Very few people associate heart attacks with thin young women, but a rare form of heart attack occurs most often in exactly that population. Spontaneous coronary artery dissection (SCAD) accounts for only one to four percent of all heart attacks, but 80 percent of SCAD patients are female. Up to 40 percent of all heart attacks in women under the age of 50 can be attributed to SCAD.
Cape Cod Hospital cardiology hospitalist Jennifer Ladner, MD, said SCAD is rare, but she had a case a couple of years ago.
“These patients tend not to have the usual risk factors,” she said. “That’s the thing that should clue you in. A young woman comes in the hospital and she doesn’t really have risk factors for cardiovascular disease. She’s not a diabetic. She’s not overweight. She’s not a smoker. That’s when you should think, oh, this person may have a spontaneous coronary artery dissection.”
The symptoms are the same as any other heart attack including:
- Chest pain or pressure
- Shortness of breath
- Clammy and sweating
- Extreme fatigue
- Arm or jaw pain
Even though the symptoms are similar, the cause is different, Dr. Ladner said. Instead of the more common reasons for a heart attack, like a build-up of plaque in the arteries, a SCAD heart attack is caused by a tear (dissection) in one of the arteries of the heart. The tear causes the blood to course in a channel underneath the lining of the inside wall of the artery, causing a second channel called a false lumen. The blood then clots, forming a hematoma that can expand to the point where it obstructs the artery, causing a heart attack.
Cardiology hospitalists verify a diagnosis of SCAD by doing an angiogram of all the vessels that feed the heart, Dr. Ladner said. Once diagnosed, the treatment protocol is to treat it conservatively, which in this case means ride it out.
“The recommendations are to let the person have the heart attack and support them through it,” she said. “We avoid putting in stents because you can actually make things worse with stents and the complication rate is quite high because of the fragility of the vessel. You can make the dissection worse.”
If the patient is in life-threatening danger, another option is to do open heart surgery to bypass the vessel.
No one knows what causes SCAD, but there are risk factors that increase the chances of it occurring, Dr. Ladner said. About 70 percent of the patients with SCAD also have fibromuscular dysplasia, which is a disorder where artery walls thicken. Since fibromuscular dysplasia causes blocked arteries, dissections and aneurysms in a lot of different arterial beds, a patient diagnosed with SCAD should also be screened for blockages in the renal arteries leading to the kidneys and the carotid arteries leading to the brain.
Women who are pregnant can develop SCAD either peri-partum, during labor or post-partum. About 30 percent of SCAD patients have recently had a child, according to the American Heart Association. High-intensity physical activity and extreme emotional stress are also considered triggers.
Once the patient is stabilized and the dissection heals, it is important to reduce other risks of heart disease like smoking, high blood pressure or high cholesterol. Cardiovascular rehabilitation is recommended. It is also critical to seek immediate medical attention if any symptoms of a heart attack occur again.
“The rate of recurrence is 20 percent, which is pretty high,” Dr. Ladner said. “But it is not usually life-threatening and fortunately, it is very rare.”
SCAD is a frightening diagnosis, but there are many online support groups to help patients and family members cope, share their stories and advocate for more research.