Spontaneous Coronary Artery Dissections: Treatment Recommendations Still Unheeded

Consensus recommendations for spontaneous coronary artery dissection (SCAD) have been applied inconsistently despite increasing awareness of this condition, according to a meta-analysis.

Observational studies showed significant variations in clinical practice around the world, particularly for fibromuscular dysplasia (FMD) screening, which had a large range of implementation rates, with the Middle East at the low end (0.6%) and North America at the high end (60.5%).

“This is despite the well-known association between SCAD and FMD, with screening recommended in all patients to look for extracardiac vascular manifestations,” wrote Sarah Zaman, MBBS, PhD, of the University of Sydney and Westmead Hospital in Australia, and colleagues in Open Heart.

They reported that other recommendations from the first scientific statements on the management of SCAD — published in 2018 by the American Heart Association and the European Society of Cardiology — also appeared to be applied in the real world to varying degrees:

• At least one antiplatelet agent: Consistently near 100% in most regions (except 78.2% in North America)
• Beta-blocker use: Consistently over 63% in all regions
• Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in the presence of left ventricular systolic dysfunction: Ranges from 44.2% to 81.3% across regions

“An improvement in adherence to recommended therapies is thus needed. Raising awareness among clinicians about these recommendations, together with further prospective evidence on their effectiveness in reducing [major adverse cardiovascular events], may help improve quality of care for patients with SCAD,” Zaman’s group concluded.

They noted that the data they analyzed suggested little change in adherence to consensus recommendations before and after they were published in 2018 — “likely a consequence of later studies including patients recruited historically, diluting any change in the quality-of-care with time.”

SCAD is increasingly recognized as a cause of acute coronary syndrome, particularly in women younger than 50. Such tears in the wall of the epicardial coronary artery are not as rare as previously thought, with the study authors reporting “nearly eight times the number of patients studied in the past 4 years, compared with the 30 years prior.”

Nevertheless, there are no randomized data to guide treatment for SCAD.

In its 2018 statement, the American Heart Association said that SCAD is best treated conservatively with in-hospital monitoring rather than invasive treatment. Newer observational data indeed suggested that SCAD patients who had presented with heart attacks and were largely treated conservatively had surprisingly favorable outcomes in the long run.

Antiplatelets and beta-blockers remain controversial as medical therapy for SCAD, Zaman and colleagues noted.

For their study, the group had performed a systematic review pooling 53 studies with 8,456 SCAD patients (mean age 50.1 years, 90.6% women) in 22 countries. These were a mix of retrospective and prospective studies, with 39 out of the 53 reports published from 2018 to 2022.

On random effects meta-analysis, 92.1% of patients received at least one antiplatelet, 78.0% received beta-blockers, 58.7% received ACE inhibitors or ARBs, and 54.4% were screened for FMD.

Although 70.2% of SCAD patients were ostensibly referred to cardiac rehabilitation, this outcome was reported only from North America.

“This systematic review is limited by the under-reporting of several quality-of-care measures, particularly cardiac rehabilitation and FMD screening. We were also unable to determine use of single versus dual antiplatelet therapy in many studies,” Zaman’s group cautioned.

“Most of the studies included in our systematic review were from higher-income countries, highlighting a paucity of data from lower-income countries. It is possible that adherence would be lower than our current data, particularly for FMD screening and rehab referral, due to limitations in resources in these countries,” they added.

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