A major milestone for the SCAD community was reached on 22 February with the publication of the first Position Paper on SCAD by the European Society of Cardiology, acute cardiovascular care association (ESC-ACCA), SCAD study group.
The Position Paper is aimed at practising clinicians caring for patients with SCAD and contains the current knowledge consensus regarding the definition of SCAD; risk factors and associations, such as hormones, Fibromuscular Dysplasia (FMD), exercise and connective tissue disorders; symptoms experienced at the time of SCAD and, for some, after; diagnostic techniques; treatment options; prognosis and aftercare recommendations. Key messages include:
- SCAD is a frequent cause of acute coronary syndrome (ACS) in young to middle-aged women and patients with heart attack in pregnancy or post-partum.
- Pregnancy-associated SCAD accounts for a minority of cases.
- The causes of SCAD are unknown but there are indicators that female sex hormones have a role, as do conditions such as Fibromuscular Dysplasia (FMD).
- There is no strong indicator that SCAD is an inherited condition.
- Delayed diagnosis is common because SCAD patients usually fall into the lowest risk groups for ACS based on traditional risk scores.
In terms of managing SCAD, the Paper says:
- There is increased risk of complications and adverse outcomes, compared to atherosclerotic heart disease, of repeated angiograms and stent placement (revascularisation).
- Conservatively managed SCADs usually heal completely over a few months.
- Further research is needed to establish the best medical treatment strategy, which may be different to the treatment for atherosclerotic heart disease.
- The prognosis following SCAD appears good but recurrent SCAD is well recognised.
- Recurrent chest pain after SCAD is common.
The Paper references studies indicating that male SCAD patients may be slightly younger and have a higher incidence of mechanical triggers in terms of preceding isometric or extreme exercise.
For patients wanting to become pregnant after having a SCAD, the Paper recommends it be managed by a multidisciplinary team, and says there is limited data on the risk of pregnancy in SCAD patients, but it should be considered high risk.
The Paper recommends SCAD patients should do cardiac rehabilitation and return to exercise, but avoid extreme or isometric exercise.
The writers also say that patients with SCAD may be particularly at risk of post-traumatic stress disorder (PTSD). They suggest that counselling, cognitive behavioural therapy, stress-reducing therapies or medical treatment for anxiety or depression may be appropriate in some cases.
Rebecca Breslin, Chair Trustee of Beat SCAD, said: “The release of this eagerly awaited Position Paper is a hugely significant step in the understanding of SCAD. This isn’t formal guidelines that make their way into the NHS and general practice, but it is certainly progress towards that goal and we now have consolidated scientific statements from numerous esteemed medics about SCAD at this moment in time.”
Rebecca continued: “The paper may be aimed at medics but there is much content of great value to patients too, including rationale for and against certain medications, plus some reassurances that ongoing chest pain after SCAD does happen and it is common among the patient group, as well as the genuine concern about suffering another event: recurrence does happen for some. This should be a wake-up call to the many doctors who have told their patients that their SCAD was a ‘one-off, freak event that won’t happen again’. The odds of not having a recurrence are certainly greater and keeping a positive outlook goes a long way but this truly emphasises the urgent need for more research to ensure optimum treatment and follow-up care strategies are defined.”
Dr Adlam, who is leading the UK SCAD research project in Leicester, chairs the ESC-ACCA SCAD study group, whose members include cardiologists from across Europe. The Position Paper writing committee included Dr Abtehale Al-Hussaini, who worked on the Leicester research project with Dr Adlam and is now leading a SCAD clinic in London.
The American Heart Association published their equivalent paper, a Scientific Statement, at the same time and Dr Adlam was a member of the writing committee that was chaired by Dr Sharonne Hayes of the Mayo Clinic and co-chaired by Dr Esther Kim of Vanderbilt Heart and Vascular Institute and Dr Jacqueline Saw of Vancouver General Hospital.
Dr David Adlam said: “The Position Paper is an important document for doctors and for the recognition of SCAD because currently neither the European nor American guidelines for heart attacks mention SCAD but, as we are learning, the considerations for managing SCAD differ from atherosclerotic heart attacks. It is also important for this paper to reach other medical disciplines such as Obstetricians because, ultimately, we need SCAD to be mentioned within their guidelines. The paper gives us a starting point and as more data comes out we will then update the paper over the course of time.”
Beat SCAD strongly encourages all SCAD patients to take a copy of this document to the doctors involved in their care to ensure the most up-to-date information is considered in the management of their condition. Ask your doctors to share with their colleagues and help to raise awareness.