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.