23-05-2025
SCAD: What's an Extreme Athlete to Do?
'Do something every day that scares you' is a favorite motto of 36-year old World Champion kayaker and freestyler Nicholas Troutman.
As an extreme athlete, he is accustomed to risk-taking; whether it's running white water rapids or navigating an 80-foot waterfall drop in Washington State. His GoPro videos attest to his undeniable thirst for adrenalin-producing life experiences.
No one would have predicted his closest brush with death would be from a heart attack as a result of spontaneous coronary artery dissection (SCAD) earlier this year.
Nick Troutman kayaking
After 4 days of '6/10 chest discomfort' occurring mostly during inclines on Nick's typical 4-mile runs, his wife asked him to get checked out. But he napped, blamed it on too much caffeine, and wondered if he had panic disorder, a condition he'd never experienced. He even 'tested' himself by going for more runs. When he had to lay on the floor until his pain remitted and took yet another nap, his wife insisted again, and he finally drove himself to the local hospital.
Nick Troutman
'I was told my ECG looked pretty good,' he said. He was also initially reassured that his athleticism and young age placed him in a super low risk category for heart attack…but his troponin level returned in the thousands. A coronary angiogram revealed 100% occlusion of the left anterior descending coronary artery. 'There was a 36 mm tear' in the vessel wall proximal to the obstruction. He was placed on aspirin, clopidogrel, and metoprolol and discharged.
'Not much information was given to me so I did what I probably should not have done,' he told me. 'I researched it on my own, online.' That's how he found Jessica Duran, MD, who runs the SCAD clinic at Vanderbilt University in Nashville, one of only a smattering of such programs across the country.
Nick says his ejection fraction is now 50%. He is scheduled for a 'head-to-tail' CT scan to evaluate for fibromuscular dysplasia, one of the possible etiologies of SCAD. He has been advised repeatedly to retire from extreme kayaking, but that advice isn't compatible with a happy life for him.
What Causes SCAD
I had the pleasure of hearing Duran speak on SCAD at the Vanderbilt Women's Heart and Neurology Symposium in Franklin, Tennessee. She pointed out that SCAD accounts for about 4% of all cases of acute coronary syndrome (ACS) and most of these are in women. Men typically present with SCAD after extreme physical exertion whereas for the usually premenopausal women with SCAD it's more likely an emotionally traumatic experience. SCAD represents about 40% of myocardial infarction events in women younger than 50 years and between 15%-40% of pregnancy associated ACS cases.
Jessica Duran, MD
During her presentation, Duran flashed a slide demonstrating three distinct SCAD patterns as described by the Yip-Saw classification: In Type I, radiographic contrast penetrates the false lumen and gives the impression of 'dye hanging up' during angiography after the contrast has cleared. It carries a lower risk of progression and fewer complications if mechanical intervention is required.
Type 2a is described as a long smooth stenosis with normal distal vessel appearance. In Type 2b the stenosis continues to the distal area of the vessel. Type 3 is more typical angiographically of atherosclerosis but in the absence of traditional risk factors and lack of atheroma in other vessels. A high index of suspicion is required, and intravascular imaging may be necessary to classify. Total coronary occlusion, as experienced by Nick, is called SCAD Type 4 by some since it doesn't easily fit into the other categories.
There are two main theories for SCAD: A hematoma spontaneously arises between two of the layers of the coronary artery or a rent occurs within the arterial wall. Patients better understand the phenomenon when I compare the walls of the coronary artery to the layers of an onion. As the walls separate, the inner most layer is displaced centrally inside the lumen limiting blood flow or obstructing it completely producing ischemia, myocardial infarction, and in some instances sudden death from ventricular fibrillation.
Medical Management Favored
Over 10 years ago, my friend Lisa (then age 40) experienced a SCAD-associated ventricular fibrillation arrest during an exercise class. Her ongoing ischemia and chest discomfort bought her a 'full-metal jacket' of stents in her right coronary artery. Fortunately, she's doing great. In counter distinction to Lisa's therapy, Duran pointed out that medical therapy is the optimal treatment, including aspirin for a minimum of 1 year, 'ideally life-long', dual anti-platelet therapy for 4-6 weeks, and beta blockers to reduce recurrence. Indications for percutaneous intervention include left main dissection, ongoing ischemia, TIMI 0-1 flow, hemodynamic instability, and refractory angina. Coronary artery bypass grafting should be reserved for extensive dissections involving the left main coronary artery.
Underlying conditions to consider according to Duran include Marfan syndrome, Ehlers-Danlos IV, Loeys-Dietz syndrome, systemic inflammation, migraine disorder, or drug use (cocaine, meth, and THC). Inflammatory disorders associated with SCAD include systemic lupus, Crohn's disease, ulcerative colitis, polyarteritis nodosa, and sarcoidosis
Because the condition is complex and occurs in a younger population, Duran admitted that 'SCAD office visits are long visits.' It also takes time to carefully assess for a family history of fibromuscular dysplasia, extracoronary findings, or multivessel involvement — any of which are indications for genetic testing, as is recurrent SCAD and male sex.
Lifestyle Changes Post SCAD
Then there is the required lifestyle discussion.
In women who've experienced SCAD, Duran recommends against pregnancy altogether but pointed out that this is based on 'limited data.' 'For women who decide to conceive, care should be delivered by a multidisciplinary cardio-obstetrics team throughout the pregnancy with delivery ideally at a level III/IV maternal care center,' she told me. 'Planned vaginal deliveries are typically recommended.'
I asked Duran about advice for very active SCAD patients. 'Moderate aerobic exercise, interval training and strength training using lower resistance and higher repetitions are recommended,' she said. However, patients are advised to avoid competitive sports, high-intensity exercise, heavy isometric exercises that require straining or prolonged Valsalva, and extreme head and neck positions.
She is fully transparent with athletes who wish to return to competitive sports. 'Athletes need to know that physical activity, particularly extreme or unconventional has been identified as a trigger in a fair number of SCAD cases and thus at present the current expert consensus advises against the return to competitive sports.'
The rate of recurrence is between 10%-20% with recommendations to avoid known triggers such as risky yoga poses, chiropractic manipulation, and roller coaster rides. She clarified further by email, 'Ultimately I strongly believe that patients want to know the unfiltered truth and receive guidance as to how to proceed with their lives. And my job as their doctor is to help guide them on their journey and empower them with the information they need to make well-informed decisions about their future and enjoy a long, healthy life,' she said.
Which brings me back to Nick Troutman.
Nick is doing well. However, against medical advice and with a bottle of nitro in his pocket, he entered yet another Kayaking competition and won. 'Does Dr Duran know that you competed in March?' I asked. 'Uh….no,' he said after which he further explained his risk-taking, 'I'm not trying to be a daredevil. I've got two kids and I'd like to live a long life and watch my kids grow up, but I'm not ready to sit on the couch for the next 60 years.'
Nick's persona revolves around being an athlete, and he doesn't want that to end with SCAD. I suggested that if he keeps competing, he should make certain EMS is available on location at all of his events.
But, I worry.
As physicians, we must accept that it's up to the individual to judge what risks they will take. Nick lives his life as the ultimate free-styler pushing boundaries and gambling that SCAD will remain in his rear-view mirror. But given the substantial rate of recurrence, his return to competitive kayaking poses a high risk.
In the end, all we can do is help our patients if they fall, even if that's 80 feet over the edge of a breathtaking waterfall in Washington State.
