Revascularization and long-term outcomes in high-acuity spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is often treated conservatively due to revascularization risks. Yet, an important number of SCAD patients have high acuity characteristics necessitating revascularization, with uncertain long-term outcomes.

Document revascularization utilization and long-term outcomes in high acuity SCAD.

Prospective/retrospective analysis of consecutive patients with acute myocardial infarction (AMI) due to first SCAD event presenting directly to the Minneapolis Heart Institute 2002-2021, median follow-up 3.8 years.

Among 139 patients (age 49 ± 12 years, 96% female), revascularization was performed in 60 (43%), utilizing percutaneous coronary intervention (PCI) (n = 56, successful in 80%) or coronary artery bypass graft (n = 4). In the entire cohort, 90 (65%) unique patients had one or more high acuity characteristic: ST-elevation (38%), proximal dissection (38%), cardiogenic shock (6.5%), cardiac arrest (9.4%), left main dissection (6.5%), peripartum dissection (7.2%). High acuity patients accounted for 51 of 60 (85%) revascularizations. Revascularization rates were: ST-elevation (60%), proximal dissection (62%), cardiogenic shock (89%), cardiac arrest (62%), left main dissection (100%), peripartum dissection (70%). Survival was 97% (revascularized) vs 100% (nonrevascularized); p = 0.2. Adverse outcomes (revascularized vs. nonrevascularized) included recurrent AMI:16.7% versus 8.9%; p = 0.2, SCAD recurrence: 13.3% versus 6.3%; p = 0.1, stroke: 5% versus 2.5%; p = 0.44, implantable cardioverter-defibrillator: 6.7% versus 6.3%; p > 0.9. Reintervention was necessary in 21% of PCI-treated patients.

High-acuity characteristics were present in nearly two-thirds of this SCAD cohort; the vast majority of revascularizations were performed in high-acuity patients. Despite high acuity, long-term survival was favorable in revascularized patients.