Antiplatelet therapy in patients with conservatively managed spontaneous coronary artery dissection from the multicentre DISCO registry

Abstract

Aims The role of antiplatelet therapy in patients with spontaneous coronary artery dissection (SCAD) undergoing initial conservative management is still a matter of debate, with theoretical arguments in favour and against its use. The aims of this article are to assess the use of antiplatelet drugs in medically treated SCAD patients and to investigate the relationship between single (SAPT) and dual (DAPT) antiplatelet regimens and 1-year patient outcomes. Methods and results We investigated the 1-year outcome of patients with SCAD managed with initial conservative treatment included in the DIssezioni Spontanee COronariche (DISCO) multicentre international registry. Patients were divided into two groups according to SAPT or DAPT prescription. Primary endpoint was 12-month incidence of major adverse cardiovascular events (MACE) defined as the composite of all-cause death, non-fatal myocardial infarction (MI), and any unplanned percutaneous coronary intervention (PCI). Out of 314 patients included in the DISCO registry, we investigated 199 patients in whom SCAD was managed conservatively. Most patients were female (89%), presented with acute coronary syndrome (92%) and mean age was 52.3 ± 9.3 years. Sixty-seven (33.7%) were given SAPT whereas 132 (66.3%) with DAPT. Aspirin plus either clopidogrel or ticagrelor were prescribed in 62.9% and 36.4% of DAPT patients, respectively. Overall, a 14.6% MACE rate was observed at 12 months of follow-up. Patients treated with DAPT had a significantly higher MACE rate than those with SAPT [18.9% vs. 6.0% hazard ratios (HR) 2.62; 95% confidence intervals (CI) 1.22–5.61; P = 0.013], driven by an early excess of non-fatal MI or unplanned PCI. At multiple regression analysis, type 2a SCAD (OR: 3.69; 95% CI 1.41–9.61; P = 0.007) and DAPT regimen (OR: 4.54; 95% CI 1.31–14.28; P = 0.016) resulted independently associated with a higher risk of 12-month MACE. Conclusions In this European registry, most patients with SCAD undergoing initial conservative management received DAPT. Yet, at 1-year follow-up, DAPT, as compared with SAPT, was independently associated with a higher rate of adverse cardiovascular events (ClinicalTrial.gov id: NCT04415762).

Clinical Features and Prognoses of Middle-Aged Women With ST-Elevation Myocardial Infarction With a Focus on Spontaneous Coronary Artery Dissection

“…Our findings are concordant with the results of the investigation by Lobo et al, 19 who studied 53 STEMI-SCAD cases and reported a 70% revascularization rate in the STEMI-SCAD group, which was significantly lower than that in their atherosclerotic patients with STEMI (97%). Cerrato et al 25 recently published a study in which 199 out of 311 patients with SCAD were treated conservatively. In our study, similar to the aforementioned study by Lobo et al, 19 adopting the revascularization strategy for the management of the STEMI-SCAD group was accompanied by a favorable 1-year MACE outcome.…”

“…18 In a recent analysis of patients with SCAD treated either with a single antiplatelet regimen or with a dual antiplatelet regimen, the latter regimen was found to be independently associated with a greater rate of MACE compared with the former regimen. 25 Considering the previously reported technical failures in PCI for patients with SCAD, 9 which may be accompanied by complications such as dissection extension, iatrogenic dissection development, and risk for false lumen stenting, 5,6 there is currently more inclination in the literature toward managing patients with SCAD conservatively and reserving PCI for hemodynamic instability, ongoing ischemia, and high-risk territory involvement. Still, most of the patients in these studies (60%-70%) were non-STEMI patients, 9,26 indicating that their management strategies might not be generalizable to patients with STEMI-SCAD.…”

The Conundrum of Anticoagulation and Antiplatelet Therapy in Spontaneous Coronary Artery Dissection

“…Most of the patients with SCAD recover normal coronary anatomy in approximately 30 days. 14 Cerrato et al 15 found that patients with SCAD receiving DAPT had higher rates of major adverse cardiac outcomes at 1-year follow-up compared to single antiplatelet therapy. Dual antiplatelet therapy for up to 4 weeks followed by aspirin alone for 12 months is a reasonable approach.…”

The Role of Antiplatelet Therapy in Patients With MINOCA

“…Some experts advocate that DAPT may increase the risk of bleeding and propagation of the hematoma/dissection plane, whereas others claim that the intimal tear can be prothrombotic and the adjunctive use of clopidogrel on top of aspirin may be justified ( 45 ). Data from the “DIssezioni Spontanee COronariche” (DISCO) registry suggests that in patients managed conservatively, DAPT may be associated with worse clinical outcomes compared to single antiplatelet therapy (SAPT) ( 46 ). The authors evaluated MACE, defined as all-cause death, non-fatal MI, and any unplanned percutaneous coronary intervention (PCI), at 12 months.…”