Treatments

Evidence suggests the majority of SCADs will heal over time if managed conservatively, so this is the preferred method of treating SCAD, unless intervention is clinically necessary. Where conservative management fails, the majority of recurrent SCAD cases occur during early follow-up, so monitoring in hospital for at least five days is advised in conservatively managed SCAD patients.

Dr David Adlam, who is leading the UK SCAD research, discusses the findings of a research paper looking at PCI and SCAD patients (starts at 12 minutes) and the research paper is here.

Treatment guidance

The following has been provided by Dr David Adlam, Professor of Acute and Interventional Cardiology, Department of Cardiovascular Sciences, University of Leicester, Cardiovascular Research Centre at Glenfield General Hospital, Leicester. Dr Adlam is leading the UK SCAD research project.

• Thrombolysis should not be used for acute management of SCAD.
• Antiplatelet therapy is controversial for various reasons, one of which is the concern about using medications that prolong bleeding time for a condition that may be caused by an intramural bleed. Also, giving patients of menstrual age antiplatelet medication can cause menorrhagia. Patients who have stents should continue with antiplatelet therapies according to conventional current international guidelines. The necessity and duration of dual antiplatelet therapy after conservatively managed (without stenting) SCAD is unknown. Clinical trials have begun to address this question. Our current practice is to stop dual therapy early (even in hospital) and discontinue aspirin after completion of follow-up imaging investigations if no other indication is either known or identified on imaging.
• Anticoagulant therapy (blood thinners) – should be used in keeping with international guidelines for other co-existent conditions but are not indicated for SCAD per se.
• Current guidelines for ACE inhibitors, angiotensin receptor blocker (ARB) and betablockers should be followed for SCAD patients with significant impairment of left ventricular systolic function and post-SCAD heart failure adding other guideline-based therapies as necessary. Low blood pressure in some SCAD patients can limit increasing the dosage. However, prescribing these for patients without significant left ventricular systolic function impairment is controversial. Some data has linked high blood pressure with an increased risk of recurrent SCAD and betablocker treatment with reduced risk of recurrence. This forms the basis of our current advice to ensure well-controlled blood pressure and continue some beta-blocker where tolerated in patients after SCAD.
• Anti-anginals can be used to treat recurrent chest pain, although most chest pain after SCAD is non-anginal and the impact of these medications on symptoms is variable and often limited
• Statins should be given to patients with high cholesterol in keeping with current recommendations for primary prevention patients. SCAD has no known links to circulating cholesterol levels and so there is no evidence to support treating SCAD patients with statins on a secondary prevention basis. Most SCAD patients do not require statin treatment. (See also the FAQ on this page for what Dr Adlam advises patients.)
• Women after SCAD of child-bearing age should be advised to ensure a secure form of contraception. Where hormonal contraception is required, this should be progesterone based. Patients of child-bearing age taking potentially teratogenic medications (eg ACE inhibitors) should be made aware of this.
• Pregnancy after SCAD requires careful consideration and individualised discussion of the potential risks. Specialist pre-conception counselling is recommended for patients contemplating pregnancy.
• Taking hormone replacement therapy after SCAD is a balance of risks and benefits but HRT is not necessarily contraindicated in the fully informed patient. At the moment the risk/benefit of HRT on the risk of SCAD-recurrence is unknown.
• Chest pain after SCAD is common (affecting 60% of patients at first follow-up). It is usually non-angina (not consistently exertional) and responds variably to medical treatment. It usually improves over time but may take 18 months to 2 years to settle into the background in most patients.

The European Position Paper recommends that every SCAD patient should have at least one ‘head to hip’ scan (high-quality brain-to-pelvis CTA or MRA) to check for vascular abnormalities. This is because many SCADs are associated with abnormalities in other arterial beds including aneurysms, dissections and Fibromuscular Dysplasia. Most findings do not cause problems for patients but some require surveillance and a few require intervention.