A different type of heart attack

Most heart attacks happen when a blood clot blocks an artery feeding the heart. But a small percentage result from a tear in the inner wall of one of the heart’s arteries. The resulting flap or swelling inside the artery wall obstructs normal blood flow. Known as a spontaneous coronary artery dissection, or SCAD, the condition strikes both sexes but is more common in women.

In women who are under 50, SCAD is the most common reason for acute coronary syndrome. This medical emergency refers to inadequate blood flow to the heart; it includes both heart attacks and unstable angina (sudden chest pain that occurs at rest).

“SCAD accounts for at least 4% of all cases of acute coronary syndrome. But that figure is probably an underestimate,” says Dr. Malissa Wood, co-director of the Corrigan Women’s Heart Health Program at Harvard-affiliated Massachusetts General Hospital. In recent years, expanded awareness of heart disease in women has increased recognition of SCAD, which was considered quite rare just a decade ago. Improved diagnostic tools have also helped, she adds.

SCAD symptomsThe symptoms of a spontaneous coronary artery dissection (SCAD) are identical to those of a classic heart attack and includechest pain or discomfortpain in the arms, shoulders, neck, or jawshortness of breathsweatingunusual, extreme fatiguenauseadizziness.

Enhanced testing

For example, the blood tests to diagnose heart attacks that detect troponin (a substance released by damaged heart muscle) are now more sensitive. Women’s hearts are smaller than men’s and may therefore release smaller amounts of troponin during a heart attack. Widespread use of high-sensitivity troponin tests mean that women with heart attack symptoms are more likely to be diagnosed with a possible heart attack and referred for more extensive testing, Dr. Wood explains.

As a result, more women are receiving coronary angiography, a special x-ray of the heart that uses dye to show areas of narrowing in the arteries supplying the heart. Because people with SCAD often have curly, corkscrew-like blood vessels, this test demands extra skill on the part of the doctor performing the angiogram. “These physicians may also use special tools that allow them to look at the blood vessel from the inside out,” says Dr. Wood. Other testing may include noninvasive imaging tests, such as CT scans and echocardiograms (heart ultrasound).

An accurate diagnosis is vital because the treatment for the more common cause of acute coronary syndrome is heparin, an injectable drug that prevents blood clots. But heparin (which also increases bleeding) can make SCAD worse. People with SCAD may be treated with medications to relieve angina and lessen the heart’s workload, depending on their symptoms. Tears in the artery wall usually heal within six weeks, and any blood trapped inside the wall is gradually reabsorbed.

Who’s at risk?

The typical SCAD patient is a middle-aged, healthy woman who doesn’t seem to be a likely candidate for a heart attack (that is, she has few or none of the classic risk factors for plaque buildup in the arteries, such as diabetes, high cholesterol, or high blood pressure). About a third of SCAD cases in women occur during or soon after pregnancy, probably because blood vessels tend to soften and become more fragile during those times.

The exact cause of SCAD isn’t entirely clear. But there’s a strong link between SCAD and fibromuscular dysplasia (FMD), a rare condition marked by narrowing and enlargement of medium-sized arteries throughout the body, especially those leading to the kidneys, neck, and head. About 70% to 80% of people diagnosed with SCAD have some sort of vascular abnormality in the blood vessels outside of the heart, Dr. Wood says. Most have FMD, but some have rare genetic conditions that affect connective tissue.

At least a third of people with SCAD have a history of depression or anxiety. And two-thirds recall severe physical or emotional stress before their artery dissection. For example, they may have experienced a death in the family, a job loss, a spouse’s extramarital affair, a car accident, or a child’s serious illness. “We know that stress contributes to all types of heart disease, which is why it’s so important for people to manage stress as much as possible,” says Dr. Wood.

Bible verses for today’s meditation and inspiration: Matthew E. McLaren

 “Finally, brothers and sisters, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable–if anything is excellent or praiseworthy–think about such things.” – Philippians 4:8

 “Therefore I tell you, whatever you ask for in prayer, believe that you have received it, and it will be yours.” – Mark 11:24

 “Anxiety weighs down the heart, but a kind word cheers it up.” – Proverbs 12:25

 “Who of you by worrying can add a single hour to your life?” – Luke 12:25

 “For I know the plans I have for you, declares the Lord, plans for welfare and not for evil, to give you a future and a hope.” – Jeremiah 29:11

“If you, then, though you are evil, know how to give good gifts to your children, how much more will your Father in heaven give good gifts to those who ask him!” – Matthew 7:11

 “A cheerful heart is good medicine, but a crushed spirit dries up the bones.” – Proverbs 17:22

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