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Getting to the Heart of SCAD

Oct 01, 2018

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Nurses Play a big role in the research...In order to generate the knowledge from which to base our practice, it is critically important that they're involved.

Cynthia Arslanian-Engoren

In February, the American Heart Association (AHA) journal, Circulation, published “Spontaneous Coronary Artery Dissection (SCAD): Current State of the Science,” clinical statements and guidelines written by a Mayo Clinic-led team of international experts. The team included Cynthia Arslanian-Engoren, senior faculty member and associate dean at the University of Michigan School of Nursing, the only nurse co-author of the first AHA scientific statement published exclusively on SCAD. Though widely considered a rare condition, SCAD is the number one cause of both myocardial infarction in women younger than 50 and pregnancy-associated myocardial infarction. Arslanian-Engoren contributed to this new expert consensus, which fills persistent knowledge gaps about the enigmatic condition and indicates SCAD may be more common than once believed.

How long have you been a nurse?

I’ve been a registered nurse for more than 30 years. Seeing the positive differences nurses make in the lives of individuals and families is an important and meaningful contribution, and one that I wanted to be part of since I was a child.

When did you decide on the nurse scientist path?

I worked for years as a clinical bedside nurse in acute and critical care. When women had cardiac disease they were not as likely as men to have certain procedures. And for those that did, their outcomes were not as good. I realized that for me to contribute and make a difference, I needed additional schooling as an adult health clinical nurse specialist and to obtain a Ph.D. in nursing.

How did you become involved in this groundbreaking research?

I was asked to join the writing team because of my expertise in heart disease in women. I was invited to represent the Cardiovascular Nursing and Stroke Council of the AHA. While my specific contribution focused on psychological implications and cardiac rehabilitation, I also provided input to the overall scientific statement. I worked on other AHA statements and am currently working on another, so I’m familiar with the process.

What are important takeaways for nurses to help identify SCAD?

Increased awareness and knowledge of SCAD among nurses will help aid rapid identification and treatment. Nurses should suspect SCAD especially in young women who present with symptoms of myocardial infarction (MI) but who have zero or few atherosclerotic risk factors. Remember, SCAD’s a frightening experience, especially in young women that nurses might consider healthy. The anxiety and concern voiced by patients and their families is understandable given the context of uncertainty.

Many women have not experienced anything like this before and will have difficulty making sense of their symptoms: chest pain, shortness of breath, cold sweats, crushing chest pressure. They may not have a history — they may be active, thin — and oftentimes it’s not recognized initially. While patients with SCAD may present with symptoms of MI and acute coronary syndrome (ACS), their initial EKG and troponin may be normal. It’s important to conduct serial EKG and troponin evaluations. About half ultimately have an ST-elevated MI (STEMI), but a large portion have non-STEMIs. Symptoms include nausea, vomiting, arm pain, diaphoresis. Very similar to how MI patients may present.

It’s also important that nurses assess for uterine bleeding in postpartum women with SCAD who receive percutaneous coronary intervention with antiplatelet therapy and anticoagulation therapy. Nurses should promote bonding between postpartum women with SCAD and their newborns. It’s important, even in the context of SCAD or an intervention to address it, that those behaviors be fostered. If the mother can’t hold the baby, the nurse can hold the baby in the mother’s arms.

Describe the psychosocial implications for patients with SCAD.

You don’t consider yourself a cardiac patient. You’re envisioning someone older. “I’m not overweight. I don’t smoke. I’m physically active. How did this happen to me? Will it happen again?” You’re young, just had a child. There are a lot of unknowns. Patients will need support and have lots of questions. We also know that, in general, women tend not to complete cardiac rehab at the same level men do, because of caregiving roles. Certainly if you have a newborn. If you’re older when it happens, you may be caring for children, a spouse or even parents. Those factors play into why some women may not complete cardiac rehab.

Were you involved in the “Good Morning America” segment on SCAD in February?

I was not involved. The guidelines came out that same morning. It [the ABC-TV report] puts a face to SCAD, instead of numbers or statistics. People may relate more, pause or self-reflect on their own risk bubble. It certainly increases awareness. For nurses, hopefully it addressed their mental template. “What do I see in my practice? Who are they? How do they present?” If they present in a way that’s consistent with my mental template, then I’m more apt to quickly recognize and move forward in an ACS, MI approach. My work shows nurses still tend to consider gallbladder cholecystitis as a cause, and not acute MI, for younger women. My work shows nurses’ triage decisions don’t always align with the physicians’ diagnoses later. The nurse is doing it with incomplete information, doesn’t have the benefit of labs at that point or other diagnostics — they’re not always able to predict correctly. My other work showed that they don’t always follow guidelines. These are disturbing, but that’s the evidence.

The statement indicates that, according to social media, SCAD is much more common than previously thought.

The statement refers to number of posts on a social network site for women with heart disease — more than 70 women made posts/contributions about their experiences for mutual support and sharing. The number of posts was almost twice the number of reported case series of SCAD.

What advice do you have for nurses who want to conduct and contribute to research and studies?

For nurses who may not be prepared to lead research investigations, I encourage them to partner with academic nurse researchers. The combination of research and clinical expertise will answer the vexing clinical questions, advance current knowledge, provide evidence to transform practice and improve patient outcomes across populations. Just this morning, while collecting data, an advanced practice clinical nurse specialist (CNS) approached me about doing a project together. It’s a fabulous opportunity to work with nurses in the clinical area. I maintain my certification as an advanced practice CNS, and my work is clinically focused. Having partners and champions who can do the work together is fantastic. Reach out. Share. Work together.

What roadblocks prevent more nurses from participating in research?

This is speculation. Maybe they don’t know who to reach out to. Maybe they don’t have a school of nursing affiliated with their clinical practice. Maybe they don’t know how to start. They have a great idea, see a problem, but think, “What do I do?” I say, reach out to someone doing this work. Email them. I’m thrilled and delighted when people contact me! I did that when I was a student. Some people were very gracious. Some were not. I pay it forward from the many who were gracious and helpful to me. Nurses play a big role in the research. You need their support. In order to generate the knowledge from which to base our practice, it is critically important that they’re involved. They have the contemporary, real-time insight to what the problem is.

What do you like to do for fun in your spare time?

I enjoy spending time with family and friends. I also enjoy heart-healthy activities such as walking and riding my bicycle, and reading for pleasure. I’ve got a book by Betty White, her life story, and another on Barbara Bush. These are fun, strong, successful women — and they’re great. I’m interested to read their stories.