SCAD: When Healthy Young Women Have Heart Attacks
When you're a healthy, vibrant woman in your 30s, the last thing you expect is to find yourself recovering from a heart attack -- and wondering when the next one might happen. This is the frightening reality for women who experience a spontaneous coronary artery dissection, or SCAD.
[See: 17 Ways Heart Health Varies in Women and Men.]
SCAD is a potentially life-threatening emergency involving tearing, or dissection, of one or more of the heart's blood vessels, most often the left anterior descending artery. As layers of the arterial wall come apart, it results in a reduction of blood flow to the heart, which may cause a heart attack, abnormal heart rhythms or sudden cardiac death.
Women between 30 and 50, usually with no history of heart disease or cardiac risk factors, are most likely to experience SCAD. Men can develop SCAD, too, although the incidence is lower. Overall, it's tough to pin down a hard estimate of cases, because SCAD has been underreported and underdiagnosed.
According to a new expert statement, first released online Feb. 22 in the journal Circulation, the condition may cause up to 1 to 4 percent of heart attacks overall. SCAD may be responsible for up to 35 percent of heart attacks in women under 50, and more than 40 percent of pregnancy-associated heart attacks.
Chest pain or pain radiating to your shoulders, arms or jaw are symptoms of SCAD (and other types of heart attack, too). A racing heartbeat or "fluttering" feeling in your chest are also symptoms, along with shortness of breath, sweating or becoming excessively tired, nauseated or dizzy. If you suddenly experience these symptoms without an obvious cause, call 911 and get help.
Who, Me?
At the time, it seemed there was no need to panic. Back in October 2009, Carrie Hamilton, of Kalamazoo, Michigan, had never heard of SCAD. At 38, the possibility of a heart attack wasn't even on her radar. As unusual chest pressure woke her twice in one night, she simply turned over and went back to sleep.
The next evening, Hamilton and her husband settled down for a late dinner. That's when the chest pressure returned. "This time it wouldn't go away no matter what I tried to do: Lay down, roll over, sit up or whatever," she says.
"We need to go for a ride," Hamilton recalls telling her husband. Together, they left their apartment, walked down three flights of stairs and drove to the nearest hospital.
In the emergency room, Hamilton waited as the triage nurse examined another patient. "By this time I had chest pressure and pressure down both arms," she says. "I was freezing cold."
When her turn came, the staff ran electrocardiograms and other tests as Hamilton continued to shiver under a pile of warmed blankets. They drew blood to check for elevated levels of troponin, a protein that indicates heart damage. "They just didn't know what was going on," she says. "I was 38 years old, and I was underweight and had zero risk factors for heart disease."
The next morning, Hamilton got the news: She had suffered a heart attack. She was taken to the catheterization lab for placement of a cardiac stent to prop up a collapsed major artery.
A week later, Hamilton was discharged with the cause of her heart attack chalked up to stress, a vague explanation that didn't sit well with her. It took nine months, several visits to specialists and, finally, a referral to the Mayo Clinic and a test called an angiogram to confirm that Hamilton had SCAD.
Getting the Word Out on SCAD
Dr. Sharonne Hayes, founder of the Women's Heart Clinic at the Mayo Clinic in Rochester, Minnesota, is the lead author of the scientific statement on SCAD appearing in Circulation. The American Heart Association statement is the combined work of researchers and specialists from the handful of medical centers that regularly see SCAD patients.
One reason SCAD awareness is so crucial is that certain interventions typically used for heart attacks can be harmful if performed by clinicians who aren't familiar with SCAD on patients who have it. Hayes believes the new statement, which provides a detailed road map for clinicians, will probably have the greatest impact on care in community hospitals where most women first seek treatment.
[See: 10 Heart Health Breakthroughs.]
Pregnancy has long been known as a risk factor for SCAD, and was previously thought to be the primary cause. More recently, and with improved diagnoses, it's now believed that only 5 to 10 percent of cases are associated with pregnancy, although pregnancy-related SCAD may be more severe.
Any subsequent pregnancy is considered high-risk after SCAD. If a woman is highly motivated to become pregnant, Hayes says, cardiology and internal medicine specialists should also be involved in her care, along with her OB-GYN.
A condition called fibromuscular dysplasia, in which artery walls are weakened, may contribute to SCAD. Certain genetic conditions of the connective tissues, like Ehlers-Danlos syndrome, are also associated with SCAD. Untreated, severely high blood pressure; extreme physical exertion and emotional stress are also related causes. Migraine headaches and hormonal medications, such as infertility treatments, may be associated as well.
SCAD Returns
In May 2011, Hamilton had her second bout with SCAD. This time, the urgency was clear. When she woke with persistent chest pains, her husband called 911 and they went by ambulance to the hospital, where she was whisked up to the catheterization lab.
Unfortunately, the catheterization didn't go well. Hamilton describes a bad-to-worse scenario in which a second arterial tear was created during the procedure. She later learned that her heart had stopped during the catheterization and that she needed to be resuscitated. Once she made it to the operating room she underwent open-heart, double bypass surgery.
Afterward, Hamilton says, she was in a medically induced coma for a week. The only silver lining was sleeping through the worst of the pain. However, her mental recovery was extremely difficult, including persistent memory lapses. Later on, she was diagnosed with post-traumatic stress disorder.
Hamilton, who sustained significant heart damage and scar tissue, now has an implantable defibrillator in her chest. Following medical advice, she no longer works and is on disability. Yet outwardly, unless her clothing happens to reveal some of the 9-inch scar in the center of her chest, her condition is largely invisible.
Cardiac rehabilitation was "super-beneficial," Hamilton says, despite her being the youngest group member by far. Connecting with fellow members of WomenHeart: The National Coalition for Women With Heart Disease, helps. Her husband is highly supportive, and they now share a split-level home with manageable stairs. She strives to maintain a sunny disposition and not dwell on the possibility of a third episode of SCAD.
Physical and Emotional Fallout
PTSD, depression and anxiety are common for SCAD survivors. After any type of heart attack, it's important that women get cardiac rehab and counseling to address their physical and mental health needs.
"It's very traumatic," says Dr. Abha Khandelwal, a cardiologist and clinical assistant professor of cardiovascular medicine with Stanford Health Care--Stanford Hospital, in California. "These are healthy, oftentimes very accomplished, high-achieving women."
Previously, SCAD patients were told to strictly limit their physical activity. "As we've learned more, our recommendations have changed," Khandelwal says. "We actually want these women to remain as active as possible, because these are young women. If you tell them to be sedentary and not work out, then you're really putting them at risk for another type of heart disease."
[See: 5 Rare Diseases You've Never Heard of Until Now.]
Khandelwal is pleased to see women with heart conditions increasingly advocate for themselves. She's also encouraged by growing professional awareness of what these symptoms might mean.
For perspective, Khandelwal says, women should understand that even though SCAD is being identified more often, it's still uncommon. "So they should not live in fear," she says. However, she adds, "If they have heart symptoms they cannot understand or they feel are not improving, they should seek attention."
Lisa Esposito is a Patient Advice reporter at U.S. News. She covers health conditions, drawing on experience as an RN in oncology and other areas and as a research coordinator at the National Institutes of Health. Esposito previously reported on health care with Gannett, and she received her journalism master's degree at Georgetown University. You can follow her on Twitter, connect with her on LinkedIn or email her at [email protected].