Differences in Demographics and Outcomes Between Men and Women With Spontaneous Coronary Artery Dissection

Sex differences in secondary prevention needs and recommendations among patients with spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is increasingly recognized as a cause of heart attacks, particularly for female patients; however, ∼10% of cases occur in male patients. While male and female differences pertaining to clinical outcomes and treatment protocols have been addressed in the literature, research is limited on sex differences in secondary prevention programming, such as cardiac rehabilitation. Cardiac rehabilitation is recommended for patients with SCAD to promote physical and mental recovery. This letter highlights sex-specific gaps in existing programming and reports patients' suggestions for enhancing the recovery of this unique patient population.

Cardiac Rehabilitation for Women with Heart Disease

Cardiovascular disease is the leading cause of morbidity and mortality in women globally. Cardiac rehabilitation (CR)-a comprehensive program including supervised progressive exercise, education, support, behavior modification, and nutritional guidance over 36 individual sessions-positively impacts morbidity, mortality, function, and quality of life. Overall, less than 30% of those who qualify are referred and participate in CR-referral and completion rates are significantly less in women compared with men despite evidence supporting equal benefit. Barriers contributing to these disparities have been identified, and CR programs can be modified to enhance the participation of women.

Left Main Spontaneous Coronary Artery Dissection: Clinical Features, Management, and Outcomes

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute myocardial infarction (MI) and is associated with substantial adverse events. SCAD involving the left main coronary artery (LM) is a rare but potentially life-threatening condition. Currently, minimal data on LM SCAD have been reported.

OBJECTIVES

The aim of this study was to investigate clinical features, contemporary management, and clinical outcomes of patients with LM SCAD.

METHODS

A systematic review and pooled analysis of published case reports was conducted using "left main" and "dissection" as keywords. The authors screened 1,106 papers in MEDLINE and Embase published between 1990 and 2023.

RESULTS

The final analysis included 132 patients (mean age 40 ± 11 years, 80% women) diagnosed with LM SCAD. Remarkably, 36% of cases occurred during pregnancy, and 95% presented with acute coronary syndrome, 22% with cardiogenic shock, and 8% with ventricular arrhythmias. At 120-day median follow-up, all-cause death occurred in 9%, left ventricular assist device implantation or heart transplantation in 4%, recurrent MI in 13%, and urgent myocardial revascularization (MR) in 21%. Compared with conservative management, early revascularization by percutaneous coronary intervention or coronary artery bypass grafting significantly reduced the composite endpoint of all-cause death, left ventricular assist device implantation or heart transplantation, recurrent MI, and urgent MR (adjusted HR: 0.37; 95% CI: 0.20-0.69; P < 0.001).

CONCLUSIONS

LM SCAD carried significant acute morbidity and mortality. Early revascularization (percutaneous coronary intervention or coronary artery bypass graft) was associated with a lower incidence of early adverse outcomes compared with conservative management, driven largely by reduction in recurrent MI and urgent MR. These hypothesis-generating data should be confirmed in future prospective registries and clinical trials.

Spontaneous Coronary Artery Dissection: A Narrative Review of Epidemiology and Public Health Implications

Spontaneous coronary artery dissection (SCAD) is an uncommon but significant cause of acute coronary syndrome (ACS), predominantly affecting younger women without traditional cardiovascular risk factors. SCAD is defined as a non-atherosclerotic, non-traumatic dissection of the coronary artery, leading to the formation of an intramural haematoma or intimal tear causing obstruction to blood flow and myocardial ischaemia. Unlike traditional atherosclerotic coronary artery disease, SCAD has unique pathophysiological mechanisms. SCAD is thought to arise secondary to a bleed and/or dissection within the arterial wall, linked to hormonal influences with potential triggers of physical or emotional stress and predisposition such as an underlying connective tissue disorder. Despite being increasingly recognised, SCAD remains underdiagnosed, and knowledge regarding SCAD epidemiology is limited. In addition, the impact of SCAD extends beyond the immediate cardiac event, encompassing psychological distress, the need for rehabilitation, and long-term surveillance. This has implications not just for the patient but also their family and the healthcare system. This narrative review summarises the current knowledge of SCAD epidemiology, including the affected population, its associated risk factors, and healthcare impact. By identifying current gaps in knowledge, this review aims to encourage targeted research, public awareness, and policy initiatives to improve outcomes for individuals affected by SCAD.

Spontaneous Coronary Artery Dissection-Different Faces of the Same Disease

In this paper, we present 2 patients with ST-elevation myocardial infarction in the course of Spontaneous Coronary Artery Dissection. The first patient, a female admitted with STEMI, was diagnosed with SCAD with intravascular imaging and treated with IVUS-guided PCI. In the second patient, a young male hospitalized due to angina and STEMI, SCAD was not identified initially, and the patient was treated conservatively. Based on these cases, we show different faces of the same disease that imply different diagnostics and management strategies. We draw attention to the fact that the disease affects not only young women without atherosclerotic risk factors and that it is not always possible to avoid generally not recommended invasive treatment and anticoagulant therapy. The paper also discusses the disease's pathophysiology and its diagnosis methods.

Relationship between personality traits and spontaneous coronary artery dissection risk: evidence from Mendelian randomization

Background

Spontaneous coronary artery dissection (SCAD) significantly contributes to myocardial infarction among young individuals. Despite the elusive nature of its etiology, empirical evidence indicates a substantial correlation between sociopsychological factors and the disorder. This investigation endeavored to discern a genetic basis for personality traits influencing SCAD susceptibility.

Methods

Bidirectional univariate and multivariate Mendelian randomization (MR) analyses were hereby conducted to investigate the putative causal nexus between personality dimensions and SCAD risk. Besides, data regarding SCAD and personality were extracted from expansive genome-wide association studies (GWAS), and rigorous statistical inferences were made using inverse variance weighting (IVW) and ancillary methodologies. Additionally, sensitivity evaluations were performed to bolster statistical assertions.

Results

Univariate MR analyses indicated heightened neuroticism scores as harbingers of increased SCAD risk [Odds Ratio (OR) = 1.31, 95% Confidence Interval (CI): 1.08-1.60, P = 0.007], while other personality characteristics revealed no causal interplay with SCAD. After excluding single nucleotide polymorphisms (SNPs) confounded by extrinsic variables, the association of neuroticism scores with SCAD susceptibility persisted. These findings were further substantiated by multivariate MR analyses.

Conclusions

In summary, this study identified a significant association between genetically predicted neuroticism scores and an elevated risk of SCAD. However, additional investigation is still required to elucidate the biological underpinnings of this relationship, as well as the impact of gender, environmental influences, and other contributing factors.

Gender disparity in morbidity and mortality among patients with ST-elevation myocardial infarction due to spontaneous coronary artery dissection complicated by cardiogenic shock

BACKGROUND

There is limited data on gender differences among patients with spontaneous coronary artery dissection (SCAD) who present as ST-elevation myocardial infarction (STEMI) and develop cardiogenic shock (CS).

OBJECTIVES

To describe outcomes of SCAD patients presenting with STEMI and CS and outline the differences between men and women.

METHODS

We queried the US Nationwide Readmissions Database (NRD) from January 2016 to December 2020 to identify patients with SCAD presenting with STEMI who developed CS. We compared the characteristics, trends, and outcomes between men and women in this cohort.

RESULTS

Out of 582,633 hospitalizations with STEMI, 0.2 % (1176 patients) had SCAD, of which 346 (29.4 %) had CS. There was no difference in median age between men and women (64 years (IQR 57-71) vs. 63 years (IQR 49-72), p = 0.181). Men had a higher prevalence of prior myocardial infarction (MI) (14.2 % vs. 6.2 %, p = 0.021). The overall mortality rate of SCAD patients with AMI-CS was 28.2 %, with no difference between men and women. Patients with SCAD who had CS and underwent CABG had a mortality of 20.3 %. ECMO was used in 6.1 % of SCAD patients presenting with STEMI and CS, with a survival rate of 49.9 %.

CONCLUSION

There were no differences in the baseline characteristics, rates of revascularization, or in-hospital mortality between men and women who had SCAD complicated by CS (SCAD-CS). Patients with SCAD-CS patients who underwent CABG had around 80 % in-hospital survival. CABG should be considered as a method of revascularization in this patient cohort.

Recurrent Spontaneous Coronary Artery Dissections in a Male Patient With Fibromuscular Dysplasia

Spontaneous coronary artery dissection (SCAD) is a rare presentation of acute coronary syndrome characterized by a tearing of the wall of the epicardial coronary artery, leading to myocardial ischemia. SCAD predominantly affects young and middle-aged women, but young men without significant cardiovascular risk factors can also present with the disease. In the setting of fibromuscular dysplasia, men may be at a higher risk for recurrence. We present the case of a young man with a history of fibromuscular dysplasia and prior SCAD in the diagonal branch and right posterolateral artery who presented with exertional chest pain. Further evaluation revealed a recurrent SCAD of the distal right coronary artery despite being on conservative management with aspirin and beta-blockers. There is a need to study the pathophysiology of fibromuscular dysplasia and SCAD in men further and develop medical therapies to treat recurrent SCAD.

The Role of Psychosocial Stress on Cardiovascular Disease in Women: JACC State-of-the-Art Review

Psychosocial stress can affect cardiovascular health through multiple pathways. Certain stressors, such as socioeconomic disadvantage, childhood adversity, intimate partner violence, and caregiving stress, are especially common among women. The consequences of stress begin at a young age and persist throughout the life course. This is especially true for women, among whom the burden of negative psychosocial experiences tends to be larger in young age and midlife. Menarche, pregnancy, and menopause can further exacerbate stress in vulnerable women. Not only is psychosocial adversity prevalent in women, but it could have more pronounced consequences for cardiovascular risk among women than among men. These differential effects could reside in sex differences in responses to stress, combined with women's propensity toward vasomotor reactivity, microvascular dysfunction, and inflammation. The bulk of evidence suggests that targeting stress could be an important strategy for cardiovascular risk reduction in women.

Sex and Gender Differences in Fibromuscular Dysplasia

Fibromuscular dysplasia (FMD) is a non-atherosclerotic, non-inflammatory vascular disease that was once underrecognized and is significantly more prevalent in women than men. Although it most commonly affects the renal and extracranial carotid arteries, FMD can affect any vascular bed. Complications of FMD can include hypertension, dissection, and stroke. Presentation may vary between the sexes, with male patients having an increased frequency of arterial dissection and aneurysms compared with female patients. Diagnosis requires a high index of suspicion by the treating physician. Several imaging studies can assist with diagnosis, and treatment focuses on the monitoring of affected vessels and intervention only as needed. Antiplatelet therapy for prevention of thrombotic complications is recommended. Studies are still underway to examine the genetic underpinnings of FMD pathophysiology and to evaluate the underlying mechanism of this disease that affects more female than male patients.

Spontaneous coronary artery dissection: a case series illustrating current challenges in diagnosis and treatment

Spontaneous coronary artery dissection (SCAD) has been increasingly recognized in recent years as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, especially among young women. However, due to the lack of clinical trials on SCAD, evidence-based guidance on management is currently lacking. Presented are four case studies that illustrate the recent insights and challenges in SCAD diagnosis and treatment.

Spontaneous coronary artery dissection (SCAD): A contemporary review

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of myocardial infarction that most frequently affects younger women, making it an important cause of morbidity and mortality within these demographics. The evolution of intracoronary imaging, improved diagnosis with coronary angiography, and ongoing research efforts and attention via social media, has led to increasing recognition of this previously underdiagnosed condition. In this review, we provide a summary of the current body of knowledge, as well as focused updates on the pathogenesis of SCAD, insights on genetic susceptibility, contemporary diagnostic tools, and immediate, short- and long-term management.

Spontaneous Left Main Coronary Artery Dissection in a Male

Spontaneous coronary artery dissection (SCAD) is one of the causes of acute coronary syndrome (ACS) that is increasingly recognized in young to middle-aged women without typical coronary risk factors. This case report describes a 46-year-old male with a rare presentation of SCAD involving the left main (LM) coronary artery. The patient underwent an emergency coronary angiogram for high-risk ACS and had percutaneous coronary intervention (PCI) of LM due to active ischemia and hemodynamic instability. The extension of intramural hematoma after the LM coronary artery stent confirmed the initial suspicion of SCAD. The diagnosis of SCAD is crucial, as its management differs from other causes of ACS. Coronary angiography is the gold standard for diagnosing SCAD, with adjunctive imaging using optical coherence tomography (OCT) and intravascular ultrasound (IVUS). In this patient, his physical examination findings and further imaging raised a suspicion for systemic connective tissue disease. Genetic analysis was executed, but no reportable variants in any of the 29 genes studied were identified. This case highlights the importance of recognizing SCAD as a potential cause of ACS even in men and emphasizes the findings during coronary angiography that can aid in an accurate diagnosis and appropriate management.

Coronary Artery Aneurysms, Arteriovenous Malformations, and Spontaneous Dissections-A Review of the Evidence

BACKGROUND

Coronary artery aneurysms (CAAs), coronary arteriovenous malformations (CAVMs), and spontaneous coronary artery dissections (SCADs) are rare clinical entities, and much is unknown about their natural history, prognosis, and management.

METHODS

A systematic search of MEDLINE, Embase, and Cochrane Library databases was performed in March 2023 to identify published papers related to CAAs, CAVMs, and SCADs.

RESULTS

CAAs are found in 0.3% to 12% of patients undergoing angiography and are often associated with coronary atherosclerosis. They are usually asymptomatic but can be complicated by thrombosis in up to 4.8% of patients and rarely by rupture (0.2%). CAAs can be managed medically, percutaneously with stents or coil embolization, and surgically. The most common surgical procedure is ligation of the aneurysm, followed by coronary artery bypass grafting. The incidence of CAVMs is 0.1% to 0.2% in patients undergoing angiography, and they are most likely associated with congenital abnormal development of the coronary vessels. The diagnosis of CAVMs is usually incidental. Surgical or percutaneous intervention is indicated for patients with large CAVMs, which carry a potential risk of myocardial infarction. SCADs represent 1% to 4% of all acute coronary syndromes and typically affect young women. SCADs are strongly correlated with pregnancy, suggesting the role of sex hormones in their pathogenesis. Conservative management of SCAD is preferred for stable patients without signs of ischemia as spontaneous resolution is frequently reported. Unstable patients should undergo revascularization either percutaneously or with coronary artery bypass grafting.

CONCLUSIONS

Further evidence regarding the management of these rare diseases is needed and can ideally be derived from multicenter collaborations.

Sex differences in patients presenting with acute coronary syndrome: a state-of-the-art review

Cardiovascular conditions in the spectrum of acute coronary syndromes are characterized by sex differences with regard to pathophysiology, risk factors, clinical presentation, invasive and pharmacologic treatment, and outcomes. This review delves into these differences, including specific subsets like myocardial infarction with non-obstructed coronary arteries or Spontaneous Coronary Artery Dissection, and alternative diagnoses like Takotsubo cardiomyopathy or myocarditis. Moreover, practical considerations are enclosed, on how a sex-specific approach should be integrated in clinical practice: in fact, personal history should focus on female-specific risk factors, and hormonal status and hormonal therapy should be assessed. Moreover, physical and psychological stressors should be investigated, particularly in the event of Spontaneous Coronary Artery Dissection or Takotsubo cardiomyopathy.

Sex-specific and ethnicity-specific differences in MINOCA

Suspected myocardial infarction with non-obstructive coronary arteries (MINOCA) has received increasing attention over the past decade. Given the heterogeneity in the mechanisms underlying acute myocardial infarction in the absence of obstructive coronary arteries, the syndrome of MINOCA is considered a working diagnosis that requires further investigation after diagnostic angiography studies have been performed, including coronary magnetic resonance angiography and functional angiography. Although once considered an infrequent and low-risk form of myocardial infarction, recent data have shown that the prognosis of MINOCA is not as benign as previously assumed. However, despite increasing awareness of the condition, many questions remain regarding the diagnosis, risk stratification and treatment of MINOCA. Women seem to be more susceptible to MINOCA, but studies on the sex-specific differences of the disease are scarce. Similarly, ethnicity-specific factors might explain discrepancies in the observed prevalence or underlying pathophysiological mechanisms of MINOCA but data are also scarce. Therefore, in this Review, we provide an update on the latest evidence available on the sex-specific and ethnicity-specific differences in the clinical features, pathophysiological mechanisms, treatment and prognosis of MINOCA.

Spontaneous Coronary Artery Dissection Resulting in Acute Myocardial Infarction With Cardiac Rupture

Spontaneous coronary artery dissection occurs predominantly in women and is associated with fibromuscular dysplasia. We illustrate a rare case of sudden coronary death as a result of cardiac rupture from spontaneous coronary artery dissection in a 54-year-old man without fibromuscular dysplasia. Cardiac rupture has been previously reported in 6 cases, mostly in women.

Spontaneous Dissection of a Septal Coronary Artery Mimicking Myocarditis

Acute chest pain and dyspnea often raise coronary disease suspicion. When echocardiography and cardiac computed tomography findings appear normal, alternative diagnoses should be explored. We present a case initially suggestive of myocarditis but later revealed as coronary dissection by cardiac magnetic resonance. This case emphasizes the role of advanced imaging in atypical cardiac presentations.

Prevalence and outcomes of select rare vascular conditions in females: A descriptive review

Rare vascular conditions frequently pose a diagnostic and therapeutic dilemma for health care providers. Several of these conditions have distinct relevance to females populations but, due to their infrequency, there has been little reported on the outcomes of rare vascular conditions specifically in females populations. We performed a literature review of a selection of three rare vascular conditions known to either disproportionately affect females (median arcuate ligament syndrome and fibromuscular dysplasia) or have unique manifestations in females populations (vascular Ehlers-Danlos syndrome). We performed a descriptive review of the literature focused on these three vascular conditions and identified aspects of the current available research describing sex-based differences in prevalence, any pathophysiology explaining the observed sex-based differences, and the contribution of sex to outcomes for each disease process. In addition, considerations for pregnant females with respect to each rare vascular disease process are discussed.

Spontaneous coronary artery dissection: an overview

The prevalence of spontaneous coronary artery dissection (SCAD) has increased over the last decades in young adults presenting with acute coronary syndrome. Although the diagnostic tools, including intracoronary imaging, have permitted a more accurate diagnosis of SCAD, the prognosis and overall outcomes remain dismal. Furthermore, the disproportionate sex distribution affecting more women and the underdiagnosis in many parts of the world render this pathology a persistent clinical challenge, particularly since the management remains largely supportive with a limited and controversial role for percutaneous or surgical interventions. The purpose of this review is to summarize the available literature on SCAD and to provide insights into the gaps in knowledge and areas requiring further investigation.

From Fibromuscular Dysplasia to Arterial Dissection and Back

Fibromuscular dysplasia (FMD) is an idiopathic and systemic non-inflammatory and non-atherosclerotic arterial disease. Fifteen to 25% of patients with FMD present with arterial dissection in at least one arterial bed. Conversely, a substantial number of patients with renal, carotid, and visceral dissection have underlying FMD. Also, while few patients with FMD develop coronary artery dissection, lesions suggestive of multifocal FMD have been reported in 30-80% of patients with spontaneous coronary artery dissection (SCAD), and the relation between these two entities remains controversial. The frequent association of FMD with arterial dissection, both in coronary and extra-coronary arteries raises a number of practical and theoretical questions: (i) Are FMD and arterial dissections two different facets of the same disease or distinct though related entities? (ii) Is SCAD just a manifestation of coronary FMD or a different disease? (iii) What is the risk and which are predictive factors of developing arterial dissection in a patient with FMD? (iv) What proportion of patients who experienced an arterial dissection have underlying FMD, and does this finding influence the risk of subsequent arterial complications? In this review we will address these different questions using fragmentary, mostly cross-sectional evidence derived from large registries and studies from Europe and the United States, as well as arguments derived from demographics, clinical presentation, imaging, and when available histology and genetics. From there we will derive practical consequences for nosology, screening and follow-up.

Sex and Gender Differences in Cardiovascular Disease: A Review of Spontaneous Coronary Artery Dissection

This review highlights sex- and gender-specific considerations in cardiovascular diseases with a particular focus on pathophysiology, epidemiology, clinical presentation, risk factors, diagnosis, and management of spontaneous coronary artery dissection. It aims to summarize the most up to date evidence and gaps in knowledge that exist in the spontaneous coronary artery dissection space while highlighting salient points with regards to sex- and gender-based differences in clinical implications, current management, and recommended counseling practices.

Current challenges in treatment and management of spontaneous coronary artery dissection

Though an infrequent cause of acute coronary syndrome, spontaneous coronary artery dissection is an increasingly recognized cardiovascular condition predominantly seen in middle-aged females. Its pathophysiology is defined by separation of coronary arterial wall layers which cause acute coronary syndrome-like presentations with relatively high recurrence rates. Overall, there is a lack of reported literature and understanding of the short- and long-term management for spontaneous coronary artery dissection. Therapeutic approaches include, but are not limited to, percutaneous coronary intervention, surgical revascularization, antithrombotic therapy, and beta-blocker therapy. There is a significant absence of randomized control trials to help guide both interventional and medical management for spontaneous coronary artery dissection. This review is aimed to review the current literature regarding risk factors and considerations for the short- and long-term management of spontaneous coronary artery dissection.

An Unusual Case of Chronic Total Occlusion Secondary to Late-Diagnosed Recurrent Spontaneous Coronary Dissection

We report a case of a male patient, aged 44 years, with a long history of percutaneous and surgical revascularizations, who presented with progressive effort angina and a "dynamic total occlusion" of the left circumflex coronary artery, which turned out to be an unrecognized spontaneous coronary artery dissection. In conclusion, spontaneous coronary artery dissection is a rare cause of acute coronary syndrome and it is even less frequent in male patients; therefore, a high level of suspicion, especially in the case of young patients without major cardiovascular risk factors, is mandatory for prompt diagnosis and adequate strategy. Our case highlights how a missed proper initial diagnosis can dramatically evolve. Furthermore, intravascular imaging can be crucial for confirming the diagnosis.

TyG index as a predictor of spontaneous coronary artery dissection in young women

OBJECTIVE

Spontaneous coronary artery dissection (SCAD) is a rare but potentially life-threatening pathology and cases are especially seen in women under 50 years of age and with relatively fewer cardiovascular risk factors. Although risk factors facilitating the development of SCAD have been defined in the literature, modifiable risk factors remain unclear. In this study, it was aimed to investigate the relationship between the triglyceride glucose index (TyG) and the development of SCAD in the population of young women.

METHODS

The results of 281 patients were analyzed and compared with each other in terms of clinical, demographic, laboratory parameters, and coronary angiography results.

RESULTS

The mean age was 45 years and all of them were female. When the groups were compared, the TyG and inflammatory parameters were higher in the SCAD group (p < 0.001). When these two groups with low cardiovascular risk factors were compared in logistic regression analysis, high TyG was found to be an independent predictor of SCAD development in young women (p < 0.001).

CONCLUSION

As a result, our study shows that the development of these non-atherosclerotic conditions can be predicted by simple biochemical tests in young women with low atherosclerotic cardiovascular risk factors.

Precipitating factors in patients with spontaneous coronary artery dissection: Clinical, laboratoristic and prognostic implications

BACKGROUND

Spontaneous coronary artery dissection (SCAD) often presents with acute coronary syndrome and underlying pathophysiology involves the interplay between predisposing factors and precipitating stressors, such as emotional and physical triggers. In our study we sought to compare clinical, angiographic and prognostic features in a cohort of patients with SCAD according to the presence and type of precipitating stressors.

METHODS

Consecutive patients with angiographic evidence of SCAD were divided into three groups: patients with emotional stressors, patients with physical stressors and those without any stressor. Clinical, laboratoristic and angiographic features were collected for each patient. The incidence of major adverse cardiovascular events, recurrent SCAD and recurrent angina was assessed at follow-up.

RESULTS

Among the total population (64 subjects), 41 [64.0%] patients presented with precipitating stressors, including emotional triggers (31 [48.4%] subjects) and physical efforts (10 [15.6%] subjects). As compared with the other groups, patients with emotional triggers were more frequently female (p = 0.009), had a lower prevalence of hypertension (p = 0.039] and dyslipidemia (p = 0.039), were more likely to suffer from chronic stress (p = 0.022) and presented with higher levels of C-reactive protein (p = 0.037) and circulating eosinophils cells (p = 0.012). At a median follow-up of 21 [7; 44] months, patients with emotional stressors experienced higher prevalence of recurrent angina (p = 0.025), as compared to the other groups.

CONCLUSIONS

Our study shows that emotional stressors leading to SCAD may identify a SCAD subtype with specific features and a trend towards a worse clinical outcome.

Characteristics and outcomes of percutaneous coronary interventions in patients with spontaneous coronary artery dissection. A study from the administrative minimum data set of the Spanish National Health System

BACKGROUND

Coronary revascularization in patients with spontaneous coronary artery dissection (SCAD) is challenging. Indications and results of percutaneous coronary interventions (PCI) in SCAD patients are not well established.

AIM

To assess indications and results of PCI in SCAD.

METHODS

The minimum basic data set of the Spanish National Health System (years 2016-2019) was used to identify 804 episodes of acute myocardial infarction (AMI) and SCAD, with a crude in-hospital mortality rate of 3%. Of these, 368 (46.8%) patients were revascularized with PCI during admission whereas 436 (54.2%) were managed conservatively.

RESULTS

Revascularization and in-hospital mortality rates both declined over the study period (p for trend both < 0.05). SCAD patients treated with PCI were older, more frequently male, and had higher frequency of diabetes, ST-segment elevation AMI and cardiogenic shock, compared to patients managed conservatively. The crude in-hospital mortality rate was higher in patients treated with PCI (4.9% vs. 1.4%; p = 0.004). However, after adjusting by propensity score (223 pairs) the in-hospital mortality rate was similar in the two groups (Adj OR: 1.21; 95%CI: 0.30-1.57; p = 0.76). Readmissions at 30-days were higher in patients managed conservatively (7.1 vs. 1.6%, p < 0.001) and this difference was maintained after propensity score adjustment (Adj average treatment effect: 2% vs. 12.2%; OR: 0.15; 95%CI: 0.04-0.45; p < 0.001).

CONCLUSION

Revascularization is frequently used in unselected patients with AMI and SCAD but its use is declining. Patients with SCAD treated with PCI have a higher in-hospital mortality but this appears to be explained by their adverse baseline clinical characteristics.