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A spontaneous split - SCAD is 'a different type of heart attack'

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Lori Heim survived multiple heart attacks caused by spontaneous coronary artery dissection (SCAD).
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Work-related pressure did not cause the feeling that settled upon Lori Heim three years ago.

"It felt like I had an elephant sitting on my chest," she said. Pain coursed through her arms.

"I sat at my desk kind of wondering what was going on … in the back of your mind you're thinking, 'This is a heart attack,'" said Heim, now 41.

At first, she avoided saying much. But when her arms felt as though they would burst, she told her supervisor. By the time they had entered the Mayo Clinic subway system, she was in so much stress that Gold Cross Ambulance Service was called.

Heim's situation is one that was once thought extremely rare — her heart attack was caused by a spontaneous coronary artery dissection (SCAD). In essence, her artery tore.

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Researchers now believe that might happen — especially to otherwise young, healthy women — more commonly than once believed.

Dr. Sharonne Hayes, founder of the Mayo Clinic Women's Heart Clinic and co-primary investigator, with Dr. Rajiv Gulati,of SCAD research at Mayo, said spontaneous dissections might be the most-common cause of heart attacks for women younger than 45, with the condition causing up to 4 percent of all heart attacks.

About 70 to 80 percent of cases occur in women, Hayes said, and there are no known ways to prevent them.

"When that artery splits, as opposed to when a plaque ruptures, the end result is the same as blood flow is reduced to the heart and so it typically causes a heart attack — or sudden death," Hayes said. "We do know some of these are diagnosed at autopsy."

Risk factors include age, collagen diseases like Marfan's syndrome, fibromuscular dysplasia, gender and having recently given birth to a child.

"This is a different type of heart attack, but the end result can be the same," Hayes said.

Guidelines for SCAD are different than for a typical heart attack because implanting a stent might actually be riskier than watchful waiting. Statin drugs might not be good for patients who are at risk for SCAD recurrence (the opposite of patients with plaque build-up).

The cause of SCAD isn't known — that makes it difficult for patients after a heart attack. If a 42-year-old smoker with high cholesterol and a family history of heart attacks has a heart attack, Hayes said,"I can tell her about six things or give her medication and I can dramatically reduce the risk of her having one again."

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"My SCAD patient, same age, she probably has normal lipids, normal blood pressure, she's probably physically fit, and I don't have a thing, not one thing, that I can tell her that she can do to prevent it because we haven't found the thing. And i also can't reassure her that this can happen again," Hayes said. In about 10 to 20 percent of patients, it does indeed happen again.

Indeed, Heim had a second dissection while out to lunch at a local Rochester restaurant. And, once again, she thought it wasn't possible she was having another heart attack.

But a sense of pain in her arms that she describes as being similar to nails poking into her skin, gave enough of a sign that an ambulance was once again called.

Hayes said patients with fibromuscular dysplasia appear more likely to develop a dissection. The tear develops, captures blood and eventually tears away. Symptoms can include:chest pain;rapid heartbeat or fluttery feeling in the chest; pain in arms, shoulders or jaw; shortness of breath; sweating; unusual, extreme tiredness; nausea and dizziness.

Research avenues Hayes hopes to pursue include devising optimal treatment by comparing approaches, finding genetic causes to help advise patients, searching for a treatment to prevent recurrence and better ways to meet needs of survivors who deal with the stress of knowing a recurrence can occur.

SCAD is still relatively rare, but Hayes said to be aware of heart attack symptoms and get medical attention if you experience them.

Hayes has treated patients as young as 19 who have experienced SCAD.

"If you get these symptoms," Hayes said, "don't ignore them, even if you don't think you're at risk."

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