Spontaneous coronary artery dissection (SCAD)

Overview

Spontaneous coronary artery dissection — sometimes referred to as SCAD — is an uncommon emergency condition that occurs when a tear forms in a blood vessel in the heart.

SCAD can slow or block blood flow to the heart, causing a heart attack, abnormalities in heart rhythm or sudden death.

SCAD most commonly affects women in their 40s and 50s, though it can occur at any age and can occur in men. People who have SCAD often don't have risk factors for heart disease, such as high blood pressure, high cholesterol or diabetes.

SCAD can cause sudden death if it isn't diagnosed and treated promptly. Seek emergency attention if you experience heart attack symptoms — even if you think you aren't at risk of a heart attack.

Symptoms

Signs and symptoms of SCAD may include:

  • Chest pain
  • A rapid heartbeat or fluttery feeling in your chest
  • Pain in your arms, shoulders or jaw
  • Shortness of breath
  • Sweating
  • Unusual, extreme tiredness
  • Nausea
  • Dizziness

When to see a doctor

If you experience chest pain or think you might be having a heart attack, call 911 or your local emergency number. If you don't have access to emergency medical services, have someone drive you to the nearest hospital. Drive yourself only as a last resort.

Causes

It's not clear what causes SCAD. However, doctors and researchers have found some similarities among people who have had SCAD.

Risk factors

Risk factors for SCAD include:

  • Female sex. Though SCAD can occur in both men and women, it tends to affect women more than men.
  • Recent childbirth. Some women who have had SCAD have recently given birth. SCAD has been found to occur most often in the first few weeks after delivery.
  • Underlying blood vessel conditions. Fibromuscular dysplasia (FMD), which causes irregular growth of cells in artery walls, is associated with SCAD. FMD can weaken artery walls, leading to blockages, dissections or aneurysms. It can also cause high blood pressure, stroke and tears in other blood vessels. Women are more likely to have FMD than men.

    Diseases that cause inflammation of the blood vessels, such as lupus and polyarteritis nodosa, have also been associated with SCAD.

    Arteries that are twisted (tortuous arteries) are more common among people who have had SCAD.

  • Inherited connective tissue diseases. Genetic diseases that cause problems with the body's connective tissues, such as vascular Ehlers-Danlos syndrome and Marfan syndrome, have been found to occur in people who have had SCAD.
  • Very high blood pressure. Severe high blood pressure can be associated with SCAD.
  • Illegal drug use. Using cocaine or other illegal drugs may increase your risk of SCAD.

It's not clear whether extreme or intense physical exercise and severe emotional stress increase the risk of SCAD. Researchers have noted that there may be a connection, but more research is needed.

Complications

SCAD is a tear inside an artery that carries blood to the heart. When the inner layers of the artery separate from the outer layers, blood can pool in the area between the layers. The pressure of the pooling blood can make a short tear much longer. Blood trapped between the layers can form a blood clot (hematoma).

SCAD may slow blood flow through the artery, which makes the heart muscle weaken. Or blood flow through the artery may be completely stopped, causing heart muscle to die (heart attack). A heart attack that occurs in SCAD is different from a heart attack caused by hardening of the arteries (atherosclerosis).

SCAD can happen more than once, despite successful treatment. It may recur soon after the initial episode or years later. People who have SCAD may also have a higher risk of other heart problems, such as heart failure due to the damage to the heart muscle from heart attacks.

Doctors are studying why SCAD recurs and who is most likely to experience a recurrence.

Blood flow in arteries in SCAD

In spontaneous coronary artery dissection (SCAD), a tear forms in an artery in the heart. This can cause blood to pool in the area between the layers. Blood trapped between the layers can form a blood clot (hematoma). SCAD can reduce or block blood flow through the artery, which can cause a heart attack. However, a heart attack in SCAD is different from a heart attack caused by hardening of the arteries (atherosclerosis), shown in the bottom image.

Diagnosis

Tests used to diagnose SCAD are similar to those used to evaluate other types of heart attacks.

Tests may include:

Coronary angiogram

During a coronary angiogram, doctors inject a special dye into your arteries so they'll show up on imaging tests. To get the dye into your arteries, doctors insert a long, thin tube (catheter) into an artery — usually in your leg or arm — and thread the tube to the arteries in your heart.

Once the dye is released, doctors use X-rays to create pictures of the arteries. The X-rays may show abnormalities in an artery that help confirm SCAD. A coronary angiogram can also show if the arteries in the heart (coronary arteries) are abnormal and twisted (tortuous arteries).

Intravascular ultrasound

During heart catheterization, a special imaging catheter may be passed into your arteries to create pictures using sound waves (ultrasound). This may be conducted in addition to coronary angiography to help doctors confirm SCAD and plan treatment.

Optical coherence tomography

A catheter equipped with a special light may be passed into your arteries to create light-based pictures. Doctors may perform this test after coronary angiography.

The images may show abnormalities in an artery that can help doctors confirm the diagnosis and gather information to guide treatment.

Cardiac computerized tomography (CT) angiography

During cardiac computerized tomography (CT) angiography, you lie on a table inside a doughnut-shaped machine. An X-ray tube inside the machine rotates around your body and collects images of your heart and chest, which can show abnormalities in your arteries.

Cardiac CT angiography may be used in addition to other tests or as a follow-up test to evaluate your condition after SCAD.

Illustration showing catheter approaches in a cardiac catheterization

In a cardiac catheterization procedure, doctors insert a catheter in an artery in your wrist (radial artery) or in your groin (femoral artery).The catheter is then threaded through your blood vessels to your heart.

Catheterization for a coronary angiogram

To complete a coronary angiogram, a catheter is inserted in an artery in your groin or arm and threaded through your blood vessels to your heart. Your doctor uses the angiogram to check for blocked or narrowed blood vessels in your heart.

A normal heart and a heart with tortuous arteries

In spontaneous coronary artery dissection (SCAD), the arteries in the heart (coronary arteries) may sometimes be twisted (tortuous arteries).

Treatment

The goal of treatment for SCAD is to restore blood flow to your heart. Sometimes, this healing will occur naturally. In others, doctors may have to restore blood flow by opening the artery with a balloon or stent. Bypass surgery may also be used.

The treatments most appropriate for you will depend on your condition, including the size and location of the tear in the artery, as well as any signs or symptoms you're experiencing. Whenever possible, doctors allow the damaged artery to heal on its own, rather than repairing it using invasive procedures.

For some people, medications may relieve the symptoms of SCAD. In these situations, it may be possible to be treated by medications alone. If chest pain or other symptoms persist, other treatments may be needed.

Placing a stent to hold the artery open

If SCAD has blocked blood flow to your heart or if medications don't control your chest pain, your doctor may recommend placing a tiny mesh tube (stent) inside your artery to hold it open. A stent can help restore blood flow to your heart.

To position the stent, doctors insert a long, thin tube (catheter) into an artery — usually in your leg or arm — and guide the tube to the arteries in your heart. X-rays are used to help the doctor see where to place the catheter.

A wire with a deflated balloon is passed through the catheter to the tear in the artery. The balloon is then inflated, expanding the stent against your artery walls. The stent is left in place to hold the artery open.

Surgery to bypass the damaged artery

If other treatments haven't worked or if you have more than one tear in an artery, your doctor may recommend surgery to create a new way for blood to reach your heart.

Coronary bypass surgery involves removing a blood vessel from another part of your body, such as your leg. That blood vessel is stitched into place so that it diverts blood flow around your damaged artery.

Medications

After SCAD, your doctor may recommend medications, including:

  • Aspirin. Aspirin may help prevent cardiovascular disease problems after SCAD.
  • Blood-thinning drugs. Drugs that reduce the number of blood-clotting platelets in your blood (anticoagulants) can reduce the risk of a clot forming in the torn artery.
  • Blood pressure drugs. Drugs used to treat high blood pressure can lower your heart's demand for blood, reducing the pressure in your damaged artery. You may continue to take blood pressure drugs indefinitely to reduce the risk of another SCAD.
  • Medications to control chest pain. These medications (nitrates and calcium channel blockers) can help treat chest pain you may experience after SCAD.
  • Cholesterol drugs. People who have abnormal cholesterol levels and other risk factors may need to take medications to control their cholesterol levels.

Continuing care

After your treatment for SCAD, you'll need regular follow-up appointments with your doctor to monitor for any changes in your condition. Your doctor may also recommend other types of care to help you recover and to prevent other health problems. These may include:

  • Undergoing cardiac rehabilitation. Cardiac rehabilitation is a customized program of exercise and education designed to help you recover from a serious heart condition. Cardiac rehabilitation often includes monitored exercise, nutritional counseling, emotional support and education.
  • Reviewing your family medical history. Some inherited conditions, such as the connective tissue disease Marfan syndrome, have been found to occur in people who have had SCAD. Your doctor may refer you to a genetic counselor to review your family medical history and determine whether genetic testing may be appropriate for you.
  • Looking for weaknesses in other blood vessels. Your doctor may recommend using CT angiography to look for weaknesses and abnormalities in other blood vessels, such as FMD.

Coping and support

SCAD can be an unexpected and shocking diagnosis. The condition can cause serious and scary symptoms, and it often affects people who may have few risk factors for heart disease.

Each person finds his or her own way of coping with a diagnosis. In time you'll find what works for you. Until then, you might try to:

  • Learn more about your diagnosis. Learn enough about SCAD to feel comfortable talking with your doctor about your care. Ask about the specifics of your situation, such as the location and size of your artery tear and descriptions of the treatments you've received.

    If you're a woman and you have had SCAD, your doctor may recommend you avoid pregnancy. Talk to your doctor about his or her recommendations.

    Ask your health care team about where you can find more information about SCAD.

  • Take care of yourself. Help your body recover by taking good care of yourself. For instance, get enough sleep so that you wake feeling rested, eat a healthy diet full of fruits and vegetables, and find healthy ways to cope with stress, such as listening to music or writing down your thoughts. If you feel anxious or depressed, talk to your doctor. Your doctor may recommend that you talk to a mental health professional (psychologist).

    If your doctor feels it's safe, try to do moderate physical activity, such as walking, for 30 to 40 minutes most days of the week.

  • Connect with others living with your diagnosis. SCAD is uncommon, but national organizations can connect you to others who share your diagnosis. Organizations such as the American Heart Association and WomenHeart: The National Coalition for Women with Heart Disease can provide telephone and online support.
  • Spend time with family and friends. Spending time with your family and friends and discussing your concerns can help you cope with your condition.

Preparing for an appointment

In most cases, SCAD is an emergency situation. If you experience chest pain or suspect you're having a heart attack, immediately call 911 or your local emergency number.

In the days after your initial diagnosis, you're likely to have many questions about your situation. Because meetings with doctors can be brief, and because there's often a lot to discuss, it's a good idea to prepare by writing down your questions. Order them from most important to least important, in case time runs out.

Some questions you may want to ask include:

  • What caused my SCAD?
  • What are other possible causes for my symptoms or condition?
  • What kinds of tests do I need?
  • What's the most appropriate treatment?
  • Will the tear in my artery heal on its own?
  • What are the alternatives to the primary approach that you're suggesting?
  • What is my risk of having another SCAD?
  • Do I have abnormalities of other blood vessels, such as FMD?
  • I have these other health conditions. How can I best manage them together?
  • Are there any restrictions that I need to follow?
  • If I would like more children, is it safe for me to be pregnant?
  • Should I see a specialist? What will that cost, and will my insurance cover it?
  • Are there brochures or other printed material that I can take with me? What websites do you recommend?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other questions that occur to you.

Last Updated Oct 31, 2019


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