Spontaneous Coronary Artery Dissection (SCAD): A Hidden Risk for All Ages

I’m Yvonne Commodore-Mensah, Board President for PCNA. I’d like to welcome you to Heart to Heart Nurses. PCNA supports your professional journey with accessible continuing education, practical patient resources and a vibrant community that understands the unique challenges and rewards of cardiovascular nursing. Together, we’re advancing the knowledge that defines excellence in cardiac care while celebrating the difference you make every day.

Geralyn Warfield (host): (00:20)

I’d like to welcome our audience to today’s episode where we are going to be talking about SCAD with two individuals who have great expertise to share. Eileen, I’m going to turn it over to you to introduce yourself first, please.

Eileen Handberg (guest): (00:31)

I’m Eileen Handberg. I’m a Professor Emeritus at the University of Florida and have been doing clinical trials in heart disease in women for the last 35 years.

Geralyn Warfield (host): (00:42)

And you are joined by…

Maggie Taliska (guest): (00:44)

I’m Maggie Taliska. survived a SCAD 10 years ago and I’m a Women Heart Champion Class of 2020 coming to you from Charleston, South Carolina.

Geralyn Warfield (host): (00:54)

So, for our audience members who maybe are not familiar with this group or this grouping of letters called SCAD, what is this and why should we care? Eileen, do you want to start us off?

Eileen Handberg (guest): (01:03)

Sure.

SCAD stands for spontaneous coronary artery dissection. It is a phenomenon that is highly prevalent in women. Actually occurs in about 95% of the cases are in women. Men, some, but not as much. It is a dissection of one of the primary coronary artery vessels.

And there are three grades to the dissection process. And basically, what happens is if you think of the blood vessel wall as a tube with multiple layers of muscle and tissue and cells, the cell lining of the vessel wall develops a hematoma or a tear and creates like a bruise within the muscle wall, which can be occlusive and can cause disrupted flow to the heart muscle.

And it generally causes a heart attack.

And it was considered rare in the past, very interestingly. And this gets at your whole journey about women. It was considered very rare, say 2010-ish. Sharon Haynes is one of the premier investigators at the Mayo Clinic.

The story she will tell if you YouTube her was that she was approached by a woman at a meeting who said, “Why doesn’t the Mayo Clinic look into this?” And she said, “Well, there’s not enough of it. And so, it would be very hard for a single center to specialize in SCAD.” And the woman said, “Well, I’m in a Facebook group and there’s 70 of us.”

And her previous research showed there had been a series reported of 45, and she was like, “Oh.” And so, this grassroots effort going to an investigator led to this longstanding relationship of SCAD, which has shown that it’s not rare, and it’s common in women.

We probably misdiagnose it a lot of the time, and the definition of, and diagnostic procedures, have evolved over time. I think in their registry they have like 1,400 women now and there are men in it as well. And so, it’s fairly new in terms of the ability to move the knowledge of this phenomenon forward because there weren’t a lot. If you only have one or two patients, trying to characterize or describes some things a little bit problematic, but now there are numbers so that we have really learned a lot about SCAD in the last 10 to 15 years since your event.

Really something we need to pay attention to. It is 44 to 55 is the average age for women. It occurs at post- pregnancy quite often as the cause of the heart attack and so it’s the leading cause of a heart attack in women under the age of 50.

Maggie Taliska (guest): (04:34)

Can I add just a little bit to that story? Because Dr. Hayes is our instructor for Women Heart. So, Women Heart champions are trained by the Mayo Clinic where Dr. Hayes does her research.

It was Katherine Leon who founded the SCAD Alliance who went up to Dr. Hayes. And I met Katherine at a patient conference and it was actually meeting them—and also talking with Dr. Hayes—that I realized I did have a SCAD.

I actually didn’t know I had one for a few years.

Eileen Handberg (guest): (04:58)

Interesting.

Maggie Taliska (guest): (05:04)

You know, reading through my diagnosis and even the events leading up to it, you know, because I had no cholesterol. I was a lot thinner. I was a healthier. No one really like figured out why I had a heart attack at 42.

Geralyn Warfield (host): (05:16)

So, what kind of symptoms were you having in this heart attack? I’ll ask Eileen to come into it next, is how that heart attack appearance might have been indicative of SCAD or maybe not. Obviously for you, it was undiagnosed. So, what did it look like?

Maggie Taliska (guest): (05:33)

So, the night before—I’d always hike sand dunes in Lake Michigan. I was headed out to San Francisco for a week for a client; I was consulting at the time. So, I wanted to get all my hiking in before I left for that.

And on a Friday night, I hiked about six miles and I felt like a deep, deep pain. I could point to it, but I felt this deep pain that night before. And I drank a couple of glasses of wine. You know, it wasn’t like pounding them or anything. It was over the course of four or five hours, but it resolved. And I went out next morning to also go and hike, get my steps in.

And during that hike I collapsed to the ground. I just had this like spontaneous like shock almost. And then I got up and my neighbor who I’d been hiking with, she goes, “You don’t look good.”

So, my husband came to pick me up. It was only a mile from our house. And then the rest of that day (this is about 12 o’clock) I was just throwing up. I was just writhing on the floor—writhing is the best way to describe it. I could not get comfortable.

And then at one point I was like I had this impending sense of doom.

And I went to the urgent care and the only reason I went to the urgent care is I never thought I was having a heart attack. My husband had similar symptoms when he got bit by a spider two years prior. So, I even went to the same urgent care in Western Michigan, same one they had taken him right back.

And me, I never used the word ‘pain.’ I used ‘I’m really uncomfortable’ so they kept saying, “Oh it’s an anxiety.” But I was like sprawled out on the nurse’s table like just trying to get comfortable and nobody, I didn’t either, I didn’t think anything of it until I went and collapsed in the waiting room.

It was nausea, but I am a believer that I don’t believe women use the same words as men, and we have more of a tolerance for pain, so my husband would have been like, “pain,” right?

Where I’m just like, “I’m uncomfortable,” and I just kept going back and forth. Where I do CPR training now, and they say, you someone’s doing this, it’s more likely a digestive, but if they’re doing this motion, it could be cardiovascular.

Geralyn Warfield (host): (07:32)

So, are those typical, Eileen, of symptoms? I mean, a SCAD just, how does it differ from a typical heart attack? How would I know as a clinician that it’s SCAD? Would I have to do additional testing? What would be my clues?

Eileen Handberg (guest): (07:45)

I mean the symptoms, what’s reported in the SCAD registries is the symptoms are very typical for a heart attack.

But, there’s a couple of issues here. First of all, women, if they deviate from the typical angina definition, which was Heberden in the 1800s of, you know, grabbing my chest, diaphoresis, radiating to my left arm.

Anything different than that, providers have this built-in bias as a rule. It’s gotten better, but they don’t tend to be as aggressive with women in general. They assign it to GERD, they assign it to anxiety, they assign it to you’re crazy. And so women who come in with fairly typical symptoms often get discharged from the emergency room. It happens more often than we would ever like to think that would happen. And so there’s that bias.

But generally, the symptoms that present with SCAD are the same. Where you get the diagnosis is when you take this woman to the cath lab. So generally, you come in with chest pain, we do an EKG and we look for markers of ST elevation indicating injury.

And then we do lab work, high sensitivity troponin, and those tend to elevate. It’s an enzyme that’s released when damage to the heart muscle. And then those are elevated. And in moments, in hours, within 90 minutes, which is the current guideline, she should have been in the cath lab.

And when they take that first picture of her coronary arteries, they would have seen this pattern of dissection and decided what to do at that point. It’s at that point where the differential has to come in for the provider to say, is this a typical heart attack? Is this obstructive disease? Is this spasm where it’s a temporary clamping down of the vessel? Or is this SCAD?

The treatment is different for all of those. And so, the differential in the cath lab is for the interventionist to sort of stop for a moment and say, okay, if it’s plaque and blockage, then it’s fairly clear. You blow up a balloon, mash the plaque back, and then you put a drug-eluting stent in, and then you go about the way.

For a patient with spasm, you give them IV nitroglycerin. It releases the spasm. The vessel goes back, and then you look and make sure there’s not underlying plaque.

For SCAD, in general, and they didn’t know this early on and probably not when she had her heart attack, SCAD patients, it’s like a bruise—or the dissection can heal up. And so, if you stick a catheter and you muck around the opening, you can actually make the dissection worse. And you can make it more complicated by putting stents in right away.

So, for a SCAD patient, if she was stable in the cath lab, they probably would have made the decision, we’ll just look at all the blood vessels, make sure what’s going on, make sure she’s got a good blood pressure, everything’s stable, then we’ll take her out of the cath lab and we’ll let it heal up and then see how she does and treat her with all the right medicines.

If she was unstable, then the decision would have been made to put in stents, but because these dissections can be long, you often don’t end up with one stent, you end up with a full metal jacket or more than one, just because of how they put them in and whether or not it makes the dissection worse or bigger. So, you know, generally they tend to leave those blood vessels alone.

Geralyn Warfield (host): (11:57)

So, Maggie, you described that you didn’t even know that you had the SCAD until later. So, how were you treated and did that treatment change over time once you had that definitive diagnosis?

Maggie Taliska (guest): (12:09)

It didn’t change over time. What happened is this doctor treated me on Saturday night, kept saying how significant it was. I was in the cath lab for two and a half hours. I definitely was not stable. And so, when I came out of it, at that point they didn’t have the Impella.® I had the balloon in my heart for a couple of days because they did expect me to go into impending heart failure.

What should have been different at that time had that care team known about SCAD is that they basically told me no salt, no water; everything that they treated it like a normal heart attack.

I had no cholesterol. All of my arteries were age appropriate—the plaque, you know, was age appropriate and everything. So, I went home. I didn’t drink any water. I didn’t want to go back to the cath lab. So, I didn’t drink any water, didn’t have any salt and kept passing out. And I thought I was dying.

So, it took a doctor in Boston to kind of say, “No, you need water and salt. You’re working out every day.” Because I was walking. I did whatever they told me. I didn’t want to go back to the cath lab.

And to kind of say, “You didn’t have this.” And she had mentioned something, she didn’t say SCAD, but she had explained to me that I had a tear and all of that. That my arteries weren’t clogged up or anything. And my cholesterol was super low at that point because I didn’t eat anything.

When I broke my ankle, I said, “I know I can’t walk, but you bring me to the cath lab, I’m finding a way to walk! I’m fine.” It was just a horrible experience.

And so, at that point, it had changed when I saw that doctor in Boston again. I had moved from Michigan to Boston at that time and found a wonderful cardiologist who really put me back together.

But she never used SCAD.

It wasn’t until I met Dr. Hayes started looking through things and we realized, wait! And she even said the night before was probably part of the tear that I felt.

And even some of my other Women Heart champions, they had SCADs, are like, “You sure you didn’t have a SCAD?” But fast forward, my cardiologist in Charleston looked through my record. She goes, “Yeah, this was SCAD.”

Eileen Handberg (guest): (14:08)

I mean, you can have a dissection when you’re in the cath lab from the catheter, but that’s not SCAD. That’s an iatrogenic cause of the dissection. But if they took that first picture and she had that dissection; but at that point when she was diagnosed, it was considered very rare. It wasn’t the common kind of differential that a provider would make.

And if she was unstable, and this I think is a question that SCAD patients have, if you’re unstable, then the treatment needs to be what the treatment needs to be so that you survive the event, right?

And so, some people have thought, because generally it’s “leave those vessels alone,” and then it got a stent and they’re thinking the providers did something wrong. If you’re unstable, they need to make sure that you have blood flow. Because depending on where that block starts, you could lose 2/3 of your heart muscle function because if you’re in the left main that feeds two blood vessels, right? So, if it’s there, hers was proximal from what you were saying early, they need to do whatever they can do to restore that blood flow.

But we’ve learned a lot over the years. Dr. Haynes has been just a pioneer in moving this science forward. There’s a lot that is not known yet. We don’t know what the predictors are. There isn’t a genetic test that can be done to determine if you’re at risk for SCAD.

But they have the registry that they’ve been in has been collecting DNA. And there’s some international collaborations that are going on trying to move the science forward.

And I would say to the people who are listening, if you are a patient who has had SCAD, you should contact Sharon Hayes at the Mayo Clinic and be part of the registry. Because the only way to get the most information is to get as many women enrolled in this so we can understand.

The registry, as I understand it, has Hispanic and African Americans, and they feel like it’s underrepresented of that population that gets SCAD. They’re just not in the registry. So, they can tell you what the prevalence is for the women that they have, but not in the population.

And so, this is a kind of a call to action. There’s great social support with the groups. And that’s really important, as you know from your Facebook efforts in the heart failure domain, which is a consequence of having blood vessels blocked, it impairs your heart function, and that’s huge.

There’s 30,000, you told us today, in that group, and Women Heart, you know, all of those things are very, very valuable opportunities for you to engage in helping move science forward about something that’s happened in your life that’s very significant, and to put a positive spin on a negative thing, right, and to really move that science forward.

Geralyn Warfield (host): (17:50)

We’re going to take a quick break and we will be right back.

Geralyn Warfield (host):

I’d like to welcome back our audience. And I know you might have some questions about SCAD after our conversation thus far. So, I’d like to turn it over to Maggie to tell us about some resources.

Maggie Taliska (guest): (18:02)

Sure, if you have a patient that you think might have gone through a SCAD event, you can go to scadalliance.org or even to womenheart.org. Dr. Sharon Hayes is our lead instructor for the Women Heart Program and she’s also the lead faculty who is studying SCAD. So, it’s scadelliance.org or to Women Heart.org.

Geralyn Warfield (host): (18:23)

And finally, what one key takeaway would you like our audience to come away from this podcast episode with? Eileen, I’ll start with you.

Eileen Handberg (guest): (18:31)

I would say there’s a couple of takeaways for patients.

I think the issue is to be your own advocate and to look for opportunities that will help you on your healthcare journey. Especially with SCAD where there’s not a lot known and there’s more to learn. So, being able to find the resources that were alluded to, finding a network of support is extremely important.

When you’re part of a rare or smaller group, it’s even more important because those resources aren’t as easy to find.

If you’re a provider and you think you’ve taken care of a woman who presents with SCAD, pointing out those same resources to that woman is extremely important because then you provide the opportunity for that social psychological support.

I mean, having an MI is an overwhelming thing and it disrupts your life, changes your feelings about mortality, can affect morbidity. So that’s extremely important.

And putting them in contact with these groups that are encouraging participation in the registry helps us understand the disease process because if it doesn’t occur a lot, and you’re a provider at a small practice in Georgia, Alabama, California, you might only see three or four of these in your career. But if we get every practice to refer those patients to these registries, to these alliances, then we have thousands and thousands of women. And then we can really understand the disease in a better way and help reframe care and delivery pathways that will help these women have a better quality of life and better outcomes.

Geralyn Warfield (host): (20:23)

And Maggie, what final words would you have for our audience?

Maggie Taliska (guest): (20:26)

Words matter.

Studies show that women use lot more words than men. And, I don’t know, I don’t have any facts on this, I think women can take more pain than men. So, we might not use the same words that a man might use during a heart attack event. Uncomfortable, not feeling right, just impending sense of doom are words that your patient could use if they’re having a SCAD, if they had a SCAD, even just a heart attack, and being mindful that it’s not always anxiety or an asthma attack.

Eileen Handberg (guest): (20:58)

I would second that wholeheartedly having worked in an emergency room. I always tell women, you need to go into triage and say, think “I’m having a heart attack.

Maggie Taliska (guest): (21:08)

Or pain.

Eileen Handberg (guest):

I think I’m having a heart attack” because that automatically starts the MI alert system. And then they have to run you through the pathway.

Maggie Taliska (guest):

They have to give you an EKG. They don’t always give women EKG.

Eileen Handberg (guest): (21:22)

Yes, If you have any doubt absolutely, absolutely.

Geralyn Warfield (host): (21:28)

Thank you both so very much for being with us today to encourage us to learn more and to help diagnose and help be part of the SCAD ecosystem, I guess I would say, in terms of patients and providers and individuals who are learning more and want to make a big difference for these patients.

This is your host, Geralyn Warfield, and we will see you next time.

Thank you for joining us for this episode of Heart to Heart Nurses. We invite you to visit pcna.net for education and resources that will empower you to provide preventive cardiovascular care with confidence and expertise.