How to prevent Spontaneous Coronary Artery Dissection (SCAD)?

Prevention of Spontaneous Coronary Artery Dissection (SCAD)

Beta-blocker therapy is the most effective pharmacological intervention for preventing recurrent SCAD, while avoiding hormone therapy and managing hypertension are critical preventive measures. 1

Understanding SCAD Risk Factors

SCAD is an important cause of myocardial infarction, particularly in young and middle-aged women, with over 90% of cases occurring in women 2. Key risk factors include:

• Arteriopathies: Fibromuscular dysplasia (FMD) is present in 62-72% of SCAD patients 1, 3
• Hormonal factors: 56.9% of female patients are postmenopausal 1
• Precipitating stressors:
  • Emotional stressors (48.3%)
  • Physical stressors (28.1%) 1
• Comorbidities:
  • Hypertension (increases risk of recurrent SCAD by 2.46 times) 1
  • Systemic inflammatory diseases (present in 11.9%) 1
  • Connective tissue disorders (present in 4.9%) 1

Prevention Strategies

1. Pharmacological Management

• Beta-blockers:

  • First-line therapy for SCAD prevention
  • Significantly reduces risk of recurrent SCAD (HR: 0.36; p=0.004) 1
  • Should be continued long-term in patients with history of SCAD

• Antiplatelet therapy:

  • Aspirin is commonly prescribed after SCAD 1
  • Evidence for dual antiplatelet therapy is mixed and based on ACS guidelines rather than SCAD-specific data 4

• Avoid medications that may increase risk:

  • Nonsteroidal anti-inflammatory drugs
  • Tranexamic acid (associated with MI and thrombosis) 5

2. Hormone Therapy Management

• Discontinue hormone therapy (HT) in patients who experienced SCAD while receiving it, unless there are compelling reasons to continue 5
• For patients requiring HT for severe symptoms:
  • Use lowest effective dose
  • Consider transdermal systemic agents (minimize thrombotic factors)
  • Locally applied vaginal estrogen may be safer due to minimal systemic absorption 5
  • Collaborate with cardiovascular and menopause specialists for management decisions

3. Lifestyle Modifications

• Avoid competitive sports involving intense physical exercise 5
• Smoking cessation is strongly recommended as smoking is an independent risk factor for sudden cardiac death 5
• Stress management given the high prevalence of emotional stressors as precipitating factors 1

4. Screening and Monitoring

• Vascular imaging from brain to pelvis should be considered in all SCAD patients to detect FMD and other vascular abnormalities 5
• Complete vascular physical examination with palpation and auscultation of abdominal aorta, cervical carotid arteries, and peripheral arteries 5
• Manage hypertension aggressively as it significantly increases recurrent SCAD risk 1

Follow-up and Recurrence Risk

• Recurrent SCAD occurs in 10.4-13.1% of patients 1, 3
• Overall major adverse cardiac event rate at median follow-up of 3.1 years is 19.9% 1
• Regular cardiovascular follow-up is essential, particularly in patients with identified risk factors

Special Considerations

Abnormal Uterine Bleeding in Women on Antiplatelet Therapy

For women experiencing heavy menstrual bleeding while on antiplatelet therapy after SCAD:

• Reassess the indication for ongoing antiplatelet therapy
• Consider progestin-eluting intrauterine devices (levonorgestrel 20 μg/d) for controlling bleeding 5
• Lower-dose progestin devices (levonorgestrel 14 μg/d) may offer advantages for SCAD patients 5

Conclusion

Prevention of SCAD requires a targeted approach addressing modifiable risk factors. Beta-blocker therapy provides the strongest evidence for recurrence prevention, while careful management of hypertension, avoidance of intense physical stressors, and discontinuation of hormone therapy are important additional measures. Regular vascular screening and monitoring are essential components of long-term management.