Spontaneous Coronary Artery Dissection Clinical Outcomes and Risk of Recurrence
Spontaneous Coronary Artery Dissection Clinical Outcomes and Risk of Recurrence
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DOI：
10.1016/j.jacc.2017.06.053
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发表时间：
2017-08-29
影响因子：
24
通讯作者：
Mancini, John
中科院分区：
文献类型：
--
作者：
Saw, Jacqueline;Humphries, Karin;Mancini, John
自发性冠状动脉夹层（SCAD）是一种未被充分诊断的疾病，也是心肌梗死（MI）的重要原因，尤其是在年轻女性中。长期心血管预后，包括复发性SCAD，报道不充分。目的：本研究旨在描述急性和长期心血管预后，并评估复发性SCAD的预测因素。方法在温哥华总医院对非动脉粥样硬化性SCAD患者进行前瞻性系统随访，以确定基线、诱发和诱发应激源、血管造影特征、血运重建、药物使用、院内和长期心血管事件。采用单因素和多因素Cox回归模型对复发性SCAD的临床预测因素进行检验。结果对327例SCAD患者进行前瞻性随访。平均年龄52.5±9.6岁，90.5%为女性（56.9%为绝经后）。均为心肌梗死；25.7%为st段抬高型心肌梗死，74.3%为非st段抬高型心肌梗死，8.9%为室性心动过速/室颤。诱发性情绪应激源占48.3%，诱发性生理应激源占28.1%。62.7%为纤维肌肉发育不良，4.9%为结缔组织紊乱，11.9%为全身性炎症性疾病。大多数患者（83.1%）最初接受了药物治疗，分别只有16.5%和2.2%的患者接受了经皮冠状动脉介入治疗或冠状动脉搭桥手术。大多数SCAD患者在出院和随访时服用阿司匹林和受体阻滞剂治疗。中位住院时间为3.0天，总体主要不良事件发生率为7.3%。中位长期随访时间为3.1年，总体主要心脏不良事件发生率为19.9%（死亡率：1.2%；复发性心肌梗死：16.8%；卒中/短暂性脑缺血发作：1.2%；血运重建术：5.8%）。复发性SCAD发生率为10.4%。在多变量模型中，只有高血压增加（危险比：2.46;p = 0.011）， β受体阻滞剂使用减少（危险比：0.36;p = 0.004）复发性SCAD。结论：在我们的大型前瞻性随访SCAD队列中，长期心血管事件很常见。高血压增加了SCAD复发的风险，而受体阻滞剂治疗似乎具有保护作用。(C) 2017年由美国心脏病学会基金会发布。
BACKGROUND Spontaneous coronary artery dissection (SCAD) is underdiagnosed and an important cause of myocardial infarction (MI), especially in young women. Long-term cardiovascular outcomes, including recurrent SCAD, are inadequately reported.OBJECTIVES This study sought to describe the acute and long-term cardiovascular outcomes and assess the predictors of recurrent SCAD.METHODS Nonatherosclerotic SCAD patients were prospectively followed at Vancouver General Hospital systematically to ascertain baseline, predisposing and precipitating stressors, angiographic features, revascularization, use of medication, and in-hospital and long-term cardiovascular events. Clinical predictors for recurrent de novo SCAD were tested using univariate and multivariate Cox regression models.RESULTS The authors prospectively followed 327 SCAD patients. Average age was 52.5 +/- 9.6 years, and 90.5% were women (56.9% postmenopausal). All presented with MI; 25.7% had ST-segment elevation MI, 74.3% had non-ST-segment elevation MI, and 8.9% had ventricular tachycardia/ventricular fibrillation. Precipitating emotional stressors were reported in 48.3% and physical stressors in 28.1%. Fibromuscular dysplasia was present in 62.7%, connective tissue disorder in 4.9%, and systemic inflammatory disease in 11.9%. The majority (83.1%) were initially treated medically, with only 16.5% or 2.2% undergoing in-hospital percutaneous coronary intervention or coronary artery bypass graft surgery, respectively. The majority of SCAD patients were taking aspirin and beta-blocker therapy at discharge and at follow-up. Median hospital stay was 3.0 days, and the overall major adverse event rate was 7.3%. Median long-term follow-up was 3.1 years, and overall major adverse cardiac event rate was 19.9% (death rate: 1.2%; recurrent MI: 16.8%; stroke/transient ischemic attack: 1.2%; revascularization: 5.8%). Recurrent SCAD occurred in 10.4% of patients. In multivariate modeling, only hypertension increased (hazard ratio: 2.46; p = 0.011) and beta-blocker use diminished (hazard ratio: 0.36; p = 0.004) recurrent SCAD.CONCLUSIONS In our large prospectively followed SCAD cohort, long-term cardiovascular events were common. Hypertension increased the risk of recurrent SCAD, whereas beta-blocker therapy appeared to be protective. (C) 2017 by the American College of Cardiology Foundation.