Frequently asked questions

Pregnancy after SCAD

Many women in the SCAD community despair at being told by their doctor that pregnancy after SCAD is too dangerous to consider, without facts or statistics to back up such advice. Some of the women already had one or more children but always planned more, whereas others were yet to begin their families and felt that SCAD had robbed them of the opportunity.

All SCAD survivors considering pregnancy should seek pre-conception counselling so they can be fully assessed, their individualised risk discussed and medications reviewed to ensure they are safe in pregnancy.

Dr Abtehale Al-Hussaini (known as Dr Abi) formerly with the Leicester SCAD research team is now in a Consultant post at Chelsea and Westminster Hospital in London and runs a SCAD clinic there. She also works with the High-risk Pregnancy Clinic at the hospital, which includes another cardiologist and obstetricians.

They have set up:

A pre-conception clinic where patients considering a future pregnancy can have their questions answered and get advice. The clinic can also advise on contraception and other issues related to SCAD.

A high-risk pregnancy clinic. This will be mainly for women who are already pregnant and will need a plan of care to be drawn up for them.

There is the capacity to have a one-off referral, or plan to deliver the baby at Chelsea. There will be access to the specialist midwife who will closely liaise with relevant teams as needed.

Please contact Dr Al-Hussaini using Abtehale.Al-hussaini@chelwest.nhs.uk for advice on how to be referred or if you would like to explore using this service.

Dr David Adlam at Glenfield Hospital in Leicester is also happy to advise on pregnancy after SCAD.  Please ask your GP or cardiologist to refer you to Dr Adlam using the NHS e-referrals system.

Contraception, Hormone Replacement Therapy (HRT) and menopause

Because women make up around 90% of the known SCAD population, and because SCAD may occur during and after pregnancy, it has long been thought that there might be a link between female sex hormones and SCAD. However, we really don’t know at the moment exactly how this works and any link that does exist is likely to be complex. At present there is no definitive evidence that hormonal contraception or HRT increase the risk of SCAD-recurrence.    

Contraception

For women of childbearing age, the most important aspect of contraception is to have a secure method which can reliably avoid unplanned pregnancy. It may be possible to achieve this without hormonal contraception (such as if a partner has had a vasectomy or with the non-hormonal copper coil). However, this is not always practical and barrier methods (condoms) are sometimes unreliable.

Where hormonal contraception is necessary, often a progesterone-based approach (such as the progesterone-only pill or progesterone-containing coil) will be recommended. Sometimes breakthrough bleeding can be an initial issue but this will often settle down over the first few months. Other forms of hormonal contraception are not necessarily precluded after SCAD but should be discussed with your doctors.

Many SCAD patients experience chest pain after SCAD.  For some this pain is primarily cyclical, usually pre-menstrual. Anecdotally, cyclical symptoms like this may respond to damping down the menstrual cycle with a hormonal contraceptive (again usually progesterone-based).  This can also be useful for women who suffer from excessive menstrual bleeding while on antiplatelet therapy – particularly if they have stents or need to take blood thinners in the long term – rarely endometrial ablation may be considered. 

HRT

Systemic HRT is a balance of risks in all women and patients who have had SCAD are no exception. If the menopause can be managed without HRT, this is clearly the best and easiest option. If menopausal issues are mainly local, topically applied oestrogen (eg vaginally) may assist. For women with intrusive systemic menopausal symptoms, low-dose HRT options may be appropriate and is not contraindicated in SCAD. 

As with all medication, contraception and HRT is a very individual matter that must take into consideration all pre-existing health factors. It should be discussed with either your GP or cardiologist.  You may also wish to seek a referral to a UK SCAD specialist to discuss your requirements further.

Menopause

Some SCAD patients are concerned that if they have a SCAD in their 20s, 30s or 40s, they are at risk of having another one when they reach menopause age. We asked the UK SCAD experts if there is any evidence of risk of recurrence at this point and they told us they haven’t done a detailed statistical analysis, but haven’t seen any signals that people who have their first SCAD when they are younger are at more risk of a recurrence when they’re approaching menopause. The follow-up hasn’t been done for long enough to provide any solid information on this, however.

Recurrence

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. See our Recurrence section for more information.

 

Genetics

We asked Dr David Adlam, UK SCAD expert what are the chances of SCAD patients’ children having SCAD?

He said: “They are very low. SCAD is not strongly familial and cases which run in families are very uncommon (we have only a handful of such families we know of in the UK and indeed the world). Most SCAD cases are sporadic (ie occur rarely).

“The latest published data from our genetics study shows 3.5% of patients have genetic changes which are likely to have caused their SCAD (so very few) and most of these are in patients who have other known diseases (for example the adult polycystic kidney disease gene was the commonest in our study).

“So, unless there is something particular (such as a strong family history or an unusual pattern of blood vessel abnormalities), we would not at present recommend family genetic screening for SCAD.”

SCAD and stress

We asked the UK SCAD experts whether there is any proven link between SCAD and stress. They told us they definitely see this reported by a lot of patients, eg following a bereavement or loss of a job, so it is an association they want to look into. It is difficult to measure as it’s a retrospective event. A stressful event causes high blood pressure and other things which could have an impact on all the arteries.

Dr Alice Wood is looking at whether people with SCAD respond differently to stress.

Dental work after SCAD

Before you visit your dentist for a check-up, a scale and polish, or for more complicated work, please do let them know about your SCAD, perhaps share our SCAD for healthcare professionals leaflet with them and also tell them about any medication that you have been prescribed.

If you need pain relief for dental work to be carried out after SCAD, do bear in mind that the injection your dentist uses might contain adrenaline.  For some SCAD patients this can produce palpitations and other unpleasant symptoms. Dentists can offer adrenaline-free injections if you ask for them.

Some dentists may be reluctant to treat a recently diagnosed SCAD patient, mentioning concerns about the possibility of a bacterial infection (for example at the site of a tooth extraction) entering the blood stream that could damage the heart, however there are no official guidelines to say that you should wait a certain number of months after your SCAD before treatment.

Flu and pneumonia prevention

The Flu virus can weaken the respiratory system, which the heart relies on, so it’s vital that people with heart disease get the Flu jab. The virus can also attack the heart muscle. If you have already had a heart attack, getting flu puts you at greater risk of having another one. Flu can be mild or severe, and you just don’t know which type you will have. The best way of treating Flu is to be vaccinated against it in the first place. There is an annual vaccination beginning in October or November each year.

Pneumonia can also have long-term consequences on the increased risk of heart attacks and strokes.

The potential impact of Covid-19 on SCAD patients is yet to be fully understood but it is thought that it might be possible to get both Flu and Covid-19 at the same time and that this might put heart patients at risk.

Many GP surgeries will automatically offer the annual flu jab and the longer term pneumonia vaccination to all heart attack patients.

Seasonal flu is typically seen in the UK between December and March, however, outbreaks can be seen as early as October and as late as May. If your surgery is unable or unwilling to offer you the jab in good time, you should be able to obtain it from your local pharmacy or (if you are pregnant) your midwife.

Troponin – what is it and why is it important?

Troponin is a protein that is released into the bloodstream during a heart attack. Raised Troponin blood test results are often part of the process that leads to a SCAD diagnosis. Raised troponin levels, together with other heart attack symptoms, should result in a request for an angiogram to confirm the diagnosis.

Troponin levels in the blood typically increase within 3-12 hours from the beginning of chest pain, peak at 24-48 hours, and return to their baseline over 5-14 days.

Measurement of Troponin levels for patients with chest pain in A&E has been studied widely. 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.

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.  Currently this is not available at every A&E.

Raised Troponin levels, together with other symptoms, often indicate a heart attack. Click here for more info about Troponin blood tests.

We asked Dr Adlam if SCAD always causes a heart attack? He told us: It depends on definitions – the overwhelming majority of SCAD patients will present with an acute event (sudden onset) and there will be a rise in the cardiac enzymes which are an indicator of a heart attack. There are some patients who don’t seem to have a rise, but in most cases the patients’ presentation is some time after the event. In this cardiac MRI study, there were 40% of patients where there was no demonstrable injury in terms of a scar. So many of the patients who have the smaller event will not have a persisting heart injury of any size that will be important going forward in terms of the heart function.

Ejection Fraction – what is it and why is it important?

Ejection fraction (EF) refers to how well the left ventricle pumps blood with each heart beat. Most times, EF refers to the amount of blood being pumped out of the left ventricle each time it contracts. The left ventricle is the heart’s main pumping chamber.

Your EF is expressed as a percentage.

  • 55-70% is considered normal
  • 40-54% the pumping ability of your heart is considered slightly below normal but you may not have any symptoms
  • 35-39% the pumping ability of your heart is considered moderately below normal and you may have mild heart failure
  • less than 35% the pumping ability of your heart is considered severely below normal and you are likely to have moderate to severe heart failure

SCAD patients should note that Ejection Fraction measurement is not an indication of whether your SCAD has healed or not. EF is often checked during an echocardiogram at the time of the SCAD and then later (6-12 months after the SCAD). Any improvement seen in the overall results of a follow up echocardiogram can be viewed as signs of the SCAD healing process. Ejection Fraction has regularly been seen to improve in SCAD patients over time, particularly after use of appropriate medications and lots of rest to allow the heart to heal.

Click on the links below for more information about Ejection Fraction and Heart Failure.

Cleveland Clinic

NHS

BHF

If you find any additional useful resources please email us so that we can review them.  Please also let us know if you discover any broken web links.