At Issue: Challenges of managing SCAD, which predominantly affects women
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Spontaneous coronary artery dissection is a life-altering event that predominantly affects women, but there is little consensus about how to best diagnose and treat it.
Spontaneous coronary artery dissection (SCAD) is a tear inside a coronary artery caused by the artery’s inner layers separating from its outer layers, and it can lead to MI, arrhythmia or sudden death, according to Mayo Clinic’s website.
The condition most often occurs in women aged in their 40s and 50s who in many cases do not have any known CV risk factors, but can occur in men and in people of any age. Symptoms include chest pain; rapid heartbeat or fluttery feeling in the chest; pain in the shoulders, back and jaw; shortness of breath; sweating; unusual or extreme tiredness; nausea; and dizziness, according to Mayo Clinic.
Aside from female sex, the following factors have been associated with SCAD: recent childbirth, fibromuscular dysplasia, hormone use, diseases causing blood vessel inflammation, genetic connective tissue diseases, severely high BP and illegal drug use.
Yet, despite the existence of various review papers and scientific statements, many clinicians are not aware of SCAD, making diagnosis difficult and treatments inconsistent.
Healio and Cardiology Today asked leading cardiologists: What are the biggest challenges in the management of patients with SCAD?
Leslie Cho, MD
SCAD is underrecognized by cardiologists.
Also, for the majority of patients with SCAD, they do not need stenting or surgery. However, because it is unrecognized, many of these women are getting unnecessary revascularization with poor outcomes.
While coronary artery dissection has been known for many years, recognition of the three different types of dissection on the cardiac angiogram is relatively new for some providers.
Continuing education for physicians is critically important.
Cho is director of Cleveland Clinic’s Women’s Cardiovascular Center.
Sharonne Hayes, MD
A big issue, still, is believing women. Patients with SCAD are often younger, healthy looking, fit people. They may present describing the feeling of having an elephant on their chest, yet our triage may not be diverted to a cardiac workup. That is foundational, and not specific to SCAD, but we have a patient population that is more vulnerable to not getting a cardiac evaluation to start with. That comes before the cardiologist. That means we, as cardiologists, need to educate our colleagues in the ED and EMTs.
Another issue is that we still are challenged by currently available diagnostic tools with consistently making the proper diagnosis in the cath lab. We have experience to gain and need to learn from the experts. I have seen a huge improvement in recognition of SCAD, the suspicion of SCAD, the original cath report stating that the patient may have SCAD. We need more of that.
Once a clinician recognizes it as SCAD, the immediate care is often appropriate. It is about getting the diagnosis up front, and not someone treating it as atherosclerosis.
The third area where we have room to grow would be the care of this patient after SCAD. This patient population is different. The mental health burden on these patients is substantial. These people need different and more psychological support, and they often do not get it. Part of this is a systems issue. Most cardiologists did not get into this specialty because they like talk therapy. The average cardiology visit is not long enough to address the many questions a patient may have about this complex condition. Across all SCAD clinics, these patients need and take time. We all get behind, because we take care of them. We must develop better sources of information that are accessible, so patients do not have to wait to get into a SCAD clinic to get some questions answered.
Hayes is professor of cardiovascular medicine, former director of the Office of Diversity and Inclusion, and founder of the Women’s Heart Clinic at Mayo Clinic in Rochester, Minnesota.
Daniella Kadian-Dodov, MD
SCAD affects mostly women without typical CV risk factors. Many are in the prime of their life and health. Therefore, the mental health aspects of a devastating and sudden event like SCAD cannot be underestimated. Many patients suffer from posttraumatic stress disorder, or at minimum severe anxiety in their recovery. Further complicating the situation is that mental health resources are scarcely (if at all available) for many. In New York, for example, it is hard to find mental health providers that will accept insurance. Continued stigma toward mental health issues is another challenge to overcome.
Kadian-Dodov is assistant professor of medicine at the Icahn School of Medicine at Mount Sinai and vascular medicine physician at Mount Sinai Heart.
Jacqueline Saw, MD
The accurate diagnosis of SCAD remains a challenge. There is underdiagnosis and sometimes we are even challenged with overdiagnosis.
After a diagnosis, there is great uncertainty about how to manage these patients. Many medications we use do not have randomized controlled trial data to support their use, even though registry data do suggest that aspirin and beta-blockers are important.
Sometimes SCAD can appear quite subtle on angiograms. The diagnostic physician, who is not used to SCAD cases, may miss these more subtle cases. It is a challenge to diagnose. It can affect the distal portion of the artery and look like a normal tapering. Or the blockages can be quite short and mimic cholesterol blockages. A physician who does not have a high index of suspicion may not image further.
Support is important. Many of these patients already have stress and anxiety. After a SCAD episode, they may not have access to a SCAD specialist. There is a lot of emotional stress and anxiety post-event. They should be referred to cardiac rehab, even if it is not SCAD-specific, because there are links to psychologists and psychiatrists available to help with the emotional aspects of MI management.
Saw is an interventional cardiologist at Vancouver General Hospital and St. Paul’s Hospital, program director of the Vancouver General Hospital Interventional Cardiology Fellowship Program and clinical assistant professor of medicine at the University of British Columbia.
Reference:
- Mayo Clinic. www.mayoclinic.org/diseases-conditions/spontaneous-coronary-artery-dissection/symptoms-causes/syc-20353711. Accessed Jan. 31, 2023.
For more information:
Leslie Cho, MD, can be reached at chol@ccf.org.
Sharonne Hayes, MD, can be reached at hayes.sharonne@mayo.edu; Twitter: @sharonnehayes.
Daniella Kadian-Dodov, MD, can be reached at daniella.kadian-dodov@mountsinai.org; Twitter: @dkadiandodov.
Jacqueline Saw, MD, can be reached at jsaw@ubc.ca; Twitter: @docsaw.
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