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

Regional and temporal variations of spontaneous coronary artery dissection care according to consensus recommendations: a systematic review and meta-analysis

AIM

The first expert consensus documents on management of patients with spontaneous coronary artery dissection (SCAD) were published in 2018. Worldwide quality of care, as measured by adherence to these recommendations, has not been systematically reviewed. We aim to review the proportion of patients with SCAD receiving consensus recommendations globally, regionally and, determine differences in practice before and after 2018.

METHODS AND RESULTS

A systematic review was performed by searching four main databases (Medline, Embase, SCOPUS, CINAHL) from their inception to 16 June 2022. Studies were selected if they included patients with SCAD and reported at least one of the consensus document recommendations. 53 studies, n=8456 patients (mean 50.1 years, 90.6% female) were included. On random effects meta-analysis, 92.1% (95% CI 89.3 to 94.8) received at least one antiplatelet, 78.0% (CI 73.5 to 82.4) received beta-blockers, 58.7% (CI 52.3 to 65.1) received ACE inhibitors or aldosterone receptor blockers (ACEIs/ARBs), 54.4% (CI 45.4 to 63.5) were screened for fibromuscular dysplasia (FMD), and 70.2% (CI 60.8 to 79.5) were referred to cardiac rehabilitation. Except for cardiac rehabilitation referral and use of ACEIs/ARBs, there was significant heterogeneity in all other quality-of-care parameters, across geographical regions. No significant difference was observed in adherence to recommendations in studies published before and after 2018, except for lower cardiac rehabilitation referrals after 2018 (test of heterogeneity, p=0.012).

CONCLUSION

There are significant variations globally in the management of patients with SCAD, particularly in FMD screening. Raising awareness about consensus recommendations and further prospective evidence about their effect on outcomes may help improve the quality of care for these patients.

Spontaneous coronary artery dissection: an overview

The prevalence of spontaneous coronary artery dissection (SCAD) has increased over the last decades in young adults presenting with acute coronary syndrome. Although the diagnostic tools, including intracoronary imaging, have permitted a more accurate diagnosis of SCAD, the prognosis and overall outcomes remain dismal. Furthermore, the disproportionate sex distribution affecting more women and the underdiagnosis in many parts of the world render this pathology a persistent clinical challenge, particularly since the management remains largely supportive with a limited and controversial role for percutaneous or surgical interventions. The purpose of this review is to summarize the available literature on SCAD and to provide insights into the gaps in knowledge and areas requiring further investigation.

Current challenges in treatment and management of spontaneous coronary artery dissection

Though an infrequent cause of acute coronary syndrome, spontaneous coronary artery dissection is an increasingly recognized cardiovascular condition predominantly seen in middle-aged females. Its pathophysiology is defined by separation of coronary arterial wall layers which cause acute coronary syndrome-like presentations with relatively high recurrence rates. Overall, there is a lack of reported literature and understanding of the short- and long-term management for spontaneous coronary artery dissection. Therapeutic approaches include, but are not limited to, percutaneous coronary intervention, surgical revascularization, antithrombotic therapy, and beta-blocker therapy. There is a significant absence of randomized control trials to help guide both interventional and medical management for spontaneous coronary artery dissection. This review is aimed to review the current literature regarding risk factors and considerations for the short- and long-term management of spontaneous coronary artery dissection.