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<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<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<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.

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.

Optimisation of imaging protocols in interventional cardiology: impact on patient doses

The purpose of this work is to evaluate the impact of the imaging protocol as part of the optimisation of patient doses in interventional cardiology. This paper reports the results of an initial study to refine the existing fluoroscopy and cine settings, evaluates a new imaging protocol by measuring the image quality and phantom entrance air kerma values, and tests the clinical implementation of the new protocol in terms of the reduction in patient doses and the impact on clinical images. The initial study developed a new fluoroscopy mode using 7.5 frames s^-1 (instead of the previous 15 frames s^-1) with a similar dose/frame and a reduction of approximately 26% in dose/frame for the existing standard cine mode. For the new imaging protocol, the reduction in entrance air kerma was characterised for water depths of 16, 20, and 24 cm and the image quality was evaluated using a Leeds test object. A reduction in dose of around 50% was observed for the low fluoroscopy mode and an 18%-38% reduction was measured for cine. The image quality was unchanged in fluoroscopy mode and did not suffer noticeable alterations in cine mode. In the clinical implementation, cardiologists evaluated the new imaging protocol in clinical practice and cooperated with medical physicists to ensure full optimisation. The image quality criteria evaluated the ability to visualise the standard coronary arteries and small vessels (<2 mm), and the proper visualisation of the heart and diaphragm. A total of 1635 interventional cardiac procedures were assessed. The median kerma-area product exhibited a reduction of 37% for CA and 43% for PTCA examinations, and the quality of the clinical images was considered sufficient for standard clinical practice.

Occupational dose reduction in cardiac catheterisation laboratory: a randomised trial using a shield drape placed on the patient

The aim of this study was to evaluate the occupational radiation dose in interventional cardiology by using a shielding drape on the patient. A random study with and without the protective material was conducted. The following control parameters were registered: demographic data, number of stents, contrast media volume, fluoroscopy time, number of cine images, kerma-area product and cumulative air kerma. Occupational dose data were obtained by electronic active dosemeters. No statistically significant differences in the analysed control parameters were registered. The median dose value received by the interventional cardiologist was 50% lower in the group with a shielding drape with a statistically significant p-value <0.001. In addition, the median value of the maximum scatter radiation dose was 31% lower in this group with a statistically significant p-value <0.001. This study showed that a shielding drape is a useful tool for reducing the occupational radiation dose in a cardiac catheterisation laboratory.

Reduction of occupational radiation dose in staff at the cardiac catheterisation laboratory by protective material placed on the patient

Reducing occupational radiation dose in cardiac catheterisation laboratories is one of the objectives of the radiation protection system because the procedures performed involve high levels of radiation compared with others in health care. Recommendations on protection methods used are referred to different structural types and personal protection tools. In this work, the effectiveness of a shielding drape above the patient in different geometric shapes for a standard procedure in interventional cardiology was evaluated. Values of personal dose equivalent Hp(10) obtained simultaneously with three active electronic semiconductor dosemeters located at the usual position of staff and at the C-arm have been used to show the usefulness of the shielding drape.

The TITAN-AMI multicenter registry evaluating the usage of Titan2 stent in patients with ST segment elevation myocardial infarction. Final result at 12-month follow-up

AIM

Primary percutaneous coronary intervention with stent implantation is the recommended treatment for patients with ST elevation myocardial infarction (STEMI). Data from randomised trials showed good performance by a titanium-nitric-oxide coated stent in this context. The aim of this study was to confirm these data.

METHODS

A multicentre registry was compiled in 23 hospitals in Spain in an all-comers population. We selected patients with STEMI from a global Titan AMI registry that included patients with acute coronary syndrome. Primary endpoint was the composite of cardiac death, non-fatal myocardial infarction, stent thrombosis and target lesion revascularisation, at 12-month follow-up.

RESULTS

The study included 893 patients with STEMI. We included all possibilities for PCI: 86.6% primary, 5% facilitated after successful fibrinolysis and 8.4% rescue PCI after failed fibrinolysis. The primary endpoint was reached in 8.4% of the patients: cardiac death 2.7%, reinfarction 3.4%, target lesion revascularisation 3.5% and definite or probable stent thrombosis 2.8%. The majority of stent thromboses presented in the first 30 days after PCI.

CONCLUSION

A bioactive stent (titanium-nitric-oxide coated stent) is a possible alternative for the treatment of patients with STEMI. One-year follow-up showed better results than those presented by a regular bare-metal stent or first-generation drug-eluting stent in terms of stent thrombosis.