Original Investigation
Spontaneous Coronary Artery Dissection: Clinical Outcomes and Risk of Recurrence

https://doi.org/10.1016/j.jacc.2017.06.053Get rights and content
Under an Elsevier user license
open archive

Abstract

Background

Spontaneous coronary artery dissection (SCAD) is underdiagnosed and an important cause of myocardial infarction (MI), especially in young women. Long-term cardiovascular outcomes, including recurrent SCAD, are inadequately reported.

Objectives

This study sought to describe the acute and long-term cardiovascular outcomes and assess the predictors of recurrent SCAD.

Methods

Nonatherosclerotic SCAD patients were prospectively followed at Vancouver General Hospital systematically to ascertain baseline, predisposing and precipitating stressors, angiographic features, revascularization, use of medication, and in-hospital and long-term cardiovascular events. Clinical predictors for recurrent de novo SCAD were tested using univariate and multivariate Cox regression models.

Results

The authors prospectively followed 327 SCAD patients. Average age was 52.5 ± 9.6 years, and 90.5% were women (56.9% postmenopausal). All presented with MI; 25.7% had ST-segment elevation MI, 74.3% had non–ST-segment elevation MI, and 8.9% had ventricular tachycardia/ventricular fibrillation. Precipitating emotional stressors were reported in 48.3% and physical stressors in 28.1%. Fibromuscular dysplasia was present in 62.7%, connective tissue disorder in 4.9%, and systemic inflammatory disease in 11.9%. The majority (83.1%) were initially treated medically, with only 16.5% or 2.2% undergoing in-hospital percutaneous coronary intervention or coronary artery bypass graft surgery, respectively. The majority of SCAD patients were taking aspirin and beta-blocker therapy at discharge and at follow-up. Median hospital stay was 3.0 days, and the overall major adverse event rate was 7.3%. Median long-term follow-up was 3.1 years, and overall major adverse cardiac event rate was 19.9% (death rate: 1.2%; recurrent MI: 16.8%; stroke/transient ischemic attack: 1.2%; revascularization: 5.8%). Recurrent SCAD occurred in 10.4% of patients. In multivariate modeling, only hypertension increased (hazard ratio: 2.46; p = 0.011) and beta-blocker use diminished (hazard ratio: 0.36; p = 0.004) recurrent SCAD.

Conclusions

In our large prospectively followed SCAD cohort, long-term cardiovascular events were common. Hypertension increased the risk of recurrent SCAD, whereas beta-blocker therapy appeared to be protective.

Key Words

beta-blocker
coronary angiography
fibromuscular dysplasia
hypertension
myocardial infarction
women

Abbreviations and Acronyms

ACS
acute coronary syndrome
CABG
coronary artery bypass graft
FMD
fibromuscular dysplasia
MACE
major adverse cardiac events
PCI
percutaneous coronary intervention
SCAD
spontaneous coronary artery dissection
VGH
Vancouver General Hospital

Cited by (0)

This research was funded by the Canadian Institutes of Health Research and University of British Columbia Division of Cardiology. Dr. Saw has received unrestricted research grant support from the Canadian Institutes of Health Research, Heart & Stroke Foundation of Canada, University of British Columbia Division of Cardiology, AstraZeneca, Abbott Vascular, St. Jude Medical, Boston Scientific, and Servier; has received speaker honoraria from AstraZeneca, St. Jude Medical, Boston Scientific, and Sunovion; is a consultant for and compensated advisory board member of AstraZeneca, St. Jude Medical, and Abbott Vascular; and is a compensated proctor for St. Jude Medical and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Listen to this manuscript's audio summary by JACC Editor-in-Chief Dr. Valentin Fuster.