By Denise Williams | News & Views
When a patient with SCAD (spontaneous coronary artery dissection) walks through the doors of cardiac rehabilitation, it wouldn’t be a stretch to assume they took a wrong turn on their way somewhere else. They might seem a more likely candidate for the sports therapy office down the hall or the new moms’ group meeting around the corner than for CR.
Not necessarily, professionals say. Programs might be more accustomed to seeing older adults with limited mobility, but more young and fit individuals are showing up for care, too – and SCAD is a big part of the reason why. The condition is an increasingly recognized cause of heart attacks in younger patients, including women, according to Malissa J. Wood, MD, an associate professor of medicine at Harvard Medical School. She estimates that SCAD accounts for at least 34% of heart attacks in females under the age of 50. It also is the No. 1 cause of pregnancy-associated heart attack.
Associated factors that are common among affected patients include post-partum depression in women. In both genders, there is a high incidence of other depression and anxiety, elevated stress levels – whether chronic or sudden – extremely vigorous physical activity beyond the individual’s normal range, history of migraine headaches, and fibromuscular dysplasia (a blood vessel condition where the arteries have extra muscle).
And although SCAD patients are generally healthier and physically stronger than the typical CR enrollee, managing their cases can be a fragile undertaking. Without diligent communication and coordination between the CR team and the clinicians handling the case, Dr. Wood warns that the SCAD patient could walk out of CR one day and not return for the remaining sessions.
In order to keep the quit rate down in this CR population, Dr. Wood says it’s important for staffers to understand what sets SCAD patients apart from other enrollees and why their rehabilitation approach requires some unique considerations. In her AACVPR live webinar on June 23, she’ll explain to attendees the nuances of rehabbing in the setting of SCAD.
The tricky nature is twofold, Dr. Wood reveals, having to do both with the timing of CR initiation and the speed of progression once it gets underway.
Staying active is vital for many of these individuals to manage their anxiety and stress, she emphasizes. Once they experience their cardiac event, they often want to resume their fitness regimen right away – which generally is not possible. Unlike with traditional heart attacks, Dr. Wood reports that two-thirds of SCAD cases do not involve stent placement. The artery then needs adequate time to heal, and mismanaging the re-start to exercise could easily result in additional chest pain and a medical setback. While waiting for the safe point to begin physical activity again, these highly anxious patients can benefit from the kind of CR that incorporates mindfulness, stress management and other behavioral health components. “Most CRs do address that, of course,” says Dr. Wood, “but it’s extremely important in this population because they have so much preexisting stress, and certainly all of them are stressed after they’ve had their heart attack.”
The second half of the conundrum, she adds, comes once SCAD patients are fully submerged in CR. What they do as part of the process isn’t remarkably different from what the general CR population experiences, Dr. Wood admits. However, the pace may need to be more aggressive with this group of patients in order to keep them coming back for their next appointment. “It’s interesting,” she muses. “There’s a little bit slower uptake of CR, because you have to wait for these patients to heal. But once they heal and they’ve enrolled, they’re going to want more from CD to keep them engaged.”
At the same time, knowing that SCAD can be a trigger for SCAD, managing CR prudently becomes all the more important. These complexities demand a careful balance “of looking at that patient and figuring out what are the safe things we can do and what are the things we should avoid,” Dr. Wood sums up. “And that’s why having a more uniform and consistent approach for managing SCAD patients will really be beneficial to any CR team.”
The recording of the June 23 presentation is available to AACVPR members, at no charge, here.