For long, cardiology assumed estrogen protected women. Rinku Ghosh writes: that shield drops after menopause, but what about women in their 30s and 40s - apparently healthy, no diabetes, no smoking, normal lipids - landing in emergency with a heart attack? The answer is increasingly Spontaneous Coronary Artery Dissection, or SCAD.
Unlike a traditional heart attack where plaque ruptures and blocks an artery, SCAD is a tear inside the artery wall itself. Blood pools inside the layers, forms a hematoma, and chokes flow. As Dr Rajiv Gulati, Chair of Division of Ischemic Heart Disease at Mayo Clinic, explains, instead of being blocked by cholesterol or clot, the blood vessel unexpectedly splits, trapping blood and blocking oxygen to the heart.
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Why disproportionately women? The incidence in women suggests hormonal link. SCAD cases rise after pregnancy, typically. Dr Gulati observed that about 5-10% of all SCAD cases occur after pregnancy. Dr Roy from AlIMS notes: "The difficulty that the postpartum structure of blood vessels, though they themselves cannot cause SCAD," fluctuating levels and reduced collagen may cause breakdown. Cases linked to pregnancy, extreme emotional/ physical stress.For India, this is a blind spot. Young women account for about 10% of acute coronary syndrome, and among women under 50 who have a heart attack, SCAD may account for as many as 1 in 4 cases, per Dr Mohit Gupta, AlIMS. Yet SCAD is under-recognised. Symptoms mimic classic heart attack - chest discomfort - but EKG changes and troponin can be similar. The classic angiogram may show a long, smooth narrowing rather than an obvious clot, so it is missed. "Do not ignore significant chest discomfort," experts warn, especially peripartum or postpartum women.
The strongest risk pattern: women under 50, average age mid-40s, with few conventional risk factors, but with fibromuscular dysplasia, or triggers like intense exertion, stress, pregnancy, emotional shock. About 80% of SCAD patients are women, mostly young to middle-aged.
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Treatment is counter-intuitive. Unlike traditional heart attack where a blocked artery is opened by angioplasty and stenting, in SCAD, stenting can worsen tear and extend hematoma. Conservative management is often preferred - blood pressure control, observation, avoiding intense exertion. Drug treatment differs. Recurrence is real - 10-30% at 3-5 years.
For Indian practice, where women's chest pain is often dismissed as anxiety, SCAD forces a rethink: not every heart attack in a young woman is lifestyle disease. It is structural, hormonal, and needs awareness.
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