Spontaneous coronary artery dissection is an important cause of heart attack for young women to understand.
When most of us think about heart attack, we think about the risk factors: older age, smoking, high blood pressure, diabetes, high cholesterol and our family histories. We have been taught well because the vast majority of heart attacks occur in people who have one, or more likely, several of these risk factors. The difficulty comes when a person suffers a heart attack but doesn’t have these traditional risk factors.
As a means of introduction to an uncommon cause of heart attack, I would like to share a common scenario I frequently encounter in the clinic. A woman in her 40s, otherwise healthy, presents to the emergency department with chest discomfort and severe fatigue. She also has some pain going down her left arm and through the back. She is diagnosed with anxiety, heartburn, or a muscle strain and is discharged. She returns later the same day with crushing chest pain and is diagnosed with a heart attack. She undergoes a coronary angiogram and is diagnosed with spontaneous coronary artery dissection.
What is spontaneous coronary artery dissection? The heart is a muscle which, like all the other muscles in the body, requires a blood supply to perform its work. The blood supply to the heart muscle is supplied through the coronary arteries. When the inner layer of the coronary artery tears away from the outer layer, it can cause a sudden, severe blockage which can lead to chest pain and heart attack. When this tearing of the artery wall occurs without apparent cause, it is called spontaneous coronary artery dissection. This is an uncommon cause of heart attack but when it does occur, it tends to affect women who are in their 40s and 50s and who do not have the traditional risk factors for heart attack.
The top 5 facts about spontaneous coronary artery dissection:
1. Most patients with it present with heart attack.
Note: Heart attack in women is known to present differently, but the most common symptom of heart attack from spontaneous coronary artery dissection is chest pain. Other symptoms include shortness of breath, arm or jaw pain, sweating, severe and unexplained fatigue.
2. The “typical” patient with spontaneous coronary artery dissection is a woman in her 40s and 50s without the usual risk factors for heart attack.
Note: Though men can suffer heart attack from spontaneous coronary artery dissection, 90 percent of these patients are women and most do not have the traditional risk factors for heart disease. This is one reason their diagnosis may be delayed. The condition is actually the most common cause of heart attack in patients around the time of pregnancy, responsible for an estimated 40 percent of heart attacks during that time.
3. The cause is unknown but it is known to be associated with other vascular diseases, including fibromuscular dysplasia and brain aneurysm.
Note: Patients who have suffered heart attack from spontaneous coronary artery dissection should talk to their doctors about further testing to identify underlying vascular diseases, which may provide a clue into the cause. Importantly, there may not be any symptoms from brain aneurysm and patients should discuss with their doctors about further testing to detect a silent aneurysm should treatment be necessary.
4. Treatment for heart attack from spontaneous coronary artery dissection differs from heart attack due to cholesterol plaque.
Note: Heart stents and coronary artery bypass surgery remain valuable treatments for the patient with heart attack from spontaneous coronary artery dissection, however, unlike blockages caused by cholesterol plaque, most blockages caused by spontaneous coronary artery dissection will heal on their own. Patients who have evidence of continued heart damage from heart attack require heart stents and bypass surgery but medical management is the treatment of choice in patients who are otherwise stable. Interventional cardiologists and cardiothoracic surgeons determine the best option at the time of diagnosis.
5. Though it is an uncommon disease, these patients do not have to suffer alone.
Note: Several support groups are available online through Facebook and other social media platforms. Organizations such as SCAD Alliance (www.scadalliance.org), a non-profit patient advocacy group for these survivors, bring patients together to educate themselves and their providers and to support research throughout the United States.
It is startling to think that an otherwise healthy young person in the prime of her life could be a heart attack survivor, but as I see in my clinic every week, spontaneous coronary artery dissection can be a life-changing event. It is the duty of the cardiologist to be able to diagnose this uncommon cause of heart attack, and patients should be aware of the signs of heart attack and not ignore them should they occur. I am hopeful that ongoing collaborative research will help us to better diagnose and ultimately prevent this important cause of heart attack.
Esther S.H. Kim, MD, MPH is a cardiologist and vascular medicine specialist who focuses on the care of patients with uncommon arterial disorders. She is an Associate Professor of Medicine and the Director of the Arteriopathy Clinic at the Vanderbilt Heart and Vascular Institute. She has several ongoing research studies on SCAD and FMD and currently serves as the Chair of the Scientific Advisory Board for SCAD Alliance.