Spontaneous Coronary Artery Dissection: Determinants of Clinical Outcomes, Quality-of-Care, and Quality-of-Life

Abstract

Background

Spontaneous coronary artery dissection (SCAD) is an increasingly recognised cause of acute coronary syndrome (ACS), predominantly in young women without traditional risk factors.

Aims

The overall aim of this thesis was to assess the long-term clinical outcomes, quality-of-life (QOL) and quality of care (QOC) for patients with SCAD.

Methods

A multi-centre cohort study, the Australia-New Zealand (ANZ) SCAD Registry, assessed clinical outcomes with multivariable Cox proportional hazard models used to explore factors associated with MACE and SCAD recurrence. QOL in SCAD survivors was assessed using the EQ-5D-3L questionnaire. A systematic review was performed to explore QOC in patients with SCAD. An online survey of Australian SCAD survivors determined patients’ perspectives on QOC and its relationship to QOL.

Results

A total of 505 were recruited to the ANZ-SCAD Registry. On multi-variable analysis, oral anticoagulation (adjusted hazard ratio [aHR] 3.8, 95% confidence interval [CI] 1.6–9.3, P = 0.003), dual-antiplatelet therapy (DAPT) comprising ticagrelor and aspirin (aHR 1.8, 95%, CI 1.04–3.2, P = 0.037), FMD (aHR 2.2, 95% CI 1.05–4.5, P = 0.037), and history of stroke (aHR 3.8, 95% CI 1.2–12.2, P = 0.03) were associated with increased risk of MACE. FMD (aHR 3.9, 95% CI 1.5–26.5, P = 0.01), DAPT comprising ticagrelor and aspirin (aHR 2.6, 95% CI 2.1–5.3, P = 0.01), and history of stroke (aHR 6.2, 95% CI 1.8–9.5, P = 0.01) were associated with increased SCAD recurrence.

Conclusion

This thesis demonstrates that SCAD was associated with ongoing risk of adverse cardiovascular outcomes, particularly in patients with fibromuscular dysplasia and dual antiplatelet therapy comprising ticagrelor. There was a significant physical and psychological burden, with QOC strongly linked to QOL. Collectively, these findings highlight the need for tailored management strategies, improved consistency of care, and greater patient support to optimise outcomes after SCAD.