Frankel, Robert

Abstract Aims Spontaneous coronary artery dissection (SCAD) has become increasingly recognized. It accounts for <1-4% of acute coronary syndrome presentations. Overall, however, it makes up over 40% of pregnancy-associated myocardial infarction. Furthermore, pregnancy-associated spontaneous coronary artery dissection (P-SCAD) is described to have a greater degree of clinical manifestations, including left ventricular dysfunction, shock, and left main or multivessel involvement. The findings are disconcerting, though many studies evaluating P-SCAD are based on case series data or are single centre studies. Methods and results The aim of this study was to evaluate a larger national dataset to evaluate the outcomes of SCAD and specifically P-SCAD in an attempt to better characterize the severity and clinical nature of this condition. To conduct this study, we analysed the National Readmission Database from January 2016 to December 2020. Propensity matching was done using the Greedy 1:1 method. Multivariate logistics and time-to-event Cox regression analysis models were built by including all confounders significantly associated with the outcome on univariable analysis with a cut-off P-value of 0.2. In multivariate regression analysis, P-SCAD patients had a non-propensity matched odds ratio (OR) of 0.21 (0.3-1.54, P = 0.123) of dying and a propensity matched OR of 0.11 (0.02-0.61, P = 0.012) of dying. Thirty-day readmission rate for P-SCAD was 15.8% (n = 93) and for non-pregnant spontaneous coronary artery dissection (NP-SCAD) was 11.2% (n = 2286); non-propensity matched OR for readmission for PSCAD patients was 1.68 (1.24-2.29, P = 0.001) and propensity matched OR was 3.39 (1.93-5.97, P < 0.001). Conclusion Among hospitalized patient, P–SCAD was associated with similar clinical outcomes and reduced incidence of death when compared with NP–SCAD, though had higher rates of 30–day readmission. Larger–scale observational data will be needed to ascertain the true incidence of cardiovascular complications as it relates to P–SCAD.

Background: Mortality benefit of routine intracoronary thrombus aspiration during primary percutaneous coronary intervention (PCI) has been questioned. The recent TASTE trial did not show a mortality benefit with thrombus aspiration at 1 month, however benefits from accompanying reductions in myocyte injury might accrue over time. A meta-analysis of randomized trials (RCTs) was performed to evaluate the effect of follow up duration on effectiveness of aspiration thrombectomy. Methods: PubMed, Cochrane Library, EMBASE, Web of Science and CINAHL databases were searched through March, 2014. We included RCTs with acute myocardial infarction (AMI) patients randomized to aspiration thrombectomy prior to primary PCI compared with conventional primary PCI alone. Two individuals reviewed the trials for inclusion and extracted data from the RCTs. We used random-effects models. Results: Data were pooled from 16 RCTs with 11,649 patients. All-cause mortality was significantly lower with aspiration thrombectomy after at least 12 months of follow up (Odds ratio [OR] =0. 61; 95% CI 0.37-0.99; p=0. 05). Pooled data for other time frames, i.e in-hospital, 1 month, 6 month follow up, did not reach statistical significance. Conclusion: Beneficial effects of thrombus aspiration on mortality are not evident until 12 months post-procedure, consistent with the long-term effects of myocardial salvage. Subsequent trials evaluating thrombus removal should accordingly be powered for long-term mortality in addition to known procedural and angiographic endpoints.