Interventional Versus Conservative Strategy in Patients With Spontaneous Coronary Artery Dissections: Insights From DISCO Registry
Stefano Benenati, Federico Giacobbe, Antonio Zingarelli, Fernando Macaya, Carloalberto Biolè, Angélica Rossi, Marco Pavani, Giorgio Quadri, Umberto Barbero, Andrea Erriquez, Tiziana Claudia Aranzulla, Chiara Cavallino, Dario Buccheri, Cristina Rolfo, Giuseppe Patti, Nieves Gonzalo, Alessandra Chinaglia, Giuseppe Musumeci, Javier Escaned, Ferdinando Varbella, Enrico Cerrato, Italo Porto, Matteo Bianco, Gianmarco Annibali, Francesco Bruno, Fabrizio D’Ascenzo, Annamaria Nicolino, Chiara Bernelli, Pablo Salinas, Luca Bettari, Elisabetta Bordoni, Vincenzo Infantino, Alfonso Gambino, Andrea Rognoni, Marco Mennuni, Sebastian Cinconze, Alberto Boi, Francesco Tomassini, Alfonso Franzè, Luca Lo Savio, Bruno Loi, Mario Iannaccone, Michele De Benedictis, Gianluca Campo, Fabrizio Ugo, Alessandra Truffa Giachet, Giuseppe Pietro Greco Lucchina, F Cassano, Andrea Gagnor, Federico Beqaraj, Luca Gaido, Matteo Perfetti, Primiano Lombardi
Abstract
Background: The optimal management of patients with spontaneous coronary artery dissection remains debated. Methods: Patients enrolled in the DISCO (Dissezioni Spontanee Coronariche) Registry up to December 2020 were included. The primary end point was major adverse cardiovascular events, a composite of all-cause death, nonfatal myocardial infarction, and repeat percutaneous coronary intervention (PCI). Independent predictors of PCI and medical management were investigated. Results: Among 369 patients, 129 (35%) underwent PCI, whereas 240 (65%) were medically managed. ST-segment–elevation myocardial infarction (68% versus 35%, P <0.001), resuscitated cardiac arrest (9% versus 3%, P <0.001), proximal coronary segment involvement (32% versus 7%, P <0.001), and Thrombolysis in Myocardial Infarction flow 0 to 1 (54% versus 20%, P <0.001) were more frequent in the PCI arm. In-hospital event rates were similar. Between patients treated with PCI and medical therapy, there were no differences in terms of major adverse cardiovascular events at 2 years (13.9% versus 11.7%, P =0.467), all-cause death (0.7% versus 0.4%, P =0.652), myocardial infarction (9.3% versus 8.3%, P =0.921) and repeat PCI (12.4% versus 8.7%, P =0.229). ST-segment–elevation myocardial infarction at presentation (odds ratio [OR], 3.30 [95% CI, 1.56–7.12]; P =0.002), proximal coronary segment involvement (OR, 5.43 [95% CI, 1.98–16.45]; P =0.002), Thrombolysis in Myocardial Infarction flow grade 0 to 1 and 2 (respectively, OR, 3.22 [95% CI, 1.08–9.96]; P =0.038; and OR, 3.98 [95% CI, 1.38–11.80]; P =0.009) and luminal narrowing (OR per 5% increase, 1.13 [95% CI, 1.01–1.28]; P =0.037) were predictors of PCI, whereas the 2B-angiographic subtype predicted medical management (OR, 0.25 [95% CI, 0.07–0.83]; P =0.026). Conclusions: Clinical presentation and procedural variables drive the choice of the initial therapeutic approach in spontaneous coronary artery dissection. If PCI is needed, it seems to be associated with a similar risk of short-to-mid-term adverse events compared to medical treatment. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04415762.