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Treatment assignment in young women with spontaneous coronary artery dissection
International Journal of Cardiology 176 (2014) 1223–1224
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Treatment assignment in young women with spontaneous coronary artery dissection Amber M. Otten a, Jan Paul Ottervanger a,⁎, Anita Kloosterman a, Arnoud W.J. van't Hof a, A.T. Marcel Gosselink a, Jan-Henk E. Dambrink a, Jan C.A. Hoorntje a, Harry Suryapranata b, Angela H.E.M. Maas b a b
Department of Cardiology, Isala Hospital, Zwolle, The Netherlands Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
a r t i c l e
i n f o
Article history: Received 1 July 2014 Accepted 27 July 2014 Available online 5 August 2014 Keywords: Treatment Coronary artery dissection STEMI Women
Spontaneous coronary artery dissection (SCAD) is a rare and poorly understood cause of myocardial infarction and sudden cardiac death [1–5]. In ST elevation myocardial infarction (STEMI), SCAD is more common in young women than men [2]. There are currently no guidelines for acute and chronic management of these patients. According to previous reports, about half of SCAD patients with STEMI are treated with percutaneous coronary intervention (PCI), but it is debatable whether this treatment is beneficial [2,4,5]. Moreover, it is unclear yet which secondary prevention strategy after SCAD is effective. In order to investigate the initial treatment assignment and angiographic success in a larger cohort, we evaluated all women b 50 years with STEMI admitted in our hospital between January 1998 and December 2010. During the study period, 263 women b50 years with STEMI were admitted. All angiographies were retrospectively reviewed by two experienced interventional cardiologists, without knowledge of the general characteristics. The presence of SCAD was suspected if there was an angiographic characteristic finding suggesting the presence of coronary artery dissection [3,6,7]. A definite diagnosis of SCAD was given if there was an agreement between both reviewers. SCAD was observed in 26 patients (10%). Differences in the general characteristics between women with and without SCAD are presented
⁎ Corresponding author at: Isala Hospital, Department of Cardiology, Dr. Van Heesweg 2, 8025 AB Zwolle, The Netherlands. Tel.: +31 384242374; fax: +31 384243222. E-mail address: [email protected] (J.P. Ottervanger).
http://dx.doi.org/10.1016/j.ijcard.2014.07.218 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
in Table 1. Though not statistically different, hypercholesterolemia was less present in women with SCAD (20% vs. 8%, p = 0.12). Other general variables, including duration of ischemic time were not different between women with and without SCAD. In both groups the prevalence of smoking was high (80% and 73%). TIMI 3 flow was comparable between women with and without SCAD at the start of the angiography (30% vs. 48%, p = 0.62). However, in women treated conservatively or with PCI, at the end of angiography, TIMI 3 flow was less prevalent in women with SCAD than in women without SCAD (73% vs. 95%, p b 0.001). Especially in women treated with PCI (n = 236), TIMI 3 flow was less often reached in patients with SCAD than in women without SCAD (61% vs 96%, p b 0.001). A worse prognosis should be expected in patients with SCAD since an impaired coronary flow is established as an important endpoint in STEMI patients, associated with a higher mortality [8]. There were important differences in treatment assignment between patients with and without SCAD (Fig. 1). Patients with SCAD were significantly more often treated conservatively compared to non-SCAD patients. Conservatively treated women with SCAD more often had TIMI 3 flow at the start of the procedure compared to women with SCAD treated with PCI (88% vs 29%, p = 0.007). Furthermore, conservatively Table 1 Patient characteristics of 263 women b50 years with ST elevation myocardial infarction.
Age (years) mean ± SD BMI (kg/cm2) mean ± SD Previous MI Previous CABG Previous PCI Previous stroke History of diabetes History of hypertension Positive family history Current smoking Hypercholesterolemia Killip class = 1 on admission Total ischemic time (min) mean ± SD SD: Standard deviation. BMI: Body mass index. MI: Myocardial infarction.
237 women without SCAD
26 women with SCAD
p-Value
44 ± 5 26 ± 4 8 (3%) 0 (0%) 9 (4%) 1 (0%) 14 (6%) 50 (22%) 142 (62%) 187 (80%) 44 (20%) 221 (95%) 260 ± 168
45 ± 4 26 ± 5 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 8 (31%) 13 (52%) 19 (73%) 2 (8%) 25 (96%) 287 ± 239
0.15 0.96 0.34 – 0.31 0.74 0.20 0.29 0.36 0.42 0.14 0.77 0.66
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A.M. Otten et al. / International Journal of Cardiology 176 (2014) 1223–1224
conservatively. PCI in women with SCAD was more often unsuccessful. More research should be encouraged to clarify mechanisms and optimal treatment. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. Acknowledgment We thank Vera Derks for the excellent editorial assistance. References
Fig. 1. Treatment assignment in women b50 years referred for ST elevation myocardial infarction.
treated SCAD patients had a smaller enzymatic infarction compared to SCAD patients treated invasively or with PCI. It is therefore likely that these conservatively treated patients were at lower risk for adverse events or impaired coronary flow at the end of the procedure. Unfortunately, OCT or IVUS was not routinely performed in our patients to provide additional information on the length and type of dissection [9]. Concluding, SCAD can be observed in 10% of women b 50 years presenting with STEMI. Women with SCAD were treated more often
[1] Thompson EA, Ferraris S, Gress T, Ferraris V. Gender differences and predictors of mortality in spontaneous coronary artery dissection: a review of reported cases. J Invasive Cardiol 2005;17:59–61. [2] Vanzetto G, Berger-Coz E, Barone-Rochette G, et al. Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection; results from a database of 11,605 patients. Eur J Cardiothorac Surg 2009;35:250–4. [3] Vrints CJM. Spontaneous coronary artery dissection. Heart 2010;96:801–8. [4] Mortensen KH, Thuesen L, Kristensen IB, Christiansen EH. Spontaneous coronary artery dissection: a Western Denmark Heart Registry study. Catheter Cardiovasc Interv 2009;74:710–7. [5] Tweet MS, Hayes SN, Pitta SR, et al. Clinical features, management and prognosis of spontaneous coronary artery dissection. Circulation 2012;126:579–88. [6] Basso C, Morgagni GL, Thiene G. Spontaneous coronary artery dissection: a neglected cause of acute myocardial ischaemia and sudden death. Heart 1996;75:451–4. [7] Eddinger J, Dietz W. Recurrent spontaneous coronary artery dissection. Catheter Cardiovasc Interv 2005;66:566–9. [8] Anderson JL, Karagounis LA, Califf RM. Meta-analysis of five reported studies on the relation of early coronary patency with mortality and outcomes after acute myocardial infarction. Am J Cardiol 1996;78:1–8. [9] Porto I, Banning AP. Intravascular ultrasound imaging in the diagnosis and treatment of spontaneous coronary dissection with drug-eluting stents. J Invasive Cardiol 2004; 16:78–80.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Treatment assignment in young women with spontaneous coronary artery dissection Amber M. Otten a, Jan Paul Ottervanger a,⁎, Anita Kloosterman a, Arnoud W.J. van't Hof a, A.T. Marcel Gosselink a, Jan-Henk E. Dambrink a, Jan C.A. Hoorntje a, Harry Suryapranata b, Angela H.E.M. Maas b a b
Department of Cardiology, Isala Hospital, Zwolle, The Netherlands Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
a r t i c l e
i n f o
Article history: Received 1 July 2014 Accepted 27 July 2014 Available online 5 August 2014 Keywords: Treatment Coronary artery dissection STEMI Women
Spontaneous coronary artery dissection (SCAD) is a rare and poorly understood cause of myocardial infarction and sudden cardiac death [1–5]. In ST elevation myocardial infarction (STEMI), SCAD is more common in young women than men [2]. There are currently no guidelines for acute and chronic management of these patients. According to previous reports, about half of SCAD patients with STEMI are treated with percutaneous coronary intervention (PCI), but it is debatable whether this treatment is beneficial [2,4,5]. Moreover, it is unclear yet which secondary prevention strategy after SCAD is effective. In order to investigate the initial treatment assignment and angiographic success in a larger cohort, we evaluated all women b 50 years with STEMI admitted in our hospital between January 1998 and December 2010. During the study period, 263 women b50 years with STEMI were admitted. All angiographies were retrospectively reviewed by two experienced interventional cardiologists, without knowledge of the general characteristics. The presence of SCAD was suspected if there was an angiographic characteristic finding suggesting the presence of coronary artery dissection [3,6,7]. A definite diagnosis of SCAD was given if there was an agreement between both reviewers. SCAD was observed in 26 patients (10%). Differences in the general characteristics between women with and without SCAD are presented
⁎ Corresponding author at: Isala Hospital, Department of Cardiology, Dr. Van Heesweg 2, 8025 AB Zwolle, The Netherlands. Tel.: +31 384242374; fax: +31 384243222. E-mail address: [email protected] (J.P. Ottervanger).
http://dx.doi.org/10.1016/j.ijcard.2014.07.218 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
in Table 1. Though not statistically different, hypercholesterolemia was less present in women with SCAD (20% vs. 8%, p = 0.12). Other general variables, including duration of ischemic time were not different between women with and without SCAD. In both groups the prevalence of smoking was high (80% and 73%). TIMI 3 flow was comparable between women with and without SCAD at the start of the angiography (30% vs. 48%, p = 0.62). However, in women treated conservatively or with PCI, at the end of angiography, TIMI 3 flow was less prevalent in women with SCAD than in women without SCAD (73% vs. 95%, p b 0.001). Especially in women treated with PCI (n = 236), TIMI 3 flow was less often reached in patients with SCAD than in women without SCAD (61% vs 96%, p b 0.001). A worse prognosis should be expected in patients with SCAD since an impaired coronary flow is established as an important endpoint in STEMI patients, associated with a higher mortality [8]. There were important differences in treatment assignment between patients with and without SCAD (Fig. 1). Patients with SCAD were significantly more often treated conservatively compared to non-SCAD patients. Conservatively treated women with SCAD more often had TIMI 3 flow at the start of the procedure compared to women with SCAD treated with PCI (88% vs 29%, p = 0.007). Furthermore, conservatively Table 1 Patient characteristics of 263 women b50 years with ST elevation myocardial infarction.
Age (years) mean ± SD BMI (kg/cm2) mean ± SD Previous MI Previous CABG Previous PCI Previous stroke History of diabetes History of hypertension Positive family history Current smoking Hypercholesterolemia Killip class = 1 on admission Total ischemic time (min) mean ± SD SD: Standard deviation. BMI: Body mass index. MI: Myocardial infarction.
237 women without SCAD
26 women with SCAD
p-Value
44 ± 5 26 ± 4 8 (3%) 0 (0%) 9 (4%) 1 (0%) 14 (6%) 50 (22%) 142 (62%) 187 (80%) 44 (20%) 221 (95%) 260 ± 168
45 ± 4 26 ± 5 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 8 (31%) 13 (52%) 19 (73%) 2 (8%) 25 (96%) 287 ± 239
0.15 0.96 0.34 – 0.31 0.74 0.20 0.29 0.36 0.42 0.14 0.77 0.66
1224
A.M. Otten et al. / International Journal of Cardiology 176 (2014) 1223–1224
conservatively. PCI in women with SCAD was more often unsuccessful. More research should be encouraged to clarify mechanisms and optimal treatment. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. Acknowledgment We thank Vera Derks for the excellent editorial assistance. References
Fig. 1. Treatment assignment in women b50 years referred for ST elevation myocardial infarction.
treated SCAD patients had a smaller enzymatic infarction compared to SCAD patients treated invasively or with PCI. It is therefore likely that these conservatively treated patients were at lower risk for adverse events or impaired coronary flow at the end of the procedure. Unfortunately, OCT or IVUS was not routinely performed in our patients to provide additional information on the length and type of dissection [9]. Concluding, SCAD can be observed in 10% of women b 50 years presenting with STEMI. Women with SCAD were treated more often
[1] Thompson EA, Ferraris S, Gress T, Ferraris V. Gender differences and predictors of mortality in spontaneous coronary artery dissection: a review of reported cases. J Invasive Cardiol 2005;17:59–61. [2] Vanzetto G, Berger-Coz E, Barone-Rochette G, et al. Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection; results from a database of 11,605 patients. Eur J Cardiothorac Surg 2009;35:250–4. [3] Vrints CJM. Spontaneous coronary artery dissection. Heart 2010;96:801–8. [4] Mortensen KH, Thuesen L, Kristensen IB, Christiansen EH. Spontaneous coronary artery dissection: a Western Denmark Heart Registry study. Catheter Cardiovasc Interv 2009;74:710–7. [5] Tweet MS, Hayes SN, Pitta SR, et al. Clinical features, management and prognosis of spontaneous coronary artery dissection. Circulation 2012;126:579–88. [6] Basso C, Morgagni GL, Thiene G. Spontaneous coronary artery dissection: a neglected cause of acute myocardial ischaemia and sudden death. Heart 1996;75:451–4. [7] Eddinger J, Dietz W. Recurrent spontaneous coronary artery dissection. Catheter Cardiovasc Interv 2005;66:566–9. [8] Anderson JL, Karagounis LA, Califf RM. Meta-analysis of five reported studies on the relation of early coronary patency with mortality and outcomes after acute myocardial infarction. Am J Cardiol 1996;78:1–8. [9] Porto I, Banning AP. Intravascular ultrasound imaging in the diagnosis and treatment of spontaneous coronary dissection with drug-eluting stents. J Invasive Cardiol 2004; 16:78–80.