Prognostic implications of left ventricular systolic dysfunction in patients with spontaneous coronary artery dissection

Abstract

Background Spontaneous coronary artery dissection (SCAD) is a relatively infrequent cause of acute coronary syndrome. Clinical features, angiographic findings, management and outcomes of SCAD patients who present reduced left ventricular ejection fraction (LVEF) remain unknown. Methods The Spanish multicentre prospective SCAD registry (NCT03607981), included 389 consecutive patients with SCAD. In 348 of these patients left ventricular ejection fraction (LVEF) could be assessed by echocardiography during the index admission. Characteristics and outcomes of patients with preserved LVEF (LVEF ≥50%, n=295, 85%) were compared with those with reduced LVEF (LVEF<50%, n=53, 15%). Results Mean age was 54 years and 90% of patients in both groups were women. The most frequent clinical presentation in patients with reduced LVEF was ST-segment elevation myocardial infarction (62% vs. 36%, p < 0.001), especially anterior STEMI. Proximal coronary segment and multi-segment involvement were also significantly more frequent in these patients. No differences were found on initial revascularization between groups. Patients with reduced LVEF significantly received more often neurohormonal antagonist therapy, and less frequently aspirin. In-hospital events were more frequent in these patients (13% vs. 5%, p = 0.01), with higher rates of death, cardiogenic shock, ventricular arrhythmia and stroke. During a median follow-up of 28 months, the occurrence of a combined adverse event did not statistically differ between the two groups (19% vs. 12%, p = 0.13). However, patients with reduced LVEF had higher mortality (9% vs. 0.7%, p < 0.001) and readmission rates for heart failure (4% vs. 0.3%, p = 0.01). Conclusions Patients with SCAD and reduced LVEF show differences in clinical characteristics and angiographic findings compared with SCAD patients with preserved LVEF. Although these patients receive specific medications at discharge, they had higher mortality and readmission rates for heart failure during follow-up.

Differences in left ventricular myocardial function and infarct size in female patients with ST elevation myocardial infarction and spontaneous coronary artery dissection

“…Type 1 and 2 SCAD patients may result in smaller myocardial infarction size, which may explain the more favorable resolution of myocardial infarct size and improvement in parameters of LV function in SCAD-STEMI patients in our study. Most experts believe that intramural hematoma is the initial mechanism in most SCAD and that there would be some time interval between intramural hematoma generation (type 2 lesion) and the development of a type 1 lesion ( 16 ). This concept may explain findings that type 1 lesions were more frequently found in “late presenters” in whom SCAD lesions had more time to produce myocardial ischemia and/or necrosis ( 16 ).…”

“…Most experts believe that intramural hematoma is the initial mechanism in most SCAD and that there would be some time interval between intramural hematoma generation (type 2 lesion) and the development of a type 1 lesion ( 16 ). This concept may explain findings that type 1 lesions were more frequently found in “late presenters” in whom SCAD lesions had more time to produce myocardial ischemia and/or necrosis ( 16 ). In addition, myocardial infarction size further depends on the characteristics of coronary vessel involvement, with larger infarctions caused by the proximal, multi-segment and/or multivessel SCAD ( 5 ).…”

“…The study by Franco et al ( 27 ) suggested that approximately 26% of SCAD patients had a slightly reduced LVEF below 50% and approximately 5.1% had an LVEF below 40%. In the Spanish Registry of SCAD patients (SR-SCAD), patients with SCAD and reduced LVEF <50% presented more often with an anterior STEMI and multi-segment involvement coronary artery disease ( 16 ). These findings are in line with our observations.…”

Spontane Koronararteriendissektion

“…Die allgemeine Prognose einer Koronardissektion ist relativ benigne: Die intrahospitale Letalität wird mit 0,2-3,1 % beschrieben, und auch im weiteren Verlauf werden bis zu 3 Jahre nach SCAD keine exzessiv hohen Sterberaten beobachtet [4,12,14]. Allerdings wird bei denjenigen Patienten, die einen Myokardinfarkt mit eingeschränkter linksventrikulärer Funktion entwickeln, eine Letali-tät von bis zu 9% beschrieben [15]. In einer Metaanalyse aus verschiedenen Studien zur SCAD waren außerdem Rauchen mit einem 15-fachen Risiko und männliches Geschlecht mit einem 3,5-fachen Letalitätsrisiko assoziiert [16].…”

The follow-up of myocardial injury and left ventricular function after spontaneous coronary artery dissection

“…The Spanish Registry on SCAD (SR-SCAD) ( 37 ) discovered differences in clinical characteristics and angiographic findings between SCAD patients with reduced LVEF (<50%) and those with preserved LVEF (≥50%). Patients with SCAD and reduced LVEF <50% presented more often with anterior STEMI and multi-segment involvement coronary disease ( 37 ).…”