INVASIVE VERSUS CONSERVATIVE STRATEGY FOR THE MANAGEMENT OF
SPONTANEOUS CORONARY
ARTERY DISSECTION: WHICH IS BETTER ?
Kenan YALTA, MD
Mustafa YILMAZTEPE, MD
Flora OZKALAYCI, MD
Nasir SIVRI, MD
Bilal GEYIK, MD
Trakya ?niversity, Cardiology Department, Edirne, Turkey
Corresponding Author: Kenan Yalta , e-mail: kyalta@gmail.com
To the Editor,
In the recent years, spontaneous coronary artery dissection
(SCAD) has been a point of debate with regard to its management
strategies. In their recently published article (1), Taleyratne JD et al
described a case of spontaneous coronary artery dissection (SCAD)
in a middle-aged woman presenting with acute coronary syndrome (ACS)
(1). As far as we understand, the case was exclusively managed with a
conservative strategy (with aspirin, ticagrelor, glycoprotein IIb/IIIa
inhibitors and heparin) after coronary angiography (CAG) and
intravascular ultrasound (IVUS). If that was the case, we strongly
oppose the exclusive use of a non-interventional approach in this
patient due to reasons described below.
Regarding the single- vessel SCAD, conservative strategy is only
warranted in asymptomatic cases in which the degree of stenosis due
to SCAD is < 50% along with a distal perfusion of TIMI 3 in the
affected vessel (2). In other terms, where applicable, PCI is strongly
recommended in the setting of a high-risk SCAD associated with a severe
luminal narrowing (70-99%) and/or a poor distal vessel perfusion (TIMI 0-
1) and presenting with an unstable condition (2) (as in the case
reported by Taleyratne JD (1)). Surgical management might also be
performed in a more selected portion of cases including those with left
main coronary artery (LMCA) or multivessel involvement in which there is
no SCAD extension to the distal segments of the affected vessel (2).
There exists a strong rationale behind these therapeutic
recommendations : SCADs treated conservatively might not always
demonstrate a resolution or spontaneous healing, and might even worsen in
some situations in the short and long terms (2,3). On follow-up,
unfavorable results might be encountered in as high as 60% of SCADs
managed with a conservative strategy alone (2,4). Among these long-term
complications , late recurrences (2, 5) and aneurysm formation (3) in the
affected vessel might be quite troublesome, and might be regarded as
major therapeutic challenges in the conservatively treated patients with
a SCAD. More importantly, witholding an early invasive strategy in the
acute phase might be associated with acute life-threatening consequences
including refractory arrhythmic events, retrograde propagation of the
dissection towards the LMCA, etc. Interestingly, propagation of SCAD
is more likely to occur in normal vessels in comparison to
atherosclerotic ones (2) . On the other hand, PCI was previously
suggested as the primary therapeutic option in the setting of SCAD
(6). However, when the final decision is PCI, it should be done by
expert hands: the operator should avoid advancing guide-wire into the
false lumen to prevent SCAD extension (2). Direct stenting without
stent oversizing should be the preferred strategy (2). Unfortunately,
despite meticulous care, additional stents might be required in a portion
of cases due to the propagation of SCAD after initial stenting (2,5).
Nevertheless, PCI when combined with endovascular imaging techniques
(IVUS, etc) seems to be a more promising therapeutic approach in
the setting of SCAD particularly with high-risk features.
In summary; conservative management might pose a significant
risk to patients with SCAD (2-4) particularly to those with high-
risk features both in the short and long terms. On the other
hand, invasive strategy including PCI, when performed by
experienced operators and with the assistance of endovascular imaging
techniques, seems to be a radical and efficient alternative in
these patients (2,6). We wonder why Taleyratne JD et al (1) preferred
a 'wait and see' approach rather than performing an IVUS-guided
urgent PCI in their high-risk patient. Furthermore, as SCAD might
be regarded as a continuum of evolving vascular pathology with an
unpredictable course even after healing, their patient (1) needs to
be monitored closely for potential late complications including
recurrence , aneurysm formation, etc. Accordingly, the authors (1) may
want to make clear their future strategies (follow-up, medication,
repeat CAG or non-invasive imaging ?, etc.) regarding their patient
in a more comprehensive manner. However, future studies are still
warranted to establish furher risk prediction models that might
help determine the initial therapeutic strategy, and more
importantly, might allow timely diagnosis and management of acute
and chronic complications in patients with SCAD.
REFERENCES:
1- Taleyratne JD, Fernandez JP. Anterior ST elevation myocardial
infarction in a 40-year-old woman. Heart. 2014 Jun 27. pii: heartjnl-2014-
305985. doi: 10.1136/heartjnl-2014-305985. [Epub ahead of print.
2- Giacoppo D, Capodanno D, Dangas G, Tamburino C. Spontaneous coronary
artery dissection. Int J Cardiol. 2014; 175(1): 8-20.
3- Furuichi, S. , Montorfano, M., Godino, C., Murino, M., Sangiorgi, G.M.,
Colombo, A. How should I treat a long and huge coronary pseudoaneurysm
after spontaneous coronary artery dissection? EuroIntervention. 2011; 6:
1131-1136.
4- Shamloo BK, Chintala RS, Nasur A, Ghazvini M, Shariat P, Diggs JA,
Singh SN. Spontaneous coronary artery dissection: aggressive vs.
conservative therapy. J Invasive Cardiol. 2010; 22(5): 222-8.
5- Tweet MS, Hayes SN, Pitta SR, Simari RD, Lerman A, Lennon RJ, Gersh BJ,
Khambatta S, Best PJ, Rihal CS, Gulati R. Clinical features, management,
and prognosis of spontaneous coronary artery dissection. Circulation.
2012; 126(5) :579-88.
6- Butler R, Webster MW, Davies G, Kerr A, Bass N, Armstrong G, Stewart
JT, Ruygrok P, Ormiston J. Spontaneous dissection of native coronary
arteries. Heart. 2005; 91(2) :223-4.
Conflict of Interest:
None declared
INVASIVE VERSUS CONSERVATIVE STRATEGY FOR THE MANAGEMENT OF SPONTANEOUS CORONARY ARTERY DISSECTION: WHICH IS BETTER ?
Kenan YALTA, MD
Mustafa YILMAZTEPE, MD
Flora OZKALAYCI, MD
Nasir SIVRI, MD
Bilal GEYIK, MD
Trakya ?niversity, Cardiology Department, Edirne, Turkey
Corresponding Author: Kenan Yalta , e-mail: kyalta@gmail.com
To the Editor,
In the recent years, spontaneous coronary artery dissection (SCAD) has been a point of debate with regard to its management strategies. In their recently published article (1), Taleyratne JD et al described a case of spontaneous coronary artery dissection (SCAD) in a middle-aged woman presenting with acute coronary syndrome (ACS) (1). As far as we understand, the case was exclusively managed with a conservative strategy (with aspirin, ticagrelor, glycoprotein IIb/IIIa inhibitors and heparin) after coronary angiography (CAG) and intravascular ultrasound (IVUS). If that was the case, we strongly oppose the exclusive use of a non-interventional approach in this patient due to reasons described below.
Regarding the single- vessel SCAD, conservative strategy is only warranted in asymptomatic cases in which the degree of stenosis due to SCAD is < 50% along with a distal perfusion of TIMI 3 in the affected vessel (2). In other terms, where applicable, PCI is strongly recommended in the setting of a high-risk SCAD associated with a severe luminal narrowing (70-99%) and/or a poor distal vessel perfusion (TIMI 0- 1) and presenting with an unstable condition (2) (as in the case reported by Taleyratne JD (1)). Surgical management might also be performed in a more selected portion of cases including those with left main coronary artery (LMCA) or multivessel involvement in which there is no SCAD extension to the distal segments of the affected vessel (2).
There exists a strong rationale behind these therapeutic recommendations : SCADs treated conservatively might not always demonstrate a resolution or spontaneous healing, and might even worsen in some situations in the short and long terms (2,3). On follow-up, unfavorable results might be encountered in as high as 60% of SCADs managed with a conservative strategy alone (2,4). Among these long-term complications , late recurrences (2, 5) and aneurysm formation (3) in the affected vessel might be quite troublesome, and might be regarded as major therapeutic challenges in the conservatively treated patients with a SCAD. More importantly, witholding an early invasive strategy in the acute phase might be associated with acute life-threatening consequences including refractory arrhythmic events, retrograde propagation of the dissection towards the LMCA, etc. Interestingly, propagation of SCAD is more likely to occur in normal vessels in comparison to atherosclerotic ones (2) . On the other hand, PCI was previously suggested as the primary therapeutic option in the setting of SCAD (6). However, when the final decision is PCI, it should be done by expert hands: the operator should avoid advancing guide-wire into the false lumen to prevent SCAD extension (2). Direct stenting without stent oversizing should be the preferred strategy (2). Unfortunately, despite meticulous care, additional stents might be required in a portion of cases due to the propagation of SCAD after initial stenting (2,5). Nevertheless, PCI when combined with endovascular imaging techniques (IVUS, etc) seems to be a more promising therapeutic approach in the setting of SCAD particularly with high-risk features.
In summary; conservative management might pose a significant risk to patients with SCAD (2-4) particularly to those with high- risk features both in the short and long terms. On the other hand, invasive strategy including PCI, when performed by experienced operators and with the assistance of endovascular imaging techniques, seems to be a radical and efficient alternative in these patients (2,6). We wonder why Taleyratne JD et al (1) preferred a 'wait and see' approach rather than performing an IVUS-guided urgent PCI in their high-risk patient. Furthermore, as SCAD might be regarded as a continuum of evolving vascular pathology with an unpredictable course even after healing, their patient (1) needs to be monitored closely for potential late complications including recurrence , aneurysm formation, etc. Accordingly, the authors (1) may want to make clear their future strategies (follow-up, medication, repeat CAG or non-invasive imaging ?, etc.) regarding their patient in a more comprehensive manner. However, future studies are still warranted to establish furher risk prediction models that might help determine the initial therapeutic strategy, and more importantly, might allow timely diagnosis and management of acute and chronic complications in patients with SCAD.
REFERENCES: 1- Taleyratne JD, Fernandez JP. Anterior ST elevation myocardial infarction in a 40-year-old woman. Heart. 2014 Jun 27. pii: heartjnl-2014- 305985. doi: 10.1136/heartjnl-2014-305985. [Epub ahead of print. 2- Giacoppo D, Capodanno D, Dangas G, Tamburino C. Spontaneous coronary artery dissection. Int J Cardiol. 2014; 175(1): 8-20. 3- Furuichi, S. , Montorfano, M., Godino, C., Murino, M., Sangiorgi, G.M., Colombo, A. How should I treat a long and huge coronary pseudoaneurysm after spontaneous coronary artery dissection? EuroIntervention. 2011; 6: 1131-1136. 4- Shamloo BK, Chintala RS, Nasur A, Ghazvini M, Shariat P, Diggs JA, Singh SN. Spontaneous coronary artery dissection: aggressive vs. conservative therapy. J Invasive Cardiol. 2010; 22(5): 222-8. 5- Tweet MS, Hayes SN, Pitta SR, Simari RD, Lerman A, Lennon RJ, Gersh BJ, Khambatta S, Best PJ, Rihal CS, Gulati R. Clinical features, management, and prognosis of spontaneous coronary artery dissection. Circulation. 2012; 126(5) :579-88. 6- Butler R, Webster MW, Davies G, Kerr A, Bass N, Armstrong G, Stewart JT, Ruygrok P, Ormiston J. Spontaneous dissection of native coronary arteries. Heart. 2005; 91(2) :223-4.
Conflict of Interest:
None declared