Breaking the norm: assessing the implications of a dedicated SCAD clinical care pathway

Background Historically spontaneous coronary artery dissection(SCAD) has been underdiagnosed leading to variations in management.To provide structured care and improve patient outcomes,a specialized SCAD care pathway was implemented, integrating standardized diagnostic criteria, individualized medical management, vascular medicine consultation and cardiac rehabilitation including psychosocial support from hospitalization up to one year follow-up.The impact of implementing care pathways on clinical outcomes of SCAD patients, however, has not been studied to date. Purpose To assess in-hospital and long-term clinical outcomes of patients managed through the specialized SCAD care pathway in comparison to those who were treated before its implementation or didnot follow the pathway due to initial diagnostic uncertainties. Methods From an ongoing SCAD registry in our tertiary center,89 consecutive SCAD patients from 2012 to2024 were included.Patients who were treated according to the specialized SCAD clinical care pathway(n=38, group 1) were compared to patients treated before implementation of the SCAD care pathway(n=51, group 2). Known cardiovascular risk factors and clinical outcomes including recurrent ACS with(out) target vessel revascularization, cardiogenic shock and stroke were collected. Furthermore, medication use and hospital visits due to angina(equivalents) were evaluated at one year. Results After implementation of a specialized SCAD care pathway more patients were treated conservatively than invasively in the acute setting(79%in group 1 vs. 23%in group 2;p<0.001). In-hospital outcomes did not differ in terms of in-hospital death, revascularization, cardiogenic shock and bleeding. In accordance with the SCAD care pathway, patients in group 1 had a median hospital stay of 4 days(IQR 3–5) compared to 2 days(IQR 2–4) in group 2(p=0.007). At discharge, patients in group 1 were less frequently prescribed DAPT compared to group 2(13% vs. 94%;p<0.001).Similar trends were observed for statin therapy(37% vs. 92%;p<0.001).At a median follow-up of 12 months(IQR 11.9-12.1 months), beta-blockers were prescribed in 82% of patients in group 1 vs. 35% in group 2(p<0.001).At 1 year follow-up there were no significant differences in left ventricular function(p=0.488)and ACS recurrence requiring revascularization. In group 1 95% of patients were screened for FMD, of whom 28%were diagnosed with FMD, whereas in group 2 25% were screened and 31%were found to have FMD(p=0.838). Furthermore,no recurrence of SCAD occurred in either group.In group 1, fewer patients(16%) presented at the emergency department with angina(equivalents) without evidence of ACS,compared to 22%in group 2(p=0.493). Conclusion This study provides insights into the effectiveness of a dedicated SCAD care pathway in improving outcomes for this unique patient population. Findings support the expansion of specialized SCAD programs and highlight the importance of tailored management strategies.Treatment and follow-up of SCAD patients