Diagnosi, gestione in acuto e al follow up dell'infarto da dissezione spontanea dell'arteria coronarica: i risultati del registro italiano multicentrico DISCO

Spontaneous coronary artery dissection (SCAD) is a challenging clinical scenario and represents an increasingly studied cause of acute coronary syndrome (ACS) in young people, especially women. Predisposing as well as precipitating factors have been identified in the most recent reports on this disease. In¿hospital management and medical therapy at discharge are to date a matter of debate since no randomized control trial is available. Regardless, medical therapy has recently been indicated in literature as preferred treatment. DISCO (DIssezioni Spontanee COronariche) is an italian, multicenter register which included 216 patients admitted with a diagnosis of SCAD from 20 different Italian centers. In this study we analyzed SCAD patients' baseline features, angiographic characteristics and MACE free survival at follow-up: we focused on the long-term impact of the single antiplatelet therapy (SAPT) over the dual one (DAPT) along with the difference between P2Y12i chosen. In the coordinator centers (Orbassano and Rivoli) a specific outpatient examination program was set up so as to obtain at least one follow-up for each patient. Our average follow-up length was 20  27 months. Major cardiovascular events (MACE) were defined as the composite of all cause death, non-fatal Myocardial infarction and any PCI performed. SCAD patients included in the DISCO register were mainly female (77.3%) with a mean age of 54,5 ± 11,7 years. 30.1% of patients reported a trigger factor related to the acute event. STEMI (ST¿segment elevation myocardial infarction) was the main admission diagnosis (49.1%), followed by NSTE (non¿ST segment elevation)¿ACS (45.8%) and stable coronary artery disease (5.1%). Type 2b SCAD (23.9%) was the main finding at coronary angiography. LAD was the predominant segment affected (56%). More than half of patients were initially treated with medical therapy (55.6%), while PCI (percutaneous coronary intervention) or CABG (coronary artery bypass graft) were performed in 40.7% and 3.7% respectively. PCI procedural success was reached in 78.6% of cases. DAPT was prescribed in 58.3% of patients medically-treated only. In these patients Ticagrelor and Clopidogrel resulted the P2Y12 inhibitors of choice. In¿Hospital MACE rate was 9.2% with a total of 20 events occurred whereas on total follow-up 31 (14.3%) MACEs were reported: all cause death, non-fatal Myocardial infarction, any PCI performed occurred in 1.4%, 7.4% and 10.2% of patients respectively. There was no significant difference of MACE free survival between patients discharged with SAPT and DAPT on the total SCAD population. Conversely, considering only medically treated patients, SAPT resulted to be a protective factor (p = 0.01). In patients only-medically treated discharged with DAPT new P2Y12i were associated to a worse prognosis than Clopidogrel (p = 0.024). However, there was no difference between new and old P2Y12i in patients discharged with DAPT after PCI + stenting (p = 0.975). SCAD affects predominantly young and middle age women and medical therapy represents the initial treatment of choice in the majority of patients. A non-negligible rate of MACE is associated to this disease with most of the events occurred during hospitalization. In only medically treated patients SAPT has proven a protective factor against adverse events on long-term follow-up. Conversely, in case of PCI + stenting in SCAD patients, a more aggressive treatment with new P2Y12i should be chosen.