Abstract
Background
Fibromuscular dysplasia (FMD) is widely recognized as an important predisposing condition
for spontaneous coronary artery dissection (SCAD). However, it remains unclear in
SCAD patients with coexistent extracoronary FMD whether SCAD can be attributed to
coronary FMD.
Methods
We retrospectively analyzed consecutive patients enrolled in our Vancouver SCAD registries
between September 2009 and October 2019 who were screened for extracoronary FMD. We
reviewed coronary angiograms for manifestations of coronary FMD that were previously
described (ie, irregular stenosis, smooth stenosis, dilatation/ectasia, and severe
tortuosity). Outcome of interest was major adverse cardiovascular event (MACE).
Results
We included 346 SCAD patients, of these, 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 myocardial infarction (7.2% vs 1.0%, P = 0.047) and stroke (4.4% vs 0%, P = 0.081) compared with non-FMD patients. On coronary angiography, severe tortuosity
was more prevalent in patients with extracoronary FMD (58.4% vs 36.5%, P < 0.001). Rates of irregular stenosis, smooth stenosis, and dilatation/ectasia were
numerically higher in patients with extracoronary FMD, but differences were not significantly
different. The rate of MACE at median follow-up of 807 (interquartile range, 392-1096)
days was not different between groups (19.6% vs 15.6%; non-FMD as a reference: hazard
ratio 1.44; 95% confidence interval, 0.76-2.71, P = 0.261).
Conclusion
SCAD patients with extracoronary FMD were more likely to have coronary FMD manifestations
on angiogram, especially severely tortuous vessels, compared with those without extracoronary
FMD, with similar clinical outcomes. This may suggest that SCAD can occur at sites
of pre-existent subclinical coronary FMD.
Résumé
Contexte
La dysplasie fibromusculaire (DFM) est largement reconnue comme un facteur de risque
important de la dissection spontanée de l’artère coronaire (DSAC). Cependant, chez
les patients présentant une DSAC atteints de DFM extracoronaire coexistante, il n’est
pas clair si la DSAC peut être attribuée à la DFM coronaire.
Méthodologie
Nous avons analysé rétrospectivement des patients consécutifs inscrits à nos registres
de DSAC de Vancouver entre septembre 2009 et octobre 2019 qui ont été soumis à un
dépistage de la DFM extracoronaire. Nous avons examiné les coronarographies à la recherche
des manifestations de la DFM coronaire décrites précédemment (c.-à-d. sténose irrégulière,
sténose lisse, dilatation/ectasie et tortuosité grave). Le résultat d’intérêt était
l’événement cardiovasculaire indésirable majeur (ECIM).
Résultats
Nous avons inclus 346 patients présentant une DSAC, parmi lesquels 250 (72,3 %) étaient
atteints de DFM extracoronaire. Les patients atteints de DFM étaient plus âgés (54,6
± 9,5 vs 51,7 ± 9,8 ans) et plus susceptibles d’avoir des antécédents d’infarctus
du myocarde (7,2 % vs 1,0 %, p = 0,047) et d’accident vasculaire cérébral (4,4 % vs 0 %, p = 0,081) que les autres patients. Sur la coronarographie, la tortuosité grave était
plus fréquente chez les patients atteints de DFM extracoronaire (58,4 % vs 36,5 %,
p < 0,001). Les taux de sténose irrégulière, de sténose lisse et de dilatation/ectasie
étaient numériquement plus élevés chez les patients atteints de DFM extracoronaire,
mais ces différences n’étaient pas significatives. Le taux d’ECIM après une durée
médiane de suivi de 807 jours (intervalle interquartile : 392-1096) n’était pas différent
entre les groupes (19,6 % vs 15,6 %; patients non atteints de DFM comme référence
– risque relatif : 1,44; intervalle de confiance à 95 % : 0,76-2,71, p = 0,261).
Conclusion
Les patients présentant une DSAC atteints de DFM extracoronaire étaient plus susceptibles
de présenter des manifestations de DFM coronaire à l’angiographie, en particulier
des vaisseaux gravement tortueux, que ceux qui ne présentaient pas de DFM extracoronaire,
avec des résultats cliniques similaires. Cela laisse supposer que la DSAC peut survenir
sur des sites de DFM coronaire subclinique préexistante.
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Article info
Publication history
Published online: August 31, 2021
Accepted:
August 26,
2021
Received:
January 18,
2021
Footnotes
See editorial by Faiella et al.,pages 1695–1698of this issue.
See page 1731 for disclosure information.
Identification
Copyright
© 2021 Published by Elsevier Inc. on behalf of the Canadian Cardiovascular Society.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Spontaneous Coronary Artery Dissection and Fibromuscular Dysplasia: Chicken or Egg? Which Comes First?Canadian Journal of CardiologyVol. 37Issue 11
- PreviewSpontaneous coronary artery dissection (SCAD) has become increasingly recognized over the last few years as a nonatherosclerotic cause of acute coronary syndrome and potential sudden cardiac death. It occurs most commonly in women aged ≤ 50 years and, at an estimated prevalence of 1% to 4% of all acute coronary syndromes, is likely underdiagnosed. SCAD is associated with obstruction to coronary blood flow due to an intramural hematoma caused by an intimal tear. Accurate diagnosis of SCAD at the time of initial coronary angiography is key to appropriate management, unless there is high-risk anatomy (left main or severe proximal multivessel involvement) or hemodynamic compromise.
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