Clinical and Prognostic Implications of Precipitating Factors in Patients With Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS), historically linked to pregnancy but increasingly associated with emotional and physical stressors. The prognostic impact of these precipitating factors remains unclear. This study aimed to evaluate their clinical and prognostic relevance in a large, nationwide prospective SCAD cohort. The prospective Spanish SCAD Registry (RN-DCE) included 388 patients from 34 centers since 2015. Coronary angiograms were centrally reviewed, and patients were categorized based on the presence and type of precipitating factor (emotional or physical). Major adverse cardiovascular and cerebrovascular events (MACCE) including all-cause death, reinfarction, unplanned revascularization, recurrent SCAD, and stroke, were centrally adjudicated. Cox regression models were used to assess associations with in-hospital and long-term outcomes. Precipitating factors were identified in 40% of patients, with emotional triggers more common than physical (26% vs 15%). Patients with triggers were younger (52 (±11.3) vs 55 (±11.8) years, p = 0.046) and had higher rates of depression and anxiety (24% vs 18%, p = 0.078 and 25% vs 13%, p <0.004). Emotional triggers were more frequent among women and strongly associated with psychiatric history. The overall presence of a trigger was not associated with increased MACCE risk (Adjusted HR: 0.90 (0.39-2.10), p = 0.794). However, SCAD events related to the peripartum period or to Valsalva maneuvers were associated with worse short- and long-term outcomes. In conclusion, in this large national cohort, most precipitating factors were not linked to worse prognosis. However, peripartum-related SCAD and events triggered by Valsalva-like maneuvers may indicate higher-risk presentations and warrant closer clinical attention.