Management and outcomes of spontaneous coronary artery dissection: a systematic review of the literature

Abstract

BackgroundContemporary management of spontaneous coronary artery dissection (SCAD) is still controversial. This systematic review of the literature aims to explore outcomes in the patients treated with conservative management vs. invasive strategy.MethodsThe PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed when we extensively searched three electronic databases: PubMed, ScienceDirect, and Web of Science, for studies that compared conservative vs. invasive revascularization treatment outcomes for patients with SCAD from 2003 to 2023. The outcomes of interest were all-cause death and major adverse cardiovascular events (MACE), including acute coronary syndrome (ACS), heart failure (HF), need for additional revascularization, target vessel revascularization (TVR), SCAD recurrence, and stroke.ResultsThe systematic review included 13 observational studies evaluating 1,801 patients with SCAD. The overall mean age was 49.12 +/− 3.41, and 88% were females. The overall prevalence of arterial hypertension was 33.2%, hyperlipidemia, 26.9%, smoking, 17.8%, and diabetes, 3.9%. Approximately 48.5% of the patients were diagnosed with non-ST elevated myocardial infarction (NSTEMI), 36.8% with ST elevated myocardial infarction (STEMI), 3.41% with unstable angina, 0.56% with stable angina, and 0.11% were diagnosed with various types of arrhythmias. The left anterior descending artery (LAD) was the most common culprit lesion in 51% of the patients. There were initially 65.2% of conservatively treated patients vs. 33.4% that underwent percutaneous coronary intervention (PCI) or 1.28% that underwent coronary artery bypass graft (CABG). SCAD-PCI revascularization was associated with a variable range of PCI failure. The most common complications were hematoma extension and iatrogenic dissection. SCAD-PCI revascularization frequently required three or more stents and had residual areas of dissection. The overall reported in-hospital and follow-up mortality rates were 1.2% and 1.3%, respectively. The follow-up range across studies was 7.3–75.6 months. The authors reported variable prevalence of MACE, recurrent SCAD up to 31%, ACS up to 27.4%, TVR up to 30%, repeat revascularization up to 14.7%, UA up to 13.3%, HF up to 17.4%, and stroke up to 3%.ConclusionOur results highlight that conservative treatment should be the preferred method of treatment in patients with SCAD. PCI revascularization is associated with a high prevalence of periprocedural complications. SCAD poses a considerable risk of MACE, mainly associated with TVR, ACS, and recurrent SCAD.

Spontaneous Coronary Artery Dissection: An Updated Comprehensive Review

“…A retrospective study of 53 SCAD patients showed a lower revascularization success rate but overall better survival in conservative versus PCI strategy than patients with atherosclerotic ST-segment elevation MI (STEMI) [50]. PCI intervention conveys a high rate of periprocedural failure and complications such as secondary iatrogenic dissections or intramural hematoma advancement by the PCI wires in existing feeble coronary structures [48,49,[51][52][53]. Larger sample retrospective studies and meta-analyses conducted have further noted a failure rate of 35-53% with PCI strategy and urgent referral to coronary artery bypass grafting (CABG) in 9-13% of patients.…”

“…The prevalence of MACE measured over 25 years was around 24% with a decreased need for intensive care admissions [73]. However, in a recent larger systematic review, MACE was reportedly increased with SCAD recurrence in 31%, ACS in 27.4%, target vessel revascularization in 30%, and others such as repeat stenting, unstable angina, heart failure, and stroke [53]. An additional benefit observed in the dedicated SCAD-CR program was the resultant decreased complaint of chest pain, higher exercise endurance, and decreased incidence of MACE and recurrent SCAD observed on follow-up [74].…”

Spontaneous coronary artery dissection and fibromuscular dysplasia: insights into recent developments

“…An increasingly important cause of ACS is spontaneous coronary artery dissection (SCAD) which is defined as the spontaneous rupture of a coronary artery wall, not caused by trauma, iatrogenesis, or atherosclerosis, resulting in the formation of a false lumen and intramural hematoma (3)(4)(5).…”

“…A retrospective cohort study published by Feldbaum et al, demonstrated that there has been a significant rise in the usage of a conservative approach before 2013-2019 going from 35% to 89% (30). A recent systematic review demonstrated that the conservative approach has been deemed as the favored treatment modality (3). The reasons opposing invasive strategies are due to the fact that vessels that undergo dissection in SCAD spontaneously heal within 4-6 weeks and that revascularization procedures carry a significant rate of failure along with decreased outcomes (25,28).…”

“…A limitation in the literature surrounding SCAD management is the lack of randomized controlled trials, therefore this is paramount to guide the future of SCAD management (28,31). vasculitides like Takayasu arteritis and granulomatosis with polyangiitis, fibromuscular dysplasia (FMD), significant emotional and mechanical stressors (Figure 1) (3,6,(32)(33)(34)(35). FMD is of particular interest, initially described in association with SCAD in 2011, and is now seen concomitantly in more than 50% of SCAD patients in large cohorts (6,15,(35)(36)(37)(38).…”