February 23, 2022 by
Roland Kielman and Jennifer Nachbur
Patient Sara Rutledge (far right) with her husband and son. (Courtesy photo)
It was an early August morning in 2021, when, two miles from home, a sudden pain stopped 44-year-old Sara Rutledge in her tracks. As a burning feeling crept into her chest, her black lab, Goose, turned and looked back, curious why their daily run was being cut short.
Could it be the poor air quality from western wildfire smoke migrating to the Green Mountains, or was she dehydrated or overexerted? As she caught her breath and took a few sips of water, the pain intensified, shifting to her back and arms.
“I didn’t know what was happening, but I knew something was very wrong,” says the Fayston, Vt., resident, adding, “I knew I had to get help.”
With no cell service available, she walked home and, accompanied by her husband, Jeremiah, went to the University of Vermont Health Network – Central Vermont Medical Center (CVMC) Emergency Department.
Amos Hare, P.A., a CVMC physician’s assistant, was concerned by the symptoms Rutledge described, and ordered a battery of medical tests, which later confirmed that Rutledge had suffered a heart attack.
Not Your Typical Heart Attack
“It was a surreal time – I was so confused,” Rutledge recalls. “How could I have had a heart attack? I was a healthy person. I ate well, exercised every day and had none of the risk factors you often associate with heart problems. Yet there I was, sitting in a hospital bed.”
She was not the only person wondering what had caused her heart attack. After reviewing her blood work, Hare consulted with cardiology colleagues at UVM Medical Center, concluding that she should be transferred there for further testing and care.
While awaiting her transfer, Rutledge forged a tight bond with her caregivers. “With everything going on with COVID-19, I expected them to be strained to the max, but they were so reassuring and made me feel so comfortable,” she says. “I’m really grateful for their efforts.”
At UVM Medical Center, Rutledge learned from cardiologist Marc Tischler, M.D., associate professor of medicine, that her heart attack was caused by a spontaneous coronary artery dissection, or SCAD. This condition occurs when a tear in an artery blocks the flow of blood to the heart, which in turn causes the heart attack and related chest pain or discomfort, shortness of breath, pain in the arm and back, among other symptoms. The more common cause of heart attack is atherosclerosis, a build-up of fats, cholesterol, and other materials on the artery walls.
While often misdiagnosed, SCAD heart attacks are “gaining recognition as an important cause of myocardial infarction, especially in young women,” states a 2016 article in the Journal of the American College of Cardiology. The report attributed a recent increase in diagnoses to newer technologies, like coronary angiography and the application of high-resolution intracoronary imaging, which provide visuals of the arterial tears.
The 2019 Canadian SCAD Study estimated that more than 90 percent of SCAD patients are female. Other studies show that roughly 35 percent of heart attacks in women under 50 are due to SCAD.
“The diagnosis of ‘heart disease’ is often unexpected and a shock to these young healthy women/patients,” says Kevin Carey, M.D., an interventional cardiologist and assistant professor of medicine who performed Rutledge’s cardiac catheterization following her heart attack.
Carey explains that during a procedure in a SCAD patient, cardiologists usually screen for associated vascular abnormalities, which is among the reported risk factors for SCAD. Other risk factors include pregnancy and childbirth; inherited connective tissue disorders; and very high blood pressure.
Dealing with the Diagnosis
Processing and making sense of a SCAD diagnosis is often challenging for patients.
“It can be very unnerving and anxiety-provoking to be faced with this diagnosis, which is almost always out of the blue,” says Carey.
Jamie Rowell, M.D., a clinical instructor and third-year internal medicine resident at UVM Medical Center who cared for Rutledge, echoes Carey’s sentiment.
“When patients are hospitalized with a rare condition and especially at such a young age, making the diagnosis is only half the battle,” she admits. In such cases, she advocates for taking the time to explain a diagnosis and discuss how the condition may affect the patient’s life after they are discharged.
Rowell says Rutledge and her husband had a list questions about SCAD and the implications for her life, and through their long discussion, she was able to walk them through a lot of information and clarify what the diagnosis meant for her moving forward.
Rehab Aids Recovery, Rebuilds Confidence
Rutledge returned home a day after her SCAD diagnosis feeling overwhelmed by the task ahead of her.
Recovery from SCAD looks different from typical heart attacks, for which many people have a stent surgically implanted to open blocked arteries. With SCAD, the tear in the artery makes it fragile and a stent can actually end up making things worse.
“[SCAD] is usually managed conservatively, with medication, and stents are only used if the patient is having high-risk complications or findings,” says Carey.
In addition to medication, patients are prescribed rest and cardiac rehabilitation. With this regimen, the damaged artery typically heals on its own over the course of several weeks or months.
“Cardiac rehab, along with close follow up with the patient’s providers, can be very helpful in monitoring clinical progress and supporting the journey back to full activity and exercise,” says Carey.
At first, it was hard for Rutledge to feel comfortable with her new routine.
“I had lost all confidence in my body,” she recalls. “Being physically active was such a big part of who I was, and suddenly, this seemed so out of reach. I was really scared that it was just going to happen again.”
Thankfully, Rutledge says, she found herself in good hands. Cathy Fetten, R.N., a member of the CVMC cardiac rehabilitation team, had worked with SCAD survivors before.
“I remember how scared and frustrated Sara was when she first arrived,” Fetten says. “With people who have suffered from SCAD, I think it’s important to focus on goals that also help them to reduce their stress. In Sara's case, she loved to run – so we focused on gradually restoring her confidence in a safe environment.”
They started small, with Rutledge taking slow walks on the treadmill while the rehab team monitored her heart for any signs of trouble.
About a month into Rutledge's rehab, Fetten says, she thought she was ready to start jogging again. "It was only for a few minutes at first, but it was a turning point for me," Rutledge says. "After that moment, I really started to feel like everything was going to be OK and I would get back to my best."
Lauren Suggs, M.D., a cardiologist and assistant professor of medicine who has been following Rutledge over the past several months, confirms that Fetten’s approach had a truly positive impact. “[Sara] has done incredibly well since her discharge,” she says. “Cardiac rehab was essential in her recovery as it gave her the confidence to begin exercising regularly.”
’They Saved My Life’
It’s been six months since Rutledge received her diagnosis. “I’m back to running and snowshoeing with Goose – two things I never thought I’d do again,” she exclaims.
Reflecting on her journey to recovery, Rutledge says that connecting with the global community of SCAD survivors has been particularly rewarding.
“Online forums have introduced me to so many women like myself, and it reminds me of how fortunate I am,” she says. “Too many of these women are sent home from ERs or misdiagnosed because they don’t look like typical heart attack patients. Looking back, it would have been easy for a doctor to think the same thing and brush me off, chalking it up to a panic attack. Instead, they saved my life.”
(Adapted and reprinted with permission. Story by Roland Kielman, UVM Health Network Communications and Engagement Strategies)