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Circ Cardiovasc Interv. 2014 Dec;7(6):777-86. doi: 10.1161/CIRCINTERVENTIONS.114.001659. Epub 2014 Nov 18.

Spontaneous coronary artery dissection: revascularization versus conservative therapy.

Author information

1
From the Divisions of Cardiovascular Diseases (M.S.T., M.F.E., P.J.M.B., A.L., C.S.R., D.R.H., S.N.H., R.G.) and Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic, Rochester, MN.
2
From the Divisions of Cardiovascular Diseases (M.S.T., M.F.E., P.J.M.B., A.L., C.S.R., D.R.H., S.N.H., R.G.) and Biomedical Statistics and Informatics (R.J.L.), Mayo Clinic, Rochester, MN. gulati.rajiv@mayo.edu.

Abstract

BACKGROUND:

Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic acute coronary syndrome for which optimal management remains undefined.

METHODS AND RESULTS:

We performed a retrospective study of 189 patients presenting with a first SCAD episode. We evaluated outcomes according to initial management: (1) revascularization versus conservative therapy and (2) percutaneous coronary intervention (PCI) versus conservative therapy stratified by vessel flow at presentation. Demographics were similar in revascularization versus conservative (mean age, 44±9 years; women 92% both groups), but vessel occlusion was more frequent in revascularization (44/95 versus 18/94). There was 1 in-hospital death (revascularization) and 1 late death (conservative). Procedural failure rate was 53% in those managed with PCI. In the subgroup of patients presenting with preserved vessel flow, rates of PCI failure were similarly high (50%), and 6 (13%) required emergency coronary artery bypass grafting. In the conservative group, 85 of 94 (90%) had an uneventful in-hospital course, but 9 (10%) experienced early SCAD progression requiring revascularization. Kaplan-Meier estimated 5-year rates of target vessel revascularization and recurrent SCAD were no different in revascularization versus conservative therapy (30% versus 19%; P=0.06 and 23% versus 31%; P=0.7).

CONCLUSIONS:

PCI for SCAD is associated with high rates of technical failure even in those presenting with preserved vessel flow and does not protect against target vessel revascularization or recurrent SCAD. A strategy of conservative management with prolonged observation may be preferable.

KEYWORDS:

acute coronary syndrome; coronary artery dissection, spontaneous; percutaneous coronary interventions

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