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Canadian Journal of Cardiology

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

      Abstract

      Background

      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.

      Methods

      We analyzed SCAD patients who presented acutely 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 SCAD patients presenting with ST-elevation MI (STEMI) vs. unstable angina or non-STEMI (UA/NSTEMI).

      Results

      Among 750 SCAD patients (mean 51.7±10.5years; 88.5% were women; median follow-up was 373 days), 234 (31.2%) presented with STEMI. More SCAD-STEMI patients (27.8%) were treated with revascularization (98.5% PCI) compared to 8.7% of UA/NSTEMI patients (93.3% PCI). For SCAD-STEMI patients, 93.9% were planned procedures versus 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.

      Conclusions

      Despite higher in-hospital events with revascularization in SCAD patients, and higher revascularization with SCAD-STEMI, 1-year MACE was not different compared to UA/NSTEMI. This is reassuring since 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.

      Keywords

      List of Abbreviations:

      SCAD (Spontaneous coronary artery dissection), MI (Myocardial infarction), PCI (Percutaneous coronary intervention), UA/NSTEMI (Unstable angina and non-ST-elevation MI), TIMI (Thrombolysis in myocardial infarction), MAE (Major adverse events), TIA (Transient ischemic attack), MACE (Major adverse cardiovascular events), VF/VT (Ventricular fibrillation or ventricular tachycardia), LMT (Left main trunk), LAD (Left anterior descending artery)
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