Medical treatment or revascularisation as the best approach for spontaneous coronary artery dissection: A systematic review and meta-analysis.

INTRODUCTION

Patients presenting with spontaneous coronary artery dissection (SCAD) may receive either conservative medical management or a revascularisation strategy. There is still a lack of consensus with respect to the best treatment approach for SCAD.

OBJECTIVES

We sought to determine whether outcomes differ between the first-line treatment approaches (conservative versus revascularisation) in patients with SCAD.

METHODS

We searched Medline, EMBASE and the Cochrane Library for studies published from January 1990 to November 2016 that compared first-line treatments for patients with SCAD. We conducted a pooled risk ratio meta-analysis for four main outcomes: mortality, myocardial infarction (MI), SCAD recurrence and target vessel revascularisation (TVR).

RESULTS

We identified 11 non-randomised studies that included a total of 631 patients. A pooled meta-analysis showed no significant difference between conservative management and revascularisation approaches in mortality (risk difference [RD] = 0.01; 95% confidence interval [CI] = -0.01 to 0.04; I = 0%; p = 1), MI (RD = -0.01; 95% CI = -0.04 to 0.03; I = 0%; p = 0.5) or SCAD recurrence (RD = -0.01; 95% CI = -0.06 to 0.05; I = 0%; p = 0.74). Revascularisation as an initial first-line approach was associated with an estimated additional risk of TVR of 6.3% (RD = 0.06; 95% CI = 0.01-0.11; I = 0%; p = 0.96).

CONCLUSION

The results demonstrate an increased risk of TVR when revascularisation was used as the initial first-line treatment approach. The treatment decision must be individualised and be based on both clinical and angiographic factors, but conservative therapy should prevail in most cases.