SCAD: Yes, Young Women Can Suffer a Heart Attack

As we age, there are a few telltale signs of scary medical conditions it’s normal to observe — one of which is the sharp chest pains signaling a heart attack.

But what if you’re young and healthy? What happens when your doctor observes your symptoms and sees no risk factors of heart disease and chooses to send you home?

This is often what happens in cases of the rare heart condition known as spontaneous coronary artery dissection (SCAD).

Recently, WebMD shared the story of 42-year-old mother of two, Christine Shockey, who went through five days and several doctors after her first SCAD heart attack before getting a proper diagnosis. Two and a half years later, she’s been told her heart may never fully recover. While that may sound surprising, it’s not out of the ordinary for SCAD patients.

Let’s look into the background of this condition, the common signs to look for and the current understanding of how to treat SCAD.

What Is SCAD?

Commonly considered to be a very rare condition, spontaneous coronary artery dissection occurs in a very different way than the plaque buildup found in atherosclerosis (a form of arteriosclerosis). In SCAD, a tear occurs in the wall of a heart artery and causes a hematoma (a buildup of blood), which interferes with blood flow from the heart and leads to a heart attack.

Because SCAD typically happens in people without risks for heart disease, the heart arteries affected by it can be damaged very quickly, very fast. There will also be no sign of damage in the other arteries, whereas with normal coronary heart disease, there would be plaque throughout the heart arteries. (1)

Although SCAD was first described in an autopsy in 1931, it’s only been in the last several years that doctors have begun to recognize the true burden of this disease. It was originally believed to occur only in women who have recently given birth. While this is definitely one subset of people who are afflicted with the disease, new moms aren’t the only people at risk — in fact, a 2018 statement from the American Heart Association stated that it was through social media and patient awareness that physicians began to realize the more common nature of SCAD.

Unfortunately, this is a very commonly misdiagnosed disease and must also be treated very differently than other heart attacks in order to provide the best chance for recovery, so patients acting as their own advocates are literally saving the lives of people who may be correctly diagnosed in the future! (2)

The survival rate of SCAD is not well-understood because most research doesn’t account for patients who do not survive a heart attack to receive medical treatment. However, it seems that over 95 percent of patients survive once arriving at a hospital. (3)

While there’s a reason they call it spontaneous coronary artery dissection (there is no known direct cause), there are some risk factors to consider, which fall into five categories:

Fibromuscular Dysplasia (FMD): The relationship between SCAD and FMD was only noted in 2005, and it’s unclear how connected the two are. Fibromuscular dysplasia is a rare, incurable disease involving twisting of the blood vessels that sometimes has no symptoms. It’s diagnosed by a doctor, many times in the course of examinations for other issues, because of the way it makes arteries look like a string of beads. FMD may never be diagnosed (remember, it’s often asymptomatic), and it seems that anywhere from 17–86 percent of people with SCAD also have FMD. (2)

Female Sex Hormones & Pregnancy: Women are much more likely to develop SCAD than men, with 90 percent of SCAD cases attributed to females and only about 10 percent to men. While it accounts for only about 4 percent of heart attacks overall, 25 percent of heart attacks in women under the age of 50 are caused by SCAD. (4) Females are more likely than males to die from SCAD. (3)

Pregnancy-associated SCAD is another major consideration — in fact, physicians originally thought spontaneous coronary artery dissection happened only in new mothers. Nearly two mothers in every 100,000 or so will be diagnosed with SCAD during pregnancy or in the first six weeks postpartum, although it has been reported as far out as 12 months postpartum, more frequently in mothers who are still lactating. Scientists believe the female sex hormones involved in pregnancy may change the “architecture” of heart arteries, but this hasn’t been proven to be the case yet. (2) It seems that pregnancy is involved in about 5 percent of all SCAD cases, covering moms at an average age of 33–36 years. (1, 2)

Chronic Inflammation: A relatively new concept in SCAD research, chronic, systemic inflammation and related autoimmune diseases may be risk factors of SCAD. So far, researchers have connected SCAD cases with the inflammatory or autoimmune conditions lupus, polyarteritis nodosa, sarcoidosis, celiac disease and inflammatory bowel diseases (Crohn’s disease and ulcerative colitis). (2) This shouldn’t be a huge surprise, considering inflammation is at the root of most diseases. (5)

Inherited Genetic Conditions: SCAD doesn’t usually run in families except for in the cases of certain inherited genetic conditions. These include Ehlers-Danlos syndrome, Marfan syndrome and Loeys-Dietz syndrome, among others. (2)

Environmental Triggers: In women, SCAD is often precipitated by emotional stress, such as the death of a loved one. Men are a bit different — their environmental stressor tends to be intense exercise.

The development of SCAD has also been loosely associated with a number of drugs, like birth control pills, hormone therapy for menopause, infertility treatments, high-dose corticosteroids and even illicit drugs — cocaine, for example. (6, 2)

There are some reports that extremely high blood pressure can contribute to a heart attack caused by SCAD. (6)

Signs and Symptoms

Patients with SCAD usually present with a heart attack, sudden cardiac arrest or cardiac death. The difference between heart attack and sudden cardiac arrest are the sources — heart attacks are caused by a block of blood flow to the heart, while sudden cardiac arrest is an electrical malfunction causing an irregular heartbeat. (7)

Typical signs and symptoms of SCAD include: (2, 4)

• Chest pain
• Shoulder, arm or epigastric pain (below the ribs/in upper abdomen)
• Shortness of breath
• Nausea
• Vomiting
• Cardiogenic shock (in about 3 percent to 5 percent of cases) symptoms, including confusion, loss of consciousness, rapid heartbeat, sweating, pale skin, decreased urine output and/or cool hands and feet
• Altered heart enzymes and electrical heart function

Please note: SCAD is a life-threatening medical emergency. If you experience the symptoms above in any combination, seek emergency medical attention right away.

A person who experiences SCAD for the first time and makes it to the hospital for a proper diagnosis and treatment is considered an “uncomplicated” case. However, there are complications common to SCAD like irregular heartbeats, sudden cardiac death and a recurrence of heart attack that may occur.

As I mentioned before, sudden coronary artery dissection is often misdiagnosed. Only in the last few years have medical professionals recognized that it may be more common than they thought, based largely on patient education efforts.

If you believe you have SCAD and feel you haven’t been properly diagnosed, you may consider requesting a coronary angiogram, the standard test for SCAD. This is a somewhat invasive test, using a contrast agent and internal catheter to look at the heart arteries; however, less invasive methods sometimes used to observe the heart (like computer tomography or magnetic resonance angiogram — CT or MRI) could miss a small dissection. (4)

Conventional Treatment

One major issue with conventional treatment of SCAD is that no clinical trials have been conducted to determine the best course of medical action once a patient has been diagnosed.

Heart attacks caused by plaque buildup are often treated with a non-surgical procedure called percutaneous coronary intervention (PCI), which helps clear heart arteries of plaque. However, physicians have observed and reported that PCI is more likely to cause complications in patients with SCAD, who usually have no plaque buildup.

Instead, doctors tend to rely on a “conservative approach” when treating this condition. Why? So far, it seems that many of the lesions/dissections spontaneously heal on their own, a phenomenon visible on follow-up observations between a few days to around one month after the heart attack has occurred.

Small case reports and studies have used another procedure called coronary artery bypass grafting (CABG) with varying measures of success in restoring blood flow to the heart. In CABG, a healthy artery or vein is used to bypass around the damaged heart arteries. This procedure is usually recommended for patients with multiple complications or very severe blockages, since it may increase the risk of heart failure in some people.

Unlike other heart attacks, SCAD requires at least a seven-day hospital stay for observation, since that’s when most of the recurrent heart attacks occur. In uncomplicated cases, doctors may send you home after this period of time with a variety of prescription medications. Again, these recommendations are based on some observation but no long-term clinical trials.

Medications sometimes used for managing SCAD include: (2)

• Anticoagulants/antiplatelets (heparin, warfarin, aspirin, etc.)
• Beta blockers for certain types of SCAD, irregular heartbeat (arrhythmia) or high blood pressure (acebutolol, atenolol, etc.)
• ACE inhibitors (benazepril, lisinopril, etc.)
• Statins, but only for patients who are at risk of atherosclerosis or who have diabetes (atorvastatin, fluvastatin, etc.)

It’s important to be aware of recurring symptoms of SCAD once it’s happened to you. One study found that in 10 years after a SCAD incident, the rate of “major adverse cardiac events (death, heart failure, myocardial infarction and SCAD recurrence) was 47%.” (8)

Your doctor will probably make recommendations like having regular stress testing, screening for FMD, limiting intense exercise and possibly avoiding hormone-impacting drugs like birth control or fertility treatments. (4)

Natural Ways to Improve Heart Health

While SCAD is a medical emergency and the underlying causes aren’t yet well-understood, there are some general ways you can protect and improve your heart health naturally.

1. Eat Anti-Inflammatory Foods

SCAD and many other heart conditions are sometimes associated with whole-body inflammation. By eating anti-inflammatory foods that help to fight free radical damage, you can give your body the fuel to naturally protect itself from disease. Try foods common to the Mediterranean diet like healthy fats, fresh fruits and veggies, nuts and seeds, legumes/beans, whole grains, wild-caught fish, high quality dairy, organic meats (particularly lean meats), a lot of water and a glass of red wine once a day. (9)

2. Take a High-Quality Omega-3 Supplement

Omega-3’s are a very lacking part of many Western diets. Particularly if you’re at risk for heart disease, you don’t want to skimp on this valuable nutrient. The American Heart Association highly recommends everyone get plenty of omega-3’s through oily fish and/or supplementation. (10) Taking a good omega-3 supplement like fish oil is associated with reduced high triglycerides, improved cholesterol levels, lower blood pressure, a reduction in plaque buildup, minimization of metabolic syndrome symptoms and prevention of blood clots. (11, 12, 13, 14, 15, 16)

3. Try CoQ10

Known for its overall health benefits, CoQ10, or coenzyme Q10, is a supplement that both reduces free radical damage and supports a healthy heart. A 2007 review even suggests it may be therapeutically valuable as a recommendation alongside conventional treatments for congestive heart failure. (17) Preliminary evidence suggests that CoQ10 may help to reduce some of the side effects and increase effectiveness of statin drugs, but the jury is still out on this for now. (18)

4. Use Garlic Essential Oil

Taking garlic in essential oil form may help to improve blood (lipid) profiles for triglycerides and cholesterol, making it a heart-protective essential oil. (19)

5. Exercise Regularly

While people who have had SCAD in the past should do more low-impact, low-weight exercises, it’s no secret that regular exercise regimens are a major factor in preventing heart disease. The American Heart Association says that regular aerobic exercise “plays a role in both primary and secondary prevention of cardiovascular disease.” (20)

Precautions

Spontaneous coronary artery dissection, or SCAD, is a medical emergency. You should never try to self-diagnose this condition or attempt to treat a heart attack on your own. If you experience symptoms of SCAD, seek immediate emergency medical attention.

Even with the improvement in understanding and education about this dangerous heart condition, SCAD is still often misdiagnosed. Don’t be afraid to request additional testing from your doctor if you feel you may have experienced this type of heart attack, particularly if you are a female in good health under the age of 50 and/or have recently been pregnant or given birth.

Final Thoughts

Spontaneous coronary artery dissection (SCAD) is a heart attack that happens mostly in people without heart disease, when artery layers separate and form a hematoma that constricts heart blood flow. It is most common in females under the age of 50, accounting for 25 percent of all heart attacks in this demographic.

There are several risk factors known to be associated with the development of this heart condition. These include:

1. Fibromuscular dysplasia (FMD)
2. Female sex hormones and pregnancy
3. Chronic inflammation
4. Inherited genetic conditions Ehlers-Danlos syndrome, Marfan syndrome and Loeys-Dietz syndrome
5. Environmental triggers like physical or emotional stress
6. Very high blood pressure

Symptoms of SCAD are:

• Chest pain
• Shoulder, arm or epigastric pain (below the ribs/in upper abdomen)
• Shortness of breath
• Nausea
• Vomiting
• Cardiogenic shock symptoms, including confusion, loss of consciousness, rapid heartbeat, sweating, pale skin, decreased urine output and/or cool hands and feet
• Altered heart enzymes and electrical heart function

SCAD is always a medical emergency requiring immediate attention. Do not try to self-diagnose or self-treat.

Because this condition is often misdiagnosed, it’s important to be aware of the signs and symptoms of SCAD so that you can act as your own advocate if necessary. Consider asking your doctor for additional tests if you believe you may have this heart condition, particularly as SCAD patients should remain in the hospital longer than the average heart attack patient (due to the elevated risk of recurrent attacks).

The long-term prognosis of SCAD is typically positive; however, there may be as high as a 47 percent chance you will experience another heart attack from the condition. Doctors typically recommend limiting intense exercise and sometimes avoiding hormone-impacting medications, such as birth control or fertility treatments.

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