Differences in Revascularization Strategy and Outcomes by Clinical Presentations in Spontaneous Coronary Artery Dissection

• Published in: Canadian journal of cardiology 2022-12, Vol.38 (12), p.1935-1943
• Main Authors: Inohara, Taku, McAlister, Cameron, Samuel, Rohit, Starovoytov, Andrew, Grewal, Tejana, Argote Parolis, Johandra, Mancini, G.B. John, Aymong, Eve, Saw, Jacqueline
• Format: Article
• Language: English
• Subjects: Angina, Unstable - diagnosis; Angina, Unstable - etiology; Angina, Unstable - surgery; Canada - epidemiology; Cohort Studies; Coronary Vessels - diagnostic imaging; Coronary Vessels - surgery; Female; Humans; Male; Non-ST Elevated Myocardial Infarction - etiology; Percutaneous Coronary Intervention - methods; ST Elevation Myocardial Infarction - diagnosis; ST Elevation Myocardial Infarction - etiology; ST Elevation Myocardial Infarction - surgery; Treatment Outcome
• ISSN: 0828-282X; 1916-7075
• DOI: 10.1016/j.cjca.2022.07.008

Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI). However, the role of revascularization for SCAD according to presentation remains unclear. We analyzed patients with SCAD who presented acutely and were participating in the Canadian SCAD Cohort Study. We compared revascularization strategy and clinical outcomes (in-hospital major adverse events and major adverse cardiovascular event [MACE] including recurrent MI at 1-year) in patients with SCAD presenting with ST-elevation MI (STEMI) vs unstable angina or non-STEMI (UA-NSTEMI). Among 750 patients with SCAD (mean 51.7 ± 10.5years; 88.5% were women; median follow-up was 373 days), 234 (31.2%) presented with STEMI. More patients with SCAD-STEMI (27.8%) were treated with revascularization (98.5% percutaneous coronary intervention [PCI]) compared with 8.7% of patients with UA-NSTEMI (93.3% PCI). For patients with SCAD and STEMI, 93.9% were planned procedures vs 71.1% for UA-NSTEMI. Successful or partially successful PCI was 65.5% for STEMI and 76.9% for UA-NSTEMI (P < 0.001). In revascularized patients, 1-year MACE was not different between STEMI and UA-NSTEMI. Revascularization was associated with higher in-hospital major adverse events and its association was more prominent in UA-NSTEMI (STEMI: 26.2% vs 10.7%, P < 0.001; UA-NSTEMI: 37.8% vs 3.6%, P < 0.001). The difference in adverse events according to revascularization diminished over time and was not evident at 1 year. Despite higher in-hospital events with revascularization in patients with SCAD, and higher revascularization with SCAD-STEMI, 1-year MACE was not different compared with UA-NSTEMI. This is reassuring, as revascularization may be required for ongoing ischemia at the time of initial presentation in STEMI-SCAD, and emphasizes the need for careful patient selection for revascularization in UA-NSTEMI. La dissection spontanée d’une artère coronaire (DSAC) est une importante cause d’infarctus du myocarde (IM). Cependant, le rôle de la revascularisation pour traiter la DSAC, selon sa manifestation, demeure mal connu. Nous avons analysé des patients atteints d’une DSAC aiguë qui participaient à l’étude canadienne de cohortes sur la DSAC. Nous avons comparé la stratégie de revascularisation et les résultats cliniques (événements indésirables majeurs [EIM] et événements cardiovasculaires indésirables majeurs [ECIM] en milieu hospitalier, y compris les récidives d’infarctus du myocarde à un an) chez des p