Spontaneous coronary artery dissection: clinical presentation, management, and long-term outcomes

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndromes, particularly among young and middle-aged women without traditional cardiovascular risk factors. However, data regarding optimal management and long-term outcomes remain limited.

To describe the clinical characteristics, angiographic findings, management strategies and long-term outcomes of patients diagnosed with SCAD at a tertiary cardiology center.

We retrospectively included patients diagnosed with SCAD between November 2009 and August 2025. Major adverse cardiovascular events (MACE) were defined as a composite of cardiovascular death, myocardial infarction, stroke, or hospitalization for heart failure.

We included 64 patients, predominantly female (93.8%), with a median age of 51 years (IQR 44–64). Hypertension was present in 51.6%, dyslipidemia in 37.5%, and diabetes in 4.7%; 28.1% had no cardiovascular risk factors. Approximately half were postmenopausal (48.5%) and one patient was pregnant. Systemic inflammatory disease was present in 7.8%, most commonly Hashimoto thyroiditis (3.1%). Psychiatric comorbidities were frequent (depression 21.9%, anxiety 9.4%), and emotional or physical triggers were identified in 18.7%. Associated conditions were found in 37.5%, including headache (10.9%) and fibromuscular dysplasia (4.7%).

Most patients presented with non–ST-segment elevation myocardial infarction (60.9%) and preserved hemodynamic status (Killip class I in 90.6%). The left anterior descending artery was most frequently involved (57.8%), and type 2 dissection predominated (62.5%). Multivessel dissection occurred in 10.9% and left main involvement in 6.3%. Atherosclerotic disease was absent in 93.8% of cases.

Most patients (90.6%) were managed conservatively. During hospitalization, 28.1% experienced recurrent chest pain and 21.9% required repeat angiography after a median of 6.5 days, with lesion progression in 14.1%. Left ventricular ejection fraction was preserved in 71.9% (median 55%, IQR 49–63). Median hospital stay was 6 days (IQR 5–11).

At discharge, 87.5% received aspirin, 57.8% dual antiplatelet therapy (mostly clopidogrel and for one year), 79.7% beta-blocker, 54.7% ACEI/ARB, and 68.8% statin. After a median follow-up of 69 months (IQR 32.8–116.8), 14.1% experienced MACE and 3.1% cardiovascular death. Persistent chest pain occurred in 20.3%, while new-onset anxiety and depression developed in 12.5% and 3.1%, respectively.

In this single-center cohort of SCAD, most patients were middle-aged women without significant atherosclerotic disease and were successfully managed conservatively. Despite overall favorable recovery and preserved ventricular function, recurrent ischemic events, persistent chest pain and psychological morbidity were frequent, underscoring the need for long-term multidisciplinary follow-up and psychosocial support.