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Postconditioning with Lactate-enriched Blood for Cardioprotection in ST-segment Elevation Myocardial Infarction
Published on: May 28, 2019
Revascularization in Patients With Spontaneous Coronary Artery Dissection and ST-Segment Elevation Myocardial
Angie S Lobo1, Stephanie M Cantu2, Scott W Sharkey3
1Medical Education Department, Abbott Northwestern Hospital, Minneapolis Minnesota.
Insights
Spontaneous coronary artery dissection (SCAD) causing ST-elevation myocardial infarction (STEMI) is more common in younger women and has better 3-year survival than atherosclerosis (ATH). Percutaneous coronary intervention is successful in most STEMI-SCAD patients.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Spontaneous coronary artery dissection (SCAD) is an emerging cause of myocardial infarction (MI), particularly in young women.
- Revascularization risks and outcomes in SCAD patients presenting with ST-segment elevation myocardial infarction (STEMI) are not well-established.
- Conservative management is often preferred for SCAD due to potential revascularization complications.
Purpose of the Study:
- To compare revascularization strategies and outcomes between STEMI patients with SCAD and those with atherosclerotic STEMI (STEMI-ATH).
- To evaluate the characteristics and clinical course of STEMI-SCAD patients.
Main Methods:
- Retrospective analysis of consecutive STEMI patients from 2003 to 2017 at two major STEMI programs.
- Inclusion criteria encompassed patients with confirmed STEMI, comparing SCAD and ATH cohorts.
- Three-year clinical outcomes were assessed for both groups.
Main Results:
- SCAD was identified in 1% of 5,208 STEMI patients (53 cases), predominantly in women (93%) and younger individuals (age 49 ± 10 years).
- STEMI-SCAD patients exhibited higher rates of cardiogenic shock (19% vs. 9%) and involvement of the left main or left anterior descending arteries compared to STEMI-ATH.
- Acute revascularization was less frequent in STEMI-SCAD (70% vs. 97%), with successful percutaneous coronary intervention (PCI) in 91% of cases. Three-year survival was significantly higher in STEMI-SCAD (98% vs. 84%).
Conclusions:
- STEMI-SCAD is a distinct patient subset, especially in younger women, often involving critical coronary arteries and presenting with cardiogenic shock.
- Primary PCI demonstrates high success rates in STEMI-SCAD patients.
- STEMI-SCAD is associated with favorable long-term survival despite acute presentation complexities.
Background:
Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of myocardial infarction (MI) in younger women, often treated conservatively due to revascularization risks. Revascularization outcomes are largely unknown in SCAD presenting with ST-segment elevation myocardial infarction (STEMI).
Objectives:
The purpose of this study was to compare revascularization strategies and outcomes of STEMI-SCAD with STEMI atherosclerosis (STEMI-ATH).
Methods:
Consecutive STEMI patients were retrospectively analyzed (2003 to 2017) at 2 regional STEMI programs (Minneapolis Heart Institute and Cedars-Sinai Smidt Heart Institute) with 3-year outcomes.
Results:
Among 5,208 STEMI patients, SCAD was present in 53 (1%; 93% female). SCAD prevalence was 19% in female STEMI patients age ≤50 years. Compared with STEMI-ATH, STEMI-SCAD patients were younger (age 49 ± 10 years vs. 63 ± 13 years), were more often female (93% vs. 27%), and had more frequent cardiogenic shock (19% vs. 9%); all p ≤ 0.03. In STEMI-SCAD, the culprit artery was more commonly left main (13% vs. 1%) or left anterior descending (47% vs. 38%); both p = 0.003. Acute revascularization was lower in STEMI-SCAD (70% vs. 97%); p < 0.001. In STEMI-SCAD, acute revascularization included percutaneous coronary intervention (PCI), n = 33 (62%), or bypass grafting, n = 4 (8%); PCI success was 91%. Those with revascularization were more likely to have shock, left main culprit, proximal dissection, and initial TIMI (Thrombolysis In Myocardial Infarction) flow grade 0 to 1. The 3-year survival was 98% for STEMI-SCAD versus 84% for STEMI-ATH; p < 0.001.
Conclusions:
STEMI-SCAD represents an important STEMI subset, particularly among younger women, characterized by significantly greater frequency of left main or left anterior descending culprit and cardiogenic shock than STEMI-ATH. Primary PCI is successful in most STEMI-SCAD patients, with low 3-year mortality.
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