Clinical Features, Management, and Prognosis of Spontaneous Coronary Artery Dissection

Aug 02, 2012
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Authors:
Tweet MS, Hayes SN, Pitta SR, et al.
Citation:
Circulation 2012;126:579-588.
Summary By:
Hitinder S. Gurm, MBBS, FACC

Study Questions:

What is the clinical history of patients presenting with spontaneous coronary artery dissection (SCAD)?

Methods:

The authors retrospectively evaluated the clinical characteristics, treatment modalities, in-hospital outcomes, and long-term risk of SCAD recurrence or major adverse cardiac events (MACE) in 87 patients who had angiographically confirmed SCAD.

Results:

The average age of the cohort was 42 years, and 82% were female. Extreme exertion at SCAD onset was more frequent in males (7/16 vs. 2/71, p < 0.001), whereas SCAD occurred postpartum in 13/71 (18%) females. Approximately one-half the patients (49%) presented with ST-segment elevation myocardial infarction (STEMI). Involvement of the left anterior descending artery was most common, and multivessel SCAD was found in 23%. Initial conservative management (31/87) and coronary artery bypass grafting (7/87) were associated with an uncomplicated in-hospital course, whereas percutaneous coronary intervention (PCI) was complicated by technical failure in 15/43 (35%) and one death. During median follow-up of 47 months, SCAD recurred in 15 patients, all of whom were female. Estimated 10-year rate of MACE (death, heart failure, MI, and SCAD recurrence) was 47%. Fibromuscular dysplasia of the iliac artery was identified incidentally in 8/16 (50%) femoral angiograms undertaken prior to closure device placement, and in the carotid arteries of two others with carotid dissection.

Conclusions:

SCAD affects a predominantly young female population, and frequently presents as STEMI. While in-hospital mortality is low regardless of initial treatment, PCI is associated with high rates of complication.

Perspective:

This elegant work will serve to guide care of patients who present with SCAD. The authors noted significant complications in association with PCI, and suggest that an initial conservative therapy may be the best strategy for care of these patients with revascularization reserved for patients with infarction or persistent ischemia.

Keywords: Prognosis, Myocardial Infarction, Recurrence, Hospital Mortality, Fibromuscular Dysplasia, Coronary Vessel Anomalies, Heart Failure, Coronary Artery Bypass, Percutaneous Coronary Intervention


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