Spontaneous Coronary Artery Dissection: Cardiovascular Events Incidence and Quality of Life Evaluation in a Single-Center 10 Years' Experience.

Abstract

Background: Despite recent advancements in the recognition and diagnosis of spontaneous coronary artery dissection (SCAD), pathophysiologic mechanisms, predisposing and precipitating factors, risk of recurrences remain poorly understood and evidence-based treatment strategies are still unavailable.

Aims: The goals of the study are to assess the characteristics of SCAD patients highlighting the predisposing and precipitating factors, to analyse the therapeutic management in the acute phase, to evaluate the incidence of SCAD recurrence and cardiovascular events during the follow-up and to assess the factors influencing the quality of life of patients after a SCAD event. We also aim to introduce our experience about the use of intra-aortic balloon pump in acute SCAD setting in order to support the percutaneous coronary intervention (PCI) or its use as part of a conservative management.

Methods: We performed a retrospective, single-center, observational cohort study of patients with non-atherosclerotic, non-iatrogenic SCAD presenting to our Cath Lab in Santa Maria Annunziata Hospital (Bagno a Ripoli, Florence, Italy) with acute coronary syndrome (ACS). We enrolled 84 patients who presented with acute coronary syndrome and SCAD documented by coronary angiography or intracoronary imaging, from January 2015 to December 2024. We excluded patients with iatrogenic dissection and coronary atherosclerotic disease.

Results: Mean age was 56.2 ± 11.6 years and 79 (94%) patients were women. At baseline, 40% had hypertension, 38.8% dyslipidaemia, 29.4% was current smoker, only 2.4% had diabetes mellitus. The most frequent hospital presentation was NSTEMI (70,6%), followed by STEMI (28,2%) and ventricular tachycardia or ventricular fibrillation (3.5%). Majority of SCAD involved a single coronary artery territory (89.3%), and the most common coronary artery dissected was the left anterior descending artery and its branches (40.5%). Majority of patients (82%) were treated conservatively as initial strategy; 15 patients (18%) underwent myocardial revascularization with PCI or coronary artery bypass grafting (CABG). In nine cases (10.6%) IABP was implanted to perform a protect PCI (4.8%), as bridge to emergency CABG in course of hemodynamic instability (2.4%) or as part of conservative management (3.6%) avoiding coronary instrumentation and PCI with positive long-term outcome. During the follow-up period (median follow-up 2.6 years with interquartile range 1.1-5.4 years) the primary endpoint, defined as major adverse cardiovascular events (MACE) incidence and new onset or recurrence of atrial fibrillation (AF), occurred in 18 patients (21.4%). Hypertension emerged as independent predictor of primary outcome (p 0.001, HR 7.965) and low-dosage aspirin at discharge appeared to be protective reducing risk of primary outcome (p < 0.001, HR 0.0034). The secondary outcome was to evaluate quality of life (QoL) of patients who suffered SCAD using EQ-5D-5L questionnaire and Seattle Angina Questionnaire-7. No significative differences emerged between patients treated by PCI and patients treated conservatively.

Conclusions: In SCAD patients, hypertension increases risk of primary outcome while low-dosage aspirin reduces risk during follow-up period. In terms of quality of life and post-SCAD chest pain, no significative differences emerged between patients treated by PCI and patients treated conservatively.