frame adiscussion about FMD before we
eventually, get into more aboutcoronary dissection for our
general cardiology audience, Ithink back to when I was a
trainee in the 1990s and we hadsuch a, cursory exposure to Non
(08:37):
coronary arterial diseasesmainly just an occasional case
of vasculitis or suspected,vasculitis, for example.
how, how do you frame ourcurrent perspective on FMD now
that there's been, a little bitmore research and understanding
about the epidemiology?
how do you approach it inrelation to other Very, very
(08:57):
common atheroscleroticcardiovascular disease in terms
of your, how you classify it,and then eventually when, what
clinical scenarios should we asclinicians suspected.
Heather (09:07):
Well, I think it starts with the fundamentals and
recognizing that all of us ascardiovascular physicians and
APPS are attentive to thevascular system as well as the
heart.
So I think it just starts withthe fundamentals and being in
practice and recognizing thatour patients with heart disease
may well have.
peripheral vascular disease aswell, so it's including that
(09:30):
review of systems for symptomslike claudication, limb
swelling, for FMD, we thinkabout pulsatile tinnitus and
headaches.
It's doing a really thoroughphysical exam, blood pressures
in both arms, auscultating forbreweries throughout the body.
palpating the pulses.
So first it's like recognizingthe peripheral vascular disease
(09:51):
beyond the heart disease.
And then once we determine thispatient has vascular disease and
that it seems to be arterialdisease, it's figuring out if
it's the horse or the zebra.
And I would say the horse isatherosclerosis.
As you said, Kenny, I mean,that's like 90 percent of
arterial disease that we seethroughout the body is
(10:12):
atherosclerotic.
But then we have the zebras.
And I think among the zebraconditions, fibromuscular
dysplasia is probably one of themore common.
And just for the, for thelisteners, as a reminder, FMD is
a disease that affects thearteries.
It's generally the medium sizedor branch arteries.
(10:33):
It can affect arteriesthroughout the body, most
commonly the renal arteries, thecarotid and vertebral arteries,
but can also affect theintracranial arteries.
the coronary arteries manifestwith SCAD the intestinal
visceral arteries, and the iliacand brachial arteries.
So it's really a total bodyprocess.
(10:54):
About 90 percent of patients,perhaps more in some series, are
women, generally diagnosed atmidlife.
Say our average patient is inthe early fifties, but can
present in children.
Then it's generally a type ofFMD called the focal type.
In the adult type it's generallycalled the multifocal type.
(11:15):
It looks like a string of beads,and again, more commonly in more
of a middle aged adultpopulation.
But we do have patients who arediagnosed in their sixties,
seventies.
I even have a few patients whoare in, in their late eighties
with FMD.
So I think the general approachis to recognize there is
peripheral vascular disease aswell as heart disease.
(11:37):
Determine that it seems to be anarterial problem, and then try
to address whether it's thehorse, the atherosclerosis, or
the zebra.
And of course, if you have anolder patient with diabetes,
hyperlipidemia, all of thoserisk factors more likely to be
athero.
But think of FMD when you haveyounger patients who don't have
a lot of atherosclerotic riskfactors and who have disease in
(12:00):
the, in the typical locations.
So, Heather,
Ellen (12:04):
I guess just to, to focus that a little bit further is
what patient population wouldyou say, or what features would
you say you need to startthinking about FMD, and what is
the role of imaging in makingthat diagnosis once you have the
question of is there possiblyFMD or not?
Heather (12:21):
Yeah, I, I think patients with FMD have three
broad classic clinicalpresentations.
One is the hypertensive patient.
So early onset hypertension,drug resistant hypertension,
hypertension in a, a.
thin middle aged woman whoreally you're surprised has
(12:43):
hypertension.
So that's the hypertensivephenotype we'll say.
The other bucket is people whomanifest with symptoms related
to the cerebrovascular disease.
So these are patients who havecarotid bruise.
have migraine headaches, havepulsatile tinnitus.
I never thought I'd be spendingmy career when I started asking
(13:05):
people about ear noises, butit's a classic symptom of FMD, a
pulsatile sound that times withthe heartbeat, and most patients
describe it as a swooshing, likea whoosh, whoosh, whoosh.
So that's another group ofpatients.
And then the third category isthe manifestations of dissection
and aneurysm.
So these are patients who have.
(13:26):
coronary dissection, carotid orvertebral dissection, renal
dissection with infarct, andthat's how they're diagnosed
with FMD.
So those are the three generalclinical categories where we
most commonly see patientspresent.
I think Absolutely, as youalluded to, we have to move
quickly to imaging.
(13:47):
I think duplex is a good startto evaluate the carotid and
renal arteries and just screenfor FMD, but to definitively
rule out or in FMD anddefinitely to screen all of the
vasculature for aneurysms anddissections, we generally need
CTA or MRA.
And these patients with FMD, werecommend they get a head to
(14:10):
pelvis cross sectional imaging.
Kanny (14:15):
Yeah, thanks, Heather.
As Ellen was mentioning andobviously we're both imagers, so
we have a big interest in thisas well.
For for us, generalcardiologists who do a lot of
consoles many times, the entrypoint is, you know, a patient
was suspected or confirmed, youknow, coronary dissection I
assume in those patients, we dowant to screen for other
(14:36):
manifestations of F.
M.
D.
With the image and you alludedto
Heather (14:40):
absolutely.
And the story of of recognizingthe link between coronary
dissection and FMD is just sointeresting.
And it really starts in WesternCanada.
And there was an interventionalcardiologist, Chris Buehler, and
his subsequent and his partnerJacqueline saw.
who did a lot of the early work.
(15:02):
This was really in the 1990s andearly 2000s.
What they did was they hadcatheter angiograms on their
patients who had acute coronarysyndrome and they would do kind
of drive by renal angiography asI, as, as some may remember, was
kind of in vogue in the 1990s.
And they reported on this seriesof patients, younger women with
(15:26):
acute coronary syndromes andquote atypical coronaries who
when they did these renalangiograms had string of beads
multifocal FMD and they sort ofpostulated could this be
coronary dissection and thatinitial publication I remember
reading it as someone takingcare of patients with FMD and
(15:47):
being very skeptical I didn'tknow what this was about what is
coronary FMD.
But now we really know that thisis SCAD, and Jacqueline Saw at
Vancouver General Hospital, thegroup at Mayo Sharon Hayes,
Marisha Tweet, many otherinvestigators have now done a
lot of work that has reallylinked these atypical
(16:09):
coronaries, determining thatthey're actually coronary
dissections, and then withimaging of the coronaries.
Extracoronary vasculature,identifying that probably about
half, it's more or lessdepending on the case series and
how the patients are imaged ofpatients with SCAD have FMD, if
(16:29):
you image them comprehensively.
So there was a really niceconsensus statement from the
American Heart Association thatI love.
I was not a part of it.
I love, I love reading in it.
It's very informative that cameout in 2019.
If any of the listeners want todownload it and it recommends
(16:49):
that patients who have acoronary artery dissection have
comprehensive imaging, which isdefined as head to pelvis CT
angiography or contrast enhancedMR angiography to look for FMD
as well as a colt.
Aneurysms or dissections.
Wow, that's
Ellen (17:07):
wonderful.
Heather, I have a question foryou regarding when should we be
referring patients tospecialists like yourself?
You know, whether, like I had apatient who we found out that
she had FMD because withhypertension that was
uncontrolled, I was looking forrenal artery stenosis and we
found the classic beatingpattern.
That person was referred.
(17:28):
if they had a spontaneousdissection, that's another
person.
But when do we send them to thespecialist and we let you all
pick up the head to pelvis CTAor, you know, at what point is
it appropriate to send?
Heather (17:42):
Well, I think I would say really at, at any time, I
think for patients with a raredisease to see a physician who,
for them, it's just another dayin clinic versus for.
For some specialists, it may bepulling out the textbook, I
think makes a big difference inthe patient's experience.
I think the opportunity to see aspecialist who's participating
(18:05):
in research.
There's a national FMD actuallynow it's North American registry
for FMD.
That other 20 centers in theUnited States which are
participating for patients tohave a chance to see an expert
who sees FMD routinely, who hasa multi specialty care team they
work with to help out withthings like brain aneurysms,
(18:27):
visceral aneurysms, pulsatiletinnitus, severe headaches, and
to participate in research Ithink has value.
I think that may not always beavailable, but I think if you
have a specialist In your areawho's interested in FMD and I'm
just up the road in inCleveland.
But there's others throughoutthe country.
(18:48):
I think, I think there's valuefor patients with a rare disease
like FMD.
Yeah, thanks,
Kanny (18:53):
Heather.
One quick question is obviouslyI know the image, it can have a
very classic appearance,especially like in the renal
bed, for example.
Is that plus a clinical eventenough to make a diagnosis?
Do we have any, have there beenany advances, for example, in
genetic testing?
Or are there any times youreally have to rely on histology
to really understand that apatient actually has FMD?
Heather (19:18):
Well, in the early days of this disease state, it was
described in the 1930s, actuallyin a pediatric patient at Johns
Hopkins who had an aphrectomy.
It was an early days ofdiagnosis was by histopathology.
In the modern era, however, it'sAlmost exclusively by imaging.
So even in my center, which is ahigh volume FMD center It's
(19:41):
maybe once a year that weactually get histopathology.
So we are really relying onimaging Similarly as of this
time, there's no biomarkers forFMD And although there have been
advances in terms ofunderstanding the genetics and
genetic markers for FMD, andthere's a large international
(20:02):
consortium of investigatorsworking on this, we do not yet
have a genetic test or a bloodtest.
So we're really relying onimaging.
I will say as we talk aboutimaging, FMD overlaps with many
other conditions on imagingstudies.
So Every woman who has a carotiddissection is not a patient with
(20:25):
FMD.
I mean, you can just havedissections without FMD.
Dissection is on thedifferential.
Atherosclerosis sometimes canmimic FMD.
Vasculitis can mimic FMD.
There's other Arterial syndromeslike Loeys Dietz syndrome,
vascular Ehlers Danlos that canmimic FMD.
There's some imaging artifactsactually with reformatting or or
(20:49):
beam hearting artifact fromdental work that can mimic
beating of FMD.
So it's imaging and then aknowledgeable person reviewing
the imaging to confirm thediagnosis and avoiding some of
the pitfalls of things thatoverlap with FMD on imaging.
So Heather, one other
Ellen (21:07):
question is, is once you make that diagnosis in that
individual patient, you said wedon't really have great genetic
markers or genetic testing.
What kind of screening do familymembers, if any, need?
And, and at what point do youstart screening
Heather (21:20):
people for this?
It's a great question.
It's one that, I think we're isevolving.
There was an internationalconsensus.
Actually, it's if anyone'sinterested.
There's an internationalconsensus on FMD led by myself
and Alexander pursue of Belgium,which was published in 2019 and
(21:41):
is available for free downloadon the journal vascular medicine
and At the time of publication,that group looked at the
literature and really felt likewe cannot broadly recommend
screening of family members forpatients with FMD.
Because if you look at the data,such as in the United States, or
now I should say North AmericanFMD registry, among the people
(22:04):
in the registry with FMD, lessthan 10 percent have an affected
family member with FMD.
What's interesting is a quarterof patients with FMD in the
registry have a family memberwith an aneurysm.
So there may be, there clearlyare genetic mechanisms and
(22:26):
familial mechanisms.
I actually published a few yearsago a set of ladies I just saw.
Within the past week who areidentical twins who have FMD and
they actually have FMD in thesame spots, carotid and renal,
although one has brain aneurysmsand one has splenic aneurysms.
(22:47):
So clearly there are familialFMD cases and families.
But it's complicated and in, inmost cases, family members are
not affected.
So what this consensusrecommends is not screening all
family members for FMD, butfocusing on history and physical
(23:07):
exam really.
So if the family members havesymptoms, they have pulsatile
tinnitus, they have migraineheadaches, they have
hypertension at an early age,those folks should be screened.
I think the one caveat I'llthrow in there is if I meet a
patient with FMD who hasaneurysms, and especially if
(23:27):
they have a family member withaneurysms, I would recommend
other family members bescreened.
That's
Kanny (23:35):
fascinating.
Fascinating case you mentioned.
Just 1 very quick questionbefore we spend the last 5
minutes talking about scadsspecifically is about serial
imaging.
You know, like a lot ofcardiologists, I have a panel of
patients who have gone through acoronary dissection had a good
recovery and we see them andthey.
You know, as you know, do verywell clinically over time.
(23:57):
Generally if they've had anegative initial screen, I
assume at some point it's worthre imaging them as well as your
established FMD patients aswell.
And would you basically stick toC.
T.
A.
Combined with occasional duplexstudies for that?
Heather (24:14):
Yeah, I say, Kenny, I would say the guidelines really
do not address this or thescientific statements.
But I like you do for mypatients with scad.
Where there's no otherexplanation and they have
initial imaging that's negativefor a number of those patients.
I've obtained repeat imaging atthe 5 to 7 year mark or so.
(24:38):
And similarly, for patients withFMD, let's say they have carotid
FMD.
and they don't have any diseaseelsewhere on that negative
imaging initially.
I have had patients where again,like five to seven years later,
I've done a repeat CTA and Ihave anecdotally very few, but
(25:00):
occasionally have picked up likean incidental Incident new
aneurysm in those patients, butcurrent scientific statements
and guidelines don't reallyaddress that.
And in general, we don't dofrequent serial CTAs on people
who've had SCAD.
Kanny (25:17):
So, Ellen, I have a question for you.
I know you're have a biginterest in heart disease in
women and in your clinic there.
As we kind of spend our last fewminutes talking more
specifically about coronarydissection, do you mind
reminding our listeners, as acardiology consultant, when
should bells be going off in ourhead that this may not be a
typical, ischemic event and maybe more likely to be a coronary
(25:40):
dissection?
Well,
Ellen (25:44):
certainly we do see scattered or, or spontaneous
coronary dissections morecommonly, I think, in women.
And oftentimes we have toremember that if we have our
postpartum or peripartumpatients at times who have chest
pain, they may have any acoronary dissection as well.
So I think, you know, as peopleget older.
(26:07):
You start thinking usual things,common things are common.
You think of atheroscleroticdisease, but certainly in
patients who you are surprisedthat they're coming in with an
acute coronary event, you lookat the cath films and you have
to look very carefully for thedissections at times, but, but,
but having a high suspicion issomething that's really
important in those people whoyou're, you're pretty surprised
(26:29):
that they're coming in,particularly in women coming in
with these syndromes.
Is that
Heather (26:34):
your experience, Heather?
Yeah.
Yeah, for sure.
I think you have to have thesuspicion.
You have to really scrutinizethose calf films.
I think, as mentioned, I wouldparticularly give a shout out to
Jacqueline saw at VancouverGeneral Hospital, who's done a
lot of work on the angiographicclassification of scad and
(26:56):
raising awareness of scad in thecalf lab.
And the scads have these verydistinctive patterns.
They're actually divided intothree groups.
And I think, With rate giving aclassification system and
raising awareness in the, in theinterventional community,
there's a lot more awareness ofSCAD.
It's actually, it's interesting.
I've actually had a few patientswho were labeled as having
(27:20):
Takotsubo or myocarditis, butwhen you get the cath films and
you really scrutinize, there'sthat type two SCAD of the LAD.
There's that branch OM SCAD.
So I think you really have tohave a high index of suspicion
and really scrutinize those calffilms.
(27:40):
And I, I'm not an interventionalcardiologist, but I have great
relationships with my colleaguesand we'll, my, my
interventionalists, and we'llshare films back and forth.
And really, do you think thiscould be SCAD and really look
for these classic types of SCADon the imaging?
So, Heather
Kanny (27:57):
My understanding as well, is that for more recent series.
FMD and SCAD that, the age rangeis a bit wider than maybe we
thought in the past and that,this can occur in in middle age
or elderly patients.
Has that been your experiencewith the more patients that you
see as well?
For sure.
Heather (28:15):
I think for SCAD, I think, I think when we start
seeing really SCAD, sometimesthere's dissections that are
related to an atheroscleroticlesion, but We absolutely are
seeing a wider range of ages forboth FMD
Kanny (28:31):
And Ellen, with you, you as an imager you know, my
understanding in reading CCTA isthat it just is much more
challenging to distinguish adissection from other types of
occlusion.
Has that been your experience,too, so that we still have to
kind of rely on angiography toreally.
kind of confirm that adissection is occurring versus,
say, a CCTA?
Ellen (28:52):
I think for the most part, we do rely on the invasive
angiography and looking at thosefilms very carefully.
I think maybe over time, wemight be able, as imaging with
CCTA gets better over time andeven more and more granularity,
it might be something we canuse.
But I think for the most part,at the current time, it's with
invasive angiography that we'llmake that
Heather (29:14):
diagnosis.
And I will just add on that, ifI may, that I think coronary CTA
in my own experience has been,has been able to detect major
SCAD.
I mean main LAD SCAD, main RCASCAD.
I think it is really challengingwith the smaller branches.
(29:34):
Yeah, I
Kanny (29:35):
agree as well.
So maybe in the last coupleminutes Heather, we can just
talk a little bit aboutmanagement of.
Yeah, scared.
I think I think most of usclinicians who are now kind of
familiar with the condition whosee it as a consultant
understand that, patients dovery, very well with
conservative management.
I think our interventionalcolleagues have also learned
over the years that interveningcan be problematic.
(29:56):
And that most patients do well,is that still kind of the
current framework when we makethis diagnosis to focus on
conservative management?
And then what medical therapyspecifically has has some
evidence base, and improvingoutcomes here?
Heather (30:10):
Well, I, I.
I do think there's stillopportunity for recognition of
SCAD in the cath lab andappropriate management.
As a referral center for SCADand participating in, we have,
there's actually aninternational SCAD registry for
which we're a site.
We see a number of patients andI have seen even recently
(30:31):
patients who had a SCAD for whomthe lesion was not recognized as
SCAD and there was actually goodflow you know, TIMI 3 flow.
But there was an attempt atintervention that led to
propagation of dissection, verylong segment stenting and a
suboptimal outcome.
(30:53):
So, I, I think not everyone haslearned that.
We need to recognize SCAD andthat the majority of patients
with SCAD, especially if they'renot having ongoing chest pain.
If there's to me good to methree or maybe to me to flow can
be managed conservatively.
That being said, there arepatients who having.
(31:13):
STEMIs who have occluded LADs,who are having ventricular
tachycardia, who are criticallyill, who need revascularization.
It's, it's beyond my strike zoneto address techniques, but there
is a subset of patients who doneed revascularization.
We've had a few patients who'vehad very severe SCAD, very high
(31:36):
risk SCAD, left main SCAD whoneeded even emergency coronary
artery bypass grafting.
So a subset of patients We'llneed intervention, but you're I
completely agree.
The large majority can bemanaged medically generally with
anti platelet therapy betablockers blood pressure control.
(31:56):
There's a lot of interest inongoing research in terms of the
optimal anti platelet regimenfor patients with scab.
There's a study that.
We did with the iSCAD registrythat showed there's a lot of
heterogeneity in terms of whatregimens are being prescribed,
even among the SCAD registrysites dual versus single, what
(32:19):
combinations of dual, andthere's really no clear data.
There's been.
Some data that has suggestedthat perhaps a dual antiplatelet
therapy may not be the besttherapy for patients who have
SCADs, especially the types, themost common type of the type 2
(32:39):
SCAD, which is that taperedlesion due to a mural hematoma,
and maybe single antiplatelettherapy is better.
But I think there are people inthe international FMD research
community who are hopefullydesigning and implementing and
getting funded some researchstudies to address this.
But for now, it's antiplatelettherapy, definitely beta blocker
(33:02):
and blood pressure control.
Kanny (33:03):
Awesome.
Well I'd love to talk about somany other aspects of this
because I think it's been agreat discussion.
I think we're kind of up againstour time.
I do want to remind ourlisteners.
I will put, you know, thereferences that you alluded to
Heather in our show notes with acouple of review articles as
well.
For a further reference, I guessI just want to thank you both.
(33:27):
I think it's been a greatdiscussion.
I think it's great to have youas a resource here in Northeast
Ohio and for Ohio in general.
And we look forward to followingprogress as we learn more about
this condition.
Thanks to questions like you.
So thanks Ellen.
And thanks Heather.
Both for joining us today.
Thank you.
Kenny.
Heather (33:49):
Thank you.
Thank you for joining today'spodcast.
For more information about thespeakers or the topics, please
go to Ohio acc.org,
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