Elsevier

International Journal of Cardiology

Volume 207, 15 March 2016, Pages 341-348
International Journal of Cardiology

Prognostic impact of spontaneous coronary artery dissection in young female patients with acute myocardial infarction: A report from the Angina Pectoris–Myocardial Infarction Multicenter Investigators in Japan

https://doi.org/10.1016/j.ijcard.2016.01.188Get rights and content

Abstract

Background

We sought to compare the prognosis of patients with spontaneous coronary artery dissection (SCAD) and atherosclerosis as the cause of acute myocardial infarction (AMI), especially in young females.

Methods and results

A total of 20,195 patients with AMI at 20 institutions between 2000 and 2013 were retrospectively studied. Major adverse cardiac event (MACE: cardiac death, AMI or urgent revascularization) was the endpoint. The overall prevalence of SCAD was 0.31% (n = 63; female, 94%). SCAD developed following emotional stress in 29% of patients. Revascularization was performed in 56% (35 of 63 patients), and SCAD recurrence developed in the originally involved vessel in 6 of 35 patients with revascularization, compared to none among 28 patients after conservative therapy (p = 0.002). We compared the clinical characteristics of young female AMI patients aged ≤ 50 years in the SCAD (n = 45) and no-SCAD groups (atherosclerotic AMI, n = 55). During a median follow-up of 50 months, SCAD recurred in 27% of patients, of which 42% was in the first 30 days. Kaplan–Meier analysis showed a significantly higher incidence of MACE in the SCAD group compared to the no-SCAD group (hazard ratio, 6.91; 95% confidence interval, 2.5 to 24.3; p < 0.001), although the rate of successful percutaneous coronary intervention for SCAD was as high as 92%.

Conclusions

Young female patients with SCAD represent a high-risk subgroup of patients with AMI and require close follow-up.

Introduction

Spontaneous coronary artery dissection (SCAD) remains a rare but challenging clinical entity, with an estimated prevalence ranging from 0.07% to 1.1% [1], [2]. Recent large single center cohort studies of SCAD reported that it could occur in both younger and older females [3], [4]. Moreover, the rate of SCAD recurrence in these cohorts were 17% and 13%, respectively, which was unexpectedly higher than those reported in previous studies [2], [5], [6]. On the other hand, SCAD has been traditionally considered to occur in young females with minimal atherosclerotic risk factors and not as part of a broader clinical spectrum that includes older patients with coronary artery disease (CAD) [7]. However, there were no systematic study focusing on young female and their prognosis remains unclear, as reported in the recent two large cohort studies [3], [4]. Hence, in this study, we focused on the short- and long-term prognosis of young female patients aged less than 50 years with SCAD.

The present study involves a large series of patients who underwent coronary angiography (CAG) due to acute myocardial infarction (AMI) that were enrolled by investigators at multiple centers by the Angina Pectoris–Myocardial Infarction (AP–MI) Study Group [8] that uses conservative and interventional strategies for SCAD in actual clinical practice. We sought to 1) evaluate the prevalence and the short- and long-term outcomes of SCAD, 2) determine the recurrence rate of SCAD, and 3) compare the prognosis of young female patients with non-atherosclerotic AMI due to SCAD and those with atherosclerotic AMI.

Section snippets

Study population of the multicenter cohort and the definition of SCAD

From January 2000 to December 2013, a total of 20,195 patients with AMI were admitted to 20 cardiovascular institutions in Japan by AP-MI investigators (Appendix A) [8]. SCAD was defined as medial dissection or intramural hematoma without atherosclerotic changes detected by CAG, intravascular ultrasonography (IVUS), or optical coherence tomography (OCT) before any catheter-based intervention [9], [10], [11]. We defined SCAD according to the report from Saw et al. [4]. Briefly, their

Prevalence, clinical characteristics, and precipitating factors for SCAD

In the study population occurred AMI, the overall prevalence of SCAD was 0.31% (63 per 20,195 subjects) (Fig. 1, Study 1). Table 1 shows the clinical characteristics of patients with SCAD. Among 63 patients with SCAD, the mean age was 46 ± 10 years and 59 (94%) were female. STEMI was the presenting diagnosis in 87% and non-STEMI in 13%. Cardiogenic shock or cardiac arrest was observed in 10 (16%) patients. Potential precipitating factors, including hormonal, vascular, or shear stress-related

Discussion

The major findings of this study are: 1) while the prevalence of SCAD was 0.31% in the AMI patients overall (n = 20,195), it was 35% in the subset of 130 young female AMI patients; 2) emotional stress was the most frequent precipitating factor; 3) 17% of the revascularization group developed recurrent SCAD in the originally involved PCI-treated vessel compared to none of the patients in the conservative therapy group; and 4) SCAD in young female AMI patients was associated a 7-fold higher rate of

Conclusions

This multicenter study demonstrated that young female patients with SCAD represent a high-risk subgroup of patients with AMI and therefore need close follow-up.

Conflicts of interest

There are no relationships with industry.

Acknowledgements

The present work was supported in part by grants from the Ministry of Health, Labor and Welfare, Japan (H26-Ippan-001) (SY). We would like to thank the investigators in all the component studies for their contributions.

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