Esther Kim, MD
Friday, July 1, 2016 | 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.
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Newlife18: Hello. My mum died following a sudden cardiac arrest caused by SCAD, and myself and my siblings are concerned about our risk following the Mayo Clinic’s study on familial SCAD. We have seen genetic consultants but they have never heard of SCAD or FMD and offered little advice other than to say that it was just bad luck and that we should go and live our lives and not worry! What do you propose that family members should do following a SCAD event in the family? Best wishes and thanks for all the work you are doing trying to help find answers.
Soo_Hyun_(Esther)_Kim,_MD: This is a fantastic question. I'm sorry about your mum but to some extent, I agree that you should live your lives! One important thing to do is to perform a thorough family history for aneurysm, dissection, and sudden cardiac death. If these are present to a high degree, the rest of your family may need screening for these issues. SCAD can be a manifestation of other vascular disease, including FMD, but also other genetic diseases that can cause spontaneous dissection and aneurysm.
nlappa: 1) The risk factor associated with my SCAD MI 2.5 months ago was "elevated hormones postpartum". I would like to know what these hormones are (Estrogen? Progesterone?) And what levels constitute an elevated amount. Is this at all studied, and if so, can you direct me to the research papers?
2) Is it considered common practice to not conduct a repeat Angiogram to verify the status of the arteries in the months following the event?
3) My arteries were described as "friable" and even "ratty". This is a term that makes me quite nervous as I fear for a repeat of the event. In your experience, once hormone levels postpartum have stabilized, do the arteries begin to resemble a normal, healthy artery?
4) Any genetic link?
5) What is the likelihood of a second/third/fourth event in the months and years following the first?
Soo_Hyun_(Esther)_Kim,_MD: I will try to address some of these as these are likely common questions for SCAD survivors: 1) We do not have levels to dictate the level at which SCAD is going to occur. There are ongoing studies - for instance Dr. Saw's prospective Canadian study which recruits patients at the time of heart attack. She is checking hormone levels during the acute SCAD. I eagerly anticipate these results. 2) Please see my answer to this question above. 3) I really hate these words because they are so scary! Basically, a - dissection, whether it is ratty or friable or hematoma - is a dissection. I have seen very "ratty" arteries return almost completely to normal in follow up angiograms. 4) Most patients with SCAD cannot identify another family member with SCAD, in my experience, but there may be a genetic link as there have been case reports of family members with SCAD. More research is needed. 5) Our most recent evidence shows a recurrence rate for all patients with SCAD (inclusive of all underlying vascular diseases) of about 20% in five years. This issue of recurrence will need to be better parsed out.
SCAD Alliance: We at SCAD Alliance appreciate your dedication, and in particular, your willingness to chair our Scientific Advisory Board. Are you at liberty to share with everyone a general overview of the SCAD Consensus Document you initiated with the American Heart Association? How will this document aid clinicians and impact survivors?
Soo_Hyun_(Esther)_Kim,_MD: Thank you so much for the opportunity to serve this wonderful group of patients. I am over the moon that we will have a consensus statement for the diagnosis and treatment of SCAD. Unfortunately, all content is embargoed until publication, but this is a document which I hope will help all of us in the diagnosis and treatment of this complex disease.
Jstanton: Are you finding any racial/ethnic correlation to SCAD?
Soo_Hyun_(Esther)_Kim,_MD: What a great question. Unfortunately, most of the information we have doesn't have wide diversity so I don't think we can really make definitive conclusions on this. What I do know is that there have been reports of SCAD from all over the world, including Asia, Europe, the UK, and Australia.
Tmgroot: From your experience/research do patients who have secondary or multiple scads present with the same symptoms as their first SCAD?
Soo_Hyun_(Esther)_Kim,_MD: What a fantastic question! This is something we need to look into. Because patients can have several types of chest pain after a SCAD, I do usually tell patients to be concerned about the one that felt like the first heart attack. I would say from my experience, yes, most patients will have similar symptoms -- but I need to learn from you!
lynda: I experience stroke-like symptoms that have been steadily increasing in severity and lasting effects, to the point that they now say I might not recover from the next one. Would you consider a consult with my vascular cardiologist? Although my doctor is a vascular cardiologist who is very knowledgeable about FMD, he is looking for help in identifying any alternatives that might exist other that just waiting until the next event occurs.
Soo_Hyun_(Esther)_Kim,_MD: I'm sorry you continue to have these symptoms. Our department is always open to collaborating with local cardiologists!
jillandnemo: I have suffered 3 SCAD non related to pregnancy, post menopause and no other heart issues, i.e., clean arteries, good cholesterol, low blood pressure, no diabetes. I have suffered from severe angina at a level 8-9 pain (12 nitro pills over 6 hours’ time does not stop the pain) on several occasions with symptoms similar to the SCAD. 3 of those angina attacks turned out to be additional SCADS. How common is angina with SCAD patients? Do you hear similar stories where we end up in the ER 6-8 times per year and we never know which one is the next SCAD?
Soo_Hyun_(Esther)_Kim,_MD: I'm sorry about all of your episodes. This is a great question and one that is being researched. I would say that most of my patients with recurrent SCAD did have angina. Part of the fear that comes with SCAD is not knowing which chest pain is the next SCAD. I always say be safe than sorry and if you think you are having a heart attack, please seek medical attention.
Heart Attack and SCAD
AONZ: I have on going SCAD symptoms pain, fluctuating from sharp pain that comes on for a few minutes on regular basis. I am not on any medication. I had blood test done, recently (April, 2014) and there were traces of Troponin enzyme, however not at a level of "great concern", according to attending cardiologist. They did not investigate if I'd had recurrent SCAD. My first diagnosed SCAD, January 2014. If I have a say, I want to know, did I have a recurrent SCAD? Or did I have a "normal" heart attack? How does one go about to investigate if I do have recurrent SCAD?
Soo_Hyun_(Esther)_Kim,_MD: First, I am sorry that you are continuing to have pain. I find that several patients have chest pains that are not necessarily similar to their heart attack pain. We don't have an explanation for this yet, however, if you are truly having new elevations in the troponin enzyme, this suggests another heart attack. In the absence of significant kidney problems, the troponin levels should come back down to normal. The only way to definitely know if you had a recurrent SCAD is to perform another angiogram. I recommend that you discuss this in detail with your cardiologist.
AONZ: I was diagnosed with SCAD in January 2014. Not on any medication anymore since August 2014. Now have only to deal with symptom of "heart attack" pain. They are ongoing, someday are more someday are less someday are fine. Had my blood test in month of May 2016, there were Troponin enzyme. Was told by attending cardiologist it is high but not enough to be too concern. My question, did I have a heart attack or recurrent SCAD? The attending cardiologist said it is definitely not SCAD, because as far as she is aware, SCAD only happen to young women and they do not re occur. Chest X-ray was taken and EKG. I ask these question, did I recently had a heart attack? The attending cardiologist said no. I also ask her why then did my blood test positive for troponin enzyme? Is my request to have a diagnosis impossible? Would angiogram be more conclusive? Would my request to check if there is damage to my heart be reasonable? What can I do to look after myself? Thank you.
Soo_Hyun_(Esther)_Kim,_MD: Without knowing your full medical history, I wouldn't be able to say what caused the troponin elevation for certain, however, SCAD does recur and it usually presents with heart attack. Please see my answer from a previous question regarding testing. If you remain concerned, a second opinion may be a good option.
SCAD and Coronary Spasm
grateful heart: It appears that many SCAD survivors have ongoing heart related issues. For most it doesn't just seem to be an event that happened. In particular coronary artery spasms are reported to be an ongoing cause of CP in survivors. What cause the arteries to spasm? Is it related to heart disease, heart damage or could it be related to some of the prescribed medications? Thank you!
Soo_Hyun_(Esther)_Kim,_MD: You have hit on a very important question and one that I have asked myself several times. I have even referred a few patients for formal testing for coronary spasm and so far, none have been positive. I think cardiologists think about spasm because it is another cause of chest pain that is very difficult to diagnose. Sometimes we will empirically treat for spasm but the drugs we use for spasm can sometimes help with chest pain that comes from other reasons as well - including esophageal problems. There will be page posted next week on our website with our coronary spasm expert. Stay tuned!
CAD Diagnostic Testing
Santa: I am currently a 62-year-old woman who had my only SCAD event at 58 years of age. I have two bare metal stents in my RCA. I will be having an ultrasound of my carotid and renal arteries next week. Will these ultrasounds definitively tell me that I do or do not have FMD? If positive, can you give me a ballpark guess as to the chance of a repeat SCAD? Will past dental work, i.e., molar implant, impact these results or possibly cause them to be imprecise?
Soo_Hyun_(Esther)_Kim,_MD: This is a very insightful question asking about the various tests for FMD. We know that over half of patients and probably up to 3/4 of patients with SCAD have underlying FMD. The diagnosis of FMD can be challenging with multiple imaging options. Unless you have your ultrasounds performed at an experienced, high volume center, FMD may be missed. Even in the best case scenario, ultrasound can miss FMD because the FMD is so high up in the neck. In my practice, I generally use CTA to screen for carotid FMD and brain aneurysm at the same time. CTA can be affected by dental work as the FMD is so high up in the neck, but most of the time, it is a good test. We do not yet know the impact of FMD for SCAD recurrence.
mekanik: I am a doctor myself. Child- and adolescent psychiatrist in Denmark, but I cannot work anymore. I got a bypass because of SCAD in 2003. My first question is whether you think my current mysterious symptoms may be due to extracardial vascular disease, which I never have been examined for. Over the last 1½ years I have had paresthesia and anesthesia in respect of dermatomes L4 , L3 , C7 and trigeminal's 2nd and 3rd branch. All in the left side. Thus, there is no neurological coherence. Also, over the last three years I have been increasingly exhausted and tired, got muscle and joint pain, had nausea, migraine and involuntary weight loss of approximately 7 kg. There is nothing abnormal found in multiple rheumatologic blood samples, MRI of the brain (without contrast) and nerve conduction velocity. My second question is whether you would advise me against to take tablets Estradiol / Drospirenone 1mg / 2mg? I take them because they help a little on muscle and joint pain.
Soo_Hyun_(Esther)_Kim,_MD: I'm sorry you are going through all of these symptoms. In a nutshell, if you have not been screened for extracoronary vascular disease, I do recommend this as we know that patients with SCAD can have aneurysms and dissections elsewhere. In relation to the hormones, this is an area of active research. Most doctors in the field are advising avoidance of hormone therapy until we have more information.
jillandnemo: In all three of my SCAD's my EKG was normal. Is this similar in other cases you have seen?
Soo_Hyun_(Esther)_Kim,_MD: Not all heart attack is evident on an EKG and doctors must combine clinical judgment with EKG and laboratory data to make the diagnosis.
SCAD Follow-up and Monitoring
Beatrice#1: I had a heart cath that confirmed a heart attack caused by SCAD last year. I was prescribed five various medications and see a cardiologist every few months just for check ins. Is there anything more that I should be doing?
Soo_Hyun_(Esther)_Kim,_MD: At this time, after a SCAD, I recommend close follow up with your cardiologist so they can monitor for any new symptoms and also constantly assess the need for the medications you are already taking. Depending on how you are doing, you may be able to slowly come off of some of them. I always also recommend cardiac rehab for all of my SCAD patients with recent heart attack.
coxmaryn: How long after your initial SCAD event sound your cardiologist perform any ' scans' or tests to see if the original dissection has healed and/or to check damage? What scans do you use?
Soo_Hyun_(Esther)_Kim,_MD: This is a great question. There is no consensus on repeat imaging and my general practice is to not look unless there is a problem. If there is a weakened heart muscle after SCAD, I will check an echocardiogram in three months to see if the muscle function has improved. I really only look at the arteries themselves, either with heart catheterization or CTA of the coronaries, if there are ongoing symptoms. Most patients are younger and we have to be cognizant of the radiation exposure that comes with these tests.
SCAD and Stents
Lady.A: In case one has almost a full metal jacket on the left side (left main artery, LAD and left circumflex) is the probability of another SCAD happening in the stented arteries low? I had my SCAD postpartum and I am trying to understand how high my risk of having another SCAD is, if I consider to get pregnant again. Are there any known cases of SCAD in the RCA associated with pregnancy/post-partum? Or is pregnancy and post-partum associated with SCAD on the left side?
Soo_Hyun_(Esther)_Kim,_MD: Technically, stented arteries cannot dissect. Yes, there are cases of SCAD pregnancy/post-partum affecting the RCA. Please have a detailed conversation with your cardiologist and maternal fetal medicine doctor before any attempts at another pregnancy.
SCAD and Risk of Recurrence
kteacher56: Hi Dr. Kim, I noticed in my Cath report the word "tortuous" when describing my LAD and "very tortuous" when describing the subdivisions of my Left Circumflex. Does this mean that I have a greater chance of recurrence of a SCAD? I will be seeing you on Wednesday, July 6, and we can discuss it further, but I thought that others might like to know the answer to this question. Thank you very much.
Soo_Hyun_(Esther)_Kim,_MD: I very much look forward to meeting you in person. That is a great question regarding tortuosity and risk for recurrence. There is some research that suggests that perhaps more tortuous arteries may be more predisposed to dissection, but I would like to see this research replicated in larger populations. The risk of recurrence and the factors that affect this are a big topic, understandably, but with many aspects of SCAD, we have much to learn. There is nothing you can do to make your blood vessels less tortuous but anatomic factors can maybe help us understand the cause of SCAD in the future.
rolynnk: Hello. I am a SCAD survivor, and would like to know the chances of having a recurrence. I am 58, have had SCAD in my LAD and had two stents. I was told that recurrence is more likely if you've had stents. Is that true?
Soo_Hyun_(Esther)_Kim,_MD: Thank you for asking this question. In theory, any portion of the artery with a stent in it can't really have further dissection, but we know that stented arteries in SCAD need to be closely monitored as they may developed blockages. Most of the research up to now has shown that recurrence tends to happen in different vessels than the first one and I have not seen the research showing more recurrence of dissection because a patient has had a stent. I tell all of my patients to pay attention to their symptoms, and if something feels like your heart attack pain, have a low threshold for further investigation.
UserI: Is there evidence that reducing inflammatory markers can reduce risk of reoccurrence of SCAD events?
Soo_Hyun_(Esther)_Kim,_MD: Great question. We know that reducing inflammation probably decreases risk of heart attack in those with coronary disease from atherosclerotic plaque, however, this information is not available for SCAD. We do not have any evidence that SCAD is inflammatory in nature for the majority of patients.
SCAD and Travel
valentine: I am 2.5 years post SCAD/MI. On beta blocker and baby aspirin. Light chest pains few days prior to my periods. I am planning to travel to Italy this coming fall during two weeks. What do you recommend to bring apart from medication, my medical bracelet, and list of nearby hospitals?
Soo_Hyun_(Esther)_Kim,_MD: A hat, sunscreen, and good reading! You could also bring Dr. Kim along! In all seriousness, SCAD survivors should live life, and I am glad that you are doing so. If you are someone that has chest pains, you may want to take some nitroglycerin with you, just in case. You could also print out a SCAD article to carry along to share with medical professionals in case you need to. Otherwise, have a great time.
SCAD and Other Medical Conditions – FMD; GCA
SCAD Alliance: Hello Dr. Kim, patients face great confusion about fibromuscular dysplasia (FMD) and its association with SCAD. Would you please clarify, and give a layman's definition of coronary FMD also?
Soo_Hyun_(Esther)_Kim,_MD: Please see my prior response, but short, this entity of coronary FMD is just beginning to be characterized. It is important to note that Dr. Saw's recent paper looked at the coronary appearance in patients with FMD in other vascular territories outside of the heart. We have not studied coronary FMD in those without FMD elsewhere. Basically, I think of SCAD as an alternative presentation of FMD, but for now, using the tools most commonly available, we are not able to diagnose coronary FMD in isolation.
Agnesvdwolfshaar: I would like to know how coronary FMD looks like; do you have an image of that? I also would like to know what method is the best to screen a patient for coronary FMD. What percentages of the SCAD patients have coronary FMD?
Soo_Hyun_(Esther)_Kim,_MD: Great question. Dr. Saw recently published an article this year on the appearance of coronary FMD -- complex, but in short, it can look like a lot of things. It is rare to see beading but we can see other findings such as "webs" and "pits" using intravascular imaging. There is no good method to screen a patient for coronary FMD, and I would not advise routine screening left heart catheterization is invasive and not without risk. We don't know the percentage of SCAD patients with coronary FMD as not all patients receive OCT or IVUS.
Beatrice#1: I had a SCAD heart attack when two coronary arteries split on Dec 17, 2015. My mother has Giant Cell Aortitis, a disease that has caused multiple aneurysms in her aorta. Is there a connection, and if so, would some type of further testing/treatment be beneficial to prevent further SCAD events?
Soo_Hyun_(Esther)_Kim,_MD: This is a great question. We know that there are some types of vasculitis, or disease processes that cause inflammation in the vessel wall, that can be associated with SCAD. The majority of SCAD patients do not have any inflammatory basis to their dissection. GCA is a disease of older adults, and it is unlikely that your SCAD is related to her GCA, unless you have an underlying vasculitis as well.
SCAD and Medical Bracelet
Beatrice#1: Do I need to wear a medical I'd bracelet post SCAD? If so, what should it say? Does it need to say that I am on blood thinner?
Soo_Hyun_(Esther)_Kim,_MD: Great question. I do advise my SCAD patients to wear a medical bracelet so that if they are unable to communicate for some reason, medical personnel can at least look up the condition if they are not familiar with it. As you know, SCAD tends to affect patients without risk factors for heart attack so having something "in case" may come in handy. The bracelet can say "SCAD heart disease" and if you are on a blood thinner, you definitely need that on the bracelet.
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