Coronary artery dissection (CD) is a rare but potentially life-threatening condition characterized by the separation of the anatomical layers of the coronary artery wall, leading to the formation of a false lumen1. The pathophysiology of coronary artery dissection begins with a tear in the tunica intima, creating a flap or channel through which blood flows abnormally into the subintimal space. This generates a false lumen, which expands, disrupting blood flow within the true lumen2.
There are several potential causes of CD including trauma, connective tissue disorders, hormonal changes, and underlying coronary artery diseases. Additionally, CD can occur spontaneously without any apparent triggering event. The dissection may be isolated to a single coronary artery or may affect multiple arteries with disease presentations varying widely in their severity2. A prior episode of CD predisposes a patient to future events with up to a 17-fold increase in the incidence of iatrogenic CD. This incidence of iatrogenic CD depends on the procedure being performed, with patients undergoing percutaneous coronary intervention having a higher risk of experiencing a dissection12, 13.
The clinical presentation of CD ranges from asymptomatic to severe and life-threatening presentations such as myocardial infarction2. Past medical history constitutes an important pretest factor with patients who have histories of acute coronary syndrome having the highest incidence rate for CD. In the general population, females have a greatly increased incidence of CD compared to men3. Invasive coronary angiography is the primary diagnostic tool to diagnose CD with the “double-lumen vessel” witnessed as contrast dye enters the false lumen. Classification of CD is based on the disease severity using the Yip-Saw classification model3.
Mortality rates in CD depend on various factors, including the extent and location of the dissection, the promptness of diagnosis and intervention, whether a myocardial infarction is presenting with the dissection, and the overall health of the affected individual. Rapid and accurate diagnosis is crucial for initiating appropriate management strategies, encompassing medical therapy, percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG). Mortality rates are reported to be relatively high for patients with CD, especially in cases of extensive and severe dissections, emphasizing the importance of timely intervention to improve outcomes4. Regarding medical therapy, data-based research is presently limited for CD and current recommendations are predominately based on the clinical decisions of the practitioner14. Often, the patient population that experienced CD was taking anticoagulation and dual antiplatelet therapy (DAPT) before the CD event. These medications are considered the keystone of CD prevention based on the hypothetical risk reduction in dissection formation 2,4. Beta-blockers and angiotensin-converting enzyme inhibitors (ACEi)/angiotensin-receptor blockers (ARBs) are medications that exist as guideline-directed medical therapy for a host of cardiovascular pathologies. These medications are pillars of medical management for cardiac conditions such as heart failure of all types, coronary artery disease, and acute myocardial infarction, and it is theoretically likely that they are essential for patients affected with CD. At present, there is limited literature support for the use of these medications for CD and therefore no concrete recommendations for their use in this context. One prospective observational study involving 327 patients who had CD revealed a 64% decrease in the incidence of recurrent CD4,5. These patients ranged from having connective tissue diseases such as fibromuscular dysplasia to structural diseases like acute myocardial infarction, arrhythmias, etc., that led to them developing CD. These patients were on medications such as aspirin, clopidogrel, a beta-blocker, a calcium channel blocker, a statin, an ACEi/ARB, and/or nitroglycerin. After following the patients for a median of 3.1 years, results revealed a significant reduction in the recurrence of CD in patients with no hypertension, and in patients taking beta-blockers. A 64% reduction in the recurrence of CD supports recommending beta-blockers for patients with a history of CD5.
Given the complexity and variability of coronary artery dissection, ongoing research is essential to enhance our understanding of its pathophysiology, refine diagnostic approaches, and optimize treatment strategies to reduce mortality and improve overall patient outcomes. Therefore, we performed a retrospective study examining patient outcomes for optimal medication regimens for CD to reduce patient mortality. Using a retrospective approach allowed us to examine a large number of patients of different ages and races, and explore new pathways for research trials.