Beyond angiography: cardiac rehabilitation after spontaneous coronary artery dissection — a systematic review and meta-analysis

Background Spontaneous coronary artery dissection (SCAD) is a recognised cause of acute coronary syndrome in younger women. Beyond acute angiographic diagnosis and predominantly conservative management, many patients report persistent chest pain, reduced confidence to exercise, impaired functional capacity, and psychological distress. Optimal secondary prevention remains uncertain, and current recommendations rely largely on limited evidence for SCAD-specific interventions. Cardiac rehabilitation (CR) may offer a structured pathway to restore exercise capacity and support psychosocial recovery beyond coronary healing. Purpose To quantify the association of CR with patient-centred recovery outcomes and to summarise available comparative evidence on clinical events after SCAD. Methods PubMed and Embase were searched through 15 February 2026 for studies reporting quantitative outcomes in SCAD patients participating in CR programmes. Outcomes included treadmill performance (METs), peak VO2, depression (PHQ-9), generalised anxiety (GAD-7), recurrent chest pain, revascularisation, MACE, angina hospitalisations, and recurrent myocardial infarction (MI). Continuous outcomes were pooled as mean differences (MD) and dichotomous outcomes as risk ratios (RR) using random-effects models. Heterogeneity was assessed using the Chi-squared test and the I2 statistic. Results Five observational studies, including 953 patients (459 CR; 494 no CR), were included. CR was associated with improved exercise capacity: pooled treadmill performance increased by 1.06 METs (MD 1.06 CI 0.48 to 1.64; p=0.0004), and pooled peak VO2 increased by 2.89 mL/kg/min (MD 2.89 CI 0.71 to 5.06; p=0.009). Chest pain prevalence decreased during CR, with study-level relative reductions ranging from 41% to 80%. Psychological outcomes improved where reported: PHQ-9 decreased by 2.33 points (MD -2.33 CI -5.58 to 0.92), and GAD-7 decreased by 4.4 points (MD -4.4 CI -6.44 to -2.36). Across pooled dichotomous clinical endpoints (revascularisation, MACE, angina hospitalisations, and recurrent MI), no significant differences were observed between CR participants and non-participants with short follow-up across studies. Conclusion(s) In patients with SCAD, CR is associated with clinically meaningful improvements in exercise capacity and patient-centred recovery outcomes, including reduced chest pain burden and improved anxiety and depressive symptoms, supporting CR as a key step beyond angiography to optimise recovery and return to function. However, available comparative data are underpowered for clinical events and cannot exclude benefit or harm. Larger prospective studies with standardised CR protocols and longer follow-up are required to define the impact of CR on recurrent events, health-care utilisation, and long-term quality of life, particularly given the prognostic relevance of cardiorespiratory fitness.