Extracoronary Vascular Events Likely Rare After Spontaneous Coronary Artery Dissection

By Marilynn Larkin

December 03, 2021

NEW YORK (Reuters Health) - In patients with spontaneous coronary artery dissection (SCAD), severe vascular events were rare in a case series with five-year follow-up.

"SCAD is a cause of acute myocardial infarction, mainly affecting women. It is known to be associated with extra-coronary arteriopathies and, in particular, fibromuscular dysplasia (FMD)," Dr. David Adlam of NIHR Leicester Biomedical Research Centre, Glenfield Hospital in the UK and Dr. Alexandre Persu of Universite Catholique de Louvain in Brussels told Reuters Health by email.

"The findings of a somewhat lower prevalence of arteriopathies in our study was expected," they said, "as we used magnetic resonance angiography (MRA), strict definitions based on the international FMD consensus and blinded analysis with healthy volunteer controls."

"The surprising and important findings were that severe manifestations (multi-vessel, aneurysms and dissections) were much less common than reported in patients with primary FMD, and clinical consequences of SCAD-associated arteriopathies (renovascular hypertension or vascular events) were very rare and much less common than reported in patients with primary FMD," they noted.

"This suggests extra-coronary manifestations of SCAD, although commonly found on screening, don't cause clinical problems for most patients," they said. "Clinicians (should) continue to screen patients for SCAD-associated arteriopathies from brain to pelvis, but patients can be reassured that clinically important findings are uncommon and, from what is currently known, the prognosis of FMD in SCAD is very good."

As reported in JAMA Cardiology, the case series included 173 patients with SCAD (mean age at diagnosis, 44.5; 97%, women). Forty-one individuals without SCAD served as controls for blinded interpretation of MRA findings.

Patients and controls underwent head-to-pelvis MRA (median time between SCAD event and MRA, one year).

FMD prevalence was 31.8% (55 patients), of whom 16 (29.1% of those with FMD) had involvement of multiple vascular beds.

Focal stenosis in at least one arterial bed was reported in 15 (8.7%) SCAD patients. Thirteen (7.5%) had extracoronary aneurysms and three (1.7%) had dissections.

The prevalence and degree of arterial tortuosity were similar in patients and controls, and in 43 patients imaged with both computed tomographic angiography and MRA, identification of clinically significant remote arteriopathies was similar.

Over a median five-year follow-up, two noncardiovascular-associated deaths and 35 recurrent myocardial infarctions occurred; however, there were no primary extracoronary vascular events.

The authors conclude, "The findings of this study suggest that clinical complications from these extracoronary arterial lesions over the short to medium term appear to be very rare."

Dr. Ismail El-Hamamsy, Director of Aortic Surgery for the Mount Sinai Health System in New York City, commented in an email to Reuters Health, "The study is very rigorous (and) I trust the findings."

That said, he noted, "The study population was relatively small, the imaging was at a single time point and the follow-up was relatively short. As these are typically young patients, longer follow-up with serial imaging to rule out the development of aneurysms or dissections is warranted."

"Additionally, 94% of patients were White, which limits applicability of the findings to non-White populations," he noted.

"While the prevalence of severe FMD, aneurysms or dissections in patients with a history of SCAD is not as high as previously thought, it is not insignificant," he added. "This emphasizes the importance of careful examination and good clinical judgment in the presence of SCAD to optimize risk stratification and avoid unnecessary testing or procedures."

SOURCE: https://bit.ly/3rtNiOv JAMA Cardiology, online November 24, 2021.