Always On EM - Mayo Clinic Emergency Medicine

In this final chapter of the 2025 season of Always on EM, Alex and Venk are thrilled to share an amazing Grand Rounds recording from the esteemed educator and clinician, Dr. Neha Raukar. She is renowned for her expertise in many areas - among them, concussion and traumatic brain injury, particularly of athletes. She breaks down imaging guidelines, evaluation of TBI, prognosis, counseling of patients and more in this fantastic talk essential for any emergency healthcare professional to hear!

 

CONTACTS

X - @AlwaysOnEM; @VenkBellamkonda; @NehaRaukarMD

YouTube - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch; @NehaRaukarMD

Email - [email protected]

 

WANT TO WORK AT MAYO?

EM Physicians: https://jobs.mayoclinic.org/emergencymedicine

EM NP PAs: https://jobs.mayoclinic.org/em-nppa-jobs  

Nursing/Techs/PAC: https://jobs.mayoclinic.org/Nursing-Emergency-Medicine

EMTs/Paramedics: https://jobs.mayoclinic.org/ambulanceservice

All groups above combined into one link: https://jobs.mayoclinic.org/EM-Jobs

Dr Sharonne Hayes, Professor of cardiovascular medicine and founding director of Mayo Clinic women’s heart clinic, and Dr. Marysia Tweet, Associate Professor of cardiovascular medicine, and co-leader of the Spontaneous Coronary Artery Dissection Registry and leader in women’s heart health join the show for this amazing November chapter of Always on EM. They are world experts on Spontaneous Coronary Artery Dissection authoring over 60 peer reviewed articles on the topic and in this chapter we explore with them the pitfalls and pearls related to making this diagnosis in the ED. SCAD is an important cause of myocardial infarction especially in patients who would not otherwise seem to be at risk for heart attacks for example active young women without comorbidities, and its imperitive that we as emergency physicians are current on this diagnosis.

 

DONATE TO DR JIM GREGOIRE SCHOLARSHIP FUND

To honor the life of Dr. Jim Gregoire, dear friend of this show, consider donating to his scholarship fund. Go to https://give.mayoclinic.org/give/616870/#!/donation/checkout

Go to: What would you like your donation to support?

Choose “other”

Enter: James Gregoire Scholarship Fund

 

CONTACTS

X - @AlwaysOnEM; @VenkBellamkonda; @Marysia_Tweet; @SharonneHayes

YouTube - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch; @SharonneHayes

Email - [email protected]

 

DO YOU HAVE SCAD? DOES YOUR PATIENT HAVE SCAD? WANT TO GET CONNECTED?

SCAD Research: www.scadresearch.org

National Coalition for Women with Heart Disease: www.womenheart.org

Mayo Clinic Womens Heart clinic: https://www.mayoclinic.org/departments-centers/womens-heart-clinic/overview/ovc-20442061

 

REFERENCES & LINKS

Saleh G, Al-Abcha A, Chaaban K, Adi MZ, Tweet M, Collins JD, Alkhouli M, Gulati R. Concomitant Takotsubo Cardiomyopathy and Spontaneous Coronary Artery Dissection: Exploring the Role of Cardiac Mechanics on Coronary Disruption. JACC Cardiovasc Imaging. 2025 Oct;18(10):1161-1166. doi: 10.1016/j.jcmg.2025.05.020. Epub 2025 Aug 5. PMID: 40758075.

Baqal O, Karikalan SA, Hasabo EA, Tareen H, Futela P, Qasba RK, Shafqat A, Qasba RK, Hayes SN, Tweet MS, El Masry HZ, Lee KS, Shen WK, Sorajja D. In- hospital and long-term outcomes in spontaneous coronary artery dissection with concurrent cardiac arrest: Systematic review and meta-analysis. Heart Rhythm O2. 2025 Apr 24;6(6):843-853. doi: 10.1016/j.hroo.2025.03.023. PMID: 40717849; PMCID: PMC12287955.

Morosato M, Gaspardone C, Romagnolo D, Pagnesi M, Baldetti L, Dormio S, Federico F, Scandroglio AM, Chieffo A, Godino C, Margonato A, Adamo M, Metra M, Tchetche D, Dumonteil N, Tweet MS, Saw J, Beneduce A. Left Main Spontaneous Coronary Artery Dissection: Clinical Features, Management, and Outcomes. JACC Cardiovasc Interv. 2025 Apr 28;18(8):975-983. doi: 10.1016/j.jcin.2025.01.427. Epub 2025 Apr 9. PMID: 40208153; PMCID: PMC12290918.

Tweet MS, Pellikka PA, Gulati R, Gochanour BR, Barrett-O'Keefe Z, Raphael CE, Best PJM, Hayes SN. Coronary Artery Tortuosity and Spontaneous Coronary Artery Dissection: Association With Echocardiography and Global Longitudinal Strain, Fibromuscular Dysplasia, and Outcomes. J Am Soc Echocardiogr. 2024 May;37(5):518-529. doi: 10.1016/j.echo.2024.02.013. Epub 2024 Mar 11. PMID: 38467311; PMCID: PMC11605948.

Tweet MS, Hayes SN, Grimaldo ABG, Rose CH. Pregnancy After Spontaneous Coronary Artery Dissection: Counseling Patients Who Intend Future Pregnancy. JACC Adv. 2023 Dec;2(10):100714. doi: 10.1016/j.jacadv.2023.100714. Epub 2023 Nov 14. PMID: 38915307; PMCID: PMC11194843.

Tarabochia AD, Tan NY, Lewis BR, Slusser JP, Hayes SN, Best PJM, Gulati R, Deshmukh AJ, Tweet MS. Association of Spontaneous Coronary Artery Dissection With Atrial Arrhythmias. Am J Cardiol. 2023 Jan 1;186:203-208. doi: 10.1016/j.amjcard.2022.09.032. Epub 2022 Oct 31. PMID: 36328832; PMCID: PMC10403149.

Murugiah K, Chen L, Dreyer RP, Bouras G, Safdar B, Lu Y, Spatz ES, Gupta A, Khera R, Ng VG, Bueno H, Tweet MS, Spertus JA, Hayes SN, Lansky A, Krumholz HM. Depression and Perceived Stress After Spontaneous Coronary Artery Dissection and Comparison With Other Acute Myocardial Infarction (the VIRGO Experience). Am J Cardiol. 2022 Jun 15;173:33-38. doi: 10.1016/j.amjcard.2022.03.005. Epub 2022 Mar 29. PMID: 35365290; PMCID: PMC9133198.

Johnson AK, Tweet MS, Rouleau SG, Sadosty AT, Hayes SN, Raukar NP. The presentation of spontaneous coronary artery dissection in the emergency department: Signs and symptoms in an unsuspecting population. Acad Emerg Med. 2022 Apr;29(4):423-428. doi: 10.1111/acem.14426. Epub 2021 Dec 26. PMID: 34897898; PMCID: PMC10403148.

Murugiah K, Chen L, Dreyer RP, Bouras G, Safdar B, Khera R, Lu Y, Spatz ES, Ng VG, Gupta A, Bueno H, Tweet MS, Spertus JA, Hayes SN, Lansky A, Krumholz HM. Health status outcomes after spontaneous coronary artery dissection and comparison with other acute myocardial infarction: The VIRGO experience. PLoS One. 2022 Mar 23;17(3):e0265624. doi: 10.1371/journal.pone.0265624. PMID: 35320296; PMCID: PMC8942215.

Adlam D, Tweet MS, Gulati R, Kotecha D, Rao P, Moss AJ, Hayes SN. Spontaneous Coronary Artery Dissection: Pitfalls of Angiographic Diagnosis and an Approach to Ambiguous Cases. JACC Cardiovasc Interv. 2021 Aug 23;14(16):1743-1756. doi: 10.1016/j.jcin.2021.06.027. PMID: 34412792; PMCID: PMC8383825.

Kok SN, Tweet MS. Recurrent spontaneous coronary artery dissection. Expert Rev Cardiovasc Ther. 2021 Mar;19(3):201-210. doi: 10.1080/14779072.2021.1877538. Epub 2021 Feb 26. PMID: 33455483.

Campbell KH, Tweet MS. Coronary Disease in Pregnancy: Myocardial Infarction and Spontaneous Coronary Artery Dissection. Clin Obstet Gynecol. 2020 Dec;63(4):852-867. doi: 10.1097/GRF.0000000000000558. PMID: 32701519; PMCID: PMC10767871.

Tweet MS, Young KA, Best PJM, Hyun M, Gulati R, Rose CH, Hayes SN. Association of Pregnancy With Recurrence of Spontaneous Coronary Artery Dissection Among Women With Prior Coronary Artery Dissection. JAMA Netw Open. 2020 Sep 1;3(9):e2018170. doi: 10.1001/jamanetworkopen.2020. PMID: 32965500; PMCID: PMC7512056.

Hayes SN, Tweet MS, Adlam D, Kim ESH, Gulati R, Price JE, Rose CH. Spontaneous Coronary Artery Dissection: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020 Aug 25;76(8):961-984. doi: 10.1016/j.jacc.2020.05.084. PMID: 32819471.

Johnson AK, Hayes SN, Sawchuk C, Johnson MP, Best PJ, Gulati R, Tweet MS. Analysis of Posttraumatic Stress Disorder, Depression, Anxiety, and Resiliency Within the Unique Population of Spontaneous Coronary Artery Dissection Survivors. J Am Heart Assoc. 2020 May 5;9(9):e014372. doi: 10.1161/JAHA.119.014372. Epub 2020 Apr 28. PMID: 32342736; PMCID: PMC7428589.

Tweet MS, Akhtar NJ, Hayes SN, Best PJ, Gulati R, Araoz PA. Spontaneous coronary artery dissection: Acute findings on coronary computed tomography angiography. Eur Heart J Acute Cardiovasc Care. 2019 Aug;8(5):467-475. doi: 10.1177/2048872617753799. Epub 2018 Jan 29. PMID: 29376398; PMCID: PMC6027604.

Tan NY, Tweet MS. Spontaneous coronary artery dissection: etiology and recurrence. Expert Rev Cardiovasc Ther. 2019 Jul;17(7):497-510. doi: 10.1080/14779072.2019.1635011. Epub 2019 Jul 5. PMID: 31232618.

Waterbury TM, Tweet MS, Hayes SN, Eleid MF, Bell MR, Lerman A, Singh M, Best PJM, Lewis BR, Rihal CS, Gersh BJ, Gulati R. Early Natural History of Spontaneous Coronary Artery Dissection. Circ Cardiovasc Interv. 2018 Sep;11(9):e006772. doi: 10.1161/CIRCINTERVENTIONS.118. PMID: 30354594.

Hayes SN, Kim ESH, Saw J, Adlam D, Arslanian-Engoren C, Economy KE, Ganesh SK, Gulati R, Lindsay ME, Mieres JH, Naderi S, Shah S, Thaler DE, Tweet MS, Wood MJ; American Heart Association Council on Peripheral Vascular Disease; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Genomic and Precision Medicine; and Stroke Council. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation. 2018 May 8;137(19):e523-e557. doi: 10.1161/CIR.0000000000000564. Epub 2018 Feb 22. PMID: 29472380; PMCID: PMC5957087.

Tweet MS, Kok SN, Hayes SN. Spontaneous coronary artery dissection in women: What is known and what is yet to be understood. Clin Cardiol. 2018 Feb;41(2):203-210. doi: 10.1002/clc.22909. Epub 2018 Mar 1. PMID: 29493808; PMCID: PMC5953427.

Tweet MS, Codsi E, Best PJM, Gulati R, Rose CH, Hayes SN. Menstrual Chest Pain in Women With History of Spontaneous Coronary Artery Dissection. J Am Coll Cardiol. 2017 Oct 31;70(18):2308-2309. doi: 10.1016/j.jacc.2017.08.071. PMID: 29073960; PMCID: PMC5957076.

Lindor RA, Tweet MS, Goyal KA, Lohse CM, Gulati R, Hayes SN, Sadosty AT. Emergency Department Presentation of Patients with Spontaneous Coronary Artery Dissection. J Emerg Med. 2017 Mar;52(3):286-291. doi: 10.1016/j.jemermed.2016.09. Epub 2016 Oct 8. PMID: 27727035.

Tweet MS, Gulati R, Williamson EE, Vrtiska TJ, Hayes SN. Multimodality Imaging for Spontaneous Coronary Artery Dissection in Women. JACC Cardiovasc Imaging. 2016 Apr;9(4):436-50. doi: 10.1016/j.jcmg.2016.01.009. PMID: 27056163.

Tweet MS, Gulati R, Hayes SN. What Clinicians Should Know Αbout Spontaneous Coronary Artery Dissection. Mayo Clin Proc. 2015 Aug;90(8):1125-30. doi: 10.1016/j.mayocp.2015.05.010. PMID: 26250728.

Prasad M, Tweet MS, Hayes SN, Leng S, Liang JJ, Eleid MF, Gulati R, Vrtiska TJ. Prevalence of extracoronary vascular abnormalities and fibromuscular dysplasia in patients with spontaneous coronary artery dissection. Am J Cardiol. 2015 Jun 15;115(12):1672-7. doi: 10.1016/j.amjcard.2015.03.011. Epub 2015 Mar 23. PMID: 25929580.

Goel K, Tweet M, Olson TM, Maleszewski JJ, Gulati R, Hayes SN. Familial spontaneous coronary artery dissection: evidence for genetic susceptibility. JAMA Intern Med. 2015 May;175(5):821-6. doi: 10.1001/jamainternmed.2014. PMID: 25798899.

Liang JJ, Prasad M, Tweet MS, Hayes SN, Gulati R, Breen JF, Leng S, Vrtiska TJ. A novel application of CT angiography to detect extracoronary vascular abnormalities in patients with spontaneous coronary artery dissection. J Cardiovasc Comput Tomogr. 2014 May-Jun;8(3):189-97. doi: 10.1016/j.jcct.2014.02.001. Epub 2014 Apr 4. PMID: 24939067.

Tweet MS, Hayes SN, Pitta SR, Simari RD, Lerman A, Lennon RJ, Gersh BJ, Khambatta S, Best PJ, Rihal CS, Gulati R. Clinical features, management, and prognosis of spontaneous coronary artery dissection. Circulation. 2012 Jul 31;126(5):579-88. doi: 10.1161/CIRCULATIONAHA.112. Epub 2012 Jul 16. PMID: 22800851.

Tweet MS, Gulati R, Aase LA, Hayes SN. Spontaneous coronary artery dissection: a disease-specific, social networking community-initiated study. Mayo Clin Proc. 2011 Sep;86(9):845-50. doi: 10.4065/mcp.2011.0312. PMID: 21878595; PMCID: PMC3257995.

 

WANT TO WORK AT MAYO?

EM Physicians: https://jobs.mayoclinic.org/emergencymedicine

EM NP PAs: https://jobs.mayoclinic.org/em-nppa-jobs  

Nursing/Techs/PAC: https://jobs.mayoclinic.org/Nursing-Emergency-Medicine

EMTs/Paramedics: https://jobs.mayoclinic.org/ambulanceservice

All groups above combined into one link: https://jobs.mayoclinic.org/EM-Jobs

In this chapter of Always on EM, Dr. Lacey Shiue, Associate Director of Emergency Ultrasound for Mayo Clinic Emergency Medicine in Rochester, challenges us to recognize the morbidity and mortality associated with rib fractures and to rethink the way we consider pain management for people suffering these injuries.

 

CONTACTS

X - @AlwaysOnEM; @VenkBellamkonda

YouTube - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch; @Lacey.Shiue

Email - [email protected]

Dr. Jim Gregoire, consultant nephrologist and master educator, joins the show again to talk about electrolytes this time. He breaks down practicalities in caring for patients with sodium, magnesium, and phosphorus disorders - who is at risk, what history and exam findings to look for, what testing to do and how to correct the problems. Join Alex and Venk as they learn the nuances of care for these conditions that we see every single shift. 

 

CONTACTS

X - @AlwaysOnEM; @VenkBellamkonda

YouTube - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

Email - [email protected]

In this chapter, Dr. Schupbach analyzes the business of healthcare and a way he believes can let patients wage war on the mis-alligned incentives. This is a continuation of our Grand Rounds sequence. Come join Alex and Venk on this adventure!

TEASER

Specifically, childhood obesity is skyrocketing--1 in 5 children are now above the 95th percentile BMI for age and sex. A recent NEJM article showed Liraglutide (a medication that costs approximately $12,000 per year) was effective in children as young as 6 years old. This is just one example of many where cheap foods, expensive drugs, and band-aid solutions are generating record profits for the most powerful voices at the table. But are we truly acting in the best interests of our patients? What are the unintended consequences of these misaligned incentives? What is our responsibility in all this and where do we start if we want to be part of the solution?