SCAD management

Diagnosis

Troponin is a protein that is released into the bloodstream during a heart attack. Troponin levels in the blood typically increase within 3-12 hours from the beginning of heart attack symptoms, peak at 24-48 hours, and return to their baseline over 5-14 days.
Baseline measurement of Troponin levels, followed by serial measurements of troponin three hours afterwards should be performed. Both the absolute value of the Troponin level as well as the degree of change in the troponin level should be considered when diagnosing SCAD. 
It is now understood that women may experience a heart attack at a lower level of troponin in the blood than men. A higher sensitivity Troponin blood test has been developed and is currently being tested.  
Raised Troponin levels, together with other heart attack symptoms, should result in a request for an angiogram.
Once the diagnosis has been made, if possible ‘conservative management’ (ie medicines only) is the preferred method of treating the SCAD, unless intervention (by inserting stent(s) or coronary artery bypass graft – CABG) is clinically necessary.  Follow-up angiograms are not advised ‘to check on healing’.  They should only be carried out if the patient is clinically unstable.

Many NHS Trusts will carry out procedures to check how the heart has healed after SCAD.  There are many ways of doing this.

  • Echocardiogram: An echocardiogram can help diagnose and monitor certain heart conditions by checking the structure of the heart and surrounding blood vessels, analysing how blood flows through them and assessing the pumping chambers of the heart. It is used to identify damage after a SCAD heart attack and to see if there are any signs of heart failure.
  • The European Position Paper recommends that every SCAD patient should have at least one ‘head to hip’ scan to check for vascular abnormalities. This is because many SCAD patients also go on to get a diagnosis of Fibromuscular Dysplasia (FMD).
  • MRI scans do not expose you to radiation as they use radio waves and magnets.
  • MRA scans (Magnetic Resonance Angiogram) are carried out exactly the same as an MRI scan apart from the use of dye which is administered through a needle in the back of your hand. This scan gives a clear picture of your arteries. The dye used in this test has no side effects.
  • CT scans do expose you to radiation as they use x-rays.

Aftercare

We asked SCAD expert Dr David Adlam some questions about aftercare for SCAD patients. 

How do I know my SCAD has healed? What is the safest way to find out if my SCAD has healed? Is a stress test useful/necessary and why is it done? When is the best time for it to be done?

Dr Adlam: “In the past, some centres performed follow-up invasive angiograms to check on healing. We do not recommend this these days as we know there is a small risk of causing dissections with the catheters used during these procedures (iatrogenic dissection). These studies, however, are helpful in that they show that virtually all SCADs heal by themselves between three and six months after the SCAD event.

“Sometimes, if the dissection is in the larger parts of the coronaries arteries, we will do a follow-up coronary CT scan to confirm healing. However, this is not particularly useful for smaller, more distal coronary dissections as the spatial resolution of CT is not really good enough to assess this with any accuracy. We also have to remember that CT scans involve X-rays (with a small lifetime associated cancer risk) and in patients without symptoms, we rarely make important findings on follow-up scans. For this reason, in many patients we will make the reasonable assumption that the dissection has healed and not go through a process of further tests to demonstrate this.

“A stress test (whether with imaging such as MRI or by an exercise test) is usually only needed to assess patients with symptoms. Sometimes we will use this kind of test in patients with post-SCAD chest pain syndrome to confirm there is no persisting issue with the blood supply to the heart (as this is reassuring if confirmed and, conversely if there is a blood supply issue, further tests can be considered).”

Patients are discharged from cardiologists at different times after their event – what happens over the following years in terms of their care? GPs may not understand SCAD and be able to manage medication long term. Where can patients turn to for support when they need it?

Dr Adlam told us: The UK SCAD specialist resource is very small and if they follow everyone up they wouldn’t be able to see anyone new! They try to get patients to a point of stability – do the scans, sort out a medication strategy and then discharge. Other patients may have more severe injuries to the heart or bigger problems with post-SCAD chest pain. If patients want to be re-referred to review things or are planning pregnancy, for instance, that’s an option, but with a limited resource they have to rely on local cardiologists and GPs to carry the medical strategy forward.

Click here for information on referral.

Medications

If your doctor wants to treat your SCAD like an atherosclerotic heart attack, we recommend highlighting the information in the European Position Paper on SCAD explaining the differences in management of these two very different conditions.

There are no randomised controlled trials to compare different conservative (ie medicine only) treatments, so current practice – as outlined in the 2018 European Position Paper on SCAD – is based on guidelines for non-SCAD ACS (Acute Coronary Syndrome):

  • Thrombolysis (treatment to dissolve blood clots) should not be used for acute management of SCAD.
  • Antiplatelet therapy (which reduces risk of blood clots) is controversial for various reasons, one of which is the concern about using medication that extends bleeding time for a condition that may be an intramural bleed (a bleed between the walls of the artery). Also, giving patients of menstrual age antiplatelet medication could cause menorrhagia (abnormally heavy bleeding during periods). Patients who have stents should be on dual antiplatelet therapy (typically aspirin and clopidogrel) for 12 months and “prolonged or lifelong monotherapy (usually with aspirin)”. Conservatively managed patients are advised to have dual antiplatelet therapy in the ‘acute’ phase of recovery. The optimal duration of antiplatelet therapy is unknown and some clinicians question the approach that calls for lifelong aspirin.
  • Anticoagulant therapy (blood thinners) – there are concerns about the same issues as antiplatelet therapies (see above) and anticoagulant therapy should probably be limited to the acute period unless there is a clinical need (eg a blood clot).
  • Blood pressure management – ACE inhibitors (blood pressure medication), angiotensin receptor blocker (ARB) (to dilate blood vessels and reduce blood pressure), mineralocorticoid receptor antagonists (MRA) (a diuretic), betablockers (to lower heart rate and therefore blood pressure) and vasodilator (dilates blood vessels to lower blood pressure) therapies – current guidelines for ACE, ARB and betablockers should be followed for SCAD patients with significant impairment of left ventricular systolic function, adding MRA (diuretic) as necessary. Low blood pressure in some SCAD patients can limit increasing the dosage. However, prescribing these for patients without significant left ventricular systolic function impairment is controversial. One study has linked high blood pressure with an increased risk of recurrent SCAD and betablocker treatment with reduced risk of recurrence. If these results are validated it may provide evidence that SCAD recurrence risk may be reduced with medication. Nitrates or calcium channel blockers (vasodilatory therapies that dilate the blood vessels) can be used to treat recurrent chest pain.
  • Statins should be given to patients with high cholesterol.
  • Contraception and hormone replacement therapy – concerns are based on the assumption that there is an association between SCAD and female sex hormones, however it is still unclear what this association is. It would be reasonable to avoid hormonal contraception where possible. In patients with recurrent cyclical chest pain, low-dose local hormone delivery via IUD (typically the Mirena Coil) has been anecdotally reported to be useful. Click here for more information.

FAQs

What if I have side effects from the medication I’ve been prescribed?

Talk to your doctor and if they are unsure what to do, ask them to discuss with one of the SCAD specialists (see the email address for the Leicester SCAD research team here or refer you to one of the SCAD experts in London or Leicester.)

 We asked SCAD expert Dr David Adlam a few questions about medication:

If you have a stent you have to take aspirin, but are you concerned about long-term use of aspirin and is there any alternative?

Dr Adlam: “There are cases where aspirin is necessary (eg stent, bypasses, FMD in the neck, a larger scar on the heart). The data outside that context (eg conservatively managed SCAD with no other reason to take aspirin) is scarce. There aren’t any clinical trials but I hope in the coming years we will be able to answer this question properly. We tend to be quite conservative – unless there’s a reason to take it then we tend to stop it. Err on the side of less medication than more. But this is opinion and it’s based on experience and my thinking about SCAD having looked after a lot of patients, but not based on solid data. There are a number of drugs that do the same thing – aspirin is the number one choice, clopidogrel does the same thing and is used in patients who can’t tolerate aspirin.”

Many people are concerned that they are put on statins because that is what you do with people who have a heart attack. Can you reiterate the guidance about statins for SCAD patients?

Dr Adlam: “There is no current evidence that the causes of SCAD are related to cholesterol. In most patients we do not recommend statins are used unless there is another indication (such as a high calculated lifetime risk of non-SCAD vascular events). We suggest SCAD patients are considered in the same way as patients who have not had a heart attack from this perspective. Potential exceptions are patients who have had bypass grafts (particularly with vein grafts). There is no firm evidence that patients who have had stents need to take statins although there are some theoretical arguments for this group.”

Many people suffer from excessive sweating after SCAD. Could this be due to medication? How do we know if it is medication or menopause? What can be done about it?

Dr Adlam: “This is not something I have heard of before and I don’t have a clear explanation (medication or SCAD-related) for this. Clearly this could relate to the menopause in some patients. I’m afraid I am not aware of any medical treatment for this, so practical measures only to my knowledge.”

Patients have told us that bad memory issues seem to be common after SCAD. How do you find out if it is medication or due to what we have been through?

Dr Adlam: “Again this is a tricky one. It is not impossible it could relate to medication in some cases. The only way of knowing is to discuss with your GP or cardiologist if it is safe to try without for a period of time to see if it makes a difference. It is also important to remember that this kind of symptom is commonly reported by non-SCAD patients and the general population so it may be neither the SCAD nor the tablets are to blame here.”

Is it safe for SCAD patients to take vitamin supplements (eg fish oil capsules) for aching joints – are there any contraindications with heart medications?

Dr Adlam: “In general, I am a pragmatist. If these things make you feel better, I am comfortable with patients taking them as long as they carefully read the label. I would avoid things (such as Chinese herbal remedies) where you cannot be sure what is in them. Broadly speaking we cannot be absolutely sure about interactions with medications but for the most part things which are commonly used (such as those you describe) are likely to be safe.”

Beat SCAD advises you always check with a pharmacist or GP before you take new medications/supplements to ensure there are no contraindications.

Can I take over-the-counter medicine?

Every individual should get advice from a doctor or pharmacist based on their own health and current prescriptions for other medicines before consuming any over-the-counter medicine. There are some over-the-counter medicines that are not advised for certain patients.

Non Steroidal Anti Inflammatory Drugs (NSAIDs) – eg ibuprofen

Asthmatics are advised not to use NSAIDs.

Prolonged use or overuse of NSAIDs has been associated with a slightly increased risk of stroke and heart attack. The NHS has information here. And NICE says to use the lowest dose for shortest time possible and be wary of lots of possible contraindications (particularly when the patient is going to be on a prescription strength NSAID for a while).

Decongestants – eg Pseudoephedrine which is found in most cold remedies with a decongestant component

These can increase blood pressure so are generally not advised for those using blood pressure lowering medicine.

So if some medications are not recommended for SCAD patients, should I stop taking them?

No. You must always check with your GP, cardiologist or the SCAD specialist looking after you before you stop or change your medication. There are good reasons for some SCAD patients to take some of the medication, so seek advice and show your doctor the current information from the European Position Paper/research.

Chest pain after SCAD

Why do I have ongoing chest pain?

60-90% of SCAD patients experience recurrent chest pain after SCAD (Post-SCAD Chest Pain Syndrome), according to studies referred to in the European Position Paper on SCAD.

Click here to read Beat SCAD’s summary of the European Position Paper.

Hospital readmission for chest pain after SCAD is also very common. Given the risk of recurrence (circa 10%), it is recommended that ECG and troponin blood tests should always be done.

In some patients the pain is cyclical, usually pre-menstrual. Anecdotally, cyclical symptoms may respond to low-dose contraception (eg progesterone hormonal coil ‘Mirena Coil’). For those who get non-cyclical spasm-like pain, vasodilator treatments may reduce vasospasms.

While the cause of post-SCAD chest pain is not fully understood, SCAD specialists recognise it and have observed that, over time, for most patients, it does get much better.

Dr Adlam told us: “We don’t know why post-SCAD chest pain happens although there are some theories, such as a persistent tendency to have artery spasms or disruption of nerves in the heart that run along the side of vessels. Anything that damages nerves takes a long time to heal.”

Typically, for most patients, it will have faded into the background by 24 months (much sooner for many). However a small number (much less than 10%) continue to experience chest pains longer than that.

Watch Dr Adlam talk about this from 42 minutes into this video.

Patients with prior pain syndromes or psychological or psychiatric disorders tend to be more at risk of Post-SCAD Chest Pain Syndrome and response to medication can be variable.

INOCA (Ischaemia with Non Obstructed Coronary Arteries) is a collective term for  conditions such as: Coronary Microvascular Dysfunction (Microvascular Angina), Coronary Artery Spasm and Takotsubo.

Like SCAD, INOCA conditions are often misunderstood and are also frequently under-recognised, under-diagnosed and under-treated.

Frustratingly, this sometimes leads to people being told there is nothing wrong with them, when there is.

Patient driven initiatives such as INOCA International hope to speed up research into microvascular angina, as well as help share information currently available regarding diagnosis and treatment of this complex and disabling condition. It is hoped that this important work will also be of help to the SCAD community.

We suggest keeping a journal: jotting down symptoms (physical and mental) and feelings may help us to spot triggers for chest pain after SCAD. Common triggers are things like dehydration, tiredness, doing too much too soon, doing some new form of physical work for the first time after our SCAD, eg vacuuming, hanging out washing, carrying heavy shopping etc. A journal is helpful for medical appointments recapping key events and dates etc. Also for illustrating that eventually the bumps in the road get smaller and spaced further apart…

Many patients worry about having another SCAD. We asked SCAD expert Dr David Adlam what the risk of recurrence is.

He told us: Recurrence does occur, but it’s not so common, with the latest data suggesting around one in 10 patients will have a recurrence in the first 3-5 years after the first event. Which means 90% of patients are not having a recurrence. This recent MRI study suggests injuries to the heart are small so outcomes after a recurrence are usually good.

Is there any advice or preventative measures to reduce the risk of having another SCAD?

Dr Adlam: “At the moment there is no clinical trial evidence on this. We have data from a single Canadian observational study which demonstrates that prevention of high blood pressure and use of beta blockers was associated with a lower risk of recurrence. Quite a lot of patients with SCAD cannot tolerate beta blockers but we try to continue them if we can. Blood pressure control is important. Otherwise we advise against the extremes of exercise and lifting weights that cause a change in your breathing pattern (a Valsalva manoeuvre) but overall encourage exercise and returning to full activities and work.”

Many patients wear a device that measures their heart rate. Would a change in heart rate give a warning of another SCAD?

It’s different for each individual and Dr Adlam is not convinced that staying within a particular heart rate is a lower risk. It’s better just to have a common-sense limit in your head. A heart rate monitor isn’t a great predictor for recurrence. There are lots of things that can change your heart rate so you’ll get lots of false positives. Patients who attend cardiac rehab usually learn about the Borg scale, which is a way to gauge your perceived level of exertion. 

We know that post-SCAD chest pain syndrome is a common problem, but most people who have a recurrence know they need to get checked out, so you don’t need a heart rate monitor to tell you.