Angiographic phenotypes and predictors of acute complications in spontaneous coronary artery dissection: insights from a single-centre registry

Background Spontaneous coronary artery dissection (SCAD) is an under-recognised cause of acute coronary syndromes, particularly in young and middle-aged women without traditional risk factors. Despite growing awareness, data linking angiographic phenotypes with clinical outcomes remain limited, and current risk stratification relies mainly on expert opinion. Identifying high-risk angiographic features could improve early management and prognosis. Purpose To identify angiographic characteristics predicting acute in-hospital complications and major adverse cardiovascular events (MACE) during follow-up in patients with SCAD. Methods A single-centre observational study included 64 patients diagnosed with SCAD between November 2009 and August 2025. Dissections were classified by Saw criteria; variables included dissection type, number of vessels, culprit artery, stenosis severity and TIMI flow. Clinical data encompassed presentation, left ventricular ejection fraction (LVEF), in-hospital complications and MACE. Non-parametric tests (Kruskal–Wallis, Mann–Whitney, Spearman, Chi-square) were applied, followed by binary logistic regression to identify independent predictors of acute complications and MACE. Results The cohort was 92% female, mean age 48 ± 9 years. Type 2 SCAD was most frequent (63%), followed by type 1 (25%) and type 3 (12%). Multivessel disease occurred in 11%, mainly involving the LAD. Median LVEF was 45% (IQR 40–55). Conservative management predominated (82%), with PCI in 18%. Greater stenosis severity (p = 0.006) and lower TIMI flow (p = 0.008) were observed in type 2/3 dissections. Overall, 16% experienced acute in-hospital complications (recurrent ischaemia, arrhythmia or urgent re-catheterisation). In multivariable analysis, type 2/3 dissections (OR 0.097, 95% CI 0.021–0.451; p = 0.002) and TIMI ≤ 2 (OR 0.480, 95% CI 0.235–0.983; p = 0.044) independently predicted acute complications—representing about a tenfold higher risk. LVEF was not associated (p = 0.909). During 24-month follow-up, MACE occurred in 10%, with no angiographic or functional predictors identified (p = 0.55). Median hospital stay was five days, and recurrence of SCAD or ischaemic events remained low. Conclusions Type 2/3 SCAD and reduced TIMI flow (≤ 2) independently predicted acute in-hospital complications, mainly recurrent ischaemia and re-catheterisation. In contrast, long-term outcomes were comparable across angiographic subtypes, reflecting vessel healing, flow restoration and preserved function achieved under conservative management. Early angiographic risk profiling may support clinical decision-making and should be validated in larger multicentre studies. OR Outcomes