Prognosis of spontaneous coronary artery dissection treated by percutaneous coronary intervention with optical coherence tomography

Regional and temporal variations of spontaneous coronary artery dissection care according to consensus recommendations: a systematic review and meta-analysis

AIM

The first expert consensus documents on management of patients with spontaneous coronary artery dissection (SCAD) were published in 2018. Worldwide quality of care, as measured by adherence to these recommendations, has not been systematically reviewed. We aim to review the proportion of patients with SCAD receiving consensus recommendations globally, regionally and, determine differences in practice before and after 2018.

METHODS AND RESULTS

A systematic review was performed by searching four main databases (Medline, Embase, SCOPUS, CINAHL) from their inception to 16 June 2022. Studies were selected if they included patients with SCAD and reported at least one of the consensus document recommendations. 53 studies, n=8456 patients (mean 50.1 years, 90.6% female) were included. On random effects meta-analysis, 92.1% (95% CI 89.3 to 94.8) received at least one antiplatelet, 78.0% (CI 73.5 to 82.4) received beta-blockers, 58.7% (CI 52.3 to 65.1) received ACE inhibitors or aldosterone receptor blockers (ACEIs/ARBs), 54.4% (CI 45.4 to 63.5) were screened for fibromuscular dysplasia (FMD), and 70.2% (CI 60.8 to 79.5) were referred to cardiac rehabilitation. Except for cardiac rehabilitation referral and use of ACEIs/ARBs, there was significant heterogeneity in all other quality-of-care parameters, across geographical regions. No significant difference was observed in adherence to recommendations in studies published before and after 2018, except for lower cardiac rehabilitation referrals after 2018 (test of heterogeneity, p=0.012).

CONCLUSION

There are significant variations globally in the management of patients with SCAD, particularly in FMD screening. Raising awareness about consensus recommendations and further prospective evidence about their effect on outcomes may help improve the quality of care for these patients.

Mortality in spontaneous coronary artery dissection: A systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis was to provide a comprehensive estimate for spontaneous coronary artery dissection (SCAD) related mortality, and explore factors associated with an increased risk of death.

BACKGROUND

SCAD is an infrequent but increasingly recognized cause of acute coronary syndrome. Despite a growing body of evidence, there have been few detailed examinations of SCAD associated mortality.

METHODS

We searched MEDLINE, EMBASE, Cochrane, Web of Science and Google Scholar databases through May 7, 2020. We included studies reporting mortality data, confirmed SCAD with coronary angiography and included ≥10 participants. We excluded non-English studies, conference abstracts, review articles and duplicate datasets. Random-effects meta-analysis and meta-regression were used to evaluate estimates and predictors of mortality.

RESULTS

From an initial 1,131 articles, 34 studies with 2,817 patients were eligible for inclusion. The weighted mean age was 50 years, and 84% of participants were female. The pooled estimate for SCAD mortality was 1% (Proportion 0.01; 95% CI, 0.00-0.02). The mean duration of follow-up was 33 months. Meta-regression showed male sex was associated with 3.5-fold increased odds of mortality (OR, 3.50; 95% CI, 1.22-10.03). In addition, smoking (current or previous) was associated with a 15-fold increased risk of mortality (OR 15.32; 95% CI, 2.88-81.41).

CONCLUSIONS

This meta-analysis has shown that SCAD is associated with favorable survival outcomes with an estimated mortality of 1% over a mean follow-up period of 33 months. We also found male sex and smoking were associated with an increased risk of mortality.

Systematic review and meta-analysis of the incidence of recurrence of spontaneous coronary artery dissection

AIM

Recurrence is a well-established complication of spontaneous coronary artery dissection (SCAD). However, the exact incidence and correlates of recurrence are unknown. We, therefore, performed a systematic review and meta-analysis to determine and consolidate the evidence on the global incidence of SCAD recurrence.

METHODS

A comprehensive search of the four major databases (EMBASE, OVID Medline, PubMed and Google Scholar) was performed from their inception to 17 January 2019. We included original research studies, recruiting ≥10 participants, with ≥12 months follow-up that reported data on recurrence in patients with SCAD.

RESULTS

Out of 556 studies searched, 19 cohorts (1538 SCAD patients) were included in the analysis. There were 153 cases of de novo recurrence over a mean follow-up period of 31.2 months (95% confidence interval, 25-41 months). Type 1, 2 and 3 SCAD was noted in 33.2, 73.2 and 5.3%, respectively. The involved coronary artery was left anterior descending artery, left anterior descending artery, right coronary artery, left circumflex artery and multivessel coronary artery disease, respectively, in 3.5, 53.4, 19.8, 20.4 and 12.6% of cases. The overall SCAD de novo recurrence was 7% (ES 0.07, 95% confidence interval, 0.04-0.10, I2 = 65.3%). On meta-regression, we found discharge medications at index admission, including β-blockers, ACE inhibitors, statins, as well as baseline cardiac risk factors, did not correlate with recurrence.

CONCLUSION

SCAD recurrence is common, occurring in 7% of patients over medium-term follow up. No specific medications at discharge were found to reduce recurrence. Further long-term and prospective data are required.

A woman complicated by sudden cardiac arrest owing to spontaneous coronary artery dissection after stillbirth

Spontaneous coronary artery dissection (SCAD) is the most important cause of acute coronary syndrome in pregnant women. Pregnancy-associated SCAD frequently occurs in the third trimester or postpartum period. However, little is known regarding the relationship between the occurrence of SCAD and stillbirth. We describe here a 41-year-old woman complicated by sudden cardiac arrest owing to SCAD in the distal segment of the right coronary artery 13 days after stillbirth. After contacting emergency medical services, she was resuscitated by an automated external defibrillator because the initial electrocardiographic waveform was ventricular fibrillation. After cardiopulmonary resuscitation, the diagnosis of SCAD was confirmed by coronary angiography and intracoronary imaging, including intravascular ultrasound and optical coherence tomography. The patient was managed with conservative medical therapy because the culprit lesion was present in the distal segment of the right coronary artery and coronary blood flow was preserved. No major adverse cardiovascular events, including recurrent ventricular arrhythmia, were observed during hospitalization. Our findings indicate that pregnancy-associated SCAD leading to sudden cardiac arrest may occur in the postpartum period, even after stillbirth. Intravascular imaging plays a pivotal role in diagnosing SCAD. <Learning objective: Pregnancy-associated spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of acute coronary syndrome in pregnant or postpartum women. However, whether the risk of pregnancy-associated SCAD in the postpartum period is different between normal birth and stillbirth remains unknown. Pregnancy-associated SCAD leading to sudden cardiac arrest owing to acute myocardial ischemia may occur in postpartum women, regardless of fetal survival.>.

Spontaneous Coronary Artery Dissection: Mechanisms, Diagnosis and Management

Spontaneous coronary artery dissection (SCAD) is a relatively infrequent cause of acute coronary syndrome that usually affects young to middle-aged women. Mainly because of its low prevalence, until recently, most of the evidence on this condition was derived from case reports and small series. Over the last 5 years, more robust evidence has become available from larger retrospective and prospective cohorts of patients with SCAD. The increase in knowledge and recognition of this entity has led to the publication of expert consensus on both sides of the Atlantic. However, new data are continuously accumulating from larger cohorts of patients with SCAD, bringing new light to this little-understood condition. The aim of this article is to update the knowledge on SCAD, including new information from recent studies published since the consensus documents from the European Society of Cardiology and the American Heart Association.

Progression of left anterior descending artery dissection due to stent implantation for spontaneous coronary artery dissection of left circumflex artery: a case report

Background

Spontaneous coronary artery dissection (SCAD) is a rare disease that predominantly affects woman. Percutaneous coronary intervention (PCI) is recommended only in patients with ongoing ischaemia because it carries a high risk of procedural complications in SCAD patients.

Case summary

A 51-year-old woman was admitted to our institution owing to severe chest pain. Coronary angiography showed a diffuse narrowing and radiolucent luminal flap which runs parallel to the vessel wall in the proximal left circumflex coronary artery and SCAD was diagnosed. After PCI was undertaken, optical coherence tomography disclosed a circular haematoma at the stent distal segment and an intimal tear at the distal left main coronary artery. A conservative approach was decided owing to patient stability without evidence of ongoing ischaemia and normal coronary flow. Thirty minutes later, the patient started to complain of chest pain with the ST-segment elevation in leads I, aVL, and V2–3. Coronary angiography demonstrated a total occlusion of the second diagonal brunch and double lumen morphology at the proximal-potion of left anterior descending with TIMI2 distal flow suggesting the extension of coronary dissection. Optical coherence tomography imaging revealed that the entry door of the dissection was located where the small intimal tear was found. Percutaneous coronary intervention was successfully performed, and the patient was discharged without any complication.

Discussion

Although the underlying mechanism of recurrent SCAD remain largely unknown, our case suggests that the residual inlet of the dissection may associate with the extension of the coronary dissection.

Spontaneous coronary artery dissection: contemporary aspects of diagnosis and patient management

Spontaneous coronary artery dissection is an increasingly recognised cause of acute coronary syndromes, especially in young and middle-age women. Recognising its particularities and differences with atherosclerotic disease is central for appropriately identifying and approaching these patients. The authors review the current state of knowledge on spontaneous coronary artery dissection and provide practical recommendations for the diagnosis and management of this condition, both in the acute and convalescence phases.

Optical Coherence Tomography of Spontaneous Basilar Artery Dissection in a Patient With Acute Ischemic Stroke

The diagnosis of intracranial arterial dissection (IAD) may be challenging and multimodal imaging techniques are often needed to confirm the diagnosis. Previous studies have based their criteria for diagnosis of IAD on conventional angiography, computed tomography, or magnetic resonance imaging. We report a case with acute ischemic stroke due to spontaneous basilar artery dissection in which intravascular optical coherence tomography (OCT) was used to show features of IAD. A 59-years-old woman presented with symptoms of acute ischemic stroke. Thrombosis related to basilar artery (BA) stenosis was assumed on conventional angiography; however, no clot was retrieved after mechanical thrombectomy (MT) and a restored BA caliber was observed after a rescue recanalization with the detachment of a self-expanding stent was performed. Spontaneous IAD was suspected; however, angiographic findings were ambiguous for confirming IAD. The patient remained symptom-free until 18-months follow-up. At this point, angiography showed restenosis at the proximal tapered length of the stent. In vivo OCT was performed to assess the pathological changes of the restenosis and confirm the diagnosis of IAD.OCT revealed BA dissection with the presence of remnant transverse flap, double lumen and mural hematoma. Imaging at multiple levels identified intimal disruption that originated in the right vertebral artery and extended distally to the BA. The use of intravascular imaging with OCT enabled the accurate diagnosis of IAD. Care should be taken as the procedure may add additional risks to the patient. Future studies are needed to validate the safety of OCT in IAD.

Complete healing of spontaneous coronary artery dissection extending from the left main trunk to the left anterior descending and the left circumflex artery

Spontaneous coronary artery dissection (SCAD) is defined as a spontaneous separation of the coronary artery wall that is not iatrogenic or related to trauma and usually affects young women. We describe a 65-year-old woman who presented with SCAD extending from the left main trunk involving the left anterior descending artery and the left circumflex artery, and coronary artery bypass graft surgery was performed to treat the dissection. Coronary angiography performed 3 months later, showed complete angiographic healing. A conservative management strategy is known to be associated with spontaneous angiographic healing in patients with SCAD who are hemodynamically stable. Healthcare providers should consider SCAD among the differential diagnoses in patients presenting with acute coronary syndrome, particularly in women. Further studies are needed to establish an optimal management strategy for SCAD. <Learning objective: Spontaneous coronary artery dissection (SCAD) might be a cause of acute coronary syndrome not only in younger but also in older women. Even if the area of the dissection is broad, healing can be expected in future. Therefore, it is important to select between conservative and invasive therapy such as percutaneous coronary intervention or coronary artery bypass graft including selection of graft, i.e. saphenous vein graft and radial arteries, and internal mammalian arteries.>.

Conservative management of severe coronary artery hematoma and dissection following stent implantation

Severe dissection and hematoma following stent implantation can cause acute vessel closure, which requires an immediate bailout procedure. However, bailout from such a situation may not be easy, especially when the hematoma extends to the distal segment of a coronary artery. We present a case of 73-year-old woman with effort angina who underwent PCI to the right coronary artery (RCA). Following stent implantation, there was a massive hematoma from the distal edge of the stent. We tried to create re-entry at the distal part of the hematoma, but were not successful. We managed her conservatively without additional stent placement or creating re-entry. Follow-up coronary angiography on day 68 showed excellent coronary flow. Intravascular ultrasound demonstrated complete healing of the hematoma. A hematoma caused by edge dissection is a challenging complication. Additional stent implantation to cover the entire length of the hematoma and/or cutting balloon dilatation to create re-entry are options; however, these procedures may worsen the situation. Our case clearly showed healing of dissection and hematoma without creating re-entry or additional stent implantation. Conservative management should be considered an option for severe edge dissection and hematoma following stent implantation.