Abstract
Objectives To compare outcomes of percutaneous coronary intervention (PCI) in spontaneous coronary artery dissection (SCAD) patients versus conservative therapy. Background SCAD is an important cause of myocardial infarction (MI) in young-to-middle-aged women. Percutaneous coronary intervention (PCI) is often pursued, but outcomes compared to conservative therapy are unclear. Methods 403 nonatherosclerotic SCAD patients were enrolled between 2011 and 2017 and prospectively followed up in our Vancouver General Hospital registries. Detailed baseline, hospital, PCI, and outcomes were recorded. We explored the outcomes of SCAD patients who underwent PCI during their initial presentation. Results PCI was performed in 75 patients, the average age was 48.9 ± 10.1 yrs, and 94.7% were women. All presented with MI; 50.7% STEMI, 49.3% NSTEMI, and 13.3% had VT/VF. PCI was successful in 34.7%, partially successful in 37.3%, and unsuccessful in 28.0%. Stents were deployed in 73.3%, 16.0% had balloon angioplasty alone, 10.7% had wiring attempts only, and 5.3% required bailout surgery. Major adverse cardiovascular event rates (MACE) were significantly higher with the PCI group in hospital (29.3% versus 2.8%, p < 0.001), and at median follow-up of 3.7 yrs (58.7% versus 22.6% (p < 0.001) compared to the non-PCI group. Conclusion PCI in SCAD patients was associated with high failure rate and MACE in hospital and at long-term follow-up. These findings support the recommendation of conservative therapy as first-line management unless high-risk features are present.
Highlights
Spontaneous Coronary Artery Dissection (SCAD) is defined as a spontaneous, nontraumatic, and noniatrogenic dissection of the coronary arterial wall, not related to atherosclerosis [1]
SCAD is characterized by the development of intramural hematoma with or without intimal disruption, leading to variable degrees of luminal narrowing causing ischemic myocardial injury. e origin of the intramural hematoma within the arterial wall could be from intimal tear leading to dissection or from bleeding due to ruptured vasa vasorum in the absence of an intimal tear [2, 3]
Patients in both groups were predominantly female and Caucasian. e mean age was lower in the Percutaneous coronary intervention (PCI) group (48.9 ± 10.1 yrs) compared to the non-PCI group (53.1 ± 9.6 yrs), p 0.001. e PCI group had a lower prevalence of hypertension (25.3% versus 38.7%, p 0.033) and fibromuscular dysplasia (FMD) (46.7% versus 64.0%, p 0.008) and were less likely to be postmenopausal (50.7% versus 67.7%, p 0.009)
Summary
Spontaneous Coronary Artery Dissection (SCAD) is defined as a spontaneous, nontraumatic, and noniatrogenic dissection of the coronary arterial wall, not related to atherosclerosis [1]. E origin of the intramural hematoma within the arterial wall could be from intimal tear leading to dissection or from bleeding due to ruptured vasa vasorum in the absence of an intimal tear [2, 3]. Recent studies showed that SCAD was the cause of 0.1–4% of all ACS cases [1, 4]. It is more prevalent in young-to-middleaged women. Percutaneous coronary intervention (PCI) is the preferred revascularization modality, and coronary artery bypass grafting (CABG) is relegated as a bailout strategy for failed PCI or for patients with left main dissection.
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