Manejo contemporáneo de la disección coronaria espontánea

espanolIntroduccion y objetivos: La diseccion coronaria espontanea (DCE) constituye una causa infrecuente, pero cada vez mas reconocida, de sindrome coronario agudo. La actitud diagnostico-terapeutica idonea sigue sin esclarecerse. Metodos: Analisis del seguimiento prospectivo y centralizado de una serie de pacientes consecutivos diagnosticados de DCE desde enero de 2010 hasta diciembre de 2018. Se definio evento cardiovascular adverso mayor como la aparicion de muerte de cualquier causa, reinfarto no mortal, revascularizacion no planificada, arritmia ventricular, insuficiencia cardiaca o ictus. Resultados: Se incluyo a 33 pacientes con DCE (41 lesiones). En el 42% se realizo un estudio con imagen intracoronaria para confirmar el diagnostico, sin identificar trombo en la luz verdadera en ninguno de ellos. En la mayoria de los casos (82%) se eligio un tratamiento medico conservador. Ningun paciente fallecio durante el ingreso, pero el 15% presento algun evento mayor. En el momento agudo se realizo tomografia computarizada coronaria al 58% de los pacientes y se identifico la DCE en el 79% de los casos. La mayoria de los pacientes con tratamiento conservador recibieron antiagregacion simple un tiempo limitado (17 meses [9-35]). Con una mediana de seguimiento de 33 meses [13-49], el 82% no sufrio ningun evento adverso. Al 48% se les realizo control angiografico a los 6 meses, que mostro resolucion en el 86% de los casos. El cribado de anomalias vasculares extracoronarias se realizo en el 97% de los pacientes y se hallaron alteraciones en el 59%, incluyendo 3 pacientes con aneurisma intracraneal. Conclusiones: En esta serie, con una amplia utilizacion de imagen intracoronaria, no se ha identificado trombo en la luz verdadera en ningun caso de DCE. En los pacientes tratados de forma conservadora, la monoterapia antiagregante es segura y se asocia a buenos resultados clinicos. La tomografia computarizada coronaria durante el ingreso es util en el seguimiento. El cribado sistematico de anomalias vasculares extracoronarias revela una alta prevalencia de alteraciones. EnglishIntroduction and objectives: Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause for acute coronary syndrome. The optimal management and treatment of SCAD is still unknown. Methods: Data analysis of a prospective protocol including centralized care management of a consecutive series of patients with SCAD diagnosed between January 2010 and December 2018. Major adverse cardiovascular events included all-cause mortality, new myocardial infarction, coronary revascularization, ventricular arrhythmia, heart failure or stroke. Results: A total of 33 consecutive patients were included (41 lesions). Intravascular imaging modalities were used to confirm the diagnosis in 42% patients. None of the patient showed images of thrombus formation in the true lumen. Conservative treatment was the initial approach in most of the cases (82%). No deaths were reported during the index admission, but 15% experienced major adverse cardiovascular events. The coronary computed tomography angiography performed in 58% of patients during the admission identified SCADs in 79% of the patients. Most of the patients managed with conservative treatment received only 1 antiplatelet agent for a limited period of time (17 months [9-35]). During a median clinical follow-up of 33 months [13-49], 82% of patients did not have any adverse events. The angiographic surveillance obtained in 48% of patients at the 6-month follow-up confirmed the complete healing of the SCAD image in 86% of the patients. The screening for extracoronary vascular findings (97% of patients) resulted in a high prevalence of abnormalities (59%). Conclusions: The unrestricted use of intravascular imaging modalities showed no thrombus in the true lumen of patients with SCAD. In patients managed with conservative treatment, a limited course of antiplatelet monotherapy is safe and provides good clinical outcomes. Performing a coronary computed tomography angiography in the acute phase of SCAD is useful at the follow-up. The screening for extracoronary vascular findings confirmed a high prevalence of abnormalities.