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
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.
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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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