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Heartbeat: Intervention for spontaneous coronary artery dissection?

Acute coronary syndrome due to spontaneous coronary artery dissection (SCAD) typically is managed conservatively because coronary anatomy returns to normal in most patients at followup and because there is a high rate of technical failure and complications with percutaneous coronary intervention (PCI). However, a subgroup of these patients is at risk of extensive myocardial infarction and might benefit from PCI, despite the risk of complications. In this issue of Heart, Kotecha and colleagues report outcomes in 215 SCAD patients (94% women, median age 48 years with a range of 42–54 years) who underwent PCI for STelevation myocardial infarction, cardiac arrest, TIMI grade 0/1 flow or proximal dissection (figure 1). As expected, PCIrelated complications were frequent, occurring in 38.6% (83/215), with 13.0% (28/215) of patients suffering a serious complication. Even so, improved TIMI flow was achieved in 84.3% (118/140) with worsened TIMI flow in only 7% of patients. At a median followup of 900 days , 9.3% suffered recurrent acute myocardial infarction, 4.7% required further revascularisation, 1.5% had a stroke and 1.4% died. However, there was no difference in outcomes in SCADPCI patients compared with a matched cohort of SCAD patients who did not undergo PCI. Adamson reminds us that SCAD may account for as many as 2%–3% of acute coronary syndromes and predominantly affects middleaged women without traditional risk factors for coronary disease. He also points out that in the study by Kotecha and colleagues the SCAD patients undergoing PCI, compared with those treated conservatively, more often suffered myocardial infarction or cardiac arrest and more often had left main or proximal left anterior descending coronary artery involvement, reflecting selection of patients in whom the risks of PCI were offset by the severity of the coronary involvement. He concludes: ‘Excellent outcomes for most conservatively managed patients suggest our default should be to ‘do no harm’. But, for an important minority where intervention is deemed a true necessity—complete vessel occlusion, haemodynamic instability—we ought to take courage that there is scope ‘to do good’.’ The effectiveness of angiotensin receptorneprilysin inhibitor (ARNI) treatment versus renin–angiotensin system (RAS) blockade alone was evaluated by Desai and colleagues in a cohort of over 50 000 older (average age 76 years) adults with heart failure due to reduced ejection