After an acute MI, SCAD readmissions are common, especially in young women.

 After an acute MI, SCAD readmissions are common, especially in young women.


According to data from the Nationwide Readmissions Database, after being hospitalized for acute MI, patients with spontaneous coronary artery dissection (SCAD) have greater rates of rehospitalization within 30 days than those without SCAD, with 80% of those readmissions being cardiac in character.

1,386 of the 2.6 million acute MI patients analyzed had SCAD (0.052 percent). SCAD patients were substantially more likely to be readmitted at 30 days (12.3 percent versus 9.9 percent; P = 0.022) than non-SCAD patients.

According to senior study author Samir R. Kapadia, MD (Cleveland Clinic Foundation, Ohio), "SCAD is quite uncommon, but this vast database is the first look at identifying who is at risk and what happens to them," in an interview with TCTMD. "What we discovered supports the fact that these patients are primarily female and young." The average age of SCAD patients was 48 years (compared to 67 years for the overall acute MI cohort), and 71% of the SCAD group were female.

Kapadia said that he was somewhat taken aback by the 12.3 percent statistic for SCAD readmissions. He stated, "The readmission rate is high." In this database, we can also see that they appear to be readmitted soon after discharge. For the SCAD group, the median duration between discharge and readmission was only 8 days.

What we discovered supports the fact that these patients are usually young and female.

It would seem to support keeping acute MI patients with SCAD hospitalized longer during the index hospitalization, write Fernando Alfonso, MD, Ph.D. (Hospital Universitario de La Princesa, Madrid, Spain) and colleagues in an editorial that is published alongside the study. For the overall cohort, 3 days was the average length of stay.

However, they add that it is currently difficult to identify patients who are more likely to experience SCAD extension or recurrences. Furthermore, we should respectfully acknowledge that there aren't any evidence-based treatments available to stop recurrences because there aren't any randomized clinical trials. We are unsure of the ideal antithrombotic regimen, its ideal length, or whether it should be tailored based on clinical presentation (for example, intramural hematoma versus communicating dissection).

Even when we feel confident about releasing patients, he said that it might be difficult to determine when it is safe to do so. He also stressed the need to inform patients, nurses, and emergency personnel that post-MI patients, especially young women, should not disregard cardiac symptoms. In light of the remarkable declines in STEMI presentations that hospitals are experiencing as a result of the COVID-19 epidemic, Kapadia said it is especially important to spread the word to people not to disregard their symptoms and to seek quick medical attention.

Younger, Female, and in better health

Researchers from the Cleveland Clinic Foundation in Ohio, under the direction of Mohamed M. Gad, MD, examined data from 2,654,087 acute MI patients who received treatment between 2010 and 2015 after 30-day readmission. SCAD patients were typically healthier, with lower prevalences of NSTEMI, CABG, and several common cardiovascular risk factors, in addition to being more likely to be young and female.

Those with STEMI reported greater readmission rates than those with NSTEMI in both men and women with SCAD (15.3 percent vs. 9.9 percent; P = 0.003). Additionally, readmission rates were greater for patients who received PCI during the index admission than for those who did not (P 0.0001; 15.5% vs. 8.7%). However, subsequent investigation revealed that only people with SCAD and NSTEMI were significantly associated between PCI and readmission. Among the non-SCAD group, PCI was related to a considerably reduced readmission rate in those with STEMI (6.5 percent vs. 13.2 percent; P 0.0001) but not with a higher incidence of readmission among those with NSTEMI.

The researchers also discovered that cardiac reasons accounted for 80% of SCAD readmissions, with recurrent MI leading the list, followed by chest discomfort and arrhythmia. Within the first two days following discharge, more than half of the readmissions took place.

SCAD was identified as an independent predictor of readmission within 30 days during the index hospitalization (OR 1.19; 95 percent CI 1.01-1.4). The additional predictors included previous MI, renal failure, heart failure, and chronic obstructive pulmonary disease.

Alfonso and colleagues point out a number of limitations in the study, such as the fact that only readmissions occurring in the same state as the index admission could be examined, that potentially pertinent clinical and angiographic variable that might have prognostic implications were not recorded, and that potential readmission triggers like physical or physiological stress and medication discontinuation were not taken into consideration. Whether readmissions were more common in patients who were discharged from the hospital sooner or later after the index diagnosis may also be helpful, they add.

The editorialists claim that SCAD is now an "obscure terrain, with significant gaps in scientific understanding," and as such, should be the subject of further research.

To better the short- and long-term management and, hopefully, the prognosis of SCAD patients, prospective coordinated research initiatives, ideally countrywide or international, are urgently required, they write.

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