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Background: Ticagrelor was shown to reduce mortality in patients who underwent coronary artery bypass grafting (CABG), but its effect on graft patency is unknown.Methods: We performed a prospective, randomised, double-blind, placebo-controlled trial, comparing ticagrelor 90 mg twice daily versus placebo for 3 months added to aspirin 81 mg/day, following isolated CABG. Aspirin was started within 12 h, and study medication within 72 h after CABG. Primary outcome was graft occlusion on CT angiography (CTA) performed 3 months post CABG. Patients were followed to 12 months for death, myocardial infarction, stroke, repeat revascularisation and bleeding.Results: The study was terminated prematurely after randomising 70 patients between September 2011 and August 2014 because of slow recruitment. CTA was performed in 56 patients who completed >1 month of study drug. Graft occlusion occurred in 7/25 (28.0%) patients on ticagrelor and 17/31 (48.3%) on placebo, p=0.044. Of 207 analysable grafts, graft occlusion occurred in 9/87 (10.3%) with ticagrelor and 22/120 (18.3%) with placebo, p=0.112. Graft occlusion or stenosis ≥50% occurred in 10/87 (11.5%) ticagrelor vs 32/120 (26.7%) placebo, p=0.007. There was no major bleeding, but minor bleeding was higher with ticagrelor (31.4% vs 2.9%, p=0.003). In univariate analysis, ticagrelor use reduced graft occlusion (OR 0.32, 95% CI 0.10 to 0.97, p=0.047), which remained significant on multivariable analysis (OR 0.25, 95% CI 0.073 to 0.873, p=0.03).Conclusions: Ticagrelor added to aspirin after CABG reduced the proportion of patients with graft occlusion, and was a significant univariate and multivariable predictor of graft occlusion. These results are hypothesis-generating and should be confirmed in larger studies.Trial Registration Number: NCT01373411: Results. [ABSTRACT FROM AUTHOR]

Background: Spontaneous coronary artery dissection (SCAD) is underdiagnosed and an important cause of myocardial infarction (MI), especially in young women. Long-term cardiovascular outcomes, including recurrent SCAD, are inadequately reported.Objectives: This study sought to describe the acute and long-term cardiovascular outcomes and assess the predictors of recurrent SCAD.Methods: Nonatherosclerotic SCAD patients were prospectively followed at Vancouver General Hospital systematically to ascertain baseline, predisposing and precipitating stressors, angiographic features, revascularization, use of medication, and in-hospital and long-term cardiovascular events. Clinical predictors for recurrent de novo SCAD were tested using univariate and multivariate Cox regression models.Results: The authors prospectively followed 327 SCAD patients. Average age was 52.5 ± 9.6 years, and 90.5% were women (56.9% postmenopausal). All presented with MI; 25.7% had ST-segment elevation MI, 74.3% had non-ST-segment elevation MI, and 8.9% had ventricular tachycardia/ventricular fibrillation. Precipitating emotional stressors were reported in 48.3% and physical stressors in 28.1%. Fibromuscular dysplasia was present in 62.7%, connective tissue disorder in 4.9%, and systemic inflammatory disease in 11.9%. The majority (83.1%) were initially treated medically, with only 16.5% or 2.2% undergoing in-hospital percutaneous coronary intervention or coronary artery bypass graft surgery, respectively. The majority of SCAD patients were taking aspirin and beta-blocker therapy at discharge and at follow-up. Median hospital stay was 3.0 days, and the overall major adverse event rate was 7.3%. Median long-term follow-up was 3.1 years, and overall major adverse cardiac event rate was 19.9% (death rate: 1.2%; recurrent MI: 16.8%; stroke/transient ischemic attack: 1.2%; revascularization: 5.8%). Recurrent SCAD occurred in 10.4% of patients. In multivariate modeling, only hypertension increased (hazard ratio: 2.46; p = 0.011) and beta-blocker use diminished (hazard ratio: 0.36; p = 0.004) recurrent SCAD.Conclusions: In our large prospectively followed SCAD cohort, long-term cardiovascular events were common. Hypertension increased the risk of recurrent SCAD, whereas beta-blocker therapy appeared to be protective. [ABSTRACT FROM AUTHOR]

Background: Stent thrombosis (ST) is rare, but is associated with significant morbidity and mortality. Methods: We analyzed data from the British Columbia (BC) Registry from April 2011-January 2012. Results: 101 ST cases were reported and verified. Based on timing, ST was considered early (≤30days) in 35.6%, late (>30days-1year) in 17.8% and very late (>1year) in 46.5%. The majority (68.5%) presented with STEMI, and the remaining with non-STEMI (31.5%). Most vessels were functionally occluded (TIM1 flow grade ≤1 in 67.1%). Thrombus burden was high (TIMI thrombus grade ≥4 in 77.2%). Aspiration thrombectomy was performed in 41% of cases. New stents were implanted in 62.4% cases. Intra-coronary imaging was low (11%). At the original stent implantation, STEMI was the clinical presentation in 39.6%, the lesion was complex in 62.1%, and thrombus was visualized in 23.0%. Prognosis after ST was unfavorable with high mortality (11.9% at 30days and 16.8% at one year), and further revascularization (5.0% repeat PCI and 6.9% coronary artery bypass graft surgery). Early ST was associated with worse clinical outcome compared to late/very late ST: 30-day mortality at 22.2% versus 6.2% (p=0.02), and 1-year mortality at 27.8% versus 10.8% (p=0.05). Conclusions: In this prospective registry from BC, all ST presented with myocardial infarction, and the majority was treated with emergency PCI. Additional stents were commonly implanted with infrequent use of intracoronary imaging. Mortality rate was higher for early ST in comparison with late/very late ST. A comprehensive approach should be developed to treat this difficult complication. [ABSTRACT FROM AUTHOR]

Objectives: Given the uncertainty regarding the degree and prevalence of spontaneous healing following spontaneous coronary artery dissection (SCAD), the aim of this study was to assess the angiographic characteristics of the dissected segments in a large cohort of patients with SCAD who underwent subsequent repeat coronary angiography., Background: SCAD is an uncommon yet important cause of myocardial infarction in women. Very little is known about the characteristics of healing of dissected arteries., Methods: Patients with nonatherosclerotic SCAD followed prospectively at Vancouver General Hospital who underwent repeat angiography were included in this study. Those who underwent percutaneous coronary intervention for SCAD were excluded. Baseline patient demographics and in-hospital and long-term cardiovascular events were recorded. Angiographic characteristics of the SCAD artery at index and repeat angiography were assessed by 2 experienced angiographers. Criteria for angiographic healing were as follows: 1) improvement of stenosis severity from index event; 2) residual stenosis <50%; and 3) TIMI (Thrombolysis In Myocardial Infarction) flow grade 3., Results: One hundred fifty-six patients with 182 noncontiguous SCAD lesions were included. The mean age was 51.5 ± 8.7 years, 88.5% were women, 83.3% were Caucasian, and 75.6% had fibromuscular dysplasia. All patients presented with myocardial infarction. At index angiography, type 2 SCAD was most commonly observed, in 126 of 182 lesions (69.2%); TIMI flow grade <3 was present in 85 of 182 (46.7%); and median lesion stenosis was 79.0% (interquartile range: 56.0% to 100%). Median time to repeat angiography was 154 days (interquartile range: 70 to 604 days), with median residual lesion stenosis improving to 25.5% (interquartile range: 12.0 to 38.8 days), and TIMI flow grade <3 observed in 10 of 182 lesions (5.5%). Angiographic healing occurred in 157 of 182 lesions (86.3%). Of repeat angiography performed ≥30 days post-SCAD, 152 of 160 (95%) showed spontaneous angiographic healing., Conclusions: The majority of coronary arteries affected by SCAD heal spontaneously on repeat angiography, with apparent time dependency, with the vast majority having complete healing after 30 days from the SCAD event., (Copyright © 2019. Published by Elsevier Inc.)

Background: Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction in women, but the role of rehabilitation after SCAD is unclear., Methods: We designed a dedicated SCAD cardiac rehabilitation (SCAD-CR) program for our SCAD survivors at Vancouver General Hospital. This program encompasses a multidisciplinary approach including exercise rehabilitation, psychosocial counselling, dietary and cardiovascular disease education, and peer group support. Exercise and educational classes were scheduled weekly with a targeted participation of 6 months. Psychosocial counselling, mindful living sessions, social worker and psychiatry evaluations, and peer-group support were offered., Results: We report our first consecutive cohort of 70 SCAD women who joined SCAD-CR from November 2011 to April 2015. The average age was 52.3 ± 8.4 years. Mean participation duration was 12.4 ± 10.5 weeks; 28 completed 6 months, 48 completed ≥ 1 month. At entry, 44 (62.9%) had recurrent chest pains and average metabolic equivalents on exercise treadmill test was 10.1 ± 3.3. At program exit, the proportion with recurrent chest pains was lower (37.1%) and average metabolic equivalents was higher 11.5 ± 3.5 (both P < 0.001). There was a significant improvement in the STOP-D depression questionnaire, with mean scores of 13.0 ± 1.4 before and 8.0 ± 1.7 after the SCAD-CR (P = 0.046). Twenty (28.6%) social worker referrals and 19 (27.1%) psychiatry referrals were made. Mean follow-up was 3.8 ± 2.9 years from the presenting SCAD event, and the major cardiac adverse event rate was 4.3%, lower than our non-SCAD-CR cohort (n = 145; 26.2%; P < 0.001)., Conclusions: This is the first dedicated SCAD-CR program to address the unique exercise and psychosocial needs of SCAD survivors. Our program appears safe and beneficial in improving chest pain, exercise capacity, psychosocial well-being and cardiovascular events., (Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Nonatherosclerotic coronary artery disease (NACAD) is an important cause of myocardial infarction (MI) in young women but is often missed on coronary angiography, especially spontaneous coronary artery dissection (SCAD). The prevalence of NACAD in young women has not been described., Methods: We retrospectively reviewed all coronary angiograms of women aged 50 years and younger at Vancouver General Hospital from December 1, 2009 to November 30, 2011. The angiograms were reviewed by 2 experienced interventional cardiologists, and reported as normal (<30% stenosis), atherosclerotic coronary artery disease (ACAD), or NACAD. NACAD was further characterized as SCAD, coronary fibromuscular dysplasia (FMD), ectasia, vasculitis, embolism, congenital anomaly, or unclear etiology., Results: Of 7605 coronary angiograms performed, 177 were done in women aged 50 years and younger. The mean age was 45.4 ± 4.9 (range, 31-50) years, 76 of 177 (42.9%) presented with acute coronary syndrome, and 66 were troponin-positive. Ninety-seven (54.8%) women had normal arteries, 54 (30.5%) had ACAD, 23 (13.0%) had NACAD, and 3 (1.7%) had unclear etiology. Of those with NACAD, SCAD was observed in 16 (all troponin-positive and 13 of 16 had noncoronary FMD), and 2 had irregular beading suspicious of coronary FMD. Coronary vasculitis was suspected in 2, and 5 had coronary ectasia. Among women with MI (66/177), 19 (28.8%) had normal arteries (3 Takotsubo cardiomyopathy), 24 (36.4%) had ACAD, 20 (30.3%) had NACAD, 16 (24.2%) had SCAD, and 3 had unclear etiology., Conclusions: NACAD was not rare among young women (aged 50 years and younger) undergoing coronary angiography and was an important cause of MI, accounting for 30%. SCAD was the most commonly encountered NACAD in young women, causing 24% of MIs., (Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Objectives: We sought to evaluate the prevalence of fibromuscular dysplasia (FMD) and other predisposing conditions among spontaneous coronary artery dissection (SCAD) patients., Background: Spontaneous coronary artery dissection is considered rare. However, we observed many young women with SCAD and concomitant FMD., Methods: Spontaneous coronary artery dissection patients were identified prospectively and retrospectively at Vancouver General Hospital over the past 6 years. Coronary angiograms were meticulously reviewed by 2 senior interventional cardiologists. Identified patients were contacted for prospective evaluation at our SCAD clinic, and screening for FMD of renal, iliac, and cerebrovascular arteries was performed with computed tomography angiography or magnetic resonance angiography, if not already screened during the index angiogram. Potential predisposing and precipitating conditions for SCAD were extracted from clinical history., Results: We identified 50 patients with nonatherosclerotic SCAD from April 2006 to March 2012. Average age was 51.0 years, and almost all were women (98.0%). All presented with myocardial infarction (MI), 30.0% had ST-segment elevation, and 70.0% had non-ST-segment elevation MI. Only 1 was postpartum, and 2 were involved in intense isometric exercises. Emotional stress was reported in 26.0% before the MI. Twelve percent had >1 dissected coronary artery. Most SCAD patients had FMD of ≥1 noncoronary territory (86.0%): 25 of 43 (58.1%) renal, 21 of 43 (48.8%) iliac, and 20 of 43 (46.5%) cerebrovascular (6 of 43, 14.0% had intracranial aneurysm). Five had incomplete FMD screening., Conclusions: Nonatherosclerotic SCAD predominantly affects women, and most have concomitant FMD. We suspect these patients have underlying coronary FMD that predisposed them to SCAD, but this requires proof from histology or intracoronary imaging of the affected coronary arteries., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Visual angiographic assessment of intermediate coronary lesions is poor at determining the functional significance. We sought to identify independent clinical and angiographic parameters associated with stenosis functional significance and applied them in a weighted fractional flow reserve angiographic scoring tool (FAST) to improve intermediate lesion selection for fractional flow reserve (FFR) assessment., Methods and Results: Data from 100 patients with intermediate lesions previously assessed by FFR were retrospectively analyzed, and four independent variables that predicted FFR of less than or equal to 0.8 were identified: quantitative coronary angiography percent diameter stenosis [odds ratio (OR) 1.22, P<0.001], length more than 20 mm (OR 7.6, P=0.004), stenosis haziness (OR 16.6, P=0.005), and multivessel disease (OR 7.8, P=0.019). Applying these variables into the FAST score, we prospectively assessed a further 109 intermediate lesions (prevalence of FFR ≤0.8 was 29% in this validation cohort) and found that FAST was highly discriminative, predicting an FFR of less than or equal to 0.8 with a c-statistic of 0.865 (95% confidence interval 0.793-0.937, P<0.0001). At the optimal cutoff value, FAST score of more than 2 had a negative predictive value of 96.5% and a sensitivity of 93.8%. It would have reduced the pressure wire usage in the validation cohort by 52.3% (57 out of 109 cases), with only two false negatives and associated cost savings., Conclusion: The FAST score is a simple angiographic assessment tool for intermediate lesions that comprises four angiographic variables. A score of 2 or lower indicates low likelihood of lesion hemodynamic significance.