10-year outcomes and antithrombotic management strategies in coronary artery ectasia: insights from a retrospective cohort

Background Coronary artery ectasia (CAE) is an abnormal vascular dilatation (≥1.5x normal diameter) predominantly associated with atherosclerosis. Altered haemodynamics predispose patients to acute coronary syndromes; however, the optimal antithrombotic strategy remains controversial due to a lack of randomised data. Purpose To determine the prevalence of CAE, characterise clinical and angiographic profiles, and evaluate the 10-year ischaemic, haemorrhagic and survival impact of antithrombotic strategies. Methods A retrospective cohort analysis was conducted identifying 1,674 patients with CAE from 18,593 consecutive coronary angiograms performed at a single centre. Outpatient antithrombotic regimens were categorised into single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), anticoagulation alone (AC), double therapy (AC + SAPT), and triple therapy (AC + DAPT). Haemorrhagic events were adjudicated via BARC criteria. Unadjusted 10-year survival (Kaplan-Meier) and independent predictors of long-term outcomes (Firth penalised Cox regression) were calculated. Results The prevalence of CAE was 9.0% (95% CI 8.6–9.4). Age had a median of 69 years (Q25:60, Q75:77). Unadjusted Kaplan-Meier analysis showed near-universal 10-year freedom from reinfarction across SAPT, DAPT, and AC regimens (99%–100%; p=0.50). Firth penalised Cox regression confirmed that antithrombotic therapy intensity did not independently predict recurrent myocardial infarction. Ischaemic recurrence was driven by anatomical severity (Markis Type III: HR 3.60, 95% CI 1.10–9.90, p=0.038) and dyslipidaemia (HR 2.10, p=0.049). Antithrombotic selection impacted safety; compared to AC alone, SAPT and DAPT were associated with reductions in bleeding risk (HR 0.31, p=0.033; and HR 0.36, p=0.044, respectively). All-cause mortality was dictated by baseline patient characteristics, notably kidney disease (HR 2.52, p<0.001). Conclusions Prevalence of CAE in this cohort (9%) was notably higher than the rates typically reported in the literature (1–5%), suggesting possible contributing factors influencing disease detection. Absence of antithrombotic therapy in CAE is associated with higher mortality. Age distribution of the cohort, suggest that further research is needed to distinguish influence of baseline frailty and CAE-associated atherosclerotic burden in mortality. Survival appears to be driven by patient’s baseline characteristics over treatment regime. In the absence of absolute indications for AC, SAPT or DAPT showed to be non-inferior in ischaemic protection while actively diminishing bleeding events. Avoiding prophylactic overtreatment with antithrombotic intensive therapies safely improves long-term outcomes in CAE. Adequately tailored, patient-centred antithrombotic strategies could effectively bridge the current gap in formal treatment consensus for this condition.10 year survival by outpatient therapyDistribution of outpatient therapy regimens