Non-atherosclerotic acute cardiac syndromes: spontaneous coronary artery dissection and Takotsubo syndrome. Comparison of long-term clinical outcomes

BACKGROUND

Spontaneous coronary artery dissection (SCAD) and Takotsubo syndrome (TTS) constitute two common causes of nonatherosclerotic acute cardiac syndrome particularly frequent in women. Currently, there is no information comparing long-term clinical outcomes in unselected patients with these conditions.

METHODS

We compared the baseline characteristics, in-hospital outcomes, and the 12-month and long-term clinical outcomes of two large prospective registries on SCAD and TTS.

RESULTS

A total of 289 SCAD and 150 TTS patients were included; 89% were women. TTS patients were older with a higher prevalence of cardiovascular risk factors. Precipitating triggers were more frequent in TTS patients, while emotional triggers and depressive disorders were more common in the SCAD group. Left ventricular ejection fraction was lower in TTS patients, but SCAD patients showed higher cardiac biomarkers. In-hospital events (43.3% vs. 5.2%, P <0.01) occurred more frequently in TTS patients. TTS patients also presented more frequent major adverse events at 12-month (14.7% vs. 7.1%, HR 5.3, 95% CI: 2.4-11.7, P <0.01) and long-term (median 36 vs. 31 months, P =0.41) follow-up (25.8% vs. 9.6%, HR 4.5, 95% CI: 2.5-8.2, P <0.01). Atrial fibrillation was also more frequent in TTS patients. Moreover, TTS patients presented a higher 12-month and long-term mortality (5.6% vs. 0.7%, P =0.01; and 12.6% vs. 0.7%, P <0.01) mainly driven by noncardiovascular deaths.

CONCLUSION

Compared to SCAD, TTS patients are older and present more cardiovascular risk factors but less frequent depressive disorder or emotional triggers. TTS patients have a worse in-hospital, mid-term, and long-term prognosis with higher noncardiac mortality than SCAD patients.

Relationship between stent length and very long-term target lesion failure following percutaneous coronary intervention for ST-elevation myocardial infarction in the drug-eluting stents era: insights from the EXAMINATION-EXTEND study

BACKGROUND

Little data exist on the relationship between total stent length (TSL) and cardiovascular outcomes at very-long follow-up in patients with ST-elevation myocardial infarction (STEMI) in the 2nd generation drug-eluting stents (DES) era.

AIM

To analyze the relationship between TSL and 10-year target-lesion failure (TLF) in STEMI patients treated with percutaneous coronary intervention enrolled in the EXAMINATION-EXTEND.

METHODS

The EXAMINATION-EXTEND was an extended-follow-up study of the EXAMINATION trial, which randomized 1:1 STEMI patients to receive DES or bare metal stent (BMS). The primary endpoint was TLF, defined as a composite of target lesion revascularization (TLR), target vessel myocardial infarction (TVMI), or definite/probable stent thrombosis (ST). Relationship between stent length and TLF was evaluated in the whole study group in a multiple-adjusted Cox regression model with TSL as a quantitative variable. Subgroup analysis was also performed according to stent type, diameter, and overlap.

RESULTS

A total of 1,489 patients with a median TSL of 23 mm (Q1-Q318-35 mm) were included. TSL was associated with TLF at 10 years (adjusted HR per 5 mm increase of 1.07; 95% CI, 1.01-1.14; P = .02). This effect was mainly driven by TLR and was consistent regardless of stent type, diameter, or overlap. There was no significant relationship between TSL and TV-MI or ST.

CONCLUSIONS

In STEMI patients, there is a direct relationship between TSL implanted in the culprit vessel and the risk of TLF at 10 years, mainly driven by TLR. The use of DES did not modify this association.

Myocardial revascularization failure among patients requiring cardiac catheterization and secondary revascularization in contemporary clinical practice: Results of the REVASEC multicenter registry

BACKGROUND

Myocardial revascularization failure (MRF) and Secondary revascularization (SR) are contemporary interventional cardiology challenges.

AIM

To investigate the characteristics, management, and prognosis of patients with myocardial revascularization failure (MRF) and need for secondary revascularization (SR) in contemporary practice.

METHODS

The REVASEC study is a prospective registry (NCT03349385), which recruited patients with prior revascularization referred for coronary angiography at 19 centers. The primary endpoint is a patient-oriented composite (POCE) at 1 year, including death, myocardial infarction, or repeat revascularization.

RESULTS

A total of 869 patients previously revascularized by percutaneous intervention (83%) or surgery (17%) were recruited. MRF was found in 83.7% (41.1% stent/graft failure, 32.1% progression of coronary disease, and 10.5% residual disease). SR was performed in 70.1%, preferably by percutaneous intervention (95%). The POCE rate at 1 year was 14% in the overall cohort, with 6.4% all-cause death. In the multivariate analysis, lower POCE rates were found in the groups without MRF (9.4%) and with disease progression (11%) compared with graft/stent failure (17%) and residual disease (18%), hazard ratio 0.67 (95% confidence interval: 0.45-0.99), p = 0.043. At 1 year, the SR group had less chronic persistent angina (19% vs. 34%, p < 0.001), but a higher rate of repeat revascularization (9% vs. 2.9%, p < 0.001).

CONCLUSION

MRF was found in 84% of patients with prior revascularization referred for coronary angiography. Stent/graft failure and residual coronary disease were associated with a worse prognosis. SR provided better symptom control at the expense of a higher rate of new revascularization.

Prognostic implications of left ventricular systolic dysfunction in patients with spontaneous coronary artery dissection

AIMS

Spontaneous coronary artery dissection (SCAD) is a relatively infrequent cause of acute coronary syndrome. Clinical features, angiographic findings, management, and outcomes of SCAD patients who present reduced left ventricular ejection fraction (LVEF) remain unknown.

METHODS AND RESULTS

The Spanish multicentre prospective SCAD registry (NCT03607981), included 389 consecutive patients with SCAD. In 348 of these patients, LVEF could be assessed by echocardiography during the index admission. Characteristics and outcomes of patients with preserved LVEF (LVEF ≥50%, n = 295, 85%) were compared with those with reduced LVEF (LVEF <50%, n = 53, 15%). Mean age was 54 years and 90% of patients in both groups were women. The most frequent clinical presentation in patients with reduced LVEF was ST-segment elevation myocardial infarction (STEMI) (62% vs. 36%, P < 0.001), especially anterior STEMI. Proximal coronary segment and multi-segment involvement were also significantly more frequent in these patients. No differences were found on initial revascularization between groups. Patients with reduced LVEF significantly received more often neurohormonal antagonist therapy, and less frequently aspirin. In-hospital events were more frequent in these patients (13% vs. 5%, P = 0.01), with higher rates of death, cardiogenic shock, ventricular arrhythmia, and stroke. During a median follow-up of 28 months, the occurrence of a combined adverse event did not statistically differ between the two groups (19% vs. 12%, P = 0.13). However, patients with reduced LVEF had higher mortality (9% vs. 0.7%, P < 0.001) and readmission rates for heart failure (HF) (4% vs. 0.3%, P = 0.01).

CONCLUSION

Patients with SCAD and reduced LVEF show differences in clinical characteristics and angiographic findings compared with SCAD patients with preserved LVEF. Although these patients receive specific medications at discharge, they had higher mortality and readmission rates for HF during follow-up.

Multivessel spontaneous coronary artery dissection: Clinical features, angiographic findings, management, and outcomes

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. Multivessel (MV) SCAD is a challenging clinical presentation that might be associated to a worse prognosis compared with patients with single-vessel (SV) involvement.

METHODS

The Spanish multicentre nationwide prospective SCAD registry included 389 consecutive patients. Patients were classified, according to the number of affected vessels, in SV or MV SCAD. Major adverse events (MAE) were analyzed during hospital stay and major cardiac or cerebrovascular adverse events (MACCE) at long-term clinical follow-up.

RESULTS

A total of 41 patients (10.5%) presented MV SCAD. These patients had more frequently a previous history of hypothyroidism (22% vs 11%, p = 0.04) and anxiety disorder (32% vs 16%, p = 0.01). MV SCAD patients presented more often as non-ST segment elevation myocardial infarction (73% vs 52%, p = 0.01) and showed less frequently type 1 angiographic lesions (12% vs 21%, p = 0.04). An impaired initial Thrombolysis In Myocardial Infarction (TIMI) flow 0-1 was less frequent (14% vs 29%, p < 0.01) in MV SCAD. In both groups, most patients were treated conservatively (71% vs 79%, p = NS). No differences were found regarding in-hospital MAE or MACCE at late follow-up (median 29 ± 11 months). However, the rate of stroke was higher in MV SCAD patients, both in-hospital (2.4% vs 0%, p < 0.01) and at follow-up (5.1% vs 0.6%, p = 0.01).

CONCLUSIONS

Patients with MV SCAD have some distinctive clinical and angiographic features. Although composite clinical outcomes, in-hospital and at long-term follow-up, were similar to those seen in patients with SV SCAD, stroke rate was significantly higher in patients with MV SCAD.

Multivessel spontaneous coronary artery dissection: clinical features, angiographic findings, management, and outcomes

Background

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. The rate of SCAD patients with multivessel (MV) involvement varies between series (6–13%)1,2. MV SCAD might be potentially associated to a worse prognosis due to a higher ischemic burden compared with patients with single-vessel (SV) involvement. However, comparative data between patients with MV versus SV SCAD is lacking.

Methods

The Spanish multicentre nationwide SCAD registry prospectively included 389 consecutive patients from 34 university hospitals. Patients were classified according to the number of affected vessels in two groups: SV or MV SCAD. In-hospital major adverse event (MAE) was defined as a composite of death, myocardial reinfarction, unplanned revascularization, cardiogenic shock, ventricular arrhythmia or stroke. A major cardiac or cerebrovascular adverse event (MACCE) was defined as a composite of death, myocardial reinfarction, unplanned revascularization, SCAD recurrence or stroke.

Results

A total of 41 patients (10.5%) presented MV SCAD (Table 1). There were no significant differences between groups regarding age, sex and distribution of most cardiovascular risk factors, with a non-significant trend towards more hypertension in the MV group (49% vs 34%, p=0.06). MV SCAD patients had more often previous history of hypothyroidism (22% vs 11%, p=0.04) and anxiety disorder (32% vs 16%, p=0.01), with a trend towards more fibromuscular dysplasia (50% vs 29%, p=0.12) among those patients screened. MV SCAD patients presented more often with NSTEMI (73% vs 52%, p=0.01). Regarding angiographic findings, MV SCAD patients presented more frequently focal type 3 lesions (19% vs 6%, p&lt;0.01) and fewer type 1 double-lumen lesions (12% vs 21%, p=0.04). The rate of lesions with an impaired initial Thrombolysis In Myocardial Infarction (TIMI) flow 0–1 was lower (14% vs 29%, p&lt;0.01) in MV SCAD. In both groups, most patients were treated conservatively (71% vs 79%, p=NS). We found no significant differences between groups in MAE during admission. At long-term follow-up (median 29 months), there were no significant differences in MACCE between groups (18% vs 12%, p=0.28). However, the rate of stroke was higher in patients with MV SCAD, both in-hospital (2.4% vs 0%, p&lt;0.01) and at follow-up (5.1% vs 0.6%, p=0.01). This finding could be explained by the basal differences found in hypertension and fibromuscular dysplasia between MV and SV SCAD patients.

Conclusions

Patients with MV SCAD have some distinctive clinical and angiographic features. We found no significant differences in our primary composite outcomes, both in-hospital and at long-term follow-up, between patients with SV and MV SCAD. Rate of stroke was significantly higher in patients with MV SCAD.

Funding Acknowledgement

Type of funding sources: None.

Clinical outcomes in spontaneous coronary artery dissection

OBJECTIVE

Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome. Our aim was to assess adverse events at follow-up from a nationwide prospective cohort.

METHODS

The Spanish Registry on SCAD (SR-SCAD) included patients from 34 hospitals. All coronary angiograms were analysed by two experts. Those cases with doubts regarding the diagnosis of SCAD were excluded. The angiographic SCAD classification by Saw et al was followed. Major adverse cardiovascular and cerebrovascular event (MACCE) was predefined as composite of death, myocardial infarction, unplanned revascularisation, SCAD recurrence or stroke. All events were assigned by a Clinical Events Committee.

RESULTS

After corelab evaluation, 389 patients were included. Most patients were women (88%); median age 53 years (IQR 47-60). Most patients presented as non-ST-segment-elevation myocardial infarction (54%). A type 2 intramural haematoma (IMH) was the most frequent angiographic pattern (61%). A conservative initial management was selected in 78% of patients. At a median time of follow-up of 29 months (IQR 17-38), 46 patients (13%) presented MACCE, mainly driven by reinfarctions (7.6%) and unplanned revascularisations (6.2%). Previous history of hypothyroidism (HR 3.79; p<0.001), proximal vessel involvement (HR 2.69; p=0.009), type 2 IMH (HR 2.12; p=0.037) and dual antiplatelet therapy (DAPT) at discharge (HR 2.18; p=0.042) were independent predictors of MACCE.

CONCLUSIONS

In this large prospective cohort of patients with SCAD, prognosis was overall favourable, with events mainly driven by reinfarctions or unplanned revascularisations. History of hypothyroidism, proximal vessel involvement, type 2 IMH and DAPT at discharge were associated with MACCE.

TRIAL REGISTRATION NUMBER

NCT03607981.

In-hospital and one-year outcomes in spontaneous coronary artery dissection. Insights from the Spanish registry on SCAD (SR-SCAD)

Background

Spontaneous coronary artery dissection (SCAD) is a relatively infrequent but well-known cause of acute coronary syndrome (ACS). Information about in-hospital evolution and adverse event during follow-up is still scarce and comes mostly from cohorts outside the European context.

Purpose

The aim of the present work was to evaluate in-hospital and one-year follow-up adverse events in a nationwide large prospective cohort of patients with SCAD.

Methods

The Spanish Registry on SCAD (NCT03607981) prospectively included patients with a diagnosis of SCAD from 34 Spanish university hospitals. All coronary angiograms were carefully reviewed by two experts at a corelab to confirm the diagnosis of SCAD. In-hospital major adverse event (MAE) was defined as a composite of death, cardiogenic shock, myocardial re-infarction (MI), unplanned revascularization, ventricular arrhythmias (ventricular tachycardia or ventricular fibrillation) or stroke. A predefined 12-month major cardiovascular adverse event (MACE) was defined as a composite of death, MI, unplanned revascularization, SCAD recurrence or stroke.

Results

From June 2015 to December 2020, a total of 388 patients (440 lesions) with SCAD were included in the present analysis. Most patients were women (89%), with median age of 53 years old (IQR 47–60). Systemic hypertension (36%), hyperlipidemia (33%) and history of smoking habit (44%) were frequently seen in our cohort. Fifty-six percent of the patients included were postmenopausal. Peripartum context was rare (1.3%). Most patients presented as non-ST-segment-elevation myocardial infarction (NSTEMI) (55%) followed by ST-segment-elevation myocardial infarction (41%). Only 3% of the cohort presented as sudden cardiac death. Left anterior descending coronary artery was most frequently affected (44%), with SCAD lesions predominantly affecting distal (38%) segments and secondary branches (55%). Multivessel involvement was present in 11% of the patients. A long intramural hematoma (type 2 lesion) was the most frequent angiographic pattern (62%). In a vast majority of patients, an initial conservative management was selected (78%). Only in 22% of the SCAD patients the initial strategy was percutaneous coronary intervention.

Twenty-four patients (6.2%) had an MAE during admission. The composite was mainly driven by unplanned revascularizations (4.4%) and reinfarctions (2.8%). Only 6 patients (1.6%) died during index admission. At 12-months, 37 patients (10.8%) presented MACE, mainly driven by reinfarctions (5.8%) and unplanned revascularizations (5.8%). Only 1 patient presented SCAD recurrence during 12-month follow-up and 8 patients (2.3%) died.

Conclusion

In a large prospective cohort of patients with SCAD, in-hospital and 12 months follow-up prognosis were good. Survival was excellent. A large proportion of the adverse events occurred during the index admission, mainly related to reinfarction and need for revascularization.

Funding Acknowledgement

Type of funding sources: None.

Spontaneous Coronary Artery Dissection and Menopause

Spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of acute coronary syndrome in women. The role of sexual hormones has been related to the pathophysiology of SCAD. However, clinical features, angiographic findings, management and outcomes of SCAD women in relation to menopause status remain unknown. The Spanish multicenter prospective SCAD registry (NCT03607981), included 318 consecutive patients with SCAD. All coronary angiograms were analyzed in a centralized Corelab. In this substudy, 245 women were classified according to their menopause state (pre-menopausal and post-menopausal). In-hospital outcomes were analyzed: 148 patients (60.4%) were post-menopausal. These patients were older (57 [52 to 66] vs 49 [44 to 54] years, p <0.01) and had more often hypertension (49% vs 27%, p <0.01) and dyslipidemia (46% vs 25%, p <0.01). Post-menopausal women showed more often previous history of acute coronary syndrome, including previous SCAD (9% vs 3%, p = 0.046), and presented less frequently as ST-segment elevation myocardial infarction on admission, compared with premenopausal women (34% vs 49%, p = 0.014). On the other hand, premenopausal women showed more often proximal and multisegment involvement (24% vs 7%, and 32% vs 18%, respectively, both p <0.01). Post-menopausal women were more often managed conservatively (85% vs 71%, p <0.01) and presented less frequently left ventricular dysfunction (both, p <0.01). There were no differences between groups in terms of in-hospital stay or mortality, new acute myocardial infarction, unplanned coronary angiography or heart failure. In conclusion, post-menopausal women with SCAD show different clinical and angiographic characteristics compared with pre-menopausal SCAD patients. Initial treatment strategy was different between groups, though in-hospital outcomes did not significantly differ (NCT03607981).

Spontaneous coronary artery dissection in the elderly: clinical features, angiographic findings, management and outcomes

Background

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). Clinical features, angiographic findings, management and outcomes of SCAD in elderly patients remain unknown.

Methods

The Spanish multicenter prospective SCAD registry included 318 consecutive patients with SCAD diagnosis. Patients were classified according to age in two groups: &lt;65 and ≥65 years old.

Results

A total of 55 patients (17%) were 65 or older (Table). Elderly patients had more often hypertension (29% vs 76%, p&lt;0.01) and dyslipidemia (30% vs 56%, p&lt;0.01), and less smoking history (51% vs 7%, p&lt;0.01). Previous history of coronary artery disease was also more frequent in older patients (4% vs 11%, p=0.044). Interestingly, an identifiable trigger was more often found among patients under 65. Coronary artery tortuosity (1±0.99 vs 1.4±1, p=0.027) and coronary artery ectasia (9% vs 24%, p&lt;0.01) were both more frequent in elderly patients, who were more often managed conservatively (75% vs 89%, p=0.025). A trend toward a higher mortality rate was found among patients ≥65, with no differences in terms of in hospital stay, new acute myocardial infarction, unplanned coronariography or heart failure.

Conclusions

Elderly patients with SCAD show different clinical and angiographic characteristics and they receive distinct management. Short-term outcomes do not significantly differ from those seen in younger patients.

Funding Acknowledgement

Type of funding source: None

An Exceptional Cause of Acute Right Heart Failure

We describe a patient with of acute right ventricular dysfunction secondary to right ventricular isolated Takotsubo syndrome (TTS). The importance of appropriate differential diagnosis for acute right ventricular dysfunction differential diagnosis of acute right ventricular dysfunction and the differences in diagnosis and management of right ventricular TTS and typical left ventricular TTS are highlighted. (Level of Difficulty: Intermediate.)