Differences in revascularization strategy and outcomes in ST-elevation and non-ST-elevation myocardial infarction with spontaneous coronary artery dissection
Bibliographic record
Abstract
Abstract Background Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in young to middle-aged women. However, the role of revascularization for SCAD, especially percutaneous coronary intervention (PCI), remains controversial. Purpose To compare revascularization strategies and outcomes in SCAD patients presenting with ST-elevation MI (STEMI) vs. unstable angina or non-STEMI (UA/NSTEMI). Methods We analyzed SCAD patients who presented acutely between June 2014 and June 2018 to 22 centers participating in the Canadian SCAD Cohort Study. We compared treatment patterns and clinical outcomes in SCAD patients with an initial clinical presentation of STEMI vs. UA/NSTEMI. We assessed follow-up major adverse cardiovascular event (MACE) rate, a composite of all-cause death, MI, and stroke. The impact of revascularization on MACE was also evaluated according to clinical presentations (STEMI vs. UA/NSTEMI). Results Among 750 SCAD patients (mean age 51.7±10.5 years; 88.5% were women), 234 (31.2%) presented with STEMI. In the STEMI group, left anterior descending artery was more commonly involved (62.0% vs. 47.5%, p<0.001) and TIMI 0 flow was more frequently observed (24.8% vs. 7.2%, p<0.001). A total of 27.8% of STEMI patients were treated with revascularization (98.5% PCI), whereas only 8.7% of UA/NSTEMI patients were revascularized (93.3% PCI). For STEMI patients, 93.9% were planned procedures, whereas, for UA/NSTEMI patients, 71.1% were planned revascularization. Successful or partially successful PCI was 65.5% for STEMI and 76.9% for UA/NSTEMI (p<0.001). The median follow-up period was 850 (interquartile range: 619–1096) days. MACE rate was not different between STEMI and UA/NSTEMI (UA/NSTEMI as a reference: hazard ratio [HR] 1.08, 95% confidence interval [CI] 0.70–1.68, p=0.72). Regardless of clinical presentations, revascularization was associated with increased risk of MACE (STEMI: HR 2.57, CI 1.25–5.25, p=0.01; UA/NSTEMI: HR 5.41, CI 3.19–9.19, p<0.001). The association of revascularization and increased risk of MACE was more prominent in UA/NSTEMI than in STEMI (Figure), but it did not reach statistical significant (P for interaction = 0.09). Conclusions In SCAD patients, long-term clinical outcome was not different between STEMI and UA/NSTEMI presentations. Revascularization was more frequently performed with STEMI; however, regardless of clinical presentations, revascularization was associated with worse clinical outcomes. Careful patient selection for revascularization is key for SCAD patients and further studies are needed to clarify selection criteria. Revasc and MACE by presentation Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Canadian Institutes of Health Research
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".