Clinical outcomes of patients presenting with spontaneous coronary artery dissection versus takotsubo syndrome: a propensity score analysis

Background: Spontaneous coronary artery dissection and takotsubo syndrome are non-atherosclerotic causes of acute coronary syndromes. They share clinical features including female predominance and frequent triggers. We compared the outcomes of patients with spontaneous coronary artery dissection and patients with takotsubo syndrome with similar clinical characteristics.

Methods: Patients with spontaneous coronary artery dissection (n=81) or takotsubo syndrome (n=341) were 1:1 propensity matched according to age, sex, cardiovascular risk factors and clinical presentation. We compared baseline characteristics, effects on left ventricular function, and recurrence of major adverse cardiovascular events; defined as a composite of new hospitalisation for cardiac cause, clinical recurrence (spontaneous coronary artery dissection/takotsubo syndrome), myocardial infarction and death.

Results: Propensity score yielded 78 pairs: 85% were women, whose average age was 55.3±12.6 years, 28% had two or more cardiovascular risk factors, 37% presented with ST-segment elevation and 5% presented with cardiogenic shock. In the spontaneous coronary artery dissection group, 50% (39/78) of cases involved the left anterior descending artery and 18% (14/78) underwent revascularisation. After a median follow-up of 5 years (interquartile range 2.4-5), major adverse cardiovascular events were significantly higher in the spontaneous coronary artery dissection group (18% (14/78) vs. 8% (6/78); hazard ratio 3.40, 95% confidence interval 1.2-9.4). This was mainly driven by early readmissions for cardiac causes (17% vs. 5%, P=0.007). Spontaneous coronary artery dissection was associated with higher peak values of creatinine kinase during admission (creatinine kinase/upper limit of normality 2.49 vs. 1.21, P<0.001). Binary left ventricular systolic dysfunction was more prevalent in the takotsubo syndrome group (22% vs. 53%, P<0.001), but no significant differences were noted at follow-up (6% vs. 1%, P=0.181).

Conclusions: In this cohort of middle-aged predominantly female patients presenting with acute coronary syndromes, the diagnosis of spontaneous coronary artery dissection compared to takotsubo syndrome conferred a worse long-term clinical outcome, mainly driven by an increased risk of rehospitalisation for cardiac causes.