SCAD chapter added to textbook for interventional cardiologists

A textbook for interventional cardiologists now includes a chapter on SCAD. This is great news for the SCAD community as it provides up-to-date information about SCAD, its diagnosis, management and aftercare to interventional cardiologists.

The new chapter in the PCR-EAPCI Textbook Percutaneous Interventional Cardiovascular Medicine, has been written by cardiologists and SCAD experts Dr David Adlam, who is leading the SCAD research in Leicester, Fernando Alfonso from Spain, Angela Maas from The Netherlands, Alexandre Persu and Christiaan Vrints from Belgium.

“It’s the first chapter dedicated to SCAD of any textbook of this sort,” said Dr Adlam, who added that the textbook will be continually updated with new information as it emerges.

The chapter defines SCAD and discusses two theories for how SCAD occurs, the ‘inside out’ and ‘outside in’ hypotheses. ‘Inside out’ suggests there is a ‘tear’ in the artery wall that allows blood to enter a false lumen that develops between the artery walls, disrupting blood flow. ‘Outside in’ suggests that the initial event is a bleed within the artery wall, where an intramural haematoma (bruise) builds up and slows or stops blood flow through the artery.

SCAD bruise

Progress in the genetics area is discussed, including common and rare genetic variants that are associated with SCAD. Click here and here for more on recent research.

Incidence of SCAD is, the authors say, hard to estimate due to under- and mis-diagnosis, but estimates range from 0.8-4%.

Around 90% of cases are in women and SCAD accounts for 23-36% of Acute Coronary Syndrome (ACS) in women under 50-60 years of age, with the average age being 50. Only around 5-10% of SCADs happen during or after pregnancy (P-SCAD).

Issues with diagnosis are covered, including the increased risk of further dissections being caused by angiography. The authors also list some conditions that can mimic SCAD on invasive angiography so, for accurate diagnosis in these cases, the authors suggest other options including intracoronary (OCT) imaging and CT coronary angiography.

Other areas covered in the chapter include conservative management and healing, risks and outcomes of stenting (which is also discussed in a recently published paper) and bypass surgery.

Contraception, HRT and ongoing chest pain

In a section about contraception and HRT, the authors say if unplanned pregnancy and menopause symptoms can be managed without hormone therapy, this is the easiest option, but if not, they suggest preferred contraception and HRT methods. They also offer various management approaches for SCAD patients who suffer from migraine, which they say happens with increased frequency in SCAD patients.

Many SCAD patients have ongoing chest pain and the authors suggest this happens more frequently in women, those who have migraine and those who experienced previous psychological or chronic pain issues. In most patients this improves over time, but this can take up to two years.

Recurrent SCAD

Around 10% of patients have a recurrence within five years of the first event. Recurrences usually happen in a different location to the first SCAD and, in observational studies, the authors say increased coronary tortuosity, FMD (Fibromuscular Dysplasia), migraine, uncontrolled hypertension and non-use of beta blockers have been associated with increased risk of recurrence.

The authors also say current data suggest there is a risk of recurrent SCAD with unplanned pregnancy following an initial SCAD.

However, there is no evidence that exercise after SCAD increases the risk of recurrence and cardiac rehab is safe and beneficial, both physically and mentally, but isometric and extreme exercises are not recommended.

Mental health

Due to the younger patient population, SCAD patients are at high risk of post-traumatic and other mental health problems and the authors advise early referral to counselling or other therapies.

Dr Adlam says in the chapter: “Once considered ‘rare’ and largely a disease of pregnancy, the advent of high-sensitivity cardiac biomarkers, early angiography and intracoronary imaging has demonstrated SCAD is a very important cause of ACS in woman and although most patients are not pregnant or post-partum, SCAD remains a key cause of ACS in this context.”

Click here to see Dr Adlam discuss the chapter with Trustee Rebecca Breslin (at 13 mins). 

And he talks with Rodney De Palma, one of the editors of the textbook in this video.

The chapter is here (behind a paywall).

The PCR-EAPCI Textbook Percutaneous Interventional Cardiovascular Medicine is the main European textbook for cardiologists and trainees across Europe and the world who work in the cath lab. It is published by the section of the European Society of Cardiologists that deals with intervention.

Risks and benefits of PCI intervention in SCAD

A new study investigating the practice and complications of PCI (invasive angiography and placing of stents) in SCAD patients has been published.

Using data from SCAD patient registries in the UK, Netherlands and Spain, this study, co-written by Dr David Adlam and colleagues on the UK research project, is the largest international observational study of PCI in SCAD. It looked at 215 SCAD patients who had undergone PCI and 221 who had been managed conservatively.

Although conservative management is preferred where possible, some patients may need intervention to reduce the risk of greater heart injury. However, there is a higher risk of complications when PCI is used in SCAD and patients sometimes need longer stents than might be used for atherosclerotic heart disease.

“While a conservative approach to revascularisation is favoured, SCAD cases with higher risk presentations may require PCI. SCAD-PCI is associated with longer stent lengths and a higher risk of complications but leads to overall improvements in coronary flow and good medium-term outcomes in patients,” said the study.

Dr Adlam, Associate Professor of Acute and Interventional Cardiology at University of Leicester & Honorary Consultant Interventional Cardiologist at University Hospitals Leicester and lead SCAD researcher, added: “There are definitely situations were stenting is the right thing to do. We don’t want the pendulum to swing too far in favour of conservative treatment when you have a more serious scenario, greater risk in terms of the heart muscle, and maybe in those cases you should, accepting those extra risks, still intervene in a careful and appropriate fashion.”

Beat SCAD asked Dr Adlam about the significance of this paper and the new chapter on SCAD in the PCI textbook. He said it’s important that clinicians who are reading the guidelines for healthcare professionals (eg NICE guidelines) are aware that SCAD is different in terms of PCI, so it’s important that this information keeps being shared and is available to clinicians dealing with SCAD.

Thanks to everyone who has signed up for and taken part in the research. Dr Adlam said: “A huge thanks to all volunteers – SCAD patients, families and healthy volunteers – because without you we wouldn’t have any of these data to analyse so we couldn’t publish these papers that take us forward with SCAD.”

Beat SCAD would also like to thank all the researchers across the world who continue to search for answers and establish best practice for managing SCAD patients.

Click here to watch Dr Adlam discuss the paper with Trustee Rebecca Breslin. 


SCAD patients benefit from creative workshops

When SCAD patient Giedre Calverley decided to run some creative workshops for other SCAD patients, she had a great response.

She told SCAD patients: “The purpose is to have a peer group where we could ‘make sense’ of changes in our lives caused by SCAD in a safe, facilitated creative space. Similar to peer groups in caring professions where people deal with difficult or even traumatic events by mutual reflection and support, this could be a confidential survivors’ group that helps in the same way.”

The idea to run the workshops came to Giedre because “Several months after my first SCAD in November 2018, I took a break from being a consultant psychiatrist in the NHS and started as a fine art student at my local college. Making art has become my main avenue for problem-solving, expression and maintenance of my health and wellbeing,” says Giedre.

“I explore ideas, think and make sense, develop meanings, tell and re-tell stories whilst drawing. I used to play music and sing as an amateur musician but in visual art I get to be a creator myself. It is as invigorating and mind-clearing as going for long walks in nature but with the added benefit of getting things off my chest. Making art takes me to a space where my mind wanders freely and I feel present and alive.”

Having benefited from making art herself, Giedre decided to share her experience with other SCAD patients. The weekly online workshops started in early March and ran for eight weeks. Five SCAD patients joined Giedre for the sessions.

Giedre explains, “Each week we had a different theme and activities to start us off: a warm-up activity and the main activity loosely based on a theme. We looked at making time to care for ourselves, being present and journalling. We explored our connections with others, looked at our strengths, explored our senses with a particular focus on touch (this session was beaming with laughter) and made drawings in response to our favourite text. We shared illustrated recipes of meals that are good for our hearts and took time to dream about our future.”

No previous experience in creating art was needed and during the workshops the group members made collages, painted with watercolour, did charcoal and pencil drawings and played some games with words and associations.

Giedre says, “An open mindset and willingness to learn, try something new and connect with others are much more important than any experience in art.”

Some of the participants said doing these sessions via Zoom meant that they could create in the privacy of their own home, and not feel they had to compare themselves and their art to others. “At the end of each session we discuss our experience in the session but image sharing is entirely optional and some people do not show what they make,” says Giedre.

Having a SCAD can shake your confidence and lead to anxiety and depression, but having a creative outlet can help recovery. One participant, Kay Deadman, said: “Giedre makes you feel so welcome and kept checking that you understood what you were doing but without any pressure to do it any particular way but to do it how you want to. This really challenged me as I had felt I had lost confidence of who I was and what I wanted when I had the SCAD and, at first, thought I wouldn’t be able to think of anything [to draw], but with Giedre’s gentle nature and guidance I was amazed with what I had done. I really enjoyed engaging with the others while doing art and we chatted and talked about our experiences and worries of SCAD, which helped me immensely.”

Giedre asked whether the workshops had improved participants’ confidence and everyone who responded to her feedback survey said their confidence had improved and they felt inspired to carry on creating, which is a great endorsement for the workshops.

Kay said the benefits of the sessions included: “Engaging with others who have experienced SCAD and starting to form friendships through art. There was something special about engaging in the same activity but each creating something totally different.”

Another participant said, “The SCAD stories and others’ advice and experience has been great in helping me deal with my own. The laughing is an additional medicine!”

Improving wellbeing was one of the aims of the workshops and, when asked if participants had seen any change and whether their feelings about SCAD had changed, the answers were extremely positive. “I have more confidence that I will be OK having met some lovely people who are further down the line than I am and are doing great,” said one.

Kay added, “Talking to other people who have experienced SCAD really helped me see that we can get our life back and to not be so scared of the future.”

The group members enjoyed the workshops so much they agreed to continue for another eight weeks and would thoroughly recommend other SCAD patients to take part in future workshops. Lucie Haddon, whose artwork is pictured here, said: “These wonderful sessions have been really beneficial for me. I have loved meeting the other SCAD ladies, including Giedre, and I have rediscovered the creative side of me. We have lots of laughs as well as the more serious conversations about our shared experiences.”

Giedre says she learnt a lot during these sessions. “The biggest and most gratifying experience for me was one of a human spirit – the depth and wisdom, the ability to create, transform, problem solve, draw and evolve meaning, see and create beauty, endure uncertainty, tolerate ambiguity, move forward despite discomfort, reflect and learn, share generously, care about others and laugh together! Each woman in the group brings her unique viewpoint, style, a collection of strengths and experiences yet underneath all the superficial differences beats a warm, brave and vast human heart.”

To see some of Giedre’s art, have a look on Instagram @giedr_art and see @Healing_scad_h_art for some of the art created by the SCAD patient group.

If you’re interested in finding out more, please click here to complete Giedre’s form. If there is enough interest Giedre plans to hold more workshops.