Emerge in EM

E22: Spontaneous Coronary Artery Dissection (SCAD)

• Mohamed Hagahmed

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In this episode of EMERGE in EM, Dr. Mohamed Hagahmed sits down with cardiology fellow Dr. Njeri Kuria to discuss Spontaneous Coronary Artery Dissection (SCAD)—an often underrecognized cause of acute myocardial infarction that predominantly affects young and otherwise healthy women.

Through a real clinical case, they explore how SCAD presents, why it's frequently mistaken for more common conditions, how it's diagnosed, and what makes its management fundamentally different from traditional heart attacks. They also discuss pregnancy-associated SCAD, recurrence, long-term follow-up, and the critical role of recognizing cognitive biases when evaluating chest pain.

Whether you're an emergency clinician, cardiologist, paramedic, nurse, medical student, or simply interested in understanding heart health, this episode offers practical insights that could change the way you think about chest pain—and perhaps even save a life.

In this episode, you'll learn:

  • Why SCAD is one of the leading causes of heart attacks in women under 50
  • How to recognize high-risk patients in the emergency setting
  • Why PCI isn't always the best treatment
  • The role of fibromuscular dysplasia and pregnancy
  • Long-term management, recurrence, and patient counseling
  • Key clinical pearls for healthcare professionals

🎧 Tune in for an engaging conversation that challenges common assumptions about heart disease and highlights the importance of listening to patients, recognizing bias, and delivering thoughtful, evidence-based care.

Resources

📖 New England Journal of Medicine Review: Spontaneous Coronary Artery Dissection
https://www.nejm.org/doi/full/10.1056/NEJMra2001524

If you enjoyed this episode, please follow, subscribe, and leave a review—it helps us reach more listeners.

📱 Connect with me for more educational content, clinical pearls, podcast clips, and behind-the-scenes updates:

  • Instagram: @HagahmedMD
  • YouTube: @HagahmedMD

Thank you for being part of the EMERGE in EM community. Until next time, stay curious, keep learning, and continue to EMERGE.

Mohamed

Hey everyone, and welcome back to Emerge in EM. I'm your host, Dr. Mohamed Hagahmed. I have to admit, today's topic is one that has always made me a little nervous. We're talking about spontaneous coronary artery dissection or SCAD, a condition that challenges many of our assumptions about heart disease. I am joined by a good friend and a cardiology fellow who is just finishing her fellowship, Dr. Njeri Kuria, and together we're going to walk through a real clinical case, talk about how these patients present, why they're often missed, and what every clinician, and honestly every listener, should know about this important condition. I learned a lot from this conversation, and I think you will too. Let's get started

Njeri

My name's Njeri. I go by Dr. Kuria in the hospital, but friends call me Njeri. I am finishing up my third year of cardiology fellowship, in just a couple days, and then I start interventional cardiology, which is really exciting 'cause I've wanted to do that since I was 15 years old. I like all things women's heart disease. I'm really passionate about prevention even though I'm going into intervention because I feel like prevention is always better than stents. and I'm from Kenya. I grew up in California, and I go back every year to see my grandparents

Mohamed

Nice. And how many languages do you speak?

Njeri

I speak Kikuyu and I speak English. I understand very little Swahili

Mohamed

That's cool. And what would be your next vacation destination?

Njeri

Ooh, next vacation destination. Probably a country outside of Kenya in Africa, 'cause I haven't been to any other African country besides Kenya. So next on my list is just to travel throughout Africa, East Africa, West Africa, South Africa.

Mohamed

I'm so excited to have you here, and I'm sure the audience also appreciate your expertise, your knowledge, and I really like to start every scenario or every d- discussion with a case. That way we can have something that we can, anchor our discussion, on and then reveal the case as our discussion evolves. This is a case of a young woman. She's thirty-eight years old, and she comes into the emergency department because she was having chest pain. And honestly, her husband forced her to go to the ED because she is very "stoic." She's a young woman. She's athletic. She just finished half marathon, doesn't have any cardiac comorbidities, doesn't take any medications. She just delivered a baby a month ago and, and the chest pain, what bothered her the most is that it's more crushing, and has some associated symptoms with sweating a little bit that is very unusual, and nausea, no vomiting. So I always like, when I approach these things as an emergency physician, I always approach these kinda symptoms with a broader list of differential diagnoses. before we jump into the scariest diagnosis of all times, a diagnosis that kept me up many nights during residency and to this day as an attending is something I always fear of missing. But let's just broaden our differential diagnoses and what's some things that come into your mind as, as a clinician who's just finished seeing this young woman?

Njeri

So any time that I hear crushing chest pain, no matter really, man or woman, I usually think of a STEMI. we now know that women tend to present outside of that with like very subtle chest pain. But typically, if they say crushing chest pain, I'm thinking this is probably a STEMI, some kind of acute coronary event. You did mention that she's postpartum, and so I'm thinking of other things. it could be anginal from either a coronary artery etiology or even takotsubo. I'm thinking of these other syndromes that, tend to affect women. Before I make any diagnosis, you know what I want to say, I'd probably get an EKG and just start from there.

Mohamed

Absolutely. The EKG is, ubiquitous. Is it- It's cheap. Everybody gets an EKG with a toe pain in the ED, in the waiting room, they get an EKG, you know that.

Njeri

It's quick. If you have a heart, you're getting an EKG.

Mohamed

yes, if you have a pulse, you get an EKG. Sometimes even if you don't have a pulse, you still get an EKG as well. But, again, like a lot of, a lot of the audience or many of the audience are clinicians, but some are also general audience, lay people that have, no idea of like medical terms. So of course, chest pain is scary, right? I think of things like pericarditis, which is inflammation of the heart layer. I think of myocarditis, inflammation of the muscle. I think of lung issues like pneumonia, infection, maybe a clot in the lungs. maybe even things like really bad stuff that is not coming from the thoracic cavity or the chest cavity, perforation in the stomach or, reflux, right? Always, it's always reflux until proven otherwise, right? No. But, especially as a woman comes into the ED like this, who's otherwise healthy, there is this kind of cognitive bias of minimizing symptom. And this is gonna be like the overlying theme in this discussion, especially when it comes to recognizing, lethal, fatal conditions in young women who are otherwise healthy. So the condition that we're talking about today is SCAD. so SCAD stands for spontaneous coronary artery dissection. And, I would like you, as my, fellow cardiology colleague, to tell us more about SCAD and what is that condition entails.

Njeri

so SCAD has been recognized more to be uncommon and not so much described as rare because I think we are more educated in looking for it. Not just cardiologists, but, our emergency medicine providers. SCAD for many years was taught as like a one-liner, in residency, one-liner in cardiology fellowship, but now we know a lot more because we've invested a lot more in it. SCAD has been described as a tear in the coronary artery, but we now know that it's more of a spontaneous, meaning that we don't know when or really why it'll happen, and slowly blood will leak into one of the layers of the coronary artery, which is, three layers. And it's really more of that intramural hematoma that causes the problem. Imagine that, you are filling, it's filling with blood, but imagine it's if you were, blowing a balloon and filling it with water in between those layers. Eventually, that hematoma will enlarge and enlarge, and if it's critical, it'll block off, the artery, and that's what produces that instant pain. This is one of those things where when we describe heart attacks in women, it's not from atherosclerosis, which is, plaque buildup where you get, hardening of the arteries. These are people who, for whatever reason, genetic, more genetic, predisposition we now know, but their arteries are more compliant, more, flexible, I guess is how I would describe, than the average person. And so that's what causes that, spontaneous tear. they'll talk more about, certain triggers, but, it's really more of that hematoma that compresses, that causes that initial symptom, and it's not subtle. It's not subtle pain, unlike a typical MI that'll happen to women

Mohamed

Two words in that term scares the heck out of me. Spontaneous

Njeri

And tear. Yes. Yes

Mohamed

to me, like, when I hear dissection, I think of a anatomy lab cadaver dissection. I'm actually cutting your body, right? So it's a very scary term, and another kind of a parallel, fatal condition is... or actually a lethal condition is aortic dissection, right? So it's the same kind of concept of this dissection of the intimal layer. So w- when we say this is a diagnosis that it's so hard to diagnose these people come to me and see me as an emergency physician, and I see this manifestation of ischemia on their EKG. So they... y- this young lady who came into the emergency department, she actually had a STEMI, so a ST segment elevation MI, right? now the terminology is moving a little bit more into OMI versus non-OMI. So OMI is occlusive MI versus non-OMI. So how is that different from STEMI? How is that, classified as something that is not occlusive or maybe not yet occlusive? What are your thoughts on that?

Njeri

It-- The thing is, it can be occlusive. And in that initial presentation, as you're describing this patient coming to the ED, if I saw her, as a cardiology fellow, I would not know, oh, maybe this is SCAD. If I saw ST elevation on her EKG, and it's in s-a very specific territory, and she's presenting, telling me, "I have chest pain, had baby a week ago," I'm thinking it's SCAD. But really, I don't know, and, nobody really truly knows. We can have, a high index of suspicion, but she needs to go to the cath lab, and we need to get some imaging to really know whether this is occlusive or not. patients coming in with a non-occlusive, SCAD may present with an NSTEMI or chest pain. It's not critical that they go to the cath lab, ninety minutes door-to-balloon time 'cause it's not a STEMI. But they still have to get some kind of angiography. And those are the ones that, we treat conservatively. But i-in any case, we just don't know whether it's SCAD, whether or not it's occlusive, if it's presenting, as ST elevation. We treat it as acute coronary syndrome, STEMI, cath lab, as if they're having, a typical plaque rupture

Mohamed

So that is a very important point, and a point worth emphasizing is that patient with SCAD can present as STEMI. They do deserve the same exact workup and management as STEMI or occlusive MI. So just going back to that question then, who gets it? Who gets SCAD?

Njeri

So it's 90% women. We do know that small percentage men can, can have SCAD, but typically it's women. in the peripartum period, it's actually a smaller population. We just hear more about it. But it's typically the patients who have some kind of connective tissue disorder. We now know that there are multiple genes that... I'm not gonna go into, the basic sciences of it, but there's a lot of research going into, tissue factor genes. our Ehlers-Danlos, Marfan patients are also a smaller population. It's typically a connective tissue disorder that is not so obvious. if you do happen to have an autoimmune disorder, like lupus, RA, those are syndromes that tell us, "Okay, you may actually, have more of a predisposition." If you have known fibromuscular dysplasia, you're also more predisposed. And then there is some kind of a correlation with patients who have migraines. And so the way that I think of it is connective tissue is one population of people, and then the other demographic is patients with some kind of, arteriopathy, of some sort. And again, we don't know really, like, why it happens to each patient, but we can say... We can narrow it down and say, "These are the patients that are more predisposed." And then unfortunately, if you have one SCAD event, you are more likely to have another SCAD event, and, we don't know when. If it's, pregnancy associated, we pretty much tell you, "Don't get pregnant." People will still do what they want to do, but there's a higher incidence that it could happen. And whether or not we stented you, it could happen in another artery. So those... another population of patients that if you've had it, you're just more at risk than anybody else

Mohamed

When I looked at the numbers, they were scary numbers. 90% are women.

Njeri

Yes

Mohamed

Nine zero percent of these patients with SCAD are women, and almost like more than a third of them are younger women. these are women that are younger than 50, 47 to 50, 53. So the issue that I have for me as, in a busy emergency department is that when I see these young women with absolutely no cardiac risk factors, how can I force my brain to think of SCAD? How can I prevent myself from anchoring or from falling into the bias of this is something benign or minimal or maybe something mental or psychiatric?

Njeri

I think it just goes back to what we've been taught in medical school. physical exam, but also like symptoms. if a patient's coming in and there's nothing like blatantly obvious on the physical exam, but they have this story that is like very convincing, especially if they're a woman and they tell you they've had SCAD or, they have, postpartum period. Earliest is usually like a week out, but if they're presenting to you and they're telling you the story, I think it's worth doing some workup. EKG, get a troponin. If the EKG has obvious, ST elevations, you probably don't need to wait for the troponin. so I think it just goes back to really like whole person care and just like letting the patient teach you and not relying on, just typical presentation of like elderly man, diabetes, hypertension, things like that.

Mohamed

What is it about being a woman, other than being amazing, increases your predisposition, to having SCAD? It- do you know? I don't know, the answer is probably difficult or maybe unknown, but I wasn't sure if you know the answer to that

Njeri

there's some theories, hypotheses, really just like observational data that, maybe hormones have to do with it. And then we get into that territory of should we be treating with hormone therapy? And like right now the answer's no. but it is an area of research that I need-- I needs, more, answers. But we know that, autoimmune diseases affect women more. I don't know really the answer to, why SCAD affects women more, but from what we know about the data on autoimmune disorders that are connected to connective tissue disorders, that predisposition probably also leaks into having those like flexible, just more compliant, arteries that are just like more, more likely to tear

Mohamed

And that leads me to the other question then in that case, since you mentioned the hormonal piece, which is interesting to me, can post-menopausal women get SCAD?

Njeri

I don't know what the trigger would be. post-menopausal women are more predisposed to have, an acute coronary syndrome that is typical, atherosclerotic plaque buildup just 'cause you're removing that protective estrogen. And so typically, they're presenting with angina, or an MI, that is like the typical, plaque rupture

Mohamed

Okay. Being a female alone is a risk factor, basically. A- and you mentioned it's as... To me is, amazing how the human body, actually functions. It's, crazy to me, but... And also humbling, too. So some of the factors you mentioned, I think you mentioned, mainly the, fibromuscular dysplasia, which is a form of connective tissue disorder. And I think along with this comes multiple other connective tissue disorders, autoimmune diseases like, lupus, Ehlers-Danlos syndrome, Marfan syndrome. interestingly enough, inflammatory bowel disease, which I find also interesting. but we also know that inflammatory bowel disease is an autoimmune disorder, so can be as such. And being postpartum. T- so let's just a little bit spend some time, about pregnancy. you mentioned briefly the time period where a patient is at highest risk of SCAD, which is a late pregnancy. Can you tell me a bit more about the presentation?

Njeri

They would present with chest pain. and a lot of these SCADs present with some kind of chest pain. H- but they will tell you that they had some kind of a trigger. It can be emotional, it can be physical, and we know that pregnancy is, it is a physical stress test. It's probably your first real physical stress test as a woman if you haven't had, like an actual cardiac stress test. And so it is a stressor on the body, and that goes for also, like non-pregnant women and men who will present, less likely, but, an emotional trigger, a pet dying, which is, more common than people think, a traumatic, family event, whether that's like a death in the family or just like a horrible conversation with your spouse. and so these triggers will usually happen before, and patients will tell you that. if they don't tell you that, we should be asking about it. and then, that's- that'll usually happen first, and then, the presentation of chest pain

Mohamed

So there is a psychiatric component, so the stressor can be either physical or emotional,

Njeri

Yeah

Mohamed

both. And so history is very important here. And does it happen, like when it comes to the emotional stressor, is it immediate, like after the fact or couple of days later or a couple of hours later after the initial emotional stressor happening?

Njeri

I don't know, like the exact time period, but from, just observational data that we've seen, they'll tell you whether it was that morning or the night before. Usually it's, like soon, not months. and it's something very memorable

Mohamed

So they come in, they have those concerns. Obviously, we have to pay attention to those concerns and those symptoms and all the symptoms you mentioned. So classically, we see with everybody with chest pain, chest pressure, diaphoresis, i.e. sweating, nausea, vomiting, maybe the atypical symptoms of jaw pain, shoulder pain, arm pain, back pain. I have seen symptoms like people actually have depressive symptoms that actually had a STEMI, which is crazy to me, too. so definitely don't underestimate, emotional symptoms as well. So the stressor can be component. So the EKG, we know the classic STEMI. Anything special about an EKG that tells me this is SCAD?

Njeri

No, you're just gonna see those ST-- I know. And that's the thing about SCAD is that I think a lot of patients, once they've been diagnosed with it, they're going to go back to the ER at some point. And I understand that 'cause you're like, if you guys didn't know the first time, I should just go to the ER." And so there's nothing special on the EKG. you'll just see a territory because usually it's one coronary artery, sometimes it can be two. usually it's in that one territory and, it'll just present as just a ST elevation and you won't know if it's SCAD. There's nothing special about the EKG that tells you if it's SCAD or not.

Mohamed

I was, man. I was hoping for that slam

Njeri

I know. I know.

Mohamed

done, next patient. SCAD, let's go.

Njeri

Nope

Mohamed

okay. So EKG can be, can be normal, right? they can be like basically no signs of ischemia at all?

Njeri

It can be. it can be like an NSTEMI, which is, non-ST elevation where you can see EKG changes like, ST depression. and those are the patients that, do they need to go to the cath lab? Absolutely. But, 24 to 48 hours, not 90 minutes as we would see with, crushing chest pain and ST elevation

Mohamed

So let's talk about testing in that case. We get the EKG. Let's say the EKG does not show STEMI, so maybe NSTEMI. she's having some chest pain, so I proceed with some testing. We classically order the troponin that every cardiologist love.

Njeri

All day, every

Mohamed

tropon- troponin number one comes back, it's normal. So it's anxiety.

Njeri

No. Please don't send her home. those are the patients that, you as the amazing ER doctor is gonna say, "I have this history. It could be SCAD. It could be a s- a small SCAD that could be treated conservatively, but we don't know." This is a patient that you keep and get serial troponins because at some point it may rise, and there's actually data that shows that SCAD can get worse. And so it could be a small tear, but like we talked about before, this is like that intramural hematoma that is probably a faster bleed than you would think because we know, the high pressure of the coronary artery. So that's a patient that you want to monitor, maybe even have cardiology admit, and keep an eye on

Mohamed

Okay. So some emergency departments out there, they do have an observational unit for chest pain obs, So as we have the ability to order a high-sensitivity troponin, so if the first one is negative in somebody who is symptomatic, we normally repeat it within the next hour and get a second one. so let's say now with this patient, her troponin came back, the second one came back elevated. So from that standpoint, I still have a normal EKG, maybe some ST segment depression, what should I do with her?"

Njeri

patient is actively having chest pain and no, no ST elevation, they should still go to the cath lab. It's just not going to be urgent. But to diagnose SCAD, we have to get imaging. and even if we say, "Oh, her symptoms are looking a little better, the troponin's coming down," we should at the very least still take her to the cath lab. And that's what I want to do. obviously I'm a little bit more excited about women's cardiovascular health. I'd wanna take her right away. But, per what we have in our guidelines, with ST elevation, MIs, door-to-balloon time, we take them immediately. Our NSTEMIs, it's 24 to 48 hours

Mohamed

Okay. So before moving to the other scenario of the ST-segment elevation scenario, which is obvious and clear on EKG, let me just get back to this NSTEMI situation. Let's

Njeri

Yes

Mohamed

she is symptomatic, NSTEMI, some ST-segment depression, second troponin is positive, and of course, me, I see this, I jump to giving aspirin. Maybe add some Plavix, maybe heparin. So all of the good stuff that we do to all of our patients. So let's go from the top. Aspirin, what do you think about that?

Njeri

Because we don't know that it's SCAD, we need to treat this as any NSTEMI. give the aspirin, put her on a heparin drip. I know it's scary because we are giving anticoagulation, and because we're talking about SCAD, I wanna say, "Don't do it," but we don't know in that, interim to go to the cath lab. We don't know. Another thing I wanna mention is I know we're not talking about plaque rupture today, but we are seeing younger and younger patients with our typical early atherosclerosis, which is very unfortunate. And so because we don't know, we need to do everything that we should do as if this was presenting as a typical, acute coronary syndrome

Mohamed

Okay. And let's say I gave the heparin, even though she was found out later to have SCAD, that's not gonna be extremely harmful. Or any- do you know anything about the literature on

Njeri

No, because because we don't know. And it's-- the reason we don't know is because we, all we have is observational data and some case series. and also remember, if it's like a cons- if we're, if it's not occlusive and go to the cath lab and it's a small tear, or we don't see it angiographically, which happens a lot, and, we'll talk more about, intravascular imaging. And she's hemodynamically stable and not having any kind of arrhythmia and no ST elevation, EF is preserved. That is somebody that we treat conservatively. I think 60 to 70% of SCAD actually heals on its own without us having to stent. yeah, we need more data on, that specifically, to give the heparin, not to give the heparin. But you don't wanna miss, a plaque rupture and then you-- we didn't give heparin. And it's an area of research I feel like is lacking, and is necessary

Mohamed

Yeah, and it's important for clinicians, emergency clinicians specifically, to become more reassured that this is actually-- there is no difference in manage- in managing these patients, right? So we're still treating them as whether STEMI, NSTEMI, the same exact way. But the whole point of this conversation is that increase your index of suspicion if this is a younger woman who tells you, "I have Ehlers-Danlos syndrome, maybe my family have Marfan syndrome, maybe I have IBD." I think the whole point of discussion is that do what you're doing. However,

Njeri

Have a higher index of suspicion

Mohamed

if she presents to you like this, then keep that in mind. So let's go to the easier route, I guess easiest slam dunk diagnosis, which is ST-segment elevation in this young lady, and of course, now slam dunk. But I'm gonna make it a little trickier for you, if you don't mind.

Njeri

go ahead

Mohamed

I am working in a three-bed ER.

Njeri

Oh gosh.

Mohamed

It's four hours away from the, cardiac center of excellence, and it's a snowy January day in Pennsylvania. So I have this young woman with ST-segment elevation. She has chest pain, meets all the criteria for occlusive MI or STEMI. I'm gonna give her TPA in this case, or thrombolysis.

Njeri

so this is, tricky because we know that lytics are going to cause that bleed to either propagate down that artery, possibly make it worse. but again, we have to have a high index of suspicion. If this is a patient, and this is like probably like the most high risk, is in the peripartum, post- in the postpartum, one week out, and it's crushing chest pain, and there's ST elevation, and that it's maybe LAD territory or even worse, left main, you probably wanna hold off giving lytics. and again, like this is just like anecdotal. there's no data from what I'm saying. but that is somebody that needs immediate, like urgent CABG or very high-risk PCI, with probably Impella. And you don't wanna stick an Impella in somebody that just got lytics. And the reason I bring that up, I know this is not about shock, but this is very much s- a patient that could very well present with shock and, you put the probe on and oh, this EF is 10%. that is very risky. and I would say lytics is probably not a good idea. You're probably safer just like putting her on a heparin drip and giving aspirin, Plavix, a statin, and transferring her out like ASAP

Mohamed

That's a hard one, I know. But I tell you, I think for the audience out there, this is a situation, this is a case where you should be actually having close conversations with the cardiologist who's receiving that person. And again, hopefully my goal out of this episode is that people realize now, "Hey, I have to worry about SCAD in this young woman who's otherwise healthy." Because now if I put this in as part of my differential, I'm like, "You know what? Maybe I shouldn't be giving them thrombolysis." so yes, this is a very tricky situation. Again, have these discussions with the family, with the patient, with the receiving facility to make sure you're doing the best thing for them in that situation. And I, actually, I like your idea. I'm a big ultrasound guy, so I love my bedside echo just to give me an idea of wall motion, of EF, and like anticipation of what to come, That way I'm ready for any impending, shock or things that I have to be, w- be prepared for. So they come to you, they go to the cath lab. I started the a- aspirin, the heparin. You go in there, and then you look obviously for signs of occlusion. Tell me what findings you'll be seeing on imaging, that hints at SCAD. This is a SCAD presentation versus an occlusive MI.

Njeri

So typically on angiography, you can see, dissection. Sometimes, we'll cause, iatrogenic, like dissection with wires. And you can see it. Usually, you can see it. it's like a linear, And it's like a linear, I guess I call it like artifact that you'll see. That's like very obvious, especially if it's happening in an area where, it's like a long segment. Now, in a patient that comes in and initially you don't see that on angiography, we use intravascular ultrasound, either with, intravascular ultrasound, IVUS, or with optical, coherence tomography, also known as OCT, which is the absolute best modality, for looking at a SCAD because you're able to actually see like that intramural hematoma and then the actual real lumen, of the actual coronary artery. And in those cases, that can tell us, this is likely a SCAD. Obviously, if this patient is still having ischemia, is still complaining of chest pain, maybe their blood pressure is dropping. We likely need a stent because they're ischemic, they have symptoms. Worst case scenario, they have a V-fib arrest or VT. We need to fix it. Now, if it's left main, it's probably the worst-case scenario, or if it's at an area where it bifurcates into two large arteries like an LAD or a circumflex, urgent cabbage, if offered at that institution. If not, high-risk PCI, where we fix that left main or the bifurcating areas. so in those cases, not conservative management. and so those are probably the two ways that we look at a SCAD, angiographically, which sometimes is not always easy to see, and then with some kind of, intravascular imaging with IVUS or OCT

Mohamed

And I know this is really harder to visualize obviously, via audio, but there is a New England, Journal of Medicine article that I really like, and it's actually shows really good imaging, like angiographic appearance of SCAD, and I'm gonna just show this reference, in the show note. But there's-- What I'm looking at right now, I'm looking at the different appearances is Type I, Type IIa, Type IIb, Type III. In terms of the ultrasound, procedure, is this something done commonly in every PCI or only in specific situations?

Njeri

So I think it depends where you train. As of right now, in my per- my personal opinion, I don't think any center should be, doing PCI without some kind of intravascular imaging. where I'm training, it is gold standard. We do intravascular ultrasound, before we place a stent, so you can see the length, and you can see exactly what kind of plaque you're dealing with, and then afterwards, to make sure that stent is, opposed and, expanded. And so where I train, we do intravascular imaging in every single PCI. and so I think it's also great because if you're not sure angiographically, you want to give your patient, the absolute, best care. that way they can, even if it's just conservative management, at least they know, that, they have a history of SCAD

Mohamed

And is there harm of the procedure if this was indeed SCAD? Is there harm of, Or maybe is there a complication from the procedure?

Njeri

Yeah, that's actually a really good question because, initially if you are, if you're suspecting it, and I think most interventional cardiologists and, future me, now that I'm, like, aware of this, when you're, injecting that contrast, you can ramp up, slowly because you don't want to just, shoot contrast so quickly through that, especially if you're not sure if it's, like a really long, tear. And initially we still have to see, just a little bit of contrast. and then if it looks like, like I said earlier, if the patient's, hemodynamically stable and you get a couple views, there's no VT, the EF was okay if got a g- quick little bedside pocus, that can be treated conservatively. We know that these tears heal on their own. and so you don't want to be, putting wires and catheters, unless it's an emergency and, there's obvious ischemia

Mohamed

you go in, you find that SCAD, the patient is otherwise hemodynamically stable, so no stenting is indicated, correct? no stenting

Njeri

Yeah, we know it'll heal. But this is not a patient that you discharge because, SCAD can, it can get worse before it heals completely. And so this is somebody you want to watch overnight for a couple days. And then, there's some SCAD experts who say, up to seven days you should be checking in with this patient, even if they're at home and just, keeping a closer eye on them. just 'cause, it's, it can be scary to tell a patient like, "You had a spontaneous dissection and we don't know why it happened." and so you still wanna keep like a close eye

Mohamed

So they get admitted at least for a couple of days. What about medications post-PCI? So continue the aspirin. Anything else you wanna add?

Njeri

So it depends. It depends. if we stented, it's going to be aspirin and some kind of P2Y12 inhibitor like Plavix, for example, for a year because we did place a stent. if no stent, we-- And there's, this is like a great debate about whether to put the patient on lifelong aspirin. If they're able to tolerate it, yes. But truthfully, there's no good answer as to why this patient has to be on aspirin long-term. And part of that is the studies that we have for typical plaque rupture MI is that you had a plaque rupture MI, you had probably a thrombus form, and you need to be on lifelong aspirin. You probably have plaque elsewhere. That's not the case with these patients. These patients had a tear from some kind of like arteriopathy or connective tissue disorder. but I think most cardiologists would say yeah, I'll probably keep you on aspirin." But that is, a lot of, debate right now. anticoagulation is not indicated. That's usually a question that I hear because we say intramural hematoma. but no anticoagulation unless you had another reason to be on anticoagulation outside of the SCAD. and then beta blockers because, it does help with, more filling and, we know that you slow the heart rate down, you get more filling, you get more coronary blood flow if the patient can tolerate it. But it's not an absolute must, because a lot of young women truly cannot tolerate, beta blockers unless they have hypertension. then that can be a first-line blood pressure medicine as well

Mohamed

Yeah, beta blocker makes sense 'cause it's same, pathogenesis in aorta dissection, so everybody needs to be on a beta blocker for that for sure. And, beta blocker is interesting to me. Beta blocker is for life, after an established diagnosis of SCAD or is it gonna be at some point discontinued?

Njeri

As long as the patient can tolerate it. ideally, you would want to keep them on that. if they have high blood pressure at baseline, they'll probably be able to tolerate it much longer. If they have low blood pressure, they likely should not be on the beta blocker because they're just gonna feel worse. and so that's, what most experts will say is beta blocker, even low dose, as long as patient can tolerate it, should be on it for life

Mohamed

Okay. So this patient, post-PCI admission was uneventful, discharged home with maybe a short course, prescription for aspirin and then beta blocker, let's say metoprolol in that case. Now, the hardest question comes from the patient to you. she's telling you, "Okay, I have this now. I am an athlete. I like to go running. I like to exercise. I like to enjoy life. What am I gonna do now, doc? what are the chances that I'm gonna get this again?" So what are you gonna tell her?

Njeri

It depends. It depends on your level of exercise. we used to tell patients long time ago, just do like aerobic exercises. But if you have to do an exercise like lifting, for example, to where you're straining, you shouldn't be doing that. So the idea is that if you're straining, that's not an exercise that you should be doing. But you should exercise, you should run, you should continue to, be as healthy as possible. But I think most cardiologists would say, we don't want you straining 'cause the idea is that, you could possibly, rupture. and then the other thing is, any kind of activity that, would cause shearing, like fast acceleration, deceleration. I don't know, like a race car. I don't know

Mohamed

Formula One,

Njeri

Yes, like probably don't be doing that where you're accelerating, decelerating. and I think I've also heard like some experts in Australia that have a SCAD center will say, roller coasters are okay as long as it's not like a roller coaster that's like a vigorous up and down. again, like patients will do what they want, but I think we should present them with whatever evidence we do have. Again, this is all from observational data. but regular exercise I think is still recommended to do.

Mohamed

And what about pregnancy? 'Cause she's still young and she wants to have more kids

Njeri

So it depends when the SCAD event happened. like 8 to 12% of patients who had a SCAD in the peripartum period are likely to dissect in another artery. And sometimes it's not the same artery that has the stent, if you needed a stent. And so most cardiologists would say, "We don't recommend that you get pregnant again." And part of that is that imagine, completely dissecting and presenting in a VFib arrest. And, some women will say it's not worth it, but, if you wanna grow your family, I can see how that can be like a very, difficult conversation, especially if you survived the first event or if it was conservative management. And so that SCAD in the peripartum is usually the most high risk, the multi-vessel left main SCAD. And as of now, we would say we really recommend that you don't get pregnant again

Mohamed

I just can't imagine all the psychological turmoil they have to go through, after this diagnosis, and the lifestyle adjustments and the changes. I tell you, I'm a man and I'm like, I work out every day, I try to move my body, I love just being active, and if someone tells me you cannot do it, I just, I become depressed, And then, and e- even like moreover, think about symptoms-wise, if I even... If someone tells me I have SCAD or I just recovered from SCAD and I have a little twinge in my chest, then I get so anxious that it might be SCAD. So just as the psychological, burden on these patients can be overwhelming. So how do you approach that in terms of like recurrence rates? 'Cause I saw some numbers, like up to 30% of SCAD can recur, within the following two years or so. So how do you approach these conversations with them?

Njeri

I think it's in the same way that we are recommending cardiac rehab, for example, for our patients. it's good for you. We should get you moving. It's the same idea of, still taking care of your wellness and taking it very seriously. We don't want our patients getting depressed, and I think, although I'm not in primary care, this is my patient, and I should make sure that if I need to refer them, or, ask clinic staff what kind of resources we have, that way we don't ignore, their overall, mental health, which is a big part of overall health. And so the same way that we say, "Oh, we recommend cardiac rehab after cabbage or high-risk PCI," then, we should still be saying, "We want you to be whole. And so if you are getting depressed..." And we should be asking, And typically, this is asked in primary care. I feel like a lot of us that are not in primary care don't really ask our patients, "Are you feeling depressed?" But I think we should be screening for that. and although that's not, typical, I do think in this specific group, we should be making sure that they're still, able to feel like their best self

Mohamed

100% agree. But, think one last thing we just have to make sure that the public knows is that if you are diagnosed with SCAD, it doesn't stop there, right? You have to screen yourself for other similar fibromuscular conditions. Can you just tell us more about this?

Njeri

Yes, and, this comes up because patients will ask, if I had a heart attack, do I need to be on a statin?" And what I would tell that patient is, "So if you had a SCAD event, we need to screen the vessels in your head, your neck, your abdomen, and in your pelvis to rule out other SCAD that can happen in those areas, or rubral, fibromuscular dysplasia, also known as FMD, which affects, typically the renal artery, but you can also get dissections in other areas. And that's gonna be either with a CT, or an MRA." If we see atherosclerotic plaque in those areas, then I can say, you probably should be on a statin." so that's the last thing I wanted to add is that, we are screening to make sure that you don't have these other, this dissection in other areas and that you also don't have FMD.

Mohamed

Screening is important, for many other conditions after this. And last question that I have for you, and I know this is great case so far, great discussion, is if an emergency clinician, so a lot of the audience here are in emergency medicine, either from a pre-hospital standpoint, paramedic, EMTs, emergency nurses, physicians. If every emergency clinician listening remembers just one thing after this episode, what do you hope, it would be?

Njeri

I would hope that as we continue as a society, but especially from our emergency medicine providers, is that women's heart health in general is very behind. We're behind many years, and we're just slowly, seeing a change since 1993, which is not that long ago. And so if you take anything from this, is that really take an extra minute with that patient, especially if she is a woman and she's young, because it could be a typical MI or it could be SCAD, or takotsubo or all these other syndromes that tend to affect women more. At the end of the day, typical MIs are going to affect the general population. And please don't tell that patient it's anxiety. I think anybody having an MI is going to be anxious, is gonna be diaphoretic. But you'd rather take an extra minute, do the testing, and if everything comes out normal, then, it might be anxiety. But I really hope that we, as all providers can, really help in, moving that needle, for women's heart health

Mohamed

Absolutely. It starts by listening, it ends with listening. And I think just having that extra time to express your concerns and actually trying to, empathize with the patients about their symptoms. Not only they will open up to you, but also you will not miss the diagnosis in the majority of cases, in my experience. And I appreciate you for having this conversation with me. I don't know, I think leaving these conversations, I'm still scared about SCAD. I'm still not gonna be able to sleep, but I'm probably feel better, maybe slightly more confident that I will always think about that, every time I see a patient with symptoms like this, especially in the setting of this background of this young lady who, comes in, who's otherwise healthy. So thank you. I just wanna know if you have any other words of wisdom you wanna share before we end the podcast?

Njeri

I think I'm just so grateful that you're doing this because your audience is the first line. your audience, especially all our emergency providers, like they see the patient before they see us. And when you guys catch it, it makes a world of a difference for a patient that, otherwise may have not gotten the help they needed. And I appreciate you doing this. it brings me a lot of joy and, yeah

Mohamed

I appreciate you joining me. This has been pleasant. Thank you so much.