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Canadian Spontaneous Coronary Artery Dissection Study: 3-Year Outcomes
Quick Takes
- Findings from this large, prospective multicenter study show that among patients with SCAD who were followed for 3 years, the mortality rate was very low (0.8%), one in ten patients had recurrent MI, and 20% had persistent chest pain.
- The majority of patients were managed conservatively; however, revascularization when performed was associated with similar outcomes.
- Predictors of recurrent events included peripartum SCAD, presence of extracoronary fibromuscular dysplasia, and genetic disorders.
Study Questions:
What are long-term outcomes among patients with spontaneous coronary artery dissection (SCAD)?
Methods:
Data from a multicenter, prospective, observational study of patients with nonatherosclerotic SCAD presenting acutely from 22 North American centers were analyzed. Baseline demographics, in-hospital characteristics, precipitating and predisposing conditions, angiographic features (adjudicated), and in-hospital and 3-year major adverse cardiovascular events (MACE) were recorded. Cox regression multivariable analysis was performed.
Results:
The registry enrolled 750 consecutive patients with SCAD from June 2014 to June 2018. Mean age was 51.7 ± 10.5 years, 88.5% were women (55.0% postmenopausal); 31.3% presented with ST-segment elevation myocardial infarction (STEMI), and 68.3% with non-STEMI. A precipitating emotional stressor was reported in 50.3%, and physical stressor in 28.9%. Predisposing conditions included fibromuscular dysplasia in 42.9% (56.4% in those with complete screening), peripartum state 4.5%, and genetic disorders 1.6%. Most patients were treated conservatively (84.3%); 14.1% underwent percutaneous coronary intervention (PCI), 0.7% coronary artery bypass grafting. At 3.0-year median follow-up, mortality was 0.8%, recurrent MI 9.9% (extension of previous SCAD 3.5%, de novo recurrent SCAD 2.4%, iatrogenic dissection 1.9%), with overall MACE 14.0%. Presence of genetic disorders, peripartum SCAD, and extracoronary fibromuscular dysplasia were independent predictors of 3-year MACE. Patients who underwent PCI at index hospitalization had similar postdischarge MACE compared with no PCI. At 3 years, 80.0% remained on aspirin and 73.5% on beta-blockade.
Conclusions:
Long-term mortality and de novo recurrent SCAD were low in this contemporary large SCAD cohort that included a low revascularization rate and high use of beta-blockade and aspirin. Genetic disorders, extracoronary fibromuscular dysplasia, and peripartum SCAD were independent predictors of long-term MACE.
Perspective:
Findings from this large, prospective multicenter study shed light on long-term outcomes among patients with SCAD. Based on the authors’ observations, the mortality rate was very low (0.8%), one in ten patients had recurrent MI, and 20% had persistent chest pain at 3 years. Emotional (50%) and physical (29%) triggers were common. Peripartum SCAD, presence of extracoronary fibromuscular dysplasia, and genetic disorders predicted recurrent events at 3 years. The majority of the patients were managed conservatively; however, revascularization when performed was associated with similar outcomes.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Vascular Medicine, Genetic Arrhythmic Conditions, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and SIHD, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina
Keywords: Adrenergic beta-Antagonists, Angiography, Aspirin, Chest Pain, Coronary Artery Bypass, Fibromuscular Dysplasia, Genetics, Myocardial Infarction, Myocardial Revascularization, Non-ST Elevated Myocardial Infarction, Patient Discharge, Percutaneous Coronary Intervention, Peripartum Period, Postmenopause, ST Elevation Myocardial Infarction, Women
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