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STEMI caused by spontaneous coronary artery dissection: prevalence, patient characteristics and outcomes
Stefan Malleier1, Luise Gaede2, Susanne Jung2
1Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany. s-malleier@hotmail.de.
Insights
Spontaneous coronary artery dissection (SCAD) affects about 1% of ST-segment elevation myocardial infarction (STEMI) patients, often missed in diagnosis. SCAD patients are younger, more frequently female, and face high complication rates with interventions.
Area of Science:
- Cardiology
- Vascular Medicine
Background:
- Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of myocardial infarction (MI).
- Real-world data on SCAD prevalence in ST-segment elevation myocardial infarction (STEMI) is limited.
Purpose of the Study:
- To determine the prevalence of SCAD in a cohort of STEMI patients.
- To characterize the clinical presentation, angiographic findings, and outcomes of SCAD-STEMI.
Main Methods:
- Retrospective analysis of medical records and coronary angiograms from consecutive STEMI patients.
- Clinical data review for SCAD patient characterization.
Main Results:
- SCAD prevalence was 0.9% (24/2707) among STEMI patients; 37.5% were initially missed.
- SCAD patients were younger (median 53.5 vs. 66.0 years) and more often female (75.0% vs. 29.7%) than non-SCAD-STEMI patients.
- Cardiac arrest occurred in 25% of SCAD patients; 50% of percutaneous coronary interventions (PCI) had complications, often due to intramural hematoma propagation.
Conclusions:
- SCAD accounts for approximately 1% of STEMI cases in this Western European cohort.
- The true incidence of SCAD may be underestimated, especially in patients presenting with cardiac arrest.
- Percutaneous coronary intervention for SCAD-STEMI carries a high complication rate.
Background:
Spontaneous coronary artery dissection (SCAD) is a rare, but increasingly recognised cause of myocardial infarction. Our aim was to provide comprehensive real-world data on the prevalence of SCAD among patients who present with ST-segment elevation myocardial infarction (STEMI).
Methods:
Retrospective analysis of medical records and review of coronary angiograms allowed identification of all SCAD cases in a cohort of consecutive patients with STEMI, and review of clinical data provided further characterisation.
Results:
Among 2707 consecutive STEMI patients, the prevalence of SCAD was 0.9% (n = 24). In 9 cases, the diagnosis of SCAD diagnosis had been missed during clinical routine (37.5%). Compared to non-SCAD-STEMI, SCAD patients were younger (median age 53.5 vs. 66.0 years, p = 0.001) and more likely to be female (75.0% vs. 29.7%, p < 0.001). The most common symptom was typical angina (chest pain limited to the thorax, 75%). Importantly, six patients (25%) experienced cardiac arrest, either as the presenting symptom before (n = 2) or after first medical contact (n = 3), or during hospitalisation (n = 1). The most common angiographic pattern was SCAD type 4 (complete vessel occlusion, 37.5%), followed by type 2a (29.2%) and 2b (25%). Intravascular imaging was used in 25% (n = 6). 58.3% of patients with SCAD-STEMI underwent percutaneous coronary intervention (PCI). Complications occurred in 50% of PCI, mostly due to propagation of intramural hematoma. All patients survived to hospital discharge. Long-term follow-up was available in 50% of patients. While event rate was low, recurrence of SCAD did occur, in some cases after several years.
Conclusion:
In a Western European cohort of STEMI patients, SCAD was the underlying cause in approximately 1% of all cases. The true incidence may be higher since cardiac arrest occurred in one quarter of all patients within the cohort. Interventional treatment, while often required in SCAD-STEMI, is fraught by a high complication rate.
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