Medical treatment or revascularisation as the best approach for spontaneous coronary artery dissection: A systematic review and meta-analysis

Introduction: Patients presenting with spontaneous coronary artery dissection (SCAD) may receive either conservative medical management or a revascularisation strategy. There is still a lack of consensus with respect to the best treatment approach for SCAD. Objectives: We sought to determine whether outcomes differ between the first-line treatment approaches (conservative versus revascularisation) in patients with SCAD. Methods: We searched Medline, EMBASE and the Cochrane Library for studies published from January 1990 to November 2016 that compared first-line treatments for patients with SCAD. We conducted a pooled risk ratio meta-analysis for four main outcomes: mortality, myocardial infarction (MI), SCAD recurrence and target vessel revascularisation (TVR). Results: We identified 11 non-randomised studies that included a total of 631 patients. A pooled meta-analysis showed no significant difference between conservative management and revascularisation approaches in mortality (risk difference [RD] = 0.01; 95% confidence interval [CI] = -0.01 to 0.04; I-2 = 0%; p = 1), MI (RD = -0.01; 95% CI = -0.04 to 0.03; I-2 = 0%; p = 0.5) or SCAD recurrence (RD = -0.01; 95% CI = -0.06 to 0.05; I-2 = 0%; p = 0.74). Revascularisation as an initial first-line approach was associated with an estimated additional risk of TVR of 6.3% (RD = 0.06; 95% CI = 0.01-0.11; I-2 = 0%; p = 0.96). Conclusion: The results demonstrate an increased risk of TVR when revascularisation was used as the initial first-line treatment approach. The treatment decision must be individualised and be based on both clinical and angiographic factors, but conservative therapy should prevail in most cases.