Spontaneous Coronary Artery Dissection Patients Research Articles

Systematic review and meta-analysis of the incidence of recurrence of spontaneous coronary artery dissection.

Recurrence is a well-established complication of spontaneous coronary artery dissection (SCAD). However, the exact incidence and correlates of recurrence are unknown. We, therefore, performed a systematic review and meta-analysis to determine and consolidate the evidence on the global incidence of SCAD recurrence. A comprehensive search of the four major databases (EMBASE, OVID Medline, PubMed and Google Scholar) was performed from their inception to 17 January 2019. We included original research studies, recruiting ≥10 participants, with ≥12 months follow-up that reported data on recurrence in patients with SCAD. Out of 556 studies searched, 19 cohorts (1538 SCAD patients) were included in the analysis. There were 153 cases of de novo recurrence over a mean follow-up period of 31.2 months (95% confidence interval, 25-41 months). Type 1, 2 and 3 SCAD was noted in 33.2, 73.2 and 5.3%, respectively. The involved coronary artery was LMCA, LAD, RCA, LCx and multi-vessel CAD respectively in 3.5%, 53.4%, 19.8%, 20.4% and 12.6% of cases. The overall SCAD de novo recurrence was 7% (ES 0.07, 95% confidence interval, 0.04-0.10, I2 = 65.3%). On meta-regression, we found discharge medications at index admission, including β-blockers, ACE inhibitors, statins, as well as baseline cardiac risk factors, did not correlate with recurrence. SCAD recurrence is common, occurring in 7% of patients over medium-term follow up. No specific medications at discharge were found to reduce recurrence. Further long-term and prospective data are required.

A Contemporary Presentation of the Incidence and Management of Spontaneous Coronary Artery Dissection (SCAD) in New Zealand: An ANZACS-QI Study

Spontaneous coronary artery dissection (SCAD) is an underdiagnosed and poorly understood condition that frequently affects younger women without cardiovascular risk factors. In this project we aimed to describe the present landscape of SCAD in New Zealand (NZ). All patients in NZ who were admitted to hospital with a diagnosis of Acute Coronary Syndrome (ACS) from July 2019 to December 2020 and who underwent coronary angiography were identified from the All NZ Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. Of 12,053 patients admitted to hospital with an ACS, 122 had SCAD (1.0%). 80% of those with SCAD were female, with mean age of 57 years, and fewer traditional cardiovascular risk factors. Non-ST elevation myocardial infarction was the most common presentation (82.0%), while 16.4% presented with ST-elevation myocardial infarction. The majority of patients were managed conservatively (91.8%) while 8.2% underwent percutaneous coronary intervention (PCI). 56.6% of SCAD patients had normal left ventricular function. Nearly 80% of patients were discharged on aspirin therapy, while 60.7% had a P2Y12 inhibitor. Beta blockers, statins and ACEI/ARB were part of the management strategy in 62.5%, 59.8% and 42.6% of patients, respectively, while 47.5% had a combination of all 3. Amongst 122 patients, only 1 in-hospital death and 1 inpatient recurrent MI occurred, with 3 patients having bleeding of any kind. In NZ, incidence of SCAD is approximately 1%. Most patients affected in NZ are female with fewer traditional cardiovascular risk factors. Management is predominantly conservative, and there is a low rate of early adverse outcomes.

Abstract 16882: Exercise Prescription Patterns After Spontaneous Coronary Artery Dissection: Insights From a Large Multinational Registry

Introduction: Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction in otherwise healthy and most times presumably fit young women. In the absence of evidence for benefit or harm, exercise prescription (EXP) after SCAD remains arbitrary. We assessed EXP patterns among participants in a large multinational SCAD registry. Methods: Participants with SCAD as confirmed by coronary angiography completed surveys detailing exercise (EX) habits prior to SCAD (initial survey), and EXP from their provider on initial and subsequent visits after SCAD (follow-up survey). Demographic and clinical characteristics were collected by electronic health record review by trained nurse abstractors. EXP was categorized according to EX components that include: type, intensity, frequency, time/session, and external conditions. Results: Among 950 participants, mean ± age was 46.8 ± 9.5 years, 96% were women and 77% reported attending ≥1 Cardiopulmonary Rehabilitation session. Prior to SCAD, 49% were aerobically exercising ≥ 3times per week, and only 32% performed strength-building EX regularly. Initial and subsequent post-SCAD visit details in 299/950 participants showed that most (93%) patients received some form of EX (Figure 1-A) counseling, namely: EXP, unspecific advice or were discouraged from any EX (Figure 1-B) . Limits regarding EX type and intensity were the most common advice received among EXP group (Figure 1-C) . Conclusions: Insights from our study show that only 40% of patients were achieving current exercise recommendations for adults prior to SCAD (vs 53% adult U.S population; CDC, 2018) which suggests that SCAD patients may not be as active as previously described. Most patients receive some form of EX counseling after SCAD; however, a structured EXP is needed to avoid overly cautious approaches that could lead to uncertainty, deconditioning, impaired quality of life, or increase risks associated with a sedentary lifestyle.

Abstract 13231: Fibromuscular Dysplasia Screening in Patients With Spontaneous Coronary Artery Dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is commonly associated with fibromuscular dysplasia (FMD), a vascular condition that can lead to aneurysm and dissection in any arterial bed. SCAD and FMD are increasingly being diagnosed, especially in women. Our objective is to describe screening patterns of FMD over time among patients with SCAD. Methods: We conducted a retrospective cohort study, identifying patients treated for SCAD in the University of Pennsylvania Health System from 2005-2019 using ICD-9 (414.12) and ICD-10 (I25.42) codes. Charts were manually reviewed and clinical data were abstracted. Screening modalities included CT angiogram (CTA) or MR angiogram (MRA) of the head, neck, or abdomen; carotid or renovascular ultrasound; or renal angiography. Complete screening was defined as having head, neck, and abdominal imaging. We indexed cases by date of SCAD event. Time categories were calculated by quartiles of patients. We used Fisher’s exact test to compare proportions and Cochran-Armitage trend test to compare trends over time. Results: We identified 121 patients with SCAD with ≥ 6 months of follow-up prior to the COVID-19 pandemic. FMD screening rates by any modality were higher among patients with SCAD in 2018-2019 compared to 1993-2011 (62% vs. 28%, p=0.009 for trend), see Figure. Rates of complete screening remained low and did not change over time (p=0.451 for trend). In 2018-2019, only 41% of patients were screened with CTA or MRA of the abdomen, 26% with CTA or MRA of the neck, and 15% with CTA or MRA of the head. Patients undergoing complete screening had higher rates of FMD diagnosis compared to those undergoing any screening (63% vs. 37%, p=0.036). Conclusions: While overall FMD screening in SCAD patients has increased, complete screening rates remain low. FMD was diagnosed more often in patients undergoing complete screening, highlighting the importance of head, neck, and abdominal imaging in all patients with SCAD.

Abstract 15755: Differences in Patient Characteristics of Peripartum Spontaneous Coronary Artery Dissection

Background: Spontaneous coronary artery dissection (SCAD) is an important cause of acute myocardial infarction in women. The peripartum period, defined as the last month of pregnancy to three months post-delivery, is known to be associated with SCAD. However, differences in patient characteristics between those with non-peripartum SCAD (npSCAD) and peripartum SCAD (pSCAD) are ill-defined. It is also unknown if the prevalence of extracoronary vascular abnormalities (EVAs) or SCAD recurrence differ between patients with npSCAD and pSCAD. Methods: Patients presenting to a dedicated SCAD clinic were enrolled in a single-center registry. Baseline characteristics, SCAD presentation, lab and imaging results, and recurrent SCAD events were assessed. All patients were screened for EVAs, defined as fibromuscular dysplasia (FMD), aneurysm, pseudoaneurysm, and dissection with cross-sectional imaging. Patient characteristics, clinical presentation, presence of EVAs, and recurrent SCAD events were stratified by peripartum status. Results: 125 SCAD patients were identified from June 2016 to March 2020. Mean age (SD) at 1st SCAD event was 45.8 (10.1) years, 94.4% were female, and 15.2% (19/125) of patients were peripartum. Differences in patient characteristics between npSCAD and pSCAD are outlined in the table. npSCAD patients were older (47.5 (9.76) vs 35.6 (0.93), p= 0.0001) at the time of their 1st SCAD event and had increased rates of hypertension (35.6% (37/105) vs 11.1% (2/18), p=0.04). Those with pSCAD had higher rates of SCAD in the left anterior descending artery (LAD) (64.8% (64/125) vs 89.5% (17/19), p=0.03). There was no significant difference in the prevalence of EVAs or SCAD recurrence between npSCAD and pSCAD. Conclusion: Peripartum SCAD is associated with higher rates of dissection in the LAD compared to non-peripartum SCAD. There is no difference in prevalence of EVAs or recurrent SCAD in patients presenting with pSCAD.

Coronary angiographic manifestations of fibromuscular dysplasia and clinical outcomes in patients with spontaneous coronary artery dissection

Abstract Background Fibromuscular dysplasia (FMD) is a common predisposing condition for spontaneous coronary artery dissection (SCAD), which is an important cause of myocardial infarction (MI) in young to middle-aged women. However, its impact on clinical presentation, coronary anatomies, and outcomes have not been reported. Purpose To evaluate coronary angiographic characteristics and clinical outcomes in SCAD patients with or without underlying extracoronary FMD. Methods We retrospectively analyzed patients enrolled in our Vancouver SCAD registries who were screened for extracoronary FMD. Extracoronary FMD was defined as the presence of multifocal FMD on catheter or noninvasive angiography (computed tomographic or magnetic resonance imaging) in ≥1 extracoronary vascular beds. We reviewed coronary angiograms for manifestations of coronary FMD that were previously described (i.e. irregular stenosis, smooth stenosis, dilatation/ectasia, and tortuosity). Severe tortuosity was defined as ≥2 consecutive bends ≥180° at any cardiac cycle or 360° loop in ≥1 epicardial artery that was ≥2 mm in diameter. Clinical outcomes of major adverse cardiovascular event (MACE), a composite of all-cause death, MI, and stroke, were evaluated. Results We included 346 SCAD patients, 250 (72.3%) had extracoronary FMD. Patients with FMD were older (54.6±9.5 vs. 51.7±9.8 years) and more likely to have prior history of MI (7.2% vs. 1.0%, p=0.047) and stroke (4.4% vs. 0%, p=0.081) compared with non-FMD patients. The proportion of multivessel SCAD and TIMI flow was not different between groups, but type 3 SCAD was more commonly observed in FMD group (11.6% vs. 3.1%, p=0.026). On coronary angiography, severe tortuosity was more prevalent in patients with extracoronary FMD (58.4% vs. 36.5%, p<0.001), whereas rates of irregular stenosis, smooth stenosis, and dilatation/ectasia were not significantly different (Figure). Percutaneous coronary intervention was performed in 13.2% of FMD and 15.6% of non-FMD group, with similar success rates (75.8% vs. 69.2%, p=0.65). In-hospital and long-term MACE rate at median follow-up of 1032 (IQR 453–1096) days were not different between FMD and non-FMD groups (in-hospital: 5.6% vs. 8.3%, p=0.492; long-term: 19.6% vs. 15.6%, p=0.185). Conclusion In SCAD patients, severe coronary tortuosity was more prevalent in patients with FMD than those without. Despite the complex coronary anatomy, FMD was not associated with worse outcomes. Differences in coronary manifestations Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Canadian Institutes of Health Research

Spontaneous coronary artery dissection (SCAD) in men: an observational study

Abstract Background/Introduction SCAD is a rare cause of acute coronary syndrome. Approximately 90% of SCAD patients are women, and factors such as the hormonal changes of the menstrual cycle are thought to be relevant. It is therefore interesting to consider why patients without such hormonal exposure may be affected. SCAD in men remains poorly understood. Purpose To study the clinical features and natural history of SCAD in men and to see how it differs from SCAD in women. Methods Patients with SCAD were recruited by self-referral and clinician referral from across the UK. Angiograms are reviewed by two experienced cardiologists and other data is obtained from patient questionnaires and from medical records. Results 53 male SCAD patients were identified from the registry. Mean age at SCAD was 47±5.4 (SD). 1 presented with cardiac arrest, 2 as chronic dissections without a clear acute event, 15 as STEMI and 32 as NSTEMI; admission ECGs were not available for 3 patients. The vessel affected was the circumflex in 15 patients, RCA in 4, LAD in 27 and multi vessel in 7. SCAD type was 1 in seven patients, 2a in 21, 2b in 16, 3 in 7 and 4 in 2. LV function post SCAD was normal in 37 out of 50 patients with data available and mean EF was 52.4%. Of 37 with cardiac MRI data, 11 had no visible late gadolinium enhancement. 23 patients had been screened for fibromuscular dysplasia and only 1/23 had this diagnosis. 2 other patients had a non-FMD aortopathy (dilated ascending aorta) and 1 had a very small cerebral aneurysm that was not thought to represent FMD. Mean follow up from the first SCAD event was 3 years (SD 2 years); over this time period 10/51 patients had recurrent SCAD (2 patients presented as chronic dissections on elective angiography and it was not possible to date the index event). Conclusions This is the largest study so far reported of SCAD in men. The mean age was similar to that seen in women, though with a narrower age range, and the proportions of STEMI and NSTEMI are also similar. The most frequently affected vessel was the LAD. Type 2 SCAD was by far the commonest angiographic appearance. The majority of patients had preserved LV systolic function and a significant proportion had no measurable scar. These findings suggest that the presenting features of SCAD in men are very similar to those in women. The incidence of FMD appears to be far lower than in women, however; studies in female SCAD patients suggest that FMD is present in 11–86% (depending on methods used for screening). Finally, rate of recurrent SCAD in men appears significant. The largest series so far reported in SCAD (327 patients, 90.5% women, followed prospectively) showed a recurrence rate of 10.4% over 3 years. We saw a recurrence rate of 19.6%. This may simply represent the play of chance in a small population, or recruitment bias as our study is primarily retrospective, however it is an intriguing observation worthy of further investigation. Funding Acknowledgement Type of funding source: Other. Main funding source(s): BeatSCAD

Late results of bioabsorbable scaffolds implanted in spontaneous coronary artery dissection evaluated with computed tomography coronary angiography

Abstract Background Percutaneous coronary intervention (PCI) in spontaneous coronary artery dissection (SCAD) should be reserved for cases presenting with ongoing extensive ischaemia. Bioresorbable scaffolds (BVS) have emerged as an alternative to avoid permanent stenting, an especially attractive concept for this clinical scenario. However, data of late angiographic outcome of this device in SCAD is lacking. Purpose To evaluate the long-term angiographic outcome of BVS in the setting of SCAD using computed tomography coronary angiography (CTCA) Methods In this multicentre prospective study, high-risk SCAD patients treated with BVS were scheduled for a follow-up CTCA at least 2 years from implantation date. Acquisition was performed according to the current recommendations. All the studies were analysed in a central core laboratory by an independent level 3 expert in CTCA blinded to the clinical and angiographic results. For this purpose, a dedicated software for coronary analysis was used to quantify coronary stenosis and evaluate coronary wall. Results Thirty-four BVS were implanted in 15 SCAD patients (51±12 years-old; 87% female) from 7 different centres in Spain and United Kingdom. The most common presentation was STEMI (n=9, 60%). Target vessels included 11 left anterior descending arteries (73.3%), 3 right coronary arteries (20%) and 1 left circumflex coronary artery (6.7%). One patient received target lesion revascularisation due to scaffold shrinkage in a proximal right coronary artery at 13 months. CTCA was performed 2.4±0.7 years after BVS implantation. No scaffold thrombosis or significant stenosis were detected. Patency of all scaffolds was confirmed with a median luminal area of 5.52 mm2 (IQR: 3.74–6.95) and median stenosis of 11% (IQR: 4–15%). Regarding coronary wall tissue characterization of segments with BVS, there was 32±9.3% of plaque burden and a median plaque volume of 45.3 mm3 (IQR: 26.6–61.9). The most common component of the plaque was fibrous (85±9.4%). Compared to the proximal reference segments, BVS showed more plaque burden (32.2% vs 25.3%; p=0.017) and fibrous percentage (84.7% vs 75.1%; p=0.004) whereas less fibrofatty (6 vs 4.8 mm3; p=0.007) and necrotic volume (0.4 vs 1.2 mm3; p=0.029). BVS segments showed lower absolute minimal luminal area (5.5 vs 8.9 mm2; p=0.004) and diameter (2.7 vs 3.4 mm; p=0.004) compared to the reference segment; however, non-significant differences were seen in percentage stenosis, in keeping with normal vessel tapering. Conclusions In this series of SCAD treated with BVS, scaffolds showed a satisfactory late angiographic outcome, with no significant restenosis and an excellent minimal luminal area and optimal coronary wall healing observed. Funding Acknowledgement Type of funding source: None

IN-HOSPITAL AND LONG-TERM OUTCOMES AMONG PATIENTS WITH SPONTANEOUS CORONARY ARTERY DISSECTION PRESENTING WITH VENTRICULAR TACHYCARDIA/FIBRILLATION

Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in young to middle-aged women. Ventricular tachycardia/ventricular fibrillation (VT/VF) may complicate acute SCAD presentations and the long-term outcomes are unknown. We sought to report the outcomes in SCAD patients presenting with VT/VF.

NATURAL HISTORY OF SPONTANEOUS CORONARY ARTERY DISSECTIONS (SCAD): FINDINGS OF A ROUTINE SURVEILLANCE ANGIOGRAPHIC STUDY

Spontaneous coronary artery dissection (SCAD) is a common non-atherosclerotic cause of acute coronary syndrome (ACS) and is predominantly managed without revascularization. There is limited data on the natural history of SCAD lesions and the timing and extent of arterial healing remains poorly understood. Herein, we describe the angiographic findings and natural history of SCAD patients initially presenting with ACS who underwent routine surveillance follow-up coronary angiography (CA) months after an initial presentation.

Rare loss-of-function mutations of PTGIR identified in fibromuscular dysplasia and spontaneous coronary artery dissection

Fibromuscular Dysplasia (FMD) and Spontaneous Coronary Artery Dissection (SCAD) are related, non-atherosclerotic arterial diseases mainly affecting middle-aged women. Little is known about their physiopathological mechanisms. We aimed to identify rare genetic causes to elucidate molecular mechanisms implicated in FMD and SCAD. We analyzed 29 exomes that included familial and sporadic FMD. Follow-up was conducted by targeted or Sanger sequencing (1,071 FMD and 365 SCAD patients) or lookups in exome (264 FMD) or genome sequences (488 SCAD), all independent and unrelated. We used TRAPD burden test to test for enrichment in patients compared to gnomAD controls. The biological effects of variants on receptor signaling and protein expression were characterized using transient overexpression in human cells. We identified one rare loss-of-function variant (LoF) (MAFgnomAD = 0.000075) shared by two FMD sisters in the prostaglandin I2 receptor (hIP) gene (PTGIR), a key player in vascular remodeling. Follow-up in > 1,300 FMD patients revealed four additional LoF allele carriers and a putative enrichment in FMD (PTRAPD = 8 × 10-4), in addition to several rare missense variants. We confirmed the LoFs (Q163X and P17RfsX6) and one missense (L67P) to severely impair hIP function in vitro. Genetic analyses of PTGIR in SCAD revealed one patient who carries Q163X, one with L67P and one carrying a rare splicing mutation (c.768 + 1C > G), but not a significant enrichment (PTRAPD = 0.12) in SCAD. Our study shows that rare genetic mutations in PTGIR are enriched among FMD patients and found in SCAD patients, suggesting a role for prostacyclin signaling in non-atherosclerotic stenosis and dissection.

Women With Spontaneous Coronary Artery Dissection Are at Increased Risk of Iatrogenic Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of acute coronary syndrome (ACS) that affects women disproportionately. Previous case series have found that patients with SCAD undergoing cardiac catheterisation have high rates of iatrogenic coronary damage. We formally compared the rate of iatrogenic coronary artery dissection in women with and without SCAD undergoing cardiac catheterisation over a 11-year period. Women with SCAD were identified by a search of the cardiac catheterisation database 2007-2017 for the keywords 'SCAD', 'spontaneous coronary artery dissection', 'spontaneous coronary dissection', and 'spontaneous dissection'. For each identified case, the medical record and the coronary angiogram images were reviewed to confirm spontaneous coronary dissection. For cases of recurrent SCAD, duplicates were removed so that each patient was included only once in this analysis. For each identified case of SCAD, a control case was chosen from women aged <70 years, without SCAD, undergoing cardiac catheterisation for an ACS during the same 10-year period. One control case was chosen to match each SCAD patient as closely as possible for age and year of cardiac catheterisation. Iatrogenic coronary dissection was defined as new, proximal, flow limiting coronary artery dissection in a different coronary segment to the presenting spontaneous coronary dissection. Eighty-five (85) cases of women with SCAD were identified. Mean age was not different between SCAD and non-SCAD women (51±11 and 51±10 years, respectively). The SCAD group had lower rates of ST elevation myocardial infarction, lower rises in serum creatine kinase (CK) and troponin levels, lower rates of diabetes and smoking, and far less placement of stents during the procedure than the control group. The rate of additional iatrogenic dissection relating to the cardiac catheterisation procedure was 4 of 85 (4.7%) versus 0 of 85 (0%), p=0.04 in SCAD and control groups, respectively, despite a much lower rate of percutaneous coronary intervention in the SCAD group. No common factors could be identified regarding particular equipment or procedural factors associated with iatrogenic dissection. The rate of iatrogenic dissection in women with SCAD during cardiac catheterisation is confirmed to be high and significantly higher than a contemporaneous age-matched group of women without SCAD. This observation likely indicates generalised coronary fragility in this disease, and emphasises the importance of the utmost care in the engagement, injection and intervention involving the coronary arteries in this disease. Development of a non-invasive coronary imaging modality or biomarker able to diagnose SCAD non-invasively would be a great advance in the care of patients with this condition, because it would avoid the need for invasive coronary angiography for diagnosis.

Psychological and clinical characteristics of patients with spontaneous coronary artery dissection: A case-control study

BackgroundThe relative frequency of psychological factors in patients with spontaneous coronary artery dissection (SCAD) compared to patients with traditional atherosclerosis-related type 1 acute coronary syndrome (ACS) is unknown. This study examines whether psychological factors and emotional or physical precipitants are more common in SCAD patients versus atherosclerosis-related ACS patients. MethodsParticipants with SCAD were recruited from a Dutch SCAD database. Given the predominance of SCAD in women (>90%), only female patients were included. The age- and sex-matched atherosclerosis-related ACS group was identified from a registry database. Online questionnaires and medical records were used to investigate psychological factors and clinical information. Univariate and multivariate logistic regression models were used to examine differences between 172 SCAD patients and 76 ACS patients on emotional and physical precipitants prior to the event and psychological factors after the event. ResultsPatients with SCAD were more likely to experience an emotional precipitant in the 24 h prior to the event (56%), compared with the ACS group (39%) (OR = 1.98, 95%CI 1.14–3.44). Multivariate analyses showed that this association remained significant after adjustment for covariates (OR = 2.17, 95%CI 1.08–4.36). At an average of 3.2 years post-hospitalization for the SCAD or atherosclerosis-related ACS event, both patient groups had similar high levels of perceived stress (50% vs. 45%, p = .471) and fatigue (56% vs. 53%, p = .643). ConclusionsThis study shows that risk profiles for SCAD differ from traditional atherosclerosis-related ACS. Our findings may help health professionals to recognize SCAD and offer tailored rehabilitation and prevention programs.

Role of Intravascular Imaging in the Diagnosis and Treatment of Spontaneous Coronary Artery Dissection

The objective of this article is to review the role of intracoronary imaging in the management of patients with spontaneous coronary artery dissection (SCAD). In this review article, we discuss the types of intracoronary imaging including intravascular ultrasound (IVUS) and optical coherence tomography (OCT) and their relative strengths and weaknesses. Additionally, we discuss in detail the findings on IVUS and OCT and how these modalities can be used for optimization of percutaneous coronary intervention (PCI) in SCAD cases. While coronary angiography is the first-line investigation for diagnosis of SCAD, it remains inconclusive in a considerable proportion of cases owing to the widely varying appearance of SCAD on angiography. Even though the vast majority of SCAD cases are treated conservatively, PCI may be required in cases with hemodynamic instability. Intracoronary imaging becomes critical in the two aforementioned situations, either for making a conclusive diagnosis of SCAD or for optimization of PCI. Intracoronary imaging has a vital role to play in the diagnosis and management of SCAD patients. Interventional cardiologists should be well versed with the findings on IVUS and OCT to diagnose SCAD and utilize it for optimization of PCI. However, it is important to exercise caution in performing intracoronary imaging and follow safe practices.

Clinical Presentation and Outcome of Patients With Spontaneous Coronary Artery Dissection Versus Atherosclerotic Coronary Plaque Dissection.

Atherosclerotic coronary plaque dissection (ACPD) is one cause of acute coronary syndrome (ACS) caused by underlying atherosclerosis. Spontaneous coronary artery dissection (SCAD) occurs outside the setting of atherosclerosis among young women and individuals with few or no conventional atherosclerotic risk factors, and has emerged as an important cause of ACS, and sudden death. A comparison between ACPD and SCAD has not been previously addressed in the literature. Our study will compare ACPD and SCAD. Patients with confirmed diagnosis of SCAD and ACPD were retrospectively identified from 30 centers in 4 Arab Gulf countries between January 2011 and December 2017. In-hospital (ventricular tachycardia/ventricular fibrillation, myocardial infarction (MI), percutaneous coronary intervention, dissection extension, cardiogenic shock, death, implantable cardioverter-defibrillator placement) and follow-up (MI, de novo SCAD, spontaneous superior mesenteric artery dissection, death) events were compared between them. Eighty-three cases of SCAD and 48 ACPD were compared. ACPD patients were more frequently male (91.67% vs. 49.40%, P < 0.001) and older (58.5 vs. 44, P < 0.001). Cardiovascular risk factors were more prevalent in patients with ACPD, including diabetes mellitus (60.4% vs. 25.3%), dyslipidemia (62.5% vs. 38.5%), and hypertension (62.5% vs. 31.3%), P < 0.001. Hospital presentation of ST-elevation MI was diagnosed in 48% of SCAD versus 27% of ACPD patients (P = 0.012). SCAD patients received medical-only treatment in 40% of cases and ACPD in 21% (P = 0.042). In-hospital and follow-up events were comparable in both groups (P = 0.25). Despite a completely different pathophysiology of ACS between SCAD and ACPD, in-hospital and follow-up events were comparable.

In-hospital and long-term outcomes among patients with spontaneous coronary artery dissection presenting with ventricular tachycardia/fibrillation

Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in young to middle-age women. Ventricular tachycardia/ventricular fibrillation (VT/VF) may complicate acute SCAD presentations, and the long-term outcomes are unknown. The purpose of this study was to report the outcomes of SCAD patients presenting with VT/VF. We analyzed our prospective Canadian SCAD registries for patients presenting with VT/VF during index hospitalization. Long-term outcomes including VT/VF and cardiac arrest were collected. Univariate and multivariable analyses were performed to identify predictors of VT/VF at follow-up. Among 1056 consecutive SCAD patients, 84 (8.0%) presented with VT/VF, and 8 underwent implantable cardioverter-defibrillator (ICD) insertion. Patients with VT/VF during index hospitalization were younger (49.3 vs 52.0 years; P = .019) and were more likely to have ST-elevation MI, lower left ventricular ejection fraction (LVEF), and left main dissection (all P <.001). Initial VT/VF was associated with in-hospital events, including recurrent MI, unplanned revascularization, heart failure, ICD insertion, and in-hospital death (all P <.05). At mean follow-up of 4.8 ± 3.3 years, 8 patients suffered VT/VF (time to event 5.2 ± 6.2 years); 5 of 8 patients had VT/VF on initial SCAD presentation, and 1 of 8 had undergone ICD insertion. Predictors of VT/VF during follow-up included LVEF <50%, LVEF <35%, peripartum SCAD, unplanned revascularization, repeat MI, heart failure, and initial VT/VF. Multivariable analysis showed initial VT/VF (odds ratio [OR] 9.5; 95% confidence interval [CI] 2.0-44; P = .004) and LVEF <50% (OR 12.9; 95% CI 1.5-111; P = .019) were independent predictors of VT/VF at follow-up. SCAD patients presenting with VT/VF were at greater risk for in-hospital events and recurrent VF/VT at follow-up. Both VT/VF and LVEF <50% were independent predictors of subsequent VT/VF.

Rare loss-of-function mutations of PTGIR are enriched in fibromuscular dysplasia.

AimsFibromuscular dysplasia (FMD) and spontaneous coronary artery dissection (SCAD) are related, non-atherosclerotic arterial diseases mainly affecting middle-aged women. Little is known about their physiopathological mechanisms. We aimed to identify rare genetic causes to elucidate molecular mechanisms implicated in FMD and SCAD.Methods and resultsWe analysed 29 exomes that included familial and sporadic FMD. We identified one rare loss-of-function variant (LoF) (frequencygnomAD = 0.000075) shared by two FMD sisters in the prostaglandin I2 receptor gene (PTGIR), a key player in vascular remodelling. Follow-up was conducted by targeted or Sanger sequencing (1071 FMD and 363 SCAD patients) or lookups in exome (264 FMD) or genome sequences (480 SCAD), all independent and unrelated. It revealed four additional LoF allele carriers, in addition to several rare missense variants, among FMD patients, and two LoF allele carriers among SCAD patients, including one carrying a rare splicing mutation (c.768 + 1C>G). We used burden test to test for enrichment in patients compared to gnomAD controls, which detected a putative enrichment in FMD (PTRAPD = 8 × 10−4), but not a significant enrichment (PTRAPD = 0.12) in SCAD. The biological effects of variants on human prostaclycin receptor (hIP) signalling and protein expression were characterized using transient overexpression in human cells. We confirmed the LoFs (Q163X and P17RfsX6) and one missense (L67P), identified in one FMD and one SCAD patient, to severely impair hIP function in vitro.ConclusionsOur study shows that rare genetic mutations in PTGIR are enriched among FMD patients and found in SCAD patients, suggesting a role for prostacyclin signalling in non-atherosclerotic stenosis and dissection.

Abstract 105: Rehospitalization After Admission With Myocardial Infarction and Spontaneous Coronary Artery Dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is one of the most common non-atherosclerotic causes of myocardial infarction (MI) in young patients, yet little is known about post-discharge outcomes. Given the high psychological stress of a SCAD diagnosis, we sought to understand the rehospitalization burden after SCAD so as to provide more prognostic data to SCAD patients. Methods: Using data from the Nationwide Readmission Database 2010-16, we identified patients 18-55 years of age hospitalized with MI with and without SCAD. We compared readmission over 1 year after index hospitalization for all-cause, MI, chest pain without MI, and heart failure. Cox proportional regression was used to examine factors associated with readmission, and we explored interactions of patient factors*SCAD to identify factors associated with differential risk of readmission in patients with SCAD. Results: Among 327,227 young patients admitted with an MI, 3704 (1.1%) had a diagnosis of SCAD. Patients with SCAD were more likely to be younger, women, have a higher burden of anxiety or depression, and longer length of stay compared with those without SCAD. While the risk of all-cause rehospitalization over 1 year was similar in those with versus without SCAD (KM-estimated rates: 22.3% vs. 24.1%; log-rank p=0.596, Figure), patients with SCAD were more likely to be rehospitalized for MI (4.9% vs. 4.2%, log-rank p=0.012) and chest pain without MI (3.6% vs. 2.8%, log-rank p=0.060) but less likely to be rehospitalized for heart failure (1.0 % vs. 1.8%, log-rank p=0.005). In the multivariable model, a diagnosis of SCAD was not associated with risk of rehospitalization (HR 1.00, 95% CI 0.92-1.08) nor was a diagnosis of SCAD associated with a differential effect of any of the patient factors on the risk of rehospitalization (all interaction p-values &gt;0.05). Conclusion: Although patients with SCAD had a similar risk of rehospitalization compared with young patients with MI but without SCAD, we identified different patterns of hospitalization, which may be explained by the different underlying conditions. Further studies are needed to investigate possible interventions to reduce the high burden of post-SCAD rehospitalizations.

Treatment pattern and outcome of spontaneous coronary artery dissection in Japan

BackgroundCharacteristics, treatment pattern, and outcome of spontaneous coronary artery dissection (SCAD) have not been thoroughly investigated, especially in non-Western countries. MethodsUsing a nationwide administrative database in Japan, we included all women hospitalized with a diagnosis of myocardial infarction (MI) who underwent coronary angiography between 2012 and 2017. Patients with SCAD were identified using the 10th revision of the International Classification of Diseases code. Patients who underwent iatrogenic procedure-related coronary dissection were excluded. Characteristics, treatment pattern, and in-hospital mortality were compared between SCAD and non-SCAD patients. For the analysis of in-hospital mortality, age-matched and propensity score matched pairs of cohort at a ratio of 1:1 were generated. ResultsOf 68,909 women patients with MI, 322 (0.5%) had SCAD. Patients with SCAD were younger (mean ± SD: 52.8 ± 13.5 years vs. 75.2 ± 11.4 years, P < 0.001) and had lower burden of comorbidity than non-SCAD patients. Percutaneous coronary intervention (PCI) was less frequently performed in SCAD patients (54.3% vs. 84.0%, P < 0.001). Among SCAD patients treated with PCI, stenting was performed in 61.7% of patients. The in-hospital mortality was significantly lower in SCAD compared with non-SCAD (2.5% vs. 7.6%, P = 0.001), which was consistent in age-matched (2.5% vs. 7.5%, P = 0.001) and propensity score matched cohorts (2.6% vs. 6.5%, P = 0.033). ConclusionsIn Japan, in-hospital mortality of SCAD patients was lower than non-SCAD patients, and comparable with other international studies. However, more than half of SCAD patients were managed with PCI; further investigation is required to clarify the optimal management for this condition.

Clinical features and prognosis of patients with spontaneous coronary artery dissection

There have been inconsistent reports regarding the clinical features and characteristics of patients diagnosed with spontaneous coronary artery dissection (SCAD). In addition, predictors of mortality in SCAD patients are unknown. We evaluated the prevalence, clinical characteristics, medical management, and predictors of in-hospital mortality of SCAD-related hospitalizations using data from a single health care system from January 1, 2008, to December 31, 2018. Among 30,425 patients who presented with an acute coronary syndrome, 375 (1.2%) patients were diagnosed with SCAD. Of these, the mean age was 52.2 ± 12.8 years, 64.3% were women, and 44% were white. SCAD was significantly associated with emotional stress, fibromuscular dysplasia (FMD), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), peripheral artery disease (PAD), and carotid artery disease compared with non-SCAD acute coronary syndrome (all p-values < 0.05). Multivariable analysis showed that atrial fibrillation (OR 2.56; 95% CI 1.01–6.23; p = 0.04), steroid use (OR 7.11; 95% CI 1.31–31.2; p = 0.01), ventricular arrhythmias (OR 4.53; 95% CI 1.58–12.3; p = 0.003), and cardiac arrest (OR 16.82; 95% CI 5.14–56.5; p < 0.001) were independent predictors of in-hospital mortality in SCAD patients. In conclusion, SCAD is an uncommon diagnosis that should be considered across all ages and both sexes and in patients with FMD, carotid artery disease, or PAD. Cardiac arrest, ventricular arrhythmia, steroid use, and atrial fibrillation were independently associated with in-hospital mortality in patients with SCAD.