Invasive versus conservative management in spontaneous coronary artery dissection: a meta-analysis and meta-regression study.

ABSTRACT Background Data regarding the best treatment for spontaneous coronary artery dissection (SCAD) are scarce. The aim of the present study was to compare the clinical outcomes of conservative versus invasive treatment in SCAD patients. Methods We systematically searched the literature for studies evaluating the comparative efficacy and safety of invasive revascularization versus medical therapy for the treatment of SCAD from 1990 to 2020. The study endpoints were all-cause death, cardiovascular death, myocardial infarction, heart failure, SCAD recurrence and target vessel revascularization (TVR) rates. Random-effect meta-analysis was performed comparing the clinical outcomes between the two groups. A univariate meta-regression analysis was also performed. Results 24 observational studies with 1720 patients were included. After 28±14 months, a conservative approach was associated with lower TVR rate compared with invasive treatment (OR=0.50; 95%CI 0.28-0.90; P=0.02). No statistical difference was found regarding all-cause death (OR=0.81; 95%CI 0.31–2.08; P=0.66), cardiovascular death (OR=0.89; 95%CI 0.15–5.40; P=0.89), myocardial infarction (OR=0.95; 95%CI 0.50-1.81; P=0.87), heart failure (OR 0.96; 95%CI 0.41–2.22; P=0.92) and SCAD recurrence (OR=0.94; 95%CI 0.52-1.72; P=0.85). The meta-regression analysis suggested that male gender, diabetes mellitus, smoking habit, prior coronary artery disease, left main coronary artery involvement, lower ejection fraction and low TIMI flow at admission are related with higher overall mortality, whereas SCAD recurrence was higher among patients with fibromuscular dysplasia. Conclusions A conservative approach was associated with similar clinical outcomes and lower TVR rates compared to with an invasive strategy in SCAD patients; future prospective studies are needed to confirm these results.