Spontaneous coronary artery dissection is an increasing cause of acute myocardial infarction, particularly in younger women. These infarctions are frequently treated conservatively given the risks entailed by revascularization, due to the possibility of causing an antegrade or retrograde expansion of the dissection.
The uncertainty around treatment for these patients gave way to this study (recently published in J Am Coll Cardiol) comparing different strategies in a setting of ST-segment elevation myocardial infarction due to spontaneous coronary artery dissection, and comparing its outcomes with those of infarction caused by atherosclerosis.
The study registered all cases of ST-segment elevation myocardial infarction between 2003 and 2017, conducting a 3-year follow-up.
Among 5208 patients admitted with infarction, in 1% of cases the cause was spontaneous coronary artery dissection. There was an absolute majority (93%) of female patients in this subgroup. Prevalence goes from 1% to almost 20% if we only consider women younger than 50 years old.
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Other than being more frequent in young women, compared with cases of atherosclerosis infarction, infarction due to dissection also came along cardiogenic shock much more frequently (19% vs. 9%; p < 0.03).
The culprit artery was more commonly left main (13% vs. 1% in patients with atherosclerosis; p = 0.003) or left anterior descending (47% vs. 38%; p = 0.003).
Despite including young patients whose culprit artery was the left main, and who had more frequent cardiogenic shock, the revascularization rate among the spontaneous dissection group was significantly lower than among patients with “conventional” infarction (70% vs. 97%; p < 0.0001).
Revascularization most frequently included primary angioplasty, while a low percentage of patients underwent surgery. Procedural success was 91% for primary angioplasty.
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As expected, the patients revascularized were those in worst condition (left main coronary artery involvement, cardiogenic shock, thrombolysis in myocardial infarction [TIMI] flow grade 0 to 1).
Despite all of that, the 3-year survival for these patients was better than for patients with “common” infarction (98% vs. 84%; p < 0.0001).
Conclusion
Patients with ST-segment elevation myocardial infarction due to spontaneous coronary artery dissection account for a significant subset, usually involving young women, with left main or left anterior descending culprit artery leading to higher rates of cardiogenic shock than in cases of infarction due to atherosclerosis. Primary angioplasty has a high rate of success among these patients, and the 3-year survival among them is considerably higher than for patients with “common” infarction.
Original Title: Revascularization in Patients With Spontaneous Coronary Artery Dissection and ST-Segment Elevation Myocardial Infarction.
Reference: Angie S. Lobo et al. J Am Coll Cardiol 2019;74:1290–300.
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