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Initial Management Strategy and Long-Term Outcomes in 186 Cases of Spontaneous Coronary Artery Dissection
Christopher W Jensen1, Lillian Kang1, Mary E Moya-Mendez2
1Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University School of Medicine.
Insights
Spontaneous coronary artery dissection (SCAD) management strategies, including revascularization versus medical therapy, show similar long-term outcomes. This study highlights SCAD
Area of Science:
- Cardiology
- Vascular Medicine
- Interventional Cardiology
Background:
- Spontaneous coronary artery dissection (SCAD) is a rare, nonatherosclerotic cause of acute coronary syndrome (ACS).
- Optimal management strategies and long-term prognosis for SCAD remain areas of active clinical investigation.
- SCAD predominantly affects younger women, presenting unique challenges in diagnosis and treatment.
Purpose of the Study:
- To evaluate the initial management strategies for SCAD.
- To assess the long-term outcomes of patients diagnosed with SCAD.
- To compare the effectiveness of revascularization versus medical management in SCAD patients.
Main Methods:
- Retrospective review of 186 patients diagnosed with SCAD between 1996 and 2021.
- Data collection included demographics, comorbidities, clinical presentation, and angiography findings.
- Kaplan-Meier survival analysis was used to compare outcomes between management groups (medical therapy, percutaneous coronary intervention, coronary artery bypass grafting).
Main Results:
- 80% of SCAD patients were female. Initial treatments included medical management (72.0%), PCI (23.1%), and CABG (4.8%).
- Revascularization was associated with younger age, ST-elevation myocardial infarction, lower ejection fraction, and left anterior descending artery dissection.
- Ten-year freedom from adverse composite outcomes (cardiac death, recurrent SCAD, heart failure, repeat revascularization) was similar between revascularized and medically managed groups (P=0.36).
Conclusions:
- SCAD with ST-elevation myocardial infarction, left anterior descending involvement, or reduced cardiac function indicates greater ischemic insult and was linked to revascularization.
- Despite presenting with more severe disease, patients undergoing revascularization had similar long-term outcomes compared to those managed medically.
- Long-term outcomes for SCAD patients are comparable between initial revascularization and medical management, suggesting a need for individualized treatment approaches.
Abstract:
Spontaneous coronary artery dissection (SCAD) is a rare but important nonatherosclerotic cause of acute coronary syndrome. Indications for revascularization and long-term outcomes of SCAD remain areas of active investigation. We report our experience with initial management strategy and long-term outcomes in SCAD. We reviewed all patients treated at our institution from 1996-2021 with a SCAD diagnosis. Demographics, comorbidities, clinical presentations, angiography findings, and management strategies were obtained by chart review. The primary outcome was a composite of cardiac death, recurrent/progressive SCAD, subsequent diagnosis of congestive heart failure, or subsequent/repeat revascularization after the initial management. Unadjusted Kaplan-Meier survival analysis was performed. Of 186 patients with a SCAD diagnosis treated at our institution, 149 (80%) were female. Medical management was the initial treatment in 134 (72.0%) patients, percutaneous coronary intervention (PCI) in 43 (23.1%), and coronary artery bypass grafting in 9 (4.8%). Surgery/PCI intervention was associated with younger age (38.8 vs 47.7 years, P = 0.01), ST elevation myocardial infarction on presentation (67.0% vs 34.0%, P < 0.001), lower ejection fraction (45.0% vs 55.0%, P = 0.002), and left anterior descending coronary artery dissection (75.0% vs 51.0%, P = 0.006). Ten-year freedom from our composite outcome was similar between revascularized patients and those managed with medical therapy (P = 0.36). Median follow-up time was 4.5 years. SCAD in the setting of ST elevation myocardial infarction, left anterior descending coronary artery involvement, or decreased cardiac function suggests greater ischemic insult and was associated with initial percutaneous or surgical revascularization. Despite worse disease on initial presentation, long-term outcomes of patients undergoing revascularization are similar to medically managed patients with SCAD.
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