Park Huijun Edelyn, Cho Leslie S, Fendrikova-Mahlay Natalia, Chaudhury Pulkit, Cameron Scott J
Lerner Research Institute, Cardiovascular and Metabolic Sciences, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA.
Heart, Vascular and Thoracic Institute, Department of Cardiovascular Medicine, Department of Interventional Cardiology, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA.
Cardiovasc Diagn Ther. 2025 Jun 30;15(3):705-713. doi: 10.21037/cdt-24-108. Epub 2025 Jun 26.
Spontaneous coronary artery dissection (SCAD) is a poorly-studied cause of acute coronary syndrome (ACS), particularly in women. SCAD is a rare cause of ACS that can lead to myocardial injury due to SCAD. This review evaluates optimal antiplatelet therapy for SCAD patients. 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.
This review included only observational studies published in English and excluded randomized controlled trials. A comprehensive search of PubMed, Ovid, and SCOPUS was conducted to identify studies that examined SCAD outcomes including mortality, recurrence, and major adverse cardiovascular events (MACEs) 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 P2Y inhibitor) were administered. SCAD for SAPT and DAPT groups were analyzed by calculating the mean, standard deviation (SD), range, and 95% confidence intervals (CIs). Results were reported as mean ± SD, with CIs indicating precision. Studies lacking comprehensive data on concurrent cardiovascular medication use (e.g., beta-blockers, statins) or key outcome measures were excluded.
DAPT treatment was associated with a worse 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 in the majority of cases. DAPT demonstrated significantly higher rates of mortality (4.96% 1.55%), MACE (12.13% 6.91%), and hospitalizations for angina (23.75% 2.60%) compared to SAPT. SCAD recurrence was also more frequent in the DAPT group (5.54% 2.33%). These adverse outcomes, primarily driven by increased non-fatal MI and unplanned percutaneous coronary interventions (PCIs), highlight the challenges of DAPT in SCAD management.
In 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 for safety and efficacy of DAPT compared with these treated with SAPT.
自发性冠状动脉夹层（SCAD）是急性冠状动脉综合征（ACS）的一个研究较少的病因，在女性中尤为如此。SCAD是ACS的一种罕见病因，可导致因SCAD引起的心肌损伤。本综述评估了SCAD患者的最佳抗血小板治疗。尽管美国心脏协会（AHA）目前的共识指南建议对心肌梗死（MI）后的患者采用由P2Y12抑制剂和阿司匹林组成的12个月双联抗血小板治疗（DAPT）方案，但对于SCAD的最佳抗血小板药物方案和治疗持续时间尚无明确共识。本研究的目的是评估DAPT与使用单一抗血小板治疗（SAPT）相比作为治疗SCAD的药物手段的安全性和有效性。
本综述仅纳入以英文发表的观察性研究，排除随机对照试验。对PubMed、Ovid和SCOPUS进行了全面检索，以确定在2000年至2023年期间抗血小板治疗后检查SCAD结局（包括死亡率、复发率和主要不良心血管事件（MACE））的研究。根据各项研究中的记录，仅确定了17项相关研究，其中使用了SAPT（主要是阿司匹林）和DAPT（阿司匹林联合P2Y抑制剂）。通过计算均值、标准差（SD）、范围和95%置信区间（CI）对SAPT组和DAPT组的SCAD进行分析。结果报告为均值±标准差，CI表示精度。缺乏关于同时使用心血管药物（如β受体阻滞剂、他汀类药物）或关键结局指标的全面数据的研究被排除。
在SCAD患者出现症状12个月后，DAPT治疗与比SAPT更差的预后相关。一个关键观察结果是SCAD患者抗血小板治疗的普遍性，大多数病例使用DAPT。与SAPT相比，DAPT的死亡率（4.96%±1.55%）、MACE（12.13%±6.91%）和心绞痛住院率（23.75%±2.60%）显著更高。DAPT组的SCAD复发也更频繁（5.54%±2.33%）。这些不良结局主要由非致命性MI和非计划经皮冠状动脉介入治疗（PCI）增加所致，凸显了DAPT在SCAD管理中的挑战。
在接受抗血小板治疗的患者中，与接受SAPT治疗的患者相比，采用更积极的抗血小板治疗（即DAPT的安全性和有效性）的患者发生不稳定型心绞痛、死亡率和重复血运重建等不良事件更多。
