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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 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).

      Results

      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.

      Conclusions

      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.

      Résumé

      Contexte

      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 connue.

      Méthodologie

      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 et événements cardiovasculaires majeurs [ECM] en milieu hospitalier, y compris les récidives d’infarctus du myocarde à un an) chez des patients présentant une DSAC et souffrant d’un IM avec surélévation du segment ST (STEMI) par rapport à des patients présentant une angine instable ou un IM sans surélévation du segment ST (UA-NSTEMI).

      Résultats

      Des 750 patients atteints de DSAC (moyenne de 51,7 ± 10,5 années; 88,5 % étaient des femmes; suivi médian de 373 jours), 234 (31,2 %) présentaient une STEMI. Le traitement par revascularisation a été plus fréquent chez les patients atteints d’une DSAC avec STEMI (27,8 %) (98,5 % d’interventions coronariennes percutanées [ICP]) que dans les cas de UA-NSTEMI (8,7 %) (93,3 % d’ICP). Cette intervention était prévue dans 93,9 % des cas de DSAC avec STEMI, et dans 71,1 % des cas de UA-NSTEMI. L’ICP a été réussie ou partiellement réussie dans 65,5 % des cas de STEMI et dans 76,9 % des cas de UA-NSTEMI (P < 0,001). Chez les patients ayant subi une revascularisation, l’incidence des ECM à un an était semblable dans les cas de STEMI et de UA-NSTEMI. La revascularisation a été associée à davantage d’événements indésirables majeurs en milieu hospitalier, et cette association était plus importante dans les cas de UA-NSTEMI (STEMI : 26,2 % vs 10,7 %, P < 0,001; UA-NSTEMI : 37,8 % vs 3,6 %, P < 0,001). L’écart sur le plan des événements indésirables associés à la revascularisation diminuait au fil du temps et n’était plus manifeste à 1 an.

      Conclusions

      Malgré une proportion accrue d’événements en milieu hospitalier associés à la revascularisation de patients présentant une DSAC et une proportion accrue de revascularisation dans les cas de DSAC avec STEMI, la fréquence des ECM à un an n’était pas différente de celle associée aux cas de UA-NSTEMI. Ce constat est rassurant, car une revascularisation peut être nécessaire en cas d’ischémie lors de la manifestation initiale de la DSAC avec STEMI, ce qui met en évidence l’importance de bien sélectionner les patients atteints d’une UA-NSTEMI admissibles à la revascularisation.
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