Esther Kim, MD
Friday, July 24, 2015 | Noon
SCAD (spontaneous coronary artery dissection) is a rare condition that occurs when a tear forms in one or more blood vessels, which can slow or block blood flow to the heart and cause a heart attack. It is mostly found in women between the ages of 30 and 50. Left untreated, it can be a serious condition Dr. Esther Kim, Vascular Medicine Specialist, answers your questions. Welcome to Katherine Leon and members of SCAD Alliance.
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Spontaneous Coronary Artery Dissection – General Questions
deinhorn: Why is a SCAD diagnosis so rare?
Esther_Kim,_MD: What a great question. 1) SCAD tends to affect women more than men. They also tend to be younger and without cardiac risk factors so their heart attack symptoms may be completely dismissed and the diagnosis may be missed. 2) SCAD requires a heart catheterization for diagnosis and not all patients with chest pain or heart attack equivalent go on to have heart catheterization. 3) SCAD can have a variety of appearances on heart cath and the dissections or intramural hematomas that are not obvious may be missed or incorrectly diagnosed as atherosclerosis. 4) we are only able to capture the SCAD that presents to medical attention. There may be people out there who have heart attacks but don't present to an ED so are not captured in the prevalence numbers.
tfahrner: Are there any studies showing a SCAD could be genetic?
Esther_Kim,_MD: This is a great question and very timely. So far, there are no definitive studies that have described the genetics of SCAD. What we do know is that patients with SCAD may have other arterial diseases and perhaps SCAD is another variant of these diseases. For instance, if we look at the FMD population, a patient with FMD may not be able to name another family member with FMD, but can identify family members who have had other arterial diseases such as aneurysm. I have a suspicion that SCAD will be a complex disease from a genetics perspective, and I, along with all of you, await the studies to be done. In the meantime, it is a good idea to obtain your family histories so that your doctors can refer you to medical genetics if there is a compelling history.
kptocs: 1) Are patients with known FMD (medial) at risk for SCAD, even if there has not been evidence of FMD in their coronary arteries (via echoes, stress tests, CTA). 2) Is the risk of having a SCAD mainly associated with stress or with vigorous exertion like very intense sprinting, or from valsalva - such as with weight lifting, or child birth, or what?
Esther_Kim,_MD: Good question as we think there is some link between FMD and SCAD. Interestingly, if you look for FMD in patients with SCAD, you may find it 70-80% of the time. In the FMDSA registry, however, a very small percentage of patients report having had a heart attack. Unfortunately, a stress test or echo or even CTA may not be sensitive enough to diagnose a SCAD.
DLR: I hear you are doing some research/trials on SCAD. Do we have to come there for a consult to be included or is there a way to do it by mail? I called asking for information and nobody ever got back to me.
Esther_Kim,_MD: Thank you for asking this question. We have one study currently enrolling and one that will be enrolling soon. The study currently enrolling is only for patients who are in the hospital with their SCAD event currently. This is the Canadian SCAD Registry, for which Dr Jackie Saw is the principle investigator. Cleveland Clinic is one of only two US sites currently for this study. The study that will be enrolling soon is our local Cleveland Clinic SCAD registry which will allow patients who have had SCAD events remotely be involved in registry research. You must be seen in the vascular medicine clinic at the Cleveland Clinic in order to be enrolled in the registry. I firmly believe that for rare disease, the best place to start is information gathering with large numbers of patients so that we can begin to think about clinical trials for treatment and diagnosis.
SCAD Alliance: The majority of SCAD patients are discharged with their diagnosis by a doctor who has never seen SCAD before and does not pursue additional guidance from experts. What are the top three issues patients should consider as "next steps" to empower themselves and ensure they receive the best possible care going forward?
Esther_Kim,_MD: Great questions and very applicable to many patients. 1) get involved with a patient advocacy group for support and guidance, 2) seek expert opinion with someone familiar with SCAD (because this is a rare disease) to assist with further diagnostic testing, 3) enroll in research for SCAD.
Brokenheart: It appears that most SCAD survivors have on going issues/sequela related to their initial event. The incidence of recurrence would seem to be higher than the 17% suggested in earlier studies. It appears that many survivors have recurrent chest pain and quite a few are subsequently diagnosed with coronary artery spasms. So my question is twofold. Is there a correlation between coronary artery spasms and SCAD and isn't this more of a disorder/disease/syndrome than a one-time event and shouldn't that be reflected in the labeling? (i.e. instead of SCAD wouldn't SCADD or SCADS be more appropriate?). Humbly submitted with gratitude for the work you and others do to increase awareness and improve outcomes related to SCAD.
Esther_Kim,_MD: Wow, this question is packed with good questions. In terms of recurrence, some recent data seems to support that the recurrence rate may be higher than initially believed and perhaps up to 25% at 5 years. I personally feel that some patients are diagnosed with coronary spasm because there appears to be no other explanation for their post-MI chest pain. There is likely to be a complex interplay of coronary dissection with endothelial function, microvascular disease, and perhaps even coronary spasm, however, none of these have been adequately addressed to firmly implicate a link. Because of this, I think it would be premature to label a SCAD “syndrome” but further research will certainly be valuable.
PeacefulHeart: I am a female, who, nearly four years ago, experienced SCAD dissections (two in three days, both causing MIs) at the age of 63, which is outside the "typical" range of women ages 30-50. Is there any information via either studies or anecdotally, that indicates, in general, different considerations, treatment and/or prognosis for older women? (FYI, my first dissection, in a branch of the circumflex artery, was treated medically, the second, in the RCA, was treated by placement of six bare metal stents.)
Esther_Kim,_MD: Thank you for this question. As you point out, the average age of the SCAD patient is around 45-50 years of age, however, there have been patients older than 70 years old included in SCAD registries, so we know that it does occur in older women. The numbers of patients in all SCAD registries is small and thus, age specific analyses have not been published. SCAD is treated the same in all patients, regardless of age (usually medically) unless a stent is necessary in the acute phase. Older women may have concomitant atherosclerosis and thus, interventional treatment may differ because of this. In these situations, the diagnosis of SCAD should be revisited as spontaneous dissection is a separate entity from atherosclerotic dissection.
Prevention of Future Spontaneous Coronary Artery Dissection
LisaL: My husband suffered Spontaneous Coronary Artery Dissection Nov. 2014. LAD artery. It was repaired with a stent. What should he do now to prevent that in the future? Should he be on cholesterol lowering medications?
Esther_Kim,_MD: The question of how to prevent recurrence in SCAD is an important one and one that many of my patients ask. Unfortunately, we do not know what causes recurrence in SCAD and if there are any identifiable risk factors for recurrence. Because of this, we counsel patients on "common sense" practices to prevent recurrence: avoidance of heavy lifting, avoidance of extreme exercise, avoidance of activities that would cause stress on the torso such as riding roller coasters. In terms of cholesterol lowering medications, unless he has high cholesterol levels, there is no evidence yet that cholesterol lowering prevents SCAD recurrence.
martica68: I would like to know if there are any supplements or medications that are known to improve vascular health.
Esther_Kim,_MD: Great question. Even in the general cardiology world, there are always questions regarding supplements that may help vascular health. I like to say that we are in a relatively "data free" zone. In other words, any claims that are made about supplements to strengthen vascular health are largely anecdotal. Supplements such as vitamin C and lysine have been brought up, however, these have not been studied in randomized trials. The other issue is how people are defining "vascular health." As far as I know, there is no medication that can "strengthen" arteries.
CindyK: My husband had a SCAD event earlier this year. He was in good health. Normal blood pressure, exercises, normal cholesterol. His cath showed all arteries were clear. What causes this and can it happen again? Are there certain things we should test for or do to prevent this?
Esther_Kim,_MD: Thank you for bringing the issue of SCAD in men to light as well. As with most SCAD patients, he sounds like he was previously healthy without other cardiac problems. The cause of SCAD is unknown but we know that there are some predisposing factors including underlying arterial/connective tissue diseases such as vascular Ehlers-Danlos and fibromuscular dysplasia, but there are also those with no underlying arterial disease and had SCAD after extreme stress or exertion or heavy retching. I recommend he undergo screening for other arterial problems and also consider a visit with a clinical geneticist.
Diagnostic Testing and SCAD
Mxmom23: I had a SCAD last July but I haven't been tested for FMD! How can I get my local cardiologist to consider testing me for it and what kind of test does it require? I was a healthy 37-year-old woman that doesn't smoke and I didn't just have a baby or as far as I know I wasn't going through early menopause!
Esther_Kim,_MD: What an astute question regarding the link between SCAD and FMD. We have some research that up to 70-80% of patients with SCAD are also found to have changes of FMD in their arteries somewhere else. Because of this possible strong association, I do advocate for testing for FMD. Perhaps you could provide your cardiologist with some literature from this webchat or from SCAD Alliance to help increase awareness. In terms of screening, I perform either an MRA or CTA of the arteries from head to pelvis, at least once to rule out brain aneurysms and also look for changes of FMD or other aneurysms/dissections elsewhere.
tatc67: Soon after my SCAD MI, my right carotid artery also dissected. I have an aneurysm on my carotid at the base of my skull. I have been advised to have another CT scan six months after the first CT scan that diagnosed the carotid dissection and aneurysm. How often do you recommend repeating scans to check for more dissections and aneurysms?
Esther_Kim,_MD: This is a good question and there aren't any firm guidelines yet, but for a new dissection, we frequently have imaging at early intervals (for example, perhaps a physician may perform one at 1 month, 3 months, and 6 months) and then if everything is stable, we may perform yearly evaluation for stable aneurysms. Certainly any symptoms would drive earlier imaging than that. Of course, every patient's interval of imaging should be driven by their doctor who knows their specific case.
DLR: Is a cardiac cath the only way to confirm a SCAD? On follow up, what can be done to check and see that it's healing? Does an echo or stress test really show it?
Esther_Kim,_MD: Yes, most of the time, cardiac cath is the only way to confirm SCAD. Because the dissections tend to be in the distal vessels, CTA of the coronaries may miss the dissection. CTA of the coronaries can be helpful for more proximal dissections, however. If you look at recent research, the majority of patients will have had their dissections heal within a month of the initial event. To me as a cardiologist, whether the vessel has healed is not as important as how the heart muscle is doing (is the ejection fraction normal?) and how the patient feels.
SCAD and Connective Tissue Disorders
ShantiHeart: I am interested in the SCAD - connective tissue correlation. As a SCAD survivor who is part of the SCAD Survivors FB group, I have found many other SCAD patients who, like me, had swallowing or other esophagus-related problems in their youth and/or as adults. My 44-year-old daughter (who has not had a SCAD) also has swallowing issues. But most of the research seems directed at FMD, Marfans, etc. Is anyone noting and/or directing research towards the esophagus function issue? Also, a large percent of SCAD patients suffer reflux/chronic heartburn AFTER our SCADs. We know that some of the meds prescribed for SCAD irritate the gastric system or, in the case of beta blockers, cause the LES to relax. But for many of us, these gastric symptoms began in the days BEFORE our SCADs, out of the blue. They are clearly gastric in nature, not chest pain mistaken for gastric discomfort. Yet we are told it's the latter. So if it is "referred" pain, what is the mechanism? What's the true cause of the symptom?
Esther_Kim,_MD: Thank you for your question. I have not noticed a large trend in esophageal complaints. As you point out, several of the medications we use to treat SCAD can irritate the stomach and cause some of the symptoms you describe. If you had GI symptoms before your SCAD, yes, I agree, it is not likely to be the medications alone. There are some connective tissue diseases that can cause gastric motility problems, but the majority of patients with SCAD are not diagnosed with a known underlying connective tissue disorder. With your history, I would probably involve the expertise of my gastroenterology colleagues.
AO: I was diagnosed having SCAD in February 2014. It has been a very tiring and frustrating road to recovery. I hope I am in recovery, even though it does not feel like it. I am still experiencing pain on my arm and neck and head and chest, similar to "heart attack", however the level of pain are not as extreme. However it is constant. The constant pain does often peak when I lay down and or when I am in resting position. I also sometime experience peak pain when I over exert myself doing low impact high cardio work out using my whole body walking. Is there any other health issue SCAD patient tend to exhibit post SCAD? Currently I am having to cope with bouts of rashes that comes through in different part of my body. Thank you for your time to respond to the above.
Esther_Kim,_MD: I am sorry to hear about your long road to recovery, but I do want to provide you some reassurance that you are not alone. Recurrent or persistent chest pain is a complaint that I hear from many patients who have suffered SCAD. When to go to the ED or seek medical attention is a question I get asked all the time. What I say is that if you feel any pains that remind you of your heart attack either in intensity or duration of pain, it is time to see immediate attention. Mild, persistent, constant pains are less likely to be from a blockage in the coronary artery or a recurrent SCAD. Many of my patients are on anti-anginal medications for months or even years after their event. I hope this help you know that this is not an uncommon symptom, and I would advise that you speak with your physician about any medications that could potentially help with chest pain.
SCAD and Hormone Replacement
wondergirl55: Does hormone replacement have any impact on SCAD? I was on hormones, had a coronary dissection, now my doctor is reluctant to put me back on the hormones and I feel lousy. No history of blood clots or high blood pressure.
Esther_Kim,_MD: Thank you for this question. The issue of the role of hormones in SCAD is the elephant in the room, but unfortunately, we have not been able to unravel this mystery yet. Certainly the vast majority of patients with SCAD are women, so many believe there must be a hormonal connection. What is puzzling is that there are women who have SCAD who are not on hormones. Thus, the connection is not a simple one. With any medication, the risks and benefits need to be weighed, and in this situation, I understand the difficulty as we cannot quantify the risk. In general, I counsel most of my patients that if they have had a prior heart attack, I advise them to avoid hormones, if at all possible, and if completely necessary, use the lowest dose. This is a tough question and one that needs much more research.
SCAD and Medications
valentine: What post SCAD medication do you recommend to take on long term? My cardiologist suggested to stop low dose of beta-blocker and stay on 80mg ASA.
Esther_Kim,_MD: Great question. I think most SCAD physicians will agree on aspirin 81 mg daily. If a patient has hypertension, I think beta blockers and angiotensin receptor blockers are good choices as these medications have been shown to be beneficial for patients with other vascular diseases, including Marfan’s and vascular Ehlers-Danlos. If a patient has high cholesterol, I choose the statin medications. Until we have randomized controlled trials of medications for SCAD, we won’t know the magnitude of benefit of these medications for SCAD patients so until then, things are “empiric.”
Cardiac Rehabilitation after a SCAD event
RobertK: I had a SCAD event and MI a couple months ago. I have had mixed opinions about doing cardiac rehab. Your thoughts?
Esther_Kim,_MD: I'm sorry to hear about your heart attack but what a great question. Most patients with SCAD are young and otherwise healthy with no other cardiac risk factors. I completely endorse and support cardiac rehab for a variety of reasons: 1) it allows your doctor to see that exercise is not causing any problems for your heart, 2) it can increase your exercise tolerance, 3) it provides reassurance that you are able to exercise without adverse consequence for your heart.
Moderator: How long should you wait after a SCAD MI should you start cardiac rehabilitation.
Esther_Kim,_MD:This will need to be determined by your home cardiologist and when they think it is safe for you to exercise. If they are doing well, I usually refer my patients at the first outpatient clinic visit to start Phase 2 cardiac rehab.
Activity and Exercise with SCAD
noellelynn: I was hoping you could talk to the group about roller coasters, straining and risk after SCAD. Many of the survivors from the SCAD Survivors group have been talking about this.
Esther_Kim,_MD: Yes, this is a hot topic. While not all SCAD is from heavy exertion or trauma to the chest, after SCAD, the understanding is that there is some weakness in the coronary arteries which predisposed to dissection. For this reason, any activity that has abrupt starts and stops and causes very quick increases in blood pressures should be avoided. Roller coasters fit into this category and I advise my own patients to avoid roller coasters. (I'm sorry). In terms of lifting and straining limitations, a flat number is hard to give as 30 pounds to me is very heavy but to others may be very easy to lift. In general, I tell my patients that if they cannot lift something without really bearing down and turning red in the face, don't lift it. I generally advise not lifting more than 50 pounds, probably not more than 30 pounds.
dennyerardi: Good morning, I had a SCAD April 2014. Previously, had been a pro athlete, still working out and competing every day at the time of my MI. I'm back to a full schedule again, tennis/racquetball/pickleball four or five times a week, weight lifting and training two - three times a week. EF is 70%, stress echo as of 7/1/15 is normal. Is there knowledge regarding physical exertion or is it primarily speculation as to whether increased exercise driven heart rate is "dangerous" as to another SCAD? Same question relative to specific types of weightlifting (Olympic style) and amount of weight lifted? Thank you. Denny.
Esther_Kim,_MD: This is a fantastic question. Most of us are not lifting heavy weights in the gym but there are some who are athletes at a high level who have had SCAD. As I stated in the previous question, weights mean different things to different people. Heart rate response to exercise is also different in the individual. Because of this, I routinely refer my patients to a program we have available at Cleveland Clinic called an "exercise prescription" which entails a stress test on the treadmill and a consultation with an exercise physiologist who can review your exercise preferences and give some guidance about what level of exercise is in the "safe range" for a SCAD patient.
MarianneP: How can I know what is an appropriate level of exercise post SCAD? I am 69 years old and had my SCAD 12 months ago. Is any research being done on SCAD in older women?
Esther_Kim,_MD: Please see answer above regarding your first question. Thank you for bringing the issue of SCAD in older patients to light. The current research on SCAD is all registry-type research which does not have age limitations, as far as I know. There are no current randomized controlled trials yet in SCAD, but because SCAD does happen in older patients as well, it is important for patients such as yourselves to be involved. This is also an important time to clarify that SCAD is coronary dissection in the absence in the absence of atherosclerosis, as coronary from atherosclerosis can also happen. This is a different disease process from SCAD.
Moderator: Other questions regarding activity:
What do you feel about SCAD survivors taking yoga classes?
Esther_Kim,_MD: As long as patients avoid the exercises that demand extreme hyperextension or torso torsion, it is probably ok. This also depends on the presence of other vascular diseases, including FMD and vascular EDS, as the presence of carotid disease may limit other types of exercises, for instance.
Is flying ok?
Esther_Kim,_MD: Airplane cabins are pressurized so flying is probably ok. I would wait until I discussed with my cardiologist that they think your symptoms are stable and you are far enough out from your heart attack to travel from home.
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