Spontaneous Coronary Arterial Dissection (SCAD)

What Is SCAD?

Like any other tissue or organ in the body, the heart requires its own supply of oxygen to function and survive. The coronary arteries, which wrap around the heart, are responsible for the transport of oxygenated blood to the heart muscle. The two main coronary arteries are the left main coronary artery (which has two primary branches: the left anterior descending and left circumflex arteries) and the right coronary. Spontaneous coronary artery dissection (SCAD) occurs when a tear forms in either one of these main coronary arteries or their branches or when there is a bleed into the wall of one of the arteries.

Because SCAD is a medical emergency that can lead to a heart attack and even sudden death, obtaining medical care as quickly as possible is critical. Always seek emergency attention immediately if you experience heart attack symptoms, even if you believe you are not at risk for having a heart attack.

The demographic most commonly affected by SCAD are women in their 40s and 50s, though the disease can strike at any age and also occurs in men. People who experience SCAD often do not have high blood pressure, high cholesterol, diabetes or other traditional risk factors for heart disease.

What are the risk factors for Spontaneous Coronary Arterial Dissection?

The exact cause of SCAD is unknown, but the condition is believed to start with the weakening of the wall of a coronary artery wall. Risk factors for developing SCAD include:

• Female sex: SCAD can occur in both women and men, but tends to affect women more often.
• Recent childbirth: Some women experience SCAD shortly after giving birth, most often in the first few weeks following delivery.
• Underlying vascular conditions: These conditions include fibromuscular dysplasia (FMD), a disorder that causes narrowing and enlargement of the medium-sized arteries in the body. FMD can weaken the arterial walls, causing dissections, blockages and aneurysms. Women are more likely to have FMD than men. Also, medical conditions that cause inflammation of the blood vessels, such as lupus and polyarteritis nodosa, may put people at higher risk for developing SCAD.
• Inherited connective tissue diseases: Genetic vascular syndromes such as vascular Ehlers-Danlos syndrome, Loeys-Dietz syndrome and Marfan syndrome that cause problems with the body's connective tissues are a risk factor for SCAD.
• High blood pressure
• Illegal drug use: The use of certain illegal drugs, including cocaine and amphetamines, has been linked to incidents of SCAD.
• Furthermore, people with twisted (tortuous) arteries are at a higher risk for SCAD.

In some cases, SCAD may occur after heavy physical exertion/stress and even as a result of extreme emotional trauma.

Symptoms of Spontaneous Coronary Arterial Dissection

SCAD is most often discovered only after it causes a heart attack. As such, the symptoms of SCAD are those commonly associated with heart attack, including:

• Pain, pressure or tightness in the chest that may also travel to the neck/jaw or arms/shoulders (angina)
• Trouble breathing
• Nausea and/or vomiting
• Excessive sweating with no clear cause
• Dizziness or passing out due to abnormal heart rhythm and low blood pressure

Diagnosis of Spontaneous Coronary Arterial Dissection

Anyone experiencing heart attack symptoms should seek immediate emergency medical services.

The first step in the diagnosis of SCAD is to determine if a heart attack occurred and look for damage to the heart muscle. Tests used in the emergency room include an electrocardiogram (ECG) and blood tests that detect heart muscle damage, such as the cardiac enzyme troponin test.

Following an initial ECG and blood tests, coronary angiography is usually needed to confirm the SCAD diagnosis. During a coronary angiogram (sometimes called a “heart cath”), doctors inject a special dye into the patient's arteries so that they are visible in x-ray imaging. X-rays may show abnormalities in the artery that confirm the SCAD diagnosis. Other tests that bay be performed include the following:

How is Spontaneous Coronary Arterial Dissection Treated?

In most cases, if a patient is being treated for SCAD, they have just had a heart attack. Therefore, the initial goal of treatment it to get blood flow restored to the heart muscle again. Treatment depends on the patient's specific, unique condition, including the size and location of the arterial dissection and their symptoms. Whenever possible, after making the diagnosis, doctors will allow the damaged artery to heal on its own rather than repairing it with an additional procedure.

Medication

Once blood flow is restored to the heart, the doctor will begin a treatment plan designed to let the damaged blood vessel heal and to prevent further complications. In most cases, medications alone may be sufficient to treat the condition and relieve the symptoms of SCAD. These medications include the following:

• Aspirin and/or clopidogrel or other blood thinners to prevent blood clots
• Beta-blockers or other medications that lower blood pressure and heart rate
• Drugs to relieve chest pain, including nitroglycerin
• Medication to lower cholesterol level (if cholesterol is elevated)

Procedures

Sometimes, medications are not enough to restore adequate blood flow to the heart, and the doctor will need to open the coronary artery with a balloon or stent. In some cases of severe SCAD, bypass surgery is performed.

• Angioplasty (with stenting): Angioplasty is a procedure in which a surgeon repairs the dissected section of an artery by inflating a special balloon inside the artery to widen it. Often in patients with SCAD, the cardiologist will insert a stent (a tiny tube made of wire mesh) into the coronary artery during the angioplasty procedure to help the artery stay open wide enough for blood to flow through freely. The stent stays in place permanently while the balloon is removed. Patients with heart attack due to SCAD are at higher risk of complications from angioplasty and stenting procedures, and these procedures are only performed in severe cases when medication alone is not adequate to treat SCAD.
• Bypass Surgery: In some cases, open-heart coronary artery bypass surgery may be need to restore adequate blood flow to the heart. In this procedure, the surgeon forms a new path for blood to reach the heart, thereby bypassing the damaged artery. To accomplish this, the surgeon removes part of a healthy blood vessel from the patient's leg, arm or chest and connects it below and above the blocked arteries in the heart. Patient's need several weeks to recover from open-heart surgery.

Continuing Care

If you are treated for SCAD, you'll require follow-up appointments with your doctor to monitor for any changes in your condition, including the development of any new tears in your arteries. Your doctor may also recommend other types of care to help you recover and to prevent other health problems. Continuing care measures may include:

• Cardiac Rehabilitation: Cardiac rehabilitation is a tailored program of education and exercise designed to help you recover from a serious heart condition. The program typically includes monitored exercise, nutritional counseling, education and emotional support.
• Genetic Testing: For some patients, genetic testing may be recommended to screen for genetic mutations associated with vascular connective tissue disorders such as Loeys-Deitz syndrome, Marfan syndrome and vascular Ehlers-Danlos syndrome.
• Check Other Blood Vessels for Abnormalities: For many patients, the doctor will recommend imaging studies of the blood vessels outside of the chest to look for aneurysms, other dissections, and signs of the underlying condition fibromuscular dysplasia (FMD).