Eighty-five percent of ICD implantations in SCAD patients with cardiac arrest were performed outside current guidelines, as most recipients had preserved or mildly impaired LVEF.
What proportion of SCAD patients presenting with cardiac arrest receive an ICD in discordance with ESC guidelines?
A significant proportion of SCAD patients presenting with cardiac arrest receive ICDs despite having preserved or mildly impaired LVEF, highlighting a frequent real-world deviation from current ESC guidelines.
Absolute Event Rate: 0% vs 0%
Abstract Introduction Spontaneous Coronary Artery Dissection (SCAD) is a significant cause of non-atherosclerotic acute myocardial infarction (AMI), predominantly affecting young to middle-aged women. It is also a leading cause of post-partum MI. Typically; SCAD occurs in patients with fewer cardiovascular risk factors than atherosclerotic AMI. Approximately 3-5% of SCAD patients present with cardiac arrest (CA). According to current ESC guidelines, patients with an LVEF below 40% at discharge following an acute myocardial infarction should undergo repeat Left Ventricular Ejection Fraction (LVEF) assessment 6–12 weeks later, and ICD implantation is recommended if significant and persistent left ventricular dysfunction is present. A previous cohort study in a SCAD population suggested an increased future risk of ventricular arrhythmia in SCAD patients whose first presentation was with ventricular fibrillation or ventricular tachycardia. Clinicians often adopt a precautionary approach, resulting in variability in real-world practice. Purpose This study investigated whether SCAD patients with cardiac arrest received ICDs despite preserved LVEF, potentially in discordance with ESC post-AMI guidelines. Results Of 2,742 SCAD patients, 100 (3.65%) presented with CA. The median age of all patients presenting with CA was 47.0 years and predominantly female (95%). Co-morbidities included hypertension (24.2%), diabetes (4.04%), a smoking history (38.4%), and a mean body mass index of 27.3 kg/m2. On initial ECG, 19.7% had ST-elevation myocardial infarction. The most common SAW class was Type 2, with 2a being most common at 44.8%, and 2b being second most common at 28.1% of cases. Type 4 SCAD was seen in 13.5% of cases. Most commonly affected vessel was the Left Anterior Descending artery (62.3%), with 10.9% having a multi-vessel SCAD. Twenty patients (20.0%) received an ICD, with no significant difference in demographics between patients with, and without ICDs. Presenting ECG showing STEMI was numerically more frequent in the ICD group (31.3% vs 17.1%, p=0.21). There was no statistical difference in SAW class, and vessel distribution (p=0.10). Overall, 50% had preserved LVEF, 45% had mildly impaired LVEF, and 3% had severely impaired LVEF. Within the ICD group, 10 patients had preserved LVEF, 7 had mildly impaired LVEF, and 3 had severely impaired LVEF. Hence, only three patients met guideline-based criteria for ICD implantation based on LVEF. Discussion: We found that 85% of ICD implantations in this SCAD cohort were outside current guidelines. This likely reflects clinician uncertainty regarding the true risk of sudden cardiac death in this group, and emphasises the need for improved risk stratification. Further study is required to evaluate long-term outcomes and recurrence risk in this subgroup. In order to better inform the balance between potential protection from sudden death, and the procedural and psychological risks of ICD implantation.
Millwood et al. (Sun,) reported a other. Eighty-five percent of ICD implantations in SCAD patients with cardiac arrest were performed outside current guidelines, as most recipients had preserved or mildly impaired LVEF.
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