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Interventional Versus Conservative Strategy in Patients With Spontaneous Coronary Artery Dissections: Insights From
Stefano Benenati1, Federico Giacobbe2, Antonio Zingarelli3
1University of Genoa, Italy (S.B., I.P.).
Insights
Optimal management for spontaneous coronary artery dissection (SCAD) is debated. Percutaneous coronary intervention (PCI) and medical management show similar 2-year adverse event rates in SCAD patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Spontaneous Coronary Artery Dissection (SCAD) management strategies are not standardized.
- Optimal therapeutic approaches for SCAD patients require further investigation.
Purpose of the Study:
- To investigate predictors of percutaneous coronary intervention (PCI) versus medical management in SCAD.
- To compare major adverse cardiovascular events (MACE) between PCI and medical management in SCAD patients.
Main Methods:
- Analysis of 369 patients from the DISCO Registry (up to December 2020).
- Primary endpoint: MACE (all-cause death, myocardial infarction, repeat PCI).
- Independent predictors for PCI and medical management were identified.
Main Results:
- 129 patients (35%) underwent PCI; 240 (65%) received medical management.
- PCI group had higher rates of ST-elevation myocardial infarction, cardiac arrest, proximal segment involvement, and reduced coronary flow.
- No significant difference in 2-year MACE between PCI and medical management groups (13.9% vs 11.7%).
Conclusions:
- Clinical presentation and procedural factors influence initial SCAD treatment choice.
- PCI for SCAD appears to have similar short-to-mid-term adverse event risks compared to medical therapy.
Background:
The optimal management of patients with spontaneous coronary artery dissection remains debated.
Methods:
Patients enrolled in the DISCO (Dissezioni Spontanee Coronariche) Registry up to December 2020 were included. The primary end point was major adverse cardiovascular events, a composite of all-cause death, nonfatal myocardial infarction, and repeat percutaneous coronary intervention (PCI). Independent predictors of PCI and medical management were investigated.
Results:
Among 369 patients, 129 (35%) underwent PCI, whereas 240 (65%) were medically managed. ST-segment-elevation myocardial infarction (68% versus 35%, P<0.001), resuscitated cardiac arrest (9% versus 3%, P<0.001), proximal coronary segment involvement (32% versus 7%, P<0.001), and Thrombolysis in Myocardial Infarction flow 0 to 1 (54% versus 20%, P<0.001) were more frequent in the PCI arm. In-hospital event rates were similar. Between patients treated with PCI and medical therapy, there were no differences in terms of major adverse cardiovascular events at 2 years (13.9% versus 11.7%, P=0.467), all-cause death (0.7% versus 0.4%, P=0.652), myocardial infarction (9.3% versus 8.3%, P=0.921) and repeat PCI (12.4% versus 8.7%, P=0.229). ST-segment-elevation myocardial infarction at presentation (odds ratio [OR], 3.30 [95% CI, 1.56-7.12]; P=0.002), proximal coronary segment involvement (OR, 5.43 [95% CI, 1.98-16.45]; P=0.002), Thrombolysis in Myocardial Infarction flow grade 0 to 1 and 2 (respectively, OR, 3.22 [95% CI, 1.08-9.96]; P=0.038; and OR, 3.98 [95% CI, 1.38-11.80]; P=0.009) and luminal narrowing (OR per 5% increase, 1.13 [95% CI, 1.01-1.28]; P=0.037) were predictors of PCI, whereas the 2B-angiographic subtype predicted medical management (OR, 0.25 [95% CI, 0.07-0.83]; P=0.026).
Conclusions:
Clinical presentation and procedural variables drive the choice of the initial therapeutic approach in spontaneous coronary artery dissection. If PCI is needed, it seems to be associated with a similar risk of short-to-mid-term adverse events compared to medical treatment.
Registration:
URL: https://www.
Clinicaltrials:
gov; Unique identifier: NCT04415762.
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