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SCD 2014: Coronary Artery Anomalies and Obstructive Disease

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Todd L. Kiefer, MD

Published in: Health & Medicine, Education
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SCD 2014: Coronary Artery Anomalies and Obstructive Disease

  1. 1. Todd L. Kiefer, M.D. Coronary Artery Anomalies and Obstructive Coronary Artery Disease
  2. 2. All Rights Reserved, Duke Medicine 2008 • Rare • Overall 1,686 patients of 126,595 catheterization patients in one database • Benign: circumflex from R sinus or RCA, separate LAD and LCx ostia • Potentially serious: ALCAPA, ARCAPA, CAF • LM or LAD from R sinus or RCA from L sinus • 196 of 126,595 cases involved coronary origin from opposite sinus Coronary Artery Anomalies Yamanaka, O. Catheterization and Cardiovascular Diagnosis, 21:28, 1990.
  3. 3. All Rights Reserved, Duke Medicine 2008 Bashore, T.M. ACCSAP8, 2012.
  4. 4. All Rights Reserved, Duke Medicine 2008 Coronary Artery Anomalies Angelini, P. Circulation,115:1296, 2007. 4 subtypes of ACAOS 1. Anterior course 2. Posterior course 3. Septal course 4. Interarterial
  5. 5. All Rights Reserved, Duke Medicine 2008 Coronary Artery Anomalies Krasuski, R et al. Circulation, 123:154, 2011. LM from R sinus RCA from L sinus
  6. 6. All Rights Reserved, Duke Medicine 2008 Bashore, T.M. ACCSAP8, 2012.
  7. 7. All Rights Reserved, Duke Medicine 2008 • 301 patients out of 210,700 cardiac catheterizations • 79% of the 301 were anomalous RCA from L sinus • 21% of the 301 were anomalous LM or LAD from R sinus • 54 of the 301 (21%) had an interarterial course Anomalous coronary from opposite sinus of Valsalva Krasuski, R et al. Circulation, 123:154, 2011.
  8. 8. All Rights Reserved, Duke Medicine 2008 Sudden Death in the Young Athlete Cause Percent Hypertrophic Cardiomyopathy 26% Commotio Cordis 20% Anomalous Coronary 14% LVH of unclear cause 7.5% Myocarditis 5% Ruptured aortic aneurysm (Marfan’s) 3% Arrhythmogenic RV Dysplasia 3% Aortic stenosis 3% Atherosclerotic coronary disease 2.6% Other, including heat stroke, MVP, dilated CM, drug use, asthma, long QT, sarcoidosis, ruptured aneurysm 13.5% Maron BJ. Sudden Death in Young Athletes. N Engl J Med. 2003:1064-1075.
  9. 9. All Rights Reserved, Duke Medicine 2008 Sudden Death in the Young Athlete Maron BJ, et al. Incidence and Causes of Sudden Death in U.S. College Athletes. JACC, 2014. ANUSCRIPT ACCEPTED MANUSCRIPT 182 Sudden deaths in NCAA athletes from 2002-2011
  10. 10. All Rights Reserved, Duke Medicine 2008 ACC/AHA Adult Congenital Guidelines • Surgical coronary revascularization for: • Anomalous LM from R sinus with course between Aorta and PA • Documented ischemia with anomalous coronary course between the great arteries • Anomalous RCA from L sinus with course between the great vessels and documented ischemia Class I Warnes CA, et al. Circulation, 118:714, 2008.
  11. 11. All Rights Reserved, Duke Medicine 2008 Coronary Artery Anomalies Frommelt, P et al. JACC, 42:148, 2003. “Unroofing”
  12. 12. All Rights Reserved, Duke Medicine 2008 36th Bethesda Conference in 2005 • Task forces examine data and provide recommendations on eligibility for competitive athletics in patients with various cardiac conditions • Coronary artery from the opposite sinus with an interarterial course should EXCLUDE participation from all competitive sports • Participation 3 months post-surgery allowed in the absence of ischemia, arrhythmias, or dysfunction during max exercise testing Graham TP et al. Task Force 2. JACC, 2005.
  13. 13. All Rights Reserved, Duke Medicine 2008 • 17 year-old man with no past medical history collapses in school cafeteria after episode of chest pain. CPR—AED. • At OSH, diagnosed with NSTEMI and undergoes coronary angiography Case #1:
  14. 14. All Rights Reserved, Duke Medicine 2008
  15. 15. All Rights Reserved, Duke Medicine 2008
  16. 16. All Rights Reserved, Duke Medicine 2008
  17. 17. All Rights Reserved, Duke Medicine 2008 Ao PA
  18. 18. All Rights Reserved, Duke Medicine 2008 Ao PA
  19. 19. All Rights Reserved, Duke Medicine 2008 Ao
  20. 20. All Rights Reserved, Duke Medicine 2008 Sudden Death in the Young Athlete Cause Percent Hypertrophic Cardiomyopathy 26% Commotio Cordis 20% Anomalous Coronary 14% LVH of unclear cause 7.5% Myocarditis 5% Ruptured aortic aneurysm (Marfan’s) 3% Arrhythmogenic RV Dysplasia 3% Aortic stenosis 3% Atherosclerotic coronary disease 2.6% Other, including heat stroke, MVP, dilated CM, drug use, asthma, long QT, sarcoidosis, ruptured aneurysm 13.5% Maron BJ. Sudden Death in Young Athletes. N Engl J Med. 2003:1064-1075.
  21. 21. All Rights Reserved, Duke Medicine 2008 Sudden Death in the Young Athlete Maron, BJ et al. Incidence and Causes of Sudden Death in U.S. College Athletes. JACC, 2014. ANUSCRIPT ACCEPTED MANUSCRIPT 182 Sudden deaths in NCAA athletes from 2002-2011
  22. 22. All Rights Reserved, Duke Medicine 2008 Screening for CAD for Exercise • 2002 ACC/AHA Guidelines for Exercise Testing • Class IIa—Exercise ECG considered for diabetic individuals starting a vigorous exercise program • Class IIb—Asymptomatic men>45, women >55 who plan to start a vigorous exercise program Gibbons, RJ et al. Circulation, 106:1883, 2002.
  23. 23. All Rights Reserved, Duke Medicine 2008 Screening for CAD for Exercise • 2010 ACC/AHA Guidelines for Assessment of Cardiovascular Risk in Asymptomatic Adults • Class IIb—Exercise ECG considered for intermediate-risk, asymptomatic adults including sedentary individuals starting a vigorous exercise program • American College of Sports Medicine recommends Exercise ECG for men>40, women>50, and other asymptomatic patients with multiple CAD risk factors prior to starting vigorous exercise program • ACP, AAFP, and ADA: do not recommend routine screening to start an exercise program
  24. 24. All Rights Reserved, Duke Medicine 2008 36th Bethesda Conference in 2005 • Task forces examine data and provide recommendations on eligibility for competitive athletics in patients with various cardiac conditions • Coronary artery disease: • Evaluation: maximal treadmill or bicycle exercise testing to close approximate the demands of the planned sport or activity Graham, TP et al. Task Force 2. JACC, 2005.
  25. 25. All Rights Reserved, Duke Medicine 2008 36th Bethesda Conference in 2005 • Task forces examine data and provide recommendations on eligibility for competitive athletics in patients with various cardiac conditions • Coronary artery disease: • Risk stratification: • Mild increased risk: all of the following are met 1. Normal resting LV function 2. Normal exercise tolerance for age (age-specific METS and O2 consumption values) 3. No exercise-induced ischemia or arrhythmia 4. Coronary angiography <50% stenosis 5. S/P successful revascularization (surgical or PCI) Graham, TP et al. Task Force 2. JACC, 2005.
  26. 26. All Rights Reserved, Duke Medicine 2008 36th Bethesda Conference in 2005 • Task forces examine data and provide recommendations on eligibility for competitive athletics in patients with various cardiac conditions • Coronary artery disease: • Risk stratification: • Substantially increased risk: any of the following 1. Reduced LV ejection fraction <50% 2. Exercise-induced ischemia or complex ventricular arrhythmias 3. Coronary angiography >50% stenosis Graham, TP et al. Task Force 2. JACC, 2005.
  27. 27. All Rights Reserved, Duke Medicine 2008 Mitchell, JH et al. Task Force 8. JACC, 2005.
  28. 28. All Rights Reserved, Duke Medicine 2008 36th Bethesda Conference in 2005 • Task forces examine data and provide recommendations on eligibility for competitive athletics in patients with various cardiac conditions • Coronary artery disease: • Recommendations: • Mild increased risk: Classes IA and IIA sports • Selected athletes with low exercise risk profiles may compete in higher intensity • Substantial increased risk: Class IA sports Graham TP et al. Task Force 2. JACC, 2005.
  29. 29. All Rights Reserved, Duke Medicine 2008

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