SCAD-Related MI Not Just the Domain of Young Women: Serbian Registry

MUNICH, Germany—Patients who experience acute myocardial infarction due to spontaneous coronary artery dissection (SCAD) can defy stereotypes, results from the Serbian SCAD Registry suggest. Moreover, researchers say the treatment these patients receive often isn’t ideal.

“The purpose of the registry is to raise awareness of SCAD and improve diagnosis,” Svetlana Apostolović, MD, PhD (University Clinical Center Nis, Serbia), said when presenting the analysis at the recent European Society of Percutaneous Cardiovascular Interventions (EAPCI) Summit. Importantly, she added, this Serbian experience is the first SCAD registry to be gathered in Eastern Europe.

No specific clinical guidelines currently exist for SCAD, but both American and European consensus documents recommend conservative management and advise cautious use of antiplatelet and anticoagulant therapy.

A surprise to emerge from their analysis, said Apostolović, is that while SCAD is typically thought to affect “young and middle-aged women,” 36.2% of patients in their registry were menopausal and 14.6% were men. Just 6.7% were pregnant or postpartum.

Serbian SCAD Registry

The researchers analyzed data collected by the Serbian SCAD Registry for 123 patients—22% retrospectively and 78% prospectively—with acute MI who were treated across 14 centers with interventional cardiology expertise between 2021 and 2024. Most (68.3%) presented with STEMI and the rest with NSTEMI.

Common risk factors for SCAD included hypertension (49.6%) and dyslipidemia (46.3%), while thyroid diseases, migraine, and diabetes mellitus each were documented in 12% or fewer patients.

What precipitated the event was not always known, but in instances where it could be identified, the most common causes were mental and physical stress. For 26%, intracoronary imaging was used to determine the SCAD diagnosis.

Typically, multiple segments were involved (56.3%), though SCAD occurred in the distal segment for 21.9%, mid for 18.8%, and proximal for 3.1%. The most commonly affected artery, at 56.1%, was the LAD. Just 8.9% of cases were in the RCA. SCAD type 2A predominated (42.1%), followed by type 1 (21.9%), type 4 (15.8%), type 2B (14%), and type 3 (6.1%).

Most  patients (58.5%) were treated conservatively with medical therapy alone, with 58.5% receiving dual antiplatelet therapy and 56.9% receiving low-molecular-weight heparin. Statins were given to 22.8%.

PCI was performed in 41.5% of all patients, and 28.5% got a stent—yet 50.4% had TIMI 3 flow before PCI.

Apostolović pointed out that while formal guidelines don’t exist on this issue, this intervention rate appears to be too high. Consensus documents essentially advise “don’t touch” when it comes to “patients with TIMI 3 flow, or TIMI 2 flow without angina [or ongoing] ischemia.” Also not ideal is the high proportion of patients—nearly six in 10—who received heparin, “because we know we have to stop heparin when we have a diagnosis of SCAD,” she said.

This speaks to the point of their registry, Apostolović noted, which is to ask: “What can we improve in everyday clinical practice?”

Regarding outcomes, the in-hospital rate of MACE (recurrent MI, hemodynamic instability, malignant arrhythmia, congestive heart failure, unplanned revascularization, or cerebrovascular event) was 23.6%. Eight percent of patients died. Within the 30 days after hospitalization, 18.1% experienced MACE and 0.8% died.

Independent predictors of higher in-hospital MACE risk were a history of cardiac interventions before SCAD and use of statins, whereas those who presented with STEMI had lower risk. For 30-day MACE, depression predicted higher risk while stent implantation and female sex were tied to lower risk.

Nearly two-thirds of patients (62.2%) saw their SCAD fully resolve after 30 days.

Their study offers several messages that might be applied going forward, according to Apostolović. “SCAD mostly affects young, stressed women and often presents as STEMI,” she said, though the prevalence of NSTEMI presentation in SCAD may be underestimated. Additionally, the data should inspire caution with regard to PCI, given that stent implantation foretold worse 30-day prognosis.

For her, the key takeaway is: “Awareness is crucial.”

Session co-moderator Stéphane Manzo-Silberman, MD (Sorbonne University, Institute of Cardiology—Hôpital Pitié‐Salpêtrière, AP‐HP, Paris, France), said the Serbian SCAD Registry makes a strong case for why it’s important to gather data such as these. In particular, “I was really impressed by the rates of PCI and in-hospital mortality,” she said, noting that in France, registry data indicate around 80% of SCAD patients had conservative management and the in-hospital mortality rate was zero.

Awareness is crucial, as are “prespecified protocols to diminish the [intervention] rate in these very high-risk patients,” commented Manzo-Silberman.

Highlighting the frequency of dual antiplatelet therapy in the Serbian SCAD Registry, co-moderator Dejan Milasinovic, MD (University Clinical Center of Serbia, Belgrade), noted that Italian, Spanish, and Australian registry data have suggested this isn’t the right tactic for SCAD. “I think single antiplatelets, according to current knowledge, is probably the way to go in most patients,” provided they haven’t received a stent.

“The consequence of this [dual therapy] is high mortality and high MACE after 30 days,” Apostolović agreed, noting that as registry findings accumulate, having more evidence will hopefully sway practice.