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Aims Whether patients with spontaneous coronary artery dissection (SCAD) should undergo an initial conservative management or immediate revascularization through percutaneous coronary intervention (PCI) remains debated. To investigate the frequency and predictors of choosing a strategy of immediate PCI for SCAD, and to compare the clinical outcomes of immediate PCI patients with those undergoing an initial strategy of medical management. Methods and results 369 patients enrolled in the multicentre international DIssezioni Spontanee COronariche (DISCO) registry between January 2009 and December 2020 were included. The primary endpoint was major adverse cardiovascular events (MACE), a composite of cardiac death, non-fatal myocardial infarction (MI) and any PCI. 240 (65%) patients underwent initial medical management, whereas 129 (35%) had immediate PCI. PCI patients presented more frequently with ST segment-elevation myocardial infarction (STEMI) (68.2% vs. 35%, P Conclusions The choice between an immediate medical or PCI management of SCAD is mostly driven by clinical presentation and procedural aspects. In the DISCO cohort, the primary treatment approach was not associated with the risk of short-to-midterm adverse events.

Aims The role of antiplatelet therapy in patients with spontaneous coronary artery dissection (SCAD) undergoing initial conservative management is still a matter of debate, with theoretical arguments in favour and against its use. The aims of this article are to assess the use of antiplatelet drugs in medically treated SCAD patients and to investigate the relationship between single (SAPT) and dual (DAPT) antiplatelet regimens and 1-year patient outcomes. Methods and results We investigated the 1-year outcome of patients with SCAD managed with initial conservative treatment included in the DIssezioni Spontanee COronariche (DISCO) multicentre international registry. Patients were divided into two groups according to SAPT or DAPT prescription. Primary endpoint was 12-month incidence of major adverse cardiovascular events (MACE) defined as the composite of all-cause death, non-fatal myocardial infarction (MI), and any unplanned percutaneous coronary intervention (PCI). Out of 314 patients included in the DISCO registry, we investigated 199 patients in whom SCAD was managed conservatively. Most patients were female (89%), presented with acute coronary syndrome (92%) and mean age was 52.3 ± 9.3 years. Sixty-seven (33.7%) were given SAPT whereas 132 (66.3%) with DAPT. Aspirin plus either clopidogrel or ticagrelor were prescribed in 62.9% and 36.4% of DAPT patients, respectively. Overall, a 14.6% MACE rate was observed at 12 months of follow-up. Patients treated with DAPT had a significantly higher MACE rate than those with SAPT [18.9% vs. 6.0% hazard ratios (HR) 2.62; 95% confidence intervals (CI) 1.22–5.61; P = 0.013], driven by an early excess of non-fatal MI or unplanned PCI. At multiple regression analysis, type 2a SCAD (OR: 3.69; 95% CI 1.41–9.61; P = 0.007) and DAPT regimen (OR: 4.54; 95% CI 1.31–14.28; P = 0.016) resulted independently associated with a higher risk of 12-month MACE. Conclusions In this European registry, most patients with SCAD undergoing initial conservative management received DAPT. Yet, at 1-year follow-up, DAPT, as compared with SAPT, was independently associated with a higher rate of adverse cardiovascular events (ClinicalTrial.gov id: NCT04415762).

Spontaneous coronary artery dissection (SCAD) is a challenging clinical scenario and represents a non-negligible cause of acute coronary syndrome in young women. In-hospital management (conservative versus interventional) and medical therapy at discharge are debated, especially dual antiplatelet

Background The feasibility and efficacy of percutaneous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) via transradial access (TRA) is still a matter of concern, mainly in an unselected population. Methods We collected data about all PCI performed in patients with ULMCA stenosis by a TRA-dedicated operator and analyzed clinical and procedural characteristics as well as in-hospital and long-term outcomes. Results From January 2008 to December 2011, 49 PCIs were performed; 27 (55%) via TRA and 22 (45%) via transfemoral access (TFA). Most patients in both groups underwent PCI for acute coronary syndrome (66.7% in the TRA group vs 77.3% in the TFA group, p = 0.73). Patients in the TRA group were more hypertensive (81.5% vs 40.9%, p = 0.008) and had a higher left ventricular ejection fraction (54.6 ± 10.3 vs 46.1 ± 12.8, p = 0.01). There were no significant differences in procedural success (100% in the TRA group vs 90.9% in the TFA group, p = 0.38), as well as in procedural time, in fluoroscopic time and in contrast volume. Bleeding complications occurred in 1 patient in the TFA group (4.5%) vs none in the TRA group (p = 0.91). In-hospital major adverse cardiac events (MACE) occurred in 1 patient (3.7%) in the TRA group vs 3 (13.6%) in the TFA group (p = 0.48). At a follow-up of 32 ± 13 months, MACE occurred in 4 cases (14.8%) in the TRA group vs 7 cases (31.8%) in the TFA group (p = 0.28). Conclusions The PCI of ULMCA via TRA is feasible with good results, provided that a rigorous learning curve was followed and a TRA volume caseload was maintained.

To assess the impact on in-hospital and long-term survival of thrombus aspiration (TA) during primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS).From September 2001 to May 2010 we collected data from 155 patients affected with STEMI complicated by CS undergoing PPCI (12.4% of all PPCI) including 70 patients (45.2%) in TA group and 85 patients (54.8%) in conventional PCI group. Patients in TA group were more likely to have right ventricular infarction (24.3% vs 5.9%, p=0.002), higher mean left ventricular ejection fraction (40% ± 9% vs 35% ± 7%, p0.0001) and lower left main coronary artery occlusion (2.8% vs 21.2%, p=0.002). TA was associated with a lower rate of in-hospital and long-term mortality (31.4% vs 48.2%, p=0.05 and 42.8% vs 64.7%, p=0.01 respectively) at a mean follow-up time of 6.1 ± 2.1 years. At multivariate analysis the only independent predictor of in-hospital and long-term survival was the procedural success (HR 0.18 95% CI 0.025-0.31, p=0.03 and HR 0.46 95% CI 0.09-0.74, p=0.034 respectively).In this retrospective study TA, performed during PPCI for STEMI complicated by CS, was not an independent predictor of in-hospital and long-term survival.

We report the case of a 55-year-old man who underwent coronary angiography in 2004 for early angina following anterior ST-elevation myocardial infarction. Angiography disclosed a critical stenosis in the proximal left anterior descending artery and significant stenoses in the right coronary artery and first obtuse marginal branch, treated with two paclitaxel-eluting stents and a sirolimus-eluting stent, respectively. After completion of a six-month thienopyridine course and while still being on lifelong aspirin, in 2007 he was readmitted for lateral ST-elevation myocardial infarction: angiography revealed stent thrombosis beginning at the proximal edge of the sirolimus-eluting stent implanted in the first obtuse marginal branch. Intravascular ultrasound was performed after thrombectomy but before balloon dilation showing suboptimal stent expansion and a thrombus partially adhering to the sirolimus-eluting stent. The procedure was then successfully completed with the implantation of another sirolimus-eluting stent. This clinical vignette suggests that suboptimal drug-eluting stent deployment may be associated with stent thrombosis well after the traditional time frame of subacute thrombosis.

We have read with great interest the report of the Grupo de Analisis de la Cardiopatia Isquemica Aguda (GRACIA) 2 trial by Fernandez-Aviles et al. ,1 suggesting the potential clinical benefit of fibrinolysis with early routine percutaneous coronary intervention (PCI) in comparison to primary PCI. However, drawbacks in study design, reporting, and interpretation severely limit its impact on readers. First, a statistically significant difference in the extent of coronary artery disease is reported between the two study groups in …