Therapeutic approach to acute coronary syndromes caused by scad: insights from the serbian (RS) SCAD registry

Background Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of acute coronary syndrome, predominantly affecting younger women. Optimal management, particularly the role of PCI, remains debated, with outcomes varying across angiographic subtypes. Methods We conducted a multicenter registry including 130 patients with angiographically confirmed SCAD from 14 PCI centers, followed during hospitalization, at 30 days, and at 1 year. Clinical presentation (STEMI/NSTEMI), SCAD type (1–4, including 2a/2b), management strategy (conservative vs PCI), TIMI flow, procedural details, low-molecular-weight heparin (LMWH) use, discharge therapy, and major adverse cardiovascular events (MACE) were analyzed. Results Mean age was 47.8 years; 85% were female. STEMI occurred in 68%. Hypertension (49%), dyslipidemia (46%), and active smoking (42%) were common. Conservative therapy was applied in 63 patients (48%), while 67 (52%) underwent PCI, including stent implantation and/or balloon-only angioplasty (POBA). Among PCI patients, the most common angiographic patterns were type 2 (n=18, mainly 2a), type 4 (n=10), type 1 (n=7). Pre-procedural TIMI flow varied by subtype; TIMI 3 flow was not achieved in all patients after intervention. Among 62 patients who achieved TIMI 3 flow, 24% underwent PCI (stent and/or POBA), while 76% achieved TIMI 3 flow without any procedure. LMWH data were available for all 130 patients; 75 (58%) received therapy, mostly short-term (1–2 doses in 43 patients). Extended LMWH dosing (3–6 doses) was used in 11, 8–10 doses in 7, 12–16 doses in 3, and 22–28 doses in 2 patients. At discharge, therapy included DAPT (n=92, 73%), beta-blockers (n=53, 42%), statins (n=49, 39%), ACE/ARBs (n=38, 30%), aspirin (n=31, 25%), and P2Y12 inhibitors (n=3, 2%). In-hospital MACE occurred in 31 patients (24%), with 8% mortality; 30-day and 1-year MACE were 8% and 8%, respectively. Prior heart disease, previous coronary interventions, and statin therapy independently predicted in-hospital MACE. Namely, MACE occurred in 17% of PCI-treated patients at 30 days and in 8% at 1 year. Conclusions This first SCAD registry from an Eastern transitional country shows that PCI and DAPT were used more frequently than recommended by guidelines. Conservative management was associated with better short-term outcomes, emphasizing that invasive procedures are not always required. Timely and accurate diagnosis, along with judicious use of LMWH and other therapies, is crucial to optimizing outcomes.