What activity restrictions are recommended following Spontaneous Coronary Artery Dissection (SCAD)?

Activity Restrictions Following Spontaneous Coronary Artery Dissection (SCAD)

Patients with SCAD should begin graduated cardiac rehabilitation starting 1-2 weeks post-event with low-intensity supervised exercise, avoiding high-intensity competitive sports and activities involving burst exertion or heavy lifting indefinitely. 1, 2

Immediate Post-SCAD Period (First 1-2 Weeks)

• Begin cardiac rehabilitation within 7-21 days after the SCAD event, as this timeframe has been shown safe and feasible in SCAD patients 1
• Start with walking as the primary mode of exercise during the initial recovery phase 3
• Avoid any strenuous physical activity, particularly heavy lifting, which has been documented as a trigger for SCAD events 4

Graduated Exercise Prescription

Exercise should be prescribed in a graduated fashion, starting with low-intensity exercise of limited duration and progressively increased based on tolerance. 3

Initial Exercise Parameters:

• Target heart rate of 40-60% of heart rate reserve calculated as: [(maximal heart rate - resting heart rate) × 40-60%] + resting heart rate 3
• Begin with supervised flexibility, stretching, aerobic, and strength training exercises 1
• Exercise sessions should be completed with reserve—patients should be able to converse during activity without difficulty breathing 3

Progressive Advancement:

• Increase exercise intensity gradually to 85% heart rate reserve only if well tolerated 3
• Standard cardiac rehabilitation programs result in 18% improvement in peak oxygen uptake and 22% increase in 6-minute walk distance in SCAD patients 1
• More intense training and competition should only be considered after graduated and progressive increase in rehabilitation training load 3

Long-Term Activity Restrictions

Prohibited Activities:

Patients with SCAD should permanently avoid:

• Competitive sports, particularly those with extreme power and endurance demands 3
• Activities involving burst exertion (e.g., sprinting) 3
• Systematic isometric exercise (e.g., heavy lifting), as this has been directly implicated in triggering SCAD events 3, 4
• Intense physical activity beyond 7 times per week or 18 hours of strenuous exercise per week, as observational data indicate this increases mortality risk in CAD patients 5

Permitted Activities:

• Leisure-time physical activity at moderate intensity for at least 30 minutes on most (preferably all) days of the week 5
• Low-to-moderate intensity aerobic exercise under supervised conditions initially 1
• Activities that can be performed without developing new symptoms, particularly chest pain, dyspnea, or syncope 3

Critical Monitoring Parameters

Signs of Over-Exercising to Watch For:

• Inability to finish exercise sessions (training should be completed with reserve) 3
• Inability to converse during activity due to breathing difficulty 3
• Faintness or nausea after exercise 3
• Chronic fatigue persisting throughout the day 3
• Sleeplessness despite feelings of fatigue 3
• Joint aches and pains or muscle cramping 3

Required Pre-Exercise Evaluation:

• Maximal exercise testing to evaluate exercise tolerance, presence of inducible ischemia, and exercise-induced electrical instability 3
• Evaluation of left ventricular function 3
• Assessment of rate control adequacy during exertion, as resting assessment is insufficient 6

Medical Management Supporting Activity

Beta-blocker therapy is mandatory and protective against recurrent SCAD, reducing recurrence risk by 64% (hazard ratio: 0.36) 2, 7

• Aspirin 75-100 mg daily for secondary prevention 8, 2
• Aggressive risk factor modification, particularly blood pressure control, as hypertension increases recurrent SCAD risk 2.5-fold 2
• Statin therapy with goal LDL-C <55 mg/dL 8

Common Pitfalls to Avoid

The most critical error is allowing premature return to high-intensity or competitive athletics. Unlike atherosclerotic CAD where some competitive sports may be permitted in low-risk patients, SCAD patients face unique recurrence risks (10.4% recurrence rate at median 3.1 years follow-up) that are not fully predicted by traditional risk stratification 2

• Do not assume SCAD patients can follow the same return-to-sport guidelines as atherosclerotic CAD patients—SCAD predominantly affects young, otherwise healthy women with different pathophysiology 9, 2, 7
• Do not permit activities involving Valsalva maneuvers or sudden increases in shear stress on coronary artery walls 9
• Do not overlook emotional stress management, as 48.3% of SCAD events are precipitated by emotional stressors 2

Cardiac Rehabilitation Benefits Specific to SCAD

Standard cardiac rehabilitation beginning 1-2 weeks after SCAD results in:

• 18% increase in peak oxygen uptake 1
• 22% increase in 6-minute walk distance 1
• 1.6 kg reduction in fat mass with 0.4 kg increase in lean mass 1
• Significant improvement in depression and stress scores (average 2.3 and 1.3 points respectively) 1
• No adverse cardiac events during supervised exercise testing or training 1

SCAD-specific cardiac rehabilitation has demonstrated long-term cardiovascular benefits and should be considered mandatory, not optional. 7, 6