SCAD: Heart Attacks in Young Women Without Classic Risk Factors

When the Coronary Artery Tears Itself

Most heart attacks follow a familiar script: years of cholesterol buildup, a plaque that ruptures, a clot that blocks blood flow. But about 4% of all heart attacks -- and a much higher share among women under 50 -- follow a completely different path. The artery wall itself splits. An inner layer peels away from the outer layer, and blood pools in the gap, compressing the vessel from the inside.

This is spontaneous coronary artery dissection, known as SCAD. It requires no buildup, no clot, and no obvious cardiovascular risk. It strikes women in their 40s, sometimes during or after pregnancy, sometimes after a moment of intense physical or emotional stress. And it has been studied far less systematically than conventional heart disease.

"SCAD was considered rare but awareness of the condition is growing," said Professor Svetlana Apostolovic from the University Clinical Center Nis, Serbia, who presented findings from the Serbian SCAD Registry at the EAPCI Summit 2026 in Munich. "SCAD still remains under-diagnosed and under-studied with few, if any, randomised trials conducted to define the most appropriate treatment approach."

Who Gets SCAD

The Serbian registry enrolled 123 patients across 14 interventional cardiology centers between November 2021 and November 2024. Of these, 27 were analyzed retrospectively and 96 prospectively. The demographic profile confirmed what smaller studies had suggested: 85.4% of patients were female, the mean age was 47.5 years, and traditional cardiovascular risk factors were common but not dominant -- hypertension was present in 49.6%, dyslipidemia in 46.3%.

Notably, 6.7% of patients were pregnant or in the postpartum period, and 36.2% were menopausal. Among known triggers, mental stress preceded the event in 38.5% of patients and physical stress in 10.7%. Intracoronary imaging was used to confirm the diagnosis in 26.0% of cases. Standard angiography alone can miss dissections, so imaging confirmation is considered best practice when available.

The Treatment Question

Because SCAD looks like a blocked artery on a scan, many patients are treated with percutaneous coronary intervention -- the stent-and-balloon procedure used for atherosclerotic heart attacks. Whether this is appropriate for SCAD has been disputed, partly because the underlying mechanism is different and partly because the vessel often heals on its own.

The Serbian data add evidence to the conservative-management side of that debate. PCI with stent implantation was performed in 28.5% of all patients. Medical therapy alone was used in 58.5%. When the researchers analyzed outcomes, stent implantation emerged as an independent predictor of major adverse cardiovascular events (p=0.010). Depression was the other independent predictor (p=0.008), underscoring the psychological dimension of this condition.

In the 30 days after hospitalization, 18.1% of patients experienced a major adverse event and 0.8% died. During the initial hospitalization, major adverse events occurred in 23.6% of patients and 8.1% died -- a figure that reflects how serious SCAD can be when it occurs.

Spontaneous Healing Is Common

Among patients followed to 30 days, 62.2% showed full radiological resolution of the dissection. The vessel healed without surgical or interventional repair. "SCAD often resolved fully and stent implantation was not beneficial in the majority of patients," Apostolovic said. "Careful observation alongside beta-blockers, blood-pressure lowering medication, cardiac rehabilitation and psychological support may improve outcomes."

This pattern supports an approach focused on symptom management and close monitoring rather than immediate mechanical intervention -- at least in hemodynamically stable patients. The decision is more complex in patients who are deteriorating or whose anatomy makes the risk of ischemia high.

Limitations and What Comes Next

The registry has real-world strengths: it captured patients from 14 centers across Serbia, including community hospitals and academic referral centers, and tracked both in-hospital and 30-day outcomes. But it is observational. Patients were not randomly assigned to treatment strategies, so the association between stenting and worse outcomes could partly reflect that sicker patients were more likely to receive intervention. Confounding cannot be excluded. The European Society of Cardiology is running a large, multinational SCAD registry that will provide greater statistical power and longer follow-up across more diverse populations.