Antiplatelet Therapy Following Spontaneous Coronary Artery Dissection: Systemic Review

BackgroundSpontaneous coronary artery dissection (SCAD) is an understudied cause of acute coronary syndrome (ACS), particularly in women. Heart muscle damage may result from spontaneous dissection of coronary arteries. There is no clear consensus regarding the optimum antiplatelet medication regimen and treatment duration for SCAD despite current American Heart Association (AHA) consensus guidelines recommending 12-month regimen of dual antiplatelet therapy (DAPT) consisting of a P2Y12 inhibitor and aspirin for patients following myocardial infarction (MI). The objective of this study was to evaluate the safety and effectiveness of DAPT compared to using a single antiplatelet therapy (SAPT) as part of the medical armamentarium to treat SCAD. MethodsA comprehensive search of the literature was conducted to identify studies that examined SCAD outcomes including mortality, recurrence, and major adverse cardiovascular events (MACE) between 2000-2023 after antiplatelet therapy was administered. Based on the documentation in various studies, only 17 relevant studies were identified in which SAPT (primarily aspirin) and DAPT (aspirin combined with a P2Y12 inhibitor) were administered. Medications used in cardiovascular medicine that did not provide comprehensive data were excluded from the studies. ResultsDAPT treatment was associated with a poorer prognosis than SAPT 12 months after patients presented with SCAD. A key observation was the prevalence of antiplatelet treatment in SCAD patients, with DAPT prescribed for the majority of cases. At the 12-month time point, DAPT demonstrated had a higher rate of mortality (P = 0.0245), MACE (P = 0.0265), and angina admission rate (P = 0.071), as well as a higher rate of recurrent SCAD (P =0.0579) (Fig. 2). An increased incidence of non-fatal myocardial infarction or emergency percutaneous coronary intervention primarily drove these adverse outcomes. O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=48 SRC="FIGDIR/small/24312989v1_fig2.gif" ALT="Figure 2"> View larger version (12K): org.highwire.dtl.DTLVardef@1a06480org.highwire.dtl.DTLVardef@126115corg.highwire.dtl.DTLVardef@3dbae3org.highwire.dtl.DTLVardef@b8b015_HPS_FORMAT_FIGEXP M_FIG O_FLOATNOFig. 2.C_FLOATNO Outcomes in Patients with SCAD on Antiplatelet Therapy. Outcomes as a % of total patient population for each study were tabulated and data distribution was interrogated for normality and expressed as median {+/-} 95% confidence interval. Group differences were assessed by the Mann-Whitney U test with the p-value as noted. The number of literature studies identified is indicated in parentheses. SAPT=Single Antiplatelet Therapy (white), DAPT= Dual Antiplatelet Therapy (black), MACE=Major Adverse Cardiovascular Events. C_FIG ConclusionIn patients treated with antiplatelet therapy, adverse events that include unstable angina, mortality, and repeat revascularization were greater in patients with more aggressive antiplatelet therapy consisting of DAPT compared with these treated with SAPT.