Publications by authors named "Fernando Macaya"

47 Publications

Prevalence and Disease Spectrum of Extracoronary Arterial Abnormalities in Spontaneous Coronary Artery Dissection.

JAMA Cardiol 2021 Nov 24. Epub 2021 Nov 24.

Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom.

Importance: Spontaneous coronary artery dissection (SCAD) has been associated with fibromuscular dysplasia (FMD) and other extracoronary arterial abnormalities. However, the prevalence, severity, and clinical relevance of these abnormalities remain unclear.

Objective: To assess the prevalence and spectrum of FMD and other extracoronary arterial abnormalities in patients with SCAD vs controls.

Design, Setting, And Participants: This case series included 173 patients with angiographically confirmed SCAD enrolled between January 1, 2015, and December 31, 2019. Imaging of extracoronary arterial beds was performed by magnetic resonance angiography (MRA). Forty-one healthy individuals were recruited to serve as controls for blinded interpretation of MRA findings. Patients were recruited from the UK national SCAD registry, which enrolls throughout the UK by referral from the primary care physician or patient self-referral through an online portal. Participants attended the national SCAD referral center for assessment and MRA.

Exposures: Both patients with SCAD and healthy controls underwent head-to-pelvis MRA (median time between SCAD event and MRA, 1 [IQR, 1-3] year).

Main Outcome And Measures: The diagnosis of FMD, arterial dissections, and aneurysms was established according to the International FMD Consensus. Arterial tortuosity was assessed both qualitatively (presence or absence of an S curve) and quantitatively (number of curves ≥45%; tortuosity index).

Results: Of the 173 patients with SCAD, 167 were women (96.5%); mean (SD) age at diagnosis was 44.5 (7.9) years. The prevalence of FMD was 31.8% (55 patients); 16 patients (29.1% of patients with FMD) had involvement of multiple vascular beds. Thirteen patients (7.5%) had extracoronary aneurysms and 3 patients (1.7%) had dissections. The prevalence and degree of arterial tortuosity were similar in patients and controls. In 43 patients imaged with both computed tomographic angiography and MRA, the identification of clinically significant remote arteriopathies was similar. Over a median 5-year follow-up, there were 2 noncardiovascular-associated deaths and 35 recurrent myocardial infarctions, but there were no primary extracoronary vascular events.

Conclusions And Relevance: In this case series with blinded analysis of patients with SCAD, severe multivessel FMD, aneurysms, and dissections were infrequent. The findings of this study suggest that, although brain-to-pelvis imaging allows detection of remote arteriopathies that may require follow-up, extracoronary vascular events appear to be rare.
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http://dx.doi.org/10.1001/jamacardio.2021.4690DOI Listing
November 2021

Antiplatelet therapy in patients with conservatively managed spontaneous coronary artery dissection from the multicentre DISCO registry.

Eur Heart J 2021 08;42(33):3161-3171

Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy.

Aims: The role of antiplatelet therapy in patients with spontaneous coronary artery dissection (SCAD) undergoing initial conservative management is still a matter of debate, with theoretical arguments in favour and against its use. The aims of this article are to assess the use of antiplatelet drugs in medically treated SCAD patients and to investigate the relationship between single (SAPT) and dual (DAPT) antiplatelet regimens and 1-year patient outcomes.

Methods And Results: We investigated the 1-year outcome of patients with SCAD managed with initial conservative treatment included in the DIssezioni Spontanee COronariche (DISCO) multicentre international registry. Patients were divided into two groups according to SAPT or DAPT prescription. Primary endpoint was 12-month incidence of major adverse cardiovascular events (MACE) defined as the composite of all-cause death, non-fatal myocardial infarction (MI), and any unplanned percutaneous coronary intervention (PCI). Out of 314 patients included in the DISCO registry, we investigated 199 patients in whom SCAD was managed conservatively. Most patients were female (89%), presented with acute coronary syndrome (92%) and mean age was 52.3 ± 9.3 years. Sixty-seven (33.7%) were given SAPT whereas 132 (66.3%) with DAPT. Aspirin plus either clopidogrel or ticagrelor were prescribed in 62.9% and 36.4% of DAPT patients, respectively. Overall, a 14.6% MACE rate was observed at 12 months of follow-up. Patients treated with DAPT had a significantly higher MACE rate than those with SAPT [18.9% vs. 6.0% hazard ratios (HR) 2.62; 95% confidence intervals (CI) 1.22-5.61; P = 0.013], driven by an early excess of non-fatal MI or unplanned PCI. At multiple regression analysis, type 2a SCAD (OR: 3.69; 95% CI 1.41-9.61; P = 0.007) and DAPT regimen (OR: 4.54; 95% CI 1.31-14.28; P = 0.016) resulted independently associated with a higher risk of 12-month MACE.

Conclusions: In this European registry, most patients with SCAD undergoing initial conservative management received DAPT. Yet, at 1-year follow-up, DAPT, as compared with SAPT, was independently associated with a higher rate of adverse cardiovascular events (ClinicalTrial.gov id: NCT04415762).
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http://dx.doi.org/10.1093/eurheartj/ehab372DOI Listing
August 2021

Safety of coronary revascularization deferral based on fractional flow reserve and instantaneous wave-free ratio in patients with chronic kidney disease.

Cardiol J 2021 Apr 12. Epub 2021 Apr 12.

Hospital Clínico San Carlos, Profesor Martín Lagos, s/n, 28040 Madrid, Spain.

Background: The safety of revascularization deferral according to pressure wire examination in patients with chronic kidney disease (CKD) has not been fully established.

Methods: From a retrospective cohort of 439 patients in whom revascularization was deferred after physiological assessment, we examined the incidence of patient-oriented composite endpoint (POCE: all-cause death, myocardial infarction [MI] and unplanned revascularization) in patients with CKD (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m²) and without it.

Results: At 4 years of follow-up, the primary endpoint was met by 25.0% of patients with CKD and by 14.4% of patients without CKD (hazard ratio [HR] 1.56, 95% confidence interval [CI] 0.96-2.53, p = 0.071). The incidence of POCE was even higher in patients with an eGFR < 30 mL/min/1.73 m²: 43.8% (HR 3.10, 95% CI 1.08-8.92, p = 0.036). However, no differences were observed in the incidence of MI (4.2% vs. 4.4% in non-CKD), target vessel revascularization (5.8% vs. 5.9%), and target vessel MI (0.8% vs. 4.6%).

Conclusions: Patients with CKD in whom pressure-wire evaluation led to deferral of coronary revascularization develop more POCE in the long term, compared to patients with normal renal function. However, the increase in POCE in patients with CKD was seldom related to deferred vessels, thus suggesting an epiphenomenon of an intrinsically higher cardiovascular risk of CKD patients.
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http://dx.doi.org/10.5603/CJ.a2021.0035DOI Listing
April 2021

Clinical Profile and 30-Day Mortality of Invasively Managed Patients with Suspected Acute Coronary Syndrome During the COVID-19 Outbreak.

Int Heart J 2021 Mar 17;62(2):274-281. Epub 2021 Mar 17.

Department of Cardiology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC).

The COVID-19 pandemic severely disrupted cardiovascular care during the spring of 2020 in Europe. Our study analyzed the clinical profile, COVID-19 impact, and 30-day prognosis of invasively managed patients with acute coronary syndrome (ACS) compared to a historical cohort.All invasively managed ACS patients from March 1st to April 30th, 2020 were compared to a cohort from the same timeframe of 2019 (n = 316). COVID-19 confirmed cases were defined by a positive SARS-CoV-2 polymerase chain reaction (PCR) test (CoV+). The primary outcome was all-cause 30-day mortality and multivariable predictors of this outcome.A 40.4% reduction in ACS patients was noted (198 cases in 2019 to 118 in 2020), and 11% of 2020 ACS patients were CoV+. Baseline characteristics were similar between groups. There were significantly more in-hospital patients with ACS (15.3% versus 6.1%, P = 0.007), and fewer patients were found to have a culprit lesion (58.5% versus 74.2%, P = 0.004) in 2020 compared to 2019. Thirty-day mortality in 2020 (7%) was not different from that in 2019 (4.2%), P = 0.294, but it was significantly higher in CoV+ patients (23.1%) compared to that in negative SARS-CoV-2 PCR test (CoV-) patients (5%), P = 0.047, in the 2020 group. In the multivariate analysis, CoV+ was an independent mortality predictor (OR = 9.8, 95% CI = 1.48-64.78), along with the left ventricular ejection fraction (LVEF) (OR = 0.91, 95% CI = 0.86-0.97), P = 0.0006.This study found increased 30-day mortality of invasively managed CoV+ ACS patients compared to that of CoV- patients during the 2020 COVID-19 spring outbreak. In the multivariable analysis, a SARS-CoV-2 positive test was independently associated with 30-day mortality. Further investigations of the underlying physiopathological relations between COVID-19 and ACS are warranted.
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http://dx.doi.org/10.1536/ihj.20-574DOI Listing
March 2021

Clinical outcomes by angiographic type of spontaneous coronary artery dissection.

EuroIntervention 2021 Aug;17(6):516-524

Hospital Clínico San Carlos, IdiSSC, Universidad Complutense de Madrid, Madrid, Spain.

Background: Spontaneous coronary artery dissection (SCAD) is an increasingly diagnosed cause of myocardial infarction. Although different SCAD angiographic classifications exist, their clinical impact remains unknown.

Aims: The aim of this study was to evaluate the relationship between an angiographic classification and the development of adverse clinical events during the follow-up of a large, unselected cohort of patients with SCAD.

Methods: We conducted an observational study of consecutive SCAD patients from 26 centres across Italy and Spain. Cases were classified into five different angiotypes according to the latest classification endorsed by the European Society of Cardiology. The main composite endpoint included all-cause death, non-fatal myocardial infarction (MI), and any unplanned revascularisation.

Results: In total, 302 SCAD patients (mean age 51.8±19 years) were followed up for a median of 22 months (IQR 12-48). At 28 days, the composite outcome was higher for the angiotypes with a circumscribed contained intramural haematoma (2A and 3): 20.0% vs 5.4%, p<0.001 (non-fatal MI: 11.0% vs 3.5%, p=0.009; unplanned revascularisation: 11.0% vs 2.5%, p<0.001). This was sustained during follow-up (24.5% vs 9.9%, p=0.001). There were no differences in mortality (0.3% overall). The presence of an angiotype 2A or 3 was an independent predictor of a higher incidence of the composite outcome (adjusted HR 2.44, CI: 1.24-4.80, p=0.010).

Conclusions: The SCAD angiographic classification correlates with outcome. Those presenting with an angiographically circumscribed contained intramural haematoma (angiotypes 2A and 3) showed an increased risk of short-term adverse clinical events that was maintained during follow-up.
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http://dx.doi.org/10.4244/EIJ-D-20-01275DOI Listing
August 2021

Spontaneous coronary artery dissection in old patients: clinical features, angiographic findings, management and outcome.

Eur Heart J Acute Cardiovasc Care 2021 Oct;10(8):926-932

Servicio de Cardiología, Hospital Universitario La Princesa, Madrid, Spain.

Aims: Spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of acute coronary syndrome. Clinical features, angiographic findings, management and outcomes of SCAD in old patients (>65 years of age) remain unknown.

Methods And Results: The Spanish multicentre prospective SCAD registry (NCT03607981), included 318 consecutive patients with SCAD. Data were collected between June 2015 and April 2019. All angiograms were analysed in a centralized corelab. For the purposes of this study, patients were classified according to age in two groups <65 and ≥65 years old and in-hospital outcomes were analysed. Fifty-five patients (17%) were ≥65 years old (95% women). Older patients had more often hypertension (76% vs. 29%, P < 0.01) and dyslipidaemia (56% vs. 30%, P < 0.01), and less previous (4% vs. 18%, P < 0.001) or current smoking habit (4% vs. 33%, P < 0.001). An identifiable trigger was less often present in old patients (27% vs. 43%, P = 0.028). They also had more often severe coronary tortuosity (36% vs. 11%, P = 0.036) and showed more frequently coronary ectasia (24% vs. 9%, P < 0.01). Older patients were more often managed conservatively (89% vs. 75%, P = 0.025), with no significant differences in major adverse cardiac events during index admission (7% vs. 8%, P = 0.858). There were no differences between groups in terms of in-hospital stay, new acute myocardial infarction, unplanned coronary angiography or heart failure.

Conclusion: Older patients with SCAD show different clinical and angiographic characteristics compared with younger patients. Initial treatment strategy was different between groups, though in-hospital outcomes do not significantly differ (NCT03607981).
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http://dx.doi.org/10.1093/ehjacc/zuaa029DOI Listing
October 2021

Spontaneous Coronary Artery Dissection and Menopause.

Am J Cardiol 2021 06 20;148:53-59. Epub 2021 Feb 20.

Servicio de Cardiología. Hospital Universitario de La Princesa, Madrid. Spain, CIBER-CV, IIS-IP, Universidad Autónoma de Mdrid, Spain. Electronic address:

Spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of acute coronary syndrome in women. The role of sexual hormones has been related to the pathophysiology of SCAD. However, clinical features, angiographic findings, management and outcomes of SCAD women in relation to menopause status remain unknown. The Spanish multicenter prospective SCAD registry (NCT03607981), included 318 consecutive patients with SCAD. All coronary angiograms were analyzed in a centralized Corelab. In this substudy, 245 women were classified according to their menopause state (pre-menopausal and post-menopausal). In-hospital outcomes were analyzed: 148 patients (60.4%) were post-menopausal. These patients were older (57 [52 to 66] vs 49 [44 to 54] years, p <0.01) and had more often hypertension (49% vs 27%, p <0.01) and dyslipidemia (46% vs 25%, p <0.01). Post-menopausal women showed more often previous history of acute coronary syndrome, including previous SCAD (9% vs 3%, p = 0.046), and presented less frequently as ST-segment elevation myocardial infarction on admission, compared with premenopausal women (34% vs 49%, p = 0.014). On the other hand, premenopausal women showed more often proximal and multisegment involvement (24% vs 7%, and 32% vs 18%, respectively, both p <0.01). Post-menopausal women were more often managed conservatively (85% vs 71%, p <0.01) and presented less frequently left ventricular dysfunction (both, p <0.01). There were no differences between groups in terms of in-hospital stay or mortality, new acute myocardial infarction, unplanned coronary angiography or heart failure. In conclusion, post-menopausal women with SCAD show different clinical and angiographic characteristics compared with pre-menopausal SCAD patients. Initial treatment strategy was different between groups, though in-hospital outcomes did not significantly differ (NCT03607981).
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http://dx.doi.org/10.1016/j.amjcard.2021.02.007DOI Listing
June 2021

Haematoma decompression for a postpartum extensive left main spontaneous dissection.

Coron Artery Dis 2021 Jun;32(4):352-353

Cardiology Department, King's College Hospital, King´s College London, London, UK.

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http://dx.doi.org/10.1097/MCA.0000000000000992DOI Listing
June 2021

Consequences of canceling elective invasive cardiac procedures during Covid-19 outbreak.

Catheter Cardiovasc Interv 2021 04 17;97(5):927-937. Epub 2020 Dec 17.

Hospital Vall D´Hebron, Barcelona, Spain.

Background: During COVID-19 pandemic in Spain, elective procedures were canceled or postponed, mainly due to health care systems overwhelming.

Objective: The objective of this study was to evaluate the consequences of interrupting invasive procedures in patients with chronic cardiac diseases due to the COVID-19 outbreak in Spain.

Methods: The study population is comprised of 2,158 patients that were pending on elective cardiac invasive procedures in 37 hospitals in Spain on the 14th of March 2020, when a state of alarm and subsequent lockdown was declared in Spain due to the COVID-19 pandemic. These patients were followed-up until April 31th.

Results: Out of the 2,158 patients, 36 (1.7%) died. Mortality was significantly higher in patients pending on structural procedures (4.5% vs. 0.8%, respectively; p < .001), in those >80 year-old (5.1% vs. 0.7%, p < .001), and in presence of diabetes (2.7% vs. 0.9%, p = .001), hypertension (2.0% vs. 0.6%, p = .014), hypercholesterolemia (2.0% vs. 0.9%, p = .026) [Correction added on December 23, 2020, after first online publication: as per Dr. Moreno's request changes in p-values were made after original publication in Abstract.], chronic renal failure (6.0% vs. 1.2%, p < .001), NYHA > II (3.8% vs. 1.2%, p = .001), and CCS > II (4.2% vs. 1.4%, p = .013), whereas was it was significantly lower in smokers (0.5% vs. 1.9%, p = .013). Multivariable analysis identified age > 80, diabetes, renal failure and CCS > II as independent predictors for mortality.

Conclusion: Mortality at 45 days during COVID-19 outbreak in patients with chronic cardiovascular diseases included in a waiting list due to cancellation of invasive elective procedures was 1.7%. Some clinical characteristics may be of help in patient selection for being promptly treated when similar situations happen in the future.
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http://dx.doi.org/10.1002/ccd.29433DOI Listing
April 2021

[Acceso vascular único en intervencionismo coronario protegido con dispositivo de asistencia mecánica ventricular].

Arch Cardiol Mex 2020 Dec 16. Epub 2020 Dec 16.

Servicio de Cardiología, Hospital Clínico San Carlos e Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España.

El dispositivo de asistencia mecánica Impella CP (Abiomed, Danvers, Massachussetts) es el más utilizado para el apoyo hemodinámico en el intervencionismo coronario percutáneo de alto riesgo. Si se desea evitar un acceso adicional radial o femoral, es posible usar el introductor 14 F del dispositivo de asistencia como acceso vascular único.
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http://dx.doi.org/10.24875/ACM.20000023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8351664PMC
December 2020

Endothelial Dysfunction and Epicardial Coronary Spasm in a Woman With Previous Spontaneous Coronary Artery Dissection.

JACC Cardiovasc Interv 2020 12 25;13(24):e219-e220. Epub 2020 Nov 25.

Cardiología Intervencionista Department, Hospital Clínico San Carlos, IDISSC Universidad Complutense de Madrid, Madrid, Spain.

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http://dx.doi.org/10.1016/j.jcin.2020.09.036DOI Listing
December 2020

Performance of the heart team approach in daily clinical practice in high-risk patients with aortic stenosis.

J Card Surg 2021 Jan 21;36(1):31-39. Epub 2020 Oct 21.

Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain.

Objective: The heart team (HT) approach plays a key role in selecting the optimal treatment strategy for patients with aortic stenosis (AS). However, little is known about the HT decision process and its impact on outcomes. The aim of this study was to identify the factors associated with the HT decision and evaluate clinical outcomes according to the treatment choice.

Methods: The study included a total of 286 consecutive patients with AS referred for discussion in the weekly HT meeting in a cardiovascular institute over 2 years. Patients were stratified according to the selected therapeutic approach: medical treatment (MT), surgical (SAVR), or transcatheter (TAVR) aortic valve replacement. Baseline characteristics involved in making a therapeutic choice were identified and a decision-making tree was built using classification and regression tree methodology.

Results: Based on HT discussion, 53 patients were assigned to SAVR, 210 to TAVR, and 23 to MT. Older patients (≥88 years old) were mainly assigned to TAVR or MT according to the logistic EuroSCORE (
Conclusion: The HT decision was determined by well-recognized risk factors that were used to define a treatment decision algorithm. Future studies with younger and lower-risk patients may identify new contributory factors that may alter the selection process and treatment choice.
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http://dx.doi.org/10.1111/jocs.15116DOI Listing
January 2021

Interaction between age and vitamin D deficiency in severe COVID-19 infection.

Nutr Hosp 2020 Oct;37(5):1039-1042

Hospital Clínico San Carlos.

Introduction: Background: coronavirus disease 2019 (COVID-19) can induce an exaggerated inflammatory response. Vitamin D is a key modulator of the immune system. We hypothesized that vitamin D deficiency (VDD) could increase the risk of developing severe COVID-19 infection. Methods: patients with confirmed COVID-19 seen at the emergency department of our hospital with recent measurements of 25(OH)D were recruited. We explored the association of vitamin D deficiency (VDD), defined as 25-hydroxyvitamin D < 20 ng/mL, with a composite of adverse clinical outcomes. Results: we included 80 patients, of which 31 (39 %) presented the endpoint. VDD tended to predict an increased risk of developing severe COVID-19 after adjusting for age, gender, obesity, cardiac disease, and kidney disease [OR 3.2 (95 % CI: 0.9-11.4), p = 0.07]. Age had a negative interaction with the effect of VDD on the composite outcome (p = 0.03), indicating that the effect was more noticeable at younger ages. Furthermore, male gender was associated with VDD and with severe COVID-19 at younger ages. Conclusions: in this retrospective study, vitamin D deficiency showed a signal of association with severe COVID-19 infection. A significant interaction with age was noted, suggesting VDD may have a greater impact in younger patients. These findings should be confirmed in larger, prospective, adequately powered studies.
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http://dx.doi.org/10.20960/nh.03193DOI Listing
October 2020

Maternal Cardiac Assessment at 35 to 37 Weeks Improves Prediction of Development of Preeclampsia.

Hypertension 2020 08 22;76(2):514-522. Epub 2020 Jun 22.

From the Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom; School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom; and Cardiology Unit, Hammersmith Hospital, Imperial College London, United Kingdom.

Preeclampsia at term accounts for half of maternal deaths from hypertensive disorders. We aimed to assess differences in maternal cardiac indices at 35 to 36 weeks' gestation between women who subsequently developed preeclampsia at term compared with those with uncomplicated pregnancy and to evaluate whether cardiac indices offer incremental prognostic value to the available screening algorithm for preeclampsia. We recruited 1602 women with singleton pregnancies who attended for a routine hospital visit at 35 to 36 weeks' gestation between April and November 2018. We recorded maternal characteristics and preeclampsia-risk-score derived from a competing risks model and measured cardiac indices. Preeclampsia developed in 3.12% (50/1602) of participants. Women with preeclampsia, compared with those without, had increased mean arterial pressure (97.6, SD, 5.53 versus 87.9, SD, 6.82 mm Hg), systemic vascular resistance (1500, interquartile range, 1393-1831 versus 1400, interquartile range, 1202-1630 PRU) and preeclampsia-risk-score (23.4, interquartile range, 9.13-40 versus 0.9, interquartile range, 0.32-3.25). Multivariable analysis demonstrated independent association between the incidence of preeclampsia and E/e' (hazard ratio, 1.19/unit [95% CI, 1.03-1.37]; =0.018) as well as left ventricular mass indexed for body surface area (hazard ratio, 1.03/[g·m] [95% CI, 1.003-1.051]; =0.029). Women with E/e' ≥7.3 and left ventricular mass indexed for body surface area ≥63.2 g/m had an increased risk for developing preeclampsia, despite low preeclampsia-risk-score <5% (hazard ratio, 20.1 [95% CI, 10.5-38.7], <0.001). Increased left ventricular mass and E/e' offer incremental information to available scoring systems and better stratify women at risk of developing preeclampsia at term.
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.120.14643DOI Listing
August 2020

Spontaneous coronary artery dissection in Spain: clinical and angiographic characteristics, management, and in-hospital events.

Rev Esp Cardiol (Engl Ed) 2021 Jan 14;74(1):15-23. Epub 2020 May 14.

Servicio de Cardiología, Hospital Universitario de La Princesa, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain. Electronic address:

Introduction And Objectives: Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndrome. The characteristics and in-hospital clinical course of patients with SCAD in Spain remain unknown.

Methods: We present data from consecutive patients included in the national prospective SCAD registry. Angiographic analysis was performed in a centralized core laboratory.

Results: Between June 2015 and April 2019, we included 318 patients with SCAD (358 lesions) from 31 centers. Median age was 53 years, and 88% were women. The most frequent presentation was non-ST-segment elevation acute myocardial infarction (53%). The most frequently involved artery was the left anterior descending coronary artery (44%), predominantly affecting the distal segments (39%) and secondary branches (54%). Most lesions (62%) appeared on angiography as intramural hematoma, without double lumen. Conservative management was selected as the initial approach in most patients (78%). During the index admission, 6% of patients had a major adverse event and 4 patients (1.3%) died. Independent predictors of adverse events were initial management with percutaneous coronary intervention (OR, 5.97; P=.004) and angiographic presentation as intramural hematoma (OR, 4.96; P=.028).

Conclusions: In Spain, SCAD affects mainly middle-aged women. In most patients, the initial management strategy was conservative with excellent in-hospital survival. Initial management with percutaneous coronary intervention and angiographic presentation as intramural hematoma were related to the presence of in-hospital adverse events. Registered at ClnicalTrials.gov (Identifier: NCT03607981).
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http://dx.doi.org/10.1016/j.rec.2020.04.002DOI Listing
January 2021

Non-invasive assessment of endothelial function in patients with spontaneous coronary artery dissection: A case-control study.

Int J Cardiol 2020 10 5;316:40-42. Epub 2020 May 5.

Hospital Clínico San Carlos, IdISSC and Universidad Complutense, Madrid, Spain.

Background: The physiopathology underlying spontaneous coronary artery dissection remains largely unknown. Endothelial dysfunction is an early feature of many vascular disorders. We sought to determine the endothelial function assessed by reactive hyperemia peripheral arterial tonometry (RH-PAT) in patients with SCAD and compare it to that of non-SCAD patients with similar cardiovascular risk profile.

Methods: This is a case-control study with the participation of 2 centers. Patients (cases) were diagnosed with SCAD between 2008 and 2018. Control subjects were individually matched 2:1 to SCAD cases from a cohort recruited for assessment with RH-PAT between 2006 and 2013. The primary measure variable was the mean difference in the log-transformed reactive hyperemia index (LnRH-PAT Index) between groups.

Results: LnRH-PAT data from 23 patients with SCAD and 46 matched controls were analyzed. No significant differences were noted in the matching variables (overall, 95.7% female with mean age 52.7 years). In the SCAD group, more patients reported migraine (61 vs. 21%) and more patients were on betablockers (70 vs 28%), ACE inhibitors (65 vs. 13%) and statins (70 vs. 28%), all differences statistically significant. The mean LnRH-PAT value was 0.55 ± 0.22 in patients with SCAD and 0.77 ± 0.23 in controls (mean difference: 0.22, p < 0.001).

Conclusions: In this observational study, patients with SCAD had a poorer endothelial function than similar subjects without prior SCAD. This finding opens a new venue in the research of the physio pathologic mechanisms underlying SCAD.
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http://dx.doi.org/10.1016/j.ijcard.2020.04.049DOI Listing
October 2020

Adjunctive Rotational Atherectomy and Intravascular Lithotripsy for Heavily Calcified Left Main Disease Via Radial Access.

J Invasive Cardiol 2020 Apr;32(4):E99

Denmark Hill, Brixton, London, SE5 9RS Great Britain.

Coronary angiography demonstrated severe distal left main disease in a patient with heavy concentric calcification extending into the left anterior descending and left circumflex arteries. Rotational atherectomy and lithotripsy were used to debulk plaque so that stenting could be performed.
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April 2020

Sex Differences in Long-Term Outcomes in Patients With Deferred Revascularization Following Fractional Flow Reserve Assessment: International Collaboration Registry of Comprehensive Physiologic Evaluation.

J Am Heart Assoc 2020 02 17;9(4):e014458. Epub 2020 Feb 17.

Cardiovascular Institute Hospital Clinico San Carlos Madrid Spain.

Background Sex-specific differences may influence prognosis after deferred revascularization following fractional flow reserve (FFR) measurement. This study sought to investigate the sex differences in long-term prognosis of patients with deferred revascularization following FFR assessment. Methods and Results A total of 879 patients (879 vessels) with deferred revascularization with FFR >0.75 who underwent FFR and coronary flow reserve measurements were enrolled from 3 countries (Korea, Japan, and Spain). Long-term outcomes were assessed in 649 men and 230 women by the patient-oriented composite outcome (POCO, a composite of any death, any myocardial infarction, and any revascularization). We applied inverse-probability weighting based on propensity scores to account for differences at baseline between women and men (age, hyperlipidemia, diabetes mellitus, diameter stenosis, lesion length, multivessel disease, FFR, coronary flow reserve. The median follow-up duration was 1855 days (745-1855 days). Median FFR values were 0.88 (0.83-0.93) in men and 0.89 (0.85-0.94) in women, respectively. The occurrences of POCO were significantly high in men compared with that in women (10.5% versus 4.2%, =0.007). Kaplan-Meier analysis revealed that women had a significantly lower risk of POCO (χ=7.2, =0.007). Multivariate COX proportional hazards regression analysis revealed that age, male, diabetes mellitus, diameter stenosis, lesion length, and coronary flow reserve were independent predictors of POCO. After applying IPW, the hazard ratio of males for POCO was 2.07 (95% CI, 1.07-4.04, =0.032). Conclusions This large multinational study reveals that long-term outcome differs between women and men in favor of women after FFR-guided revascularization deferral. Clinical Trial Registration URL: http://www.ClinicalTrials.gov. Unique identifier: NCT02186093.
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http://dx.doi.org/10.1161/JAHA.119.014458DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7070212PMC
February 2020

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

Eur Heart J Acute Cardiovasc Care 2020 Oct 15;9(7):694-702. Epub 2019 Nov 15.

Hospital Clínico San Carlos, IdISSC and Universidad Complutense, Spain.

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 (=81) or takotsubo syndrome (=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%, =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, <0.001). Binary left ventricular systolic dysfunction was more prevalent in the takotsubo syndrome group (22% vs. 53%, <0.001), but no significant differences were noted at follow-up (6% vs. 1%, =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.
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http://dx.doi.org/10.1177/2048872619886311DOI Listing
October 2020

Reply.

Ann Thorac Surg 2020 04 30;109(4):1308. Epub 2019 Sep 30.

Hospital Clínico San Carlos, Instituto Cardiovascular, s/n 28040 Madrid, Spain.

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http://dx.doi.org/10.1016/j.athoracsur.2019.08.062DOI Listing
April 2020

Angiography-derived functional assessment of non-culprit coronary stenoses in primary percutaneous coronary intervention.

EuroIntervention 2020 04 3;15(18):e1594-e1601. Epub 2020 Apr 3.

Hospital Clinico San Carlos IDISSC and Complutense University of Madrid, Madrid, Spain.

Aims: Functional assessment of non-culprit lesions (NCL) in patients presenting with ST-elevation myocardial infarction (STEMI) and multivessel disease constitutes an unmet need. This study aimed to evaluate the diagnostic accuracy of quantitative flow ratio (QFR) in the functional assessment of NCL during the acute phase of STEMI.

Methods And Results: This was a retrospective, observational, multicentre study including patients with STEMI and staged fractional flow reserve (FFR) assessment of NCL. QFR in NCL was calculated from the coronary angiogram acquired during primary PCI in a blinded fashion with respect to FFR. The diagnostic value of QFR in the STEMI population was compared with a propensity score-matched population of stable angina patients. Eighty-two patients (91 NCL) were included. Target lesions were of both angiographic and functional (mean FFR 0.82±0.09) intermediate severity. The diagnostic performance of QFR was high (AUC 0.91 [95% CI: 0.85-0.97]) and similar to that observed in the matched control population (AUC 0.91 vs 0.94, p=0.5). The diagnostic accuracy of QFR was very high (>95%) in those vessels (61.5%) with QFR values out of a ROC-defined "grey zone" (0.75-0.85). A hybrid FFR/QFR approach (FFR only when QFR is in the grey zone) would adequately classify 96.7% of NCL, avoiding 58.5% of repeat diagnostic procedures.

Conclusions: QFR has a good diagnostic accuracy in assessing the functional relevance of NCL during primary PCI, similar to the accuracy observed in stable patients.
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http://dx.doi.org/10.4244/EIJ-D-18-01165DOI Listing
April 2020

Role of Invasive and Non-invasive Imaging Tools in the Diagnosis and Optimal Treatment of Patients with Spontaneous Coronary Artery Dissection.

Curr Cardiol Rep 2019 09 3;21(10):122. Epub 2019 Sep 3.

Interventional Cardiology Unit, Orbassano, and Infermi Hospital, San Luigi Gonzaga University Hospital, Rivoli, Turin, Italy.

Purpose Of Review: Spontaneous coronary artery dissection (SCAD) is a serious non-atherosclerotic disease, most frequently presenting as an acute coronary syndrome and affecting female patients. Considering that diagnosis of SCAD is often elusive, and its interventional treatment is associated to a higher rate of complications than obstructive atherosclerotic disease, we aim to review all the imaging tools currently available for the optimal diagnosis and treatment of this condition.

Recent Findings: The developments in both invasive and non-invasive imaging alternatives to coronary angiography, such as intravascular ultrasound, optical coherence tomography, and computed coronary angiography, have largely contributed to appraise the epidemiology of SCAD, understand its causative pathophysiological mechanisms, and improve our ability to confirm doubtful cases of SCAD. Intracoronary imaging is also a valuable in deciding the best therapeutic approach and in guiding interventions in those patients requiring percutaneous treatment. Furthermore, non-invasive imaging is a key tool in ruling out significant extracoronary vascular abnormalities which frequently occur in patients with underlying conditions like fibromuscular dysplasia who develop SCAD. Main imaging tools employed in SCAD cases could have advantages and drawbacks. Focusing on different types of SCAD, operators should be able to choose the best imaging technique for diagnosis, management, and follow-up.
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http://dx.doi.org/10.1007/s11886-019-1202-0DOI Listing
September 2019

Screening of extra-coronary arteriopathy with magnetic resonance angiography in patients with spontaneous coronary artery dissection: a single-centre experience.

Cardiovasc Diagn Ther 2019 Jun;9(3):229-238

Hospital Clínico San Carlos, IdISSC, Universidad Complutense, Madrid, Spain.

Background: Current consensus recommends extended vascular investigation in patients with spontaneous coronary artery dissection (SCAD). We here report our experience with the use of magnetic resonance angiography (MRA) for screening extra-coronary arteriopathy in patients presenting with SCAD.

Methods: Patients presenting with SCAD in a Spanish centre underwent prospective contrast-enhanced MRA to assess the cephalic and abdominopelvic arterial territories. Fibromuscular dysplasia (FMD) was diagnosed following European consensus criteria. Other vascular abnormalities were recorded separately. Two vascular radiologists supervised the acquisitions and independently analysed the results for all cases.

Results: Forty patients with SCAD [mean age 50.9±8.6 years, 90% (n=36) women] were included in the study, 12 patients declined to participate and 5 were excluded (metallic implanted devices). All enrolled patients underwent the screening protocol without complications. MRA demonstrated at least one extra-coronary vascular abnormality in 16 patients (40%): 5 (12.5%) were diagnosed with FMD, 6 (15%) showed arterial tortuosity, 3 (7.5%) had non-FMD focal stenoses, and 2 (5%) were found to have small aneurysms at the celiac trunk and splenic artery. No intracranial aneurysms were detected. At a mean follow-up of 4±3 years from the index episode, two cases experienced SCAD recurrences, one in a patient with FMD and the other one in a patient with arterial tortuosity. No deaths or strokes occurred.

Conclusions: Systematic extended vascular study with MRA was feasible and demonstrated associated extra-coronary arteriopathy in a substantial proportion of patients presenting with SCAD; however, none required additional intervention or led to vascular events. MRA, being a radiation-free modality, may be the preferred method for screening extracoronary arteriopathy in SCAD, a condition primarily affecting young and middle-age women sensitive to the risks of radiation.
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http://dx.doi.org/10.21037/cdt.2019.04.09DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6603500PMC
June 2019

Coexistence of Spontaneous Coronary Artery Dissection and Ascending Aortic Aneurysm.

Ann Thorac Surg 2019 10 20;108(4):e249-e252. Epub 2019 Mar 20.

Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain; Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain; Universidad Complutense, Madrid, Spain.

Spontaneous coronary artery dissection is associated with several conditions and vascular disorders. We describe the management of 2 patients presenting with spontaneous coronary artery dissection and unruptured ascending aortic aneurysms. Coexistence of spontaneous coronary artery dissection with extracoronary vascular disorders should be considered by clinicians.
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http://dx.doi.org/10.1016/j.athoracsur.2019.02.031DOI Listing
October 2019

Spontaneous Coronary Artery Dissection: Pathophysiological Insights From Optical Coherence Tomography.

JACC Cardiovasc Imaging 2019 12 13;12(12):2475-2488. Epub 2019 Mar 13.

Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, United Kingdom, and National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom. Electronic address:

Objectives: This study used optical coherence tomography to investigate the mechanism of false lumen (FL) formation in spontaneous coronary artery dissection (SCAD) by studying: 1) differences between fenestrated and nonfenestrated SCAD; 2) vasa vasorum density; and 3) light attenuation characteristics of the FL.

Background: SCAD is an increasingly recognized cause of acute coronary syndromes, characterized by FL formation and compression of the true lumen (TL). The mechanisms underlying FL formation remain poorly understood.

Methods: A total of 65 SCAD patients (68 vessels) who underwent acute OCT imaging as part of routine clinical care were included. Images were classified by the absence or presence of a connection (fenestration) between the TL and FL. Indexed measurements of TL stenosis, external elastic lamina (EEL) area, FL area, and light attenuation of the FL were assessed. Vasa vasorum densities of SCAD cases were compared with those in control non-SCAD myocardial infarction cases.

Results: In nonfenestrated cases, there was significantly larger expansion of the EEL area (9.1% vs. -1.9%; p <0.05) and a larger FL area (73.6% vs. 53.2%, respectively; p <0.05) in dissected segments. No significant differences were found between vasa vasorum density in SCAD and those in control subjects. The FL contents were heterogeneous but attenuated less light than whole blood or thrombus (4.28 ± 0.55 mm vs. 5.08 ± 0.56 mm; p < 0.05; vs. 4.96 ± 0.56 mm; p < 0.05).

Conclusions: These observational data suggest that the absence of a fenestration leads to increased FL pressure and compression of the TL. Although vasa vasorum may still be implicated in pathogenesis, increased vasa vasorum density could be an epiphenomenon of vascular healing.
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http://dx.doi.org/10.1016/j.jcmg.2019.01.015DOI Listing
December 2019

Letter by Macaya et al Regarding Article, "Early Natural History of Spontaneous Coronary Artery Dissection".

Circ Cardiovasc Interv 2019 01;12(1):e007611

Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), and Universidad Complutense Madrid, Spain.

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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.118.007611DOI Listing
January 2019
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