Usefulness of Cardiac Rehabilitation After Spontaneous

Coronary Artery Dissection

Chayakrit Krittanawong, MDa, Marysia S. Tweet, MDa,*, Sarah E. Hayes, MS, MPHb,
Melissa J. Bowman, BSa, Rajiv Gulati, MD, PhDa, Ray W. Squires, PhDa, and Sharonne N. Hayes, MDa
Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of
myocardial infarction; however, the role of cardiac rehabilitation (CR) for patients with
SCAD has not been well dened. To further understand CR in patients with SCAD, we
studied a large cohort of patients with conrmed SCAD enrolled in the Mayo Clinic SCAD
Registry from January 2010 to December 2014 (n [ 354). Demographics, clinical characteristics, mental health status, and details about CR participation and experience were
collected through medical record review and questionnaires. Participants at time of SCAD
were 46 10 years old; 96% were women. Most (76%) attended 1 CR sessions, averaging
18 12 sessions. Most reported CR-related physical and emotional benets (82% and 75%,
respectively). Of the CR nonparticipants, 57 of 85 reported not participating because CR
was not recommended by their health care provider. Other reasons included inadequate
transportation (10 of 85), no insurance coverage (7 of 85), cost (2 of 85), no energy (2 of 85),
being too ill (2 of 85), and miscellaneous comments (5 of 85). In conclusion, 3 of 4 of patients
with SCAD participated in CR, most of whom reported benet. Lack of recommendation
for CR by a health care provider was the primary reason patients did not participate. 2016 Elsevier Inc. All rights reserved. (Am J Cardiol 2016;-:-e-)

Despite cardiac rehabilitation (CR) being a class I, national guideline-recommended therapy that reduces
morbidity/mortality and improves quality of life after acute
myocardial infarction (AMI),1e3 CR services are vastly
underutilized.4 Studies have shown that young, healthy
women are less likely to be referred for CR, and when
referred, they are less likely to attend.5e8 The benet of CR
has not been well studied in patients with spontaneous
coronary artery dissection (SCAD), who are frequently
otherwise healthy, previously t young women. In addition,
the association of SCAD with physical activity9 may raise
concerns regarding safety of CR referral and treatment.
However, a hypothesis-generating case series of 9 patients
demonstrated that CR after SCAD AMI can improve aerobic
capacity, body composition, and overall mental health
without adverse events.10 We aimed to understand the role
of CR in patients with SCAD in the Mayo Clinic SCAD
Registry.

a
Division of Cardiovascular Diseases, Department of Internal Medicine,
Mayo Clinic, Rochester, Minnesota; and bDepartment of Psychology, West
Virginia University, Morgantown, West Virginia. Manuscript received
December 8, 2015; revised manuscript received and accepted February 18,
2016.
This study was funded in part by the Mayo Clinic Division of
Cardiovascular Diseases, Rochester, MN; Chicago Mercantile Exchange
Foundation, Chicago, IL; and SCAD Research, Incorporated, Scottsdale,
AZ.
See page 5 for disclosure information.
*Corresponding author: Tel: (1) 507-284-3545; fax: (1) 507-2552550.
E-mail address: Tweet.Marysia@mayo.edu (M.S. Tweet).

0002-9149/16/$ - see front matter 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjcard.2016.02.034

Methods
This study was approved by the Mayo Clinic Institutional
Review Board, and written informed consent was obtained
from each patient as part of the Mayo Clinic SCAD Registry. The Mayo Clinic SCAD Registry was created in
response to an organized effort of an online community of
patients with SCAD.11 Participants are recruited to the
Mayo Clinic SCAD Registry through social media, the
Mayo Clinic SCAD Research Program website and/or provider referral and are enrolled on coronary angiographic
conrmation of the diagnosis by
2 interventional cardiologists. We reviewed 419 patients enrolled in the Mayo
Clinic SCAD Registry from January 2010 to December
2014 of whom 354 had complete CR surveys. Patient data
including demographics, socioeconomics, clinical characteristics, medical history, and current health status were
obtained from a series of questionnaires including as follows: Generalized Anxiety Disorder 7-Item Scale (GAD-7),
Patient Health Questionnaire-9 (PHQ-9), Rand 36 Items SF
Health Survey (SF-36), Mayo Clinic Women Heart Clinic
Risk Assessment, Mayo Clinic Women/Men with Heart
Disease Survey, Mayo Clinic SCAD Questionnaire, and
Mayo Clinic SCAD Supplemental Survey. In this patient
population, indications for CR included AMI and/or
percutaneous transluminal coronary intervention. Participation in CR was dened as attendance in
1 CR sessions. In
addition to extensive clinical and mental health data, these
questionnaires also included specic questions about the
patients participation or lack thereof in CR including the
level of attendance, barriers to attendance, and perceived
emotional and physical benets (Figure 1).
Statistical analyses were performed using JMP statistical
software, version 10.0.0 (SAS, Cary, North Carolina).
www.ajconline.org

The American Journal of Cardiology (www.ajconline.org)

Figure 1. Mayo clinic women with heart disease cardiac rehabilitation survey questions. Rehab rehabilitation.

Continuous variables are presented as mean  SD. Categorical variables are presented as frequencies or percentages. Baseline characteristics were compared between CR
participants and nonparticipants using a chi-square test for
categorical variables and Wilcoxon rank-sum test for
continuous variables. Univariate analyses were performed to
determine the differences between baseline characteristics
and outcomes according to CR participation status. All
comparisons were 2-sided, and a p-value <0.05 was
considered statistically signicant.
Results
Of the 354 patients in our study, patients geographically
represented 48 of 50 US states, Canada, Europe, Australia,
and New Zealand. The mean age of participants at time of
survey was 50  10 years, and the mean age of participants
at time of SCAD was 46  10 years. Mean between time of
surveys and time of SCAD events was 3.3  4 years.
Ninety-six percent of patients were women. After hospital
dismissal, 269 patients (76%) participated in
1 CR sessions, and those users averaged 18  12 sessions. One
hundred seventy-eight subjects (66%) participated in >10
CR sessions. There were no notable differences between the
CR participants versus nonparticipants at baseline except
that participants were more likely to be taking aspirin and
angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and less likely to have a history of right
coronary artery SCAD (Table 1).
Of those 269 patients who participated in CR, 82%
perceived physical health benets, 75% perceived emotional
health benets, and 45% reported still experiencing the
benets of participating in CR at the time of survey
(Figure 2). Of those 85 patients who did not participate in
CR, the primary reason was because their health care provider did not recommend CR. Other barriers included
inadequate transportation, no insurance coverage, cost, no
energy, and being too ill to do any physical activities
(Figure 3).
Other reasons for limited or no participation was due to
the CR programs not meeting the needs of several patients
with SCAD who were considerably active and physically t
before their event. This concern was reected by the
following comments in the survey: I found it too slow for

me and left the program, it was a waste of my time, my

own workout routine was more than the rehab program,
and I tried going and did not think it was worthwhile.
For the entire group, mean PHQ-9 and GAD-7 scores
were 3.9  3.6 and 4.7  4.8, respectively, at a mean time
of 2.8  4.2 years between the survey date and initial SCAD
event (Table 2). On comparative analyses, the PHQ-9 scores
were similar in the CR participants and nonparticipants. CR
participants had slightly higher mean GAD-7 scores.
Despite this, 37 CR participants and 11 nonparticipants had
GAD-7 scores >10 (p 0.45) suggesting similar rates of
moderate or greater GAD among the 2 groups. Healthrelated quality of life as evaluated by the SF-36 was
similar between CR participants and nonparticipants,
including scores on physical functioning, general health,
and vitality.
As compared with the nonparticipants, CR participants
after the rst SCAD event reported higher overall duration
and frequency in both aerobic and nonaerobic exercise, with
most exercising >3 times per week and >20 minutes at a
time. Fewer CR participants reported no regular aerobic
exercise as compared nonparticipants. CR participants and
nonparticipants did not differ in their reasons for not exercising, which included lack of appropriate facility or
equipment, no one with whom to exercise, physically unable
to exercise, not enough time, do not like exercise, lack of
motivation, cost, and other reasons including concerns about
uncertainties about care for patients with SCAD; one patient
commented, Dont have clear guidelines/feel at risk.
Younger patients (aged <55 years) less commonly
participated in CR (79% vs 21%; p <0.0001). In addition,
patients aged <55 years had higher GAD-7 scores than
patients aged
55 years (5.2  0.3 vs 3.7  0.4; p 0.004).
The 2 groups had similar PHQ-9 scores, SF-36 subscales,
and amount of regular exercise.
Discussion
This is the rst study to our knowledge to assess CR
participation in a large cohort of patients with SCAD. Those
with SCAD represent a unique population as they are usually young, women, and have few to no atherosclerotic risk
factors. In our study, we found that most patients with
SCAD reported CR as being benecial and were more likely

Coronary Artery Disease/Cardiac Rehabilitation and SCAD

Table 1
Baseline characteristics of patients with spontaneous coronary artery dissection
Variables

Age (years) at time of SCAD, mean  SD

Age (years) at time of survey, mean  SD
Female
White
Married
Living in own home/apartment
Yearly income >$50,000
Yearly income >$80,000
Employed full time
Employed part time
Completed 12 years of school
Completed 16 years of school
Body mass index, mean  SD (kg/m2)
Hypertension
Diabetes mellitus
Hypercholesterolemia
Fibromuscular dysplasia
Migraines
Connective tissue disease
Former tobacco use
Non-smoker
Left ventricular ejection fraction at last follow up,
mean  SD (self-reported)
Details of initial SCAD event (self-reported)
Unstable angina pectoris
Non-ST segment elevation myocardial infarction
ST segment elevation myocardial infarction
Cardiac arrest
Ventricular arrhythmia
Medical treatment only
Thrombolysis
Coronary artery bypass grafting
Percutaneous coronary intervention
Coronary artery SCAD location (self-reported)
Left main
Left anterior descending
Left circumex
Right
Recurrent SCAD (self-reported)
Current medications
Aspirin
Beta-blockers
Statin
Thienopyridine
Angiotension converting enzyme inhibitor/
Angiotension receptor blocker

Overall
(n354)

45.6  9.8
50.1  9.6
341 (96%)
319 (95%)
296 (84%)
344 (97%)
300 (85%)
234 (66%)
184 (52%)
60 (17%)
348 (98%)
245 (69%)
23.6  7.1
90 (25%)
9 (3%)
92 (38%)
49 (22%)
88 (37%)
13 (5%)
96 (27%)
242 (68%)
52.0  12.2

Cardiac Rehabilitation

P-value

Yes
(n269)

No
(n85)

45.4  9.9
49.9  9.3
262 (97%)
245 (91%)
222 (83%)
260 (97%)
223 (83%)
172 (64%)
139 (52%)
51 (19%)
263 (98%)
189 (70%)
23.5  5.8
65 (24%)
6 (2%)
77 (41%)
41 (24%)
72 (38%)
9 (5%)
76 (28%)
185 (69%)
55.9  10.6

46.6  9.8
50.9  10.6
79 (93%)
74 (87%)
74 (87%)
84 (99%)
77 (91%)
62 (73%)
45 (53%)
9 (11%)
85 (100%)
56 (66%)
24.0  10.3
25 (29%)
3 (4%)
15 (31%)
8 (17%)
16 (33%)
4 (8%)
20 (24%)
57 (67%)
57.8  9.3

0.49
0.48
0.06
0.28
0.33
0.29
0.09
0.13
0.84
0.07
0.16
0.45
0.64
0.33
0.51
0.20
0.29
0.50
0.35
0.39
0.77
0.23

35
125
84
16
17
98
22
23
102

(16%)
(57%)
(38%)
(7%)
(8%)
(46%)
(10%)
(11%)
(47%)

25
94
70
14
15
71
19
18
85

(15%)
(55%)
(41%)
(8%)
(9%)
(43%)
(11%)
(11%)
(50%)

10
31
14
2
2
27
3
5
17

(21%)
(65%)
(29%)
(4%)
(4%)
(56%)
(6%)
(10%)
(35%)

0.32
0.25
0.14
0.34
0.29
0.09
0.53
0.98
0.07

12
130
33
30
71

(5%)
(60%)
(15%)
(14%)
(21%)

7
105
25
19
58

(4%)
(61%)
(15%)
(11%)
(22%)

5
25
8
11
13

(10%)
(53%)
(17%)
(23%)
(16%)

0.20
0.31
0.71
0.04
0.23

313
125
134
107
78

(93%)
(35%)
(38%)
(30%)
(22%)

245
96
108
87
67

(91%)
(36%)
(40%)
(32%)
(25%)

68
29
26
20
11

(81%)
(34%)
(31%)
(22%)
(13%)

0.01
0.07
0.11
0.09
0.02

SCAD spontaneous coronary artery dissection.

Figure 2. Patient-perceived benets of cardiac rehabilitation (269 patients).

Rehab rehabilitation.
Figure 3. Reasons given by patients with SCAD for not participating in
cardiac rehabilitation (85 patients). Rehab rehabilitation.

The American Journal of Cardiology (www.ajconline.org)

Table 2
Mental health surveys and exercise training in spontaneous coronary artery dissection
Variables

Time from SCAD to survey, mean SD (months)

Generalized Anxiety Disorder 7 score, mean SD
Patient Health Questionnaire 9 score, mean SD
Rand 36 Items SF Health Survey subscales, mean SD
Physical functioning
Role functioning-physical
Bodily pain
General health
Vitality
Social functioning
Role functioning-emotional
Mental health
Duration of aerobic exercise (minutes)
Never
<20
20-30
30-60
>60
Frequency of aerobic exercise sessions/week
Never
<1
1-2
>3
Frequency of non-aerobic exercise/week (hours)
<1
1
2
3
>4
Regularly do strength building exercises with
resistance or weight lifting equipment
Reasons for not exercising
Lack of appropriate facility or equipment
No one to exercise with
Physically unable to exercise
Not enough time
Dont like exercise
Lack of motivation
Cost
Other reasons
No reason

Overall
(n354)

Cardiac Rehabilitation

P-value

Yes
(n269)

No
(n85)

33.6  50.6
4.7  4.8
3.9  3.6

33.4  51.9
4.9  4.7
4.0  3.5

34.3  46.5
3.9  4.9
4.0  3.8

0.81
0.03
0.71

80.5  19.9
63.8  41.1
55.5  7.8
65.6  20.9
51.9  22.5
78.9  24.3
78.2  35.8
73.7  15.7

81.1  18.7
63.0  41.5
55.2  7.5
65.3  20.8
52.4  22.5
78.8  24.5
78.2  36.0
72.9  16.0

78.4  23.4
66.5  39.6
56.5  8.9
66.2  21.2
50.6  22.7
79.4  23.8
78.0  35.5
76.3  14.4

0.79
0.50
0.36
0.73
0.49
0.87
0.83
0.09

45
31
89
147
24

(13%)
(9%)
(26%)
(44%)
(7%)

26
24
69
119
21

(10%)
(9%)
(27%)
(46%)
(8%)

19
7
20
28
3

(25%)
(9%)
(26%)
(36%)
(4%)

50
30
66
195

(15%)
(9%)
(19%)
(57%)

28
25
55
154

(11%)
(10%)
(21%)
(59%)

22
5
11
41

(28%)
(6%)
(14%)
(52%)

55
51
81
55
92
105

(16%)
(15%)
(24%)
(16%)
(28%)
(30%)

40
41
70
41
66
86

(16%)
(16%)
(27%)
(16%)
(26%)
(32%)

15
10
11
14
26
19

(20%)
(13%)
(14%)
(18%)
(34%)
(22%)

0.09

21
37
36
147
49
89
22
40
88

(6%)
(10%)
(10%)
(42%)
(14%)
(25%)
(6%)
(11%)
(25%)

16
28
25
119
38
69
18
28
70

(6%)
(10%)
(9%)
(44%)
(14%)
(26%)
(7%)
(10%)
(26%)

5
9
11
28
11
20
4
12
18

(6%)
(11%)
(13%)
(33%)
(13%)
(24%)
(5%)
(14%)
(21%)

0.98
0.96
0.33
0.07
0.78
0.69
0.51
0.35
0.37

0.01

0.002

0.16

SCAD spontaneous coronary artery dissection.

to report regular exercise compared with nonparticipants. In

addition, among our cohort of patients with SCAD who
were referred to CR, participation in
1 sessions was higher
than previously reported12e14; this may reect either a
motivated patient group and/or selection bias.
Despite clear benets of CR in patients with all types of
AMI, we found that lack of referral by a health care provider
was the primary reason for lack of CR participation in our
study. Furthermore, subgroup analyses stratied by age
demonstrated that CR participation rates were lower for
younger patients (age <55 years). Most of the patients with
SCAD were women, in whom, low referral rates, underrepresentation in CR, and notable dropout rates have been
observed in other studies.6,8,15e18 Lack of referral may also

be related to health care providers perception that it is

unsafe for these patients to complete CR as SCAD has been
associated with extreme physical activity.1 Other reasons
may be due to a perception that otherwise healthy patients
with SCAD may not benet, the fact that guidelines and
studies regarding CR do not differentiate CR after SCAD,
and CR programs are often insufciently customized to
account for patients current tness level. This factor is
supported by patient survey comments suggesting that lack
of or incomplete CR participation may be due to the program not meeting the needs of patients with SCAD. Those
with SCAD not only have minimal atherosclerotic risk
factors but also have been observed to be physically t.
Therefore, instead of a rigid protocol with a discrete number

Coronary Artery Disease/Cardiac Rehabilitation and SCAD

of exercise sessions, CR programs for stable patients at low

to moderate risk such as those with SCAD may be better
focused on independent exercise with exible regimens19,20
tailored to specic needs.21,22 As such, recommendations
may also include instruction of problem-solving approaches
for reducing barriers to exercise and expansion of nuclear
social support systems.22,23
A previous study of 158 SCAD survivors showed that
depression and/or anxiety symptoms are common, especially in young women and those with peripartum SCAD.24
Even in those with atherosclerotic MI, anxiety is one of the
earliest and most intense psychological responses after an
event.25,26 A randomized control trial in a group of patients
who had been hospitalized for AMI (n 237) demonstrated
that an anxiety reduction intervention group was associated
with a reduction in mortality in women with AMI compared
with nonintervention group27 emphasizing the signicance
of addressing mental health after AMI.
In our study, there was no difference in the prevalence of
moderate or higher anxiety in the CR participants compared
with the nonparticipants; however, the mean GAD-7 scores
were slightly greater in those who participated in CR. It is
possible that patients with higher anxiety follow through
with CR as a means to secure emotional support. Most
participants reported emotional benet from CR and also
more often reported regular exercise at home compared to
nonparticipants. These observations are consistent with CR
studies that have shown that patient-perceived benets as an
independent predictor of total amount of exercise and
physical activity after CR in women.23,28
CR is considered to be a safe approach to reintroducing
regular exercise to a patient with SCAD,15 and we found
that most patients with SCAD perceived both physical and
emotional health benets. In addition to conducting further
research studying patients with SCAD and CR, further work
can be aimed toward tailoring CR programs to patients with
SCAD including incorporation of a patient-specic, exible
exercise regimen with emphasis on psychosocial factors,
and support networks.
Although this study reviews CR in the largest series of
patients with SCAD to date, it is limited by selection,
referral, and recall bias as most of the data were selfreported and derived from patient questionnaires which
were collected at a single time point which varied from time
of SCAD and may affect overall generalizability of the
ndings. Most patients were white women. Furthermore, as
these patients lived in various locations, the services available, practice patterns, and training intensity may have
differed in the CR programs. Despite these limitations, this
large cohort is the rst to describe the participation rates,
potential benet, and barriers to CR in patients with SCAD.
Referral to and participation in CR is encouraged for patients with SCAD with an emphasis of tailoring therapy to
the individual.
Acknowledgment: The authors are grateful to Sue Ward,
RN, Shu Loh, MBChB, Diane Vrieze and Jill Boyum for
assistance with data collection and contributions to the
project. The authors also thank Nate Foster, MS, and Ryan
Lennon, MS for statistical consultation on this project.

Disclosures
The authors have no conicts of interest to disclose.
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