SCAD management

Diagnosis

In the first instance, most SCADs will be diagnosed by 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.

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.

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.)

 

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, 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.

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…