Rethinking potent antiplatelet therapy in spontaneous coronary artery dissection before it harms

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This commentary refers to ‘The Australian–New Zealand spontaneous coronary artery dissection cohort study: predictors of major adverse cardiovascular events and recurrence’, by Q.M. Dang et al., https://doi.org/10.1093/eurheartj/ehaf097 and the discussion piece ‘Managing spontaneous coronary artery dissection: the less, the better’, by E. Cerrato et al., https://doi.org/10.1093/eurheartj/ehaf1051. As investigators of the Australian–New Zealand Spontaneous Coronary Artery Dissection (ANZ-SCAD) Registry,1 we thank Cerrato et al. for their thoughtful commentary and for highlighting the converging evidence between the DISCO and ANZ-SCAD registry studies. The pathophysiology of SCAD-related acute coronary syndrome (ACS) differs fundamentally from atherosclerotic ACS, where intramural haematoma and vessel wall fragility, rather than plaque rupture and thrombus, are the dominant mechanisms of flow limitation. The first European Society of Cardiology (ESC) consensus statement on SCAD (2018)2 acknowledged uncertainty regarding antiplatelet therapy, whereas the 2023 ESC ACS Guidelines3 recommended pharmacotherapy akin to atherosclerotic ACS. Accumulating registry data now challenges this approach. Both the DISCO and Spanish SCAD registries reported higher major adverse cardiovascular events (MACEs) with dual vs single antiplatelet therapy (DAPT).4,5 Our ANZ-SCAD study extended these observations: with DAPT comprising the more potent antiplatelet therapy, ticagrelor, associated with increased MACE [adjusted hazard ratio (HR), 1.8; 95% confidence interval (CI), 1.04–3.2; P = .037] and recurrence [adjusted HR, 2.6; 95% CI, 2.1–5.3; P = .01). Notably, Cerrato et al. report that ticagrelor-based DAPT similarly predicted MACE in an unpublished DISCO analysis. These concordant findings reinforce the hypothesis that intramural bleeding, potentially exacerbated by potent antiplatelet therapy, is central to SCAD formation and recurrence.

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