Spontaneous Coronary Artery Dissection: Association With Predisposing Arteriopathies and Precipitating Stressors and Cardiovascular Outcomes

• Published in: Circulation. Cardiovascular interventions Vol. 7; no. 5; pp. 645 - 655
• Main Authors: Saw, Jacqueline, Aymong, Eve, Sedlak, Tara, Buller, Christopher E., Starovoytov, Andrew, Ricci, Donald, Robinson, Simon, Vuurmans, Tycho, Gao, Min, Humphries, Karin, Mancini, G.B. John
• Format: Journal Article
• Language: English
• Published: United States American Heart Association, Inc 01.10.2014
• Subjects: Adult; Canada; Causality; Coronary Angiography; Coronary Vessel Anomalies - epidemiology; Coronary Vessel Anomalies - etiology; Coronary Vessels - diagnostic imaging; Coronary Vessels - pathology; Coronary Vessels - surgery; Female; Fibromuscular Dysplasia - diagnosis; Fibromuscular Dysplasia - epidemiology; Fibromuscular Dysplasia - surgery; Follow-Up Studies; Humans; Male; Myocardial Infarction - diagnosis; Myocardial Infarction - epidemiology; Myocardial Infarction - surgery; Outcome Assessment (Health Care); Percutaneous Coronary Intervention; Prospective Studies; Risk Factors; Stress, Psychological - epidemiology; Vascular Diseases - congenital; Vascular Diseases - epidemiology; Vascular Diseases - etiology; Young Adult; coronary artery dissection, spontaneous; fibromuscular dysplasia; coronary angiography; myocardial infarction; women
• ISSN: 1941-7640; 1941-7632; 1941-7632
• DOI: 10.1161/CIRCINTERVENTIONS.114.001760

BACKGROUND—Nonatherosclerotic spontaneous coronary artery dissection (NA-SCAD) is underdiagnosed and an important cause of myocardial infarction in young women. The frequency of predisposing and precipitating conditions and cardiovascular outcomes remains poorly described. METHODS AND RESULTS—Patients with NA-SCAD prospectively evaluated (retrospectively or prospectively identified) at Vancouver General Hospital were included. Angiographic SCAD diagnosis was confirmed by 2 experienced interventional cardiologists and categorized as type 1 (multiple lumen), 2 (diffuse stenosis), or 3 (mimic atherosclerosis). Fibromuscular dysplasia screening of renal, iliac, and cerebrovascular arteries were performed with angiography or computed tomographic angiography/MR angiography. Baseline, predisposing and precipitating conditions, angiographic, revascularization, in-hospital, and long-term events were recorded. We prospectively evaluated 168 patients with NA-SCAD. Average age was 52.1±9.2 years, 92.3% were women (62.3% postmenopausal). All presented with myocardial infarction. ECG showed ST-segment elevation in 26.1%, and 3.6% had ventricular tachycardia/ventricular fibrillation arrest. Fibromuscular dysplasia was diagnosed in 72.0%. Precipitating emotional or physical stress was reported in 56.5%. Majority had type 2 angiographic SCAD (67.0%), only 29.1% had type 1, and 3.9% had type 3. The majority (134/168) were initially treated conservatively. Overall, 6 of 168 patients had coronary artery bypass surgery and 33 of 168 had percutaneous coronary intervention in-hospital. Of those treated conservatively (n=134), 3 required revascularization for SCAD extension, and all 79 who had repeat angiogram ≥26 days later had spontaneous healing. Two-year major adverse cardiac events were 16.9% (retrospectively identified group) and 10.4% (prospectively identified group). Recurrent SCAD occurred in 13.1%. CONCLUSIONS—Majority of patients with NA-SCAD had fibromuscular dysplasia and type 2 angiographic SCAD. Conservative therapy was associated with spontaneous healing. NA-SCAD survivors are at risk for recurrent cardiovascular events, including recurrent SCAD.