After the dissection: the invisible recovery after SCAD (spontaneous coronary artery dissection)

Keywords

Anxiety and fear of recurrence; cardiac rehabilitation; resilience; return to work; spontaneous coronary artery dissection

Abbreviations list

CBT: cognitive behavioural therapy

SCAD: spontaneous coronary artery dissection

CR: cardiac rehabilitation

Take-home messages

1. Recovery after SCAD extends beyond vascular healing and is shaped by a dynamic interplay of biological, psychological, and social factors.
2. Fear of recurrence and anxiety are central drivers of reduced physical activity and delayed recovery and should be addressed as core targets within cardiac rehabilitation.
3. Fatigue is a common yet under-recognised symptom after SCAD and may significantly impact daily functioning, return to work, and long-term recovery.
4. Cardiac rehabilitation for SCAD should be individualised and include condition-specific education, graded physical activity, and integrated psychosocial support.
5. Return to work should be considered a key outcome of recovery and approached as a gradual, supported process rather than a single endpoint.

Introduction

Spontaneous coronary artery dissection (SCAD) is increasingly recognised as an important cause of myocardial infarction, particularly among younger and middle-aged women who often lack traditional cardiovascular risk factors. Although advances in acute diagnosis and management have improved outcomes, the recovery phase remains insufficiently understood and inadequately addressed within current cardiac rehabilitation (CR) models [1].

While clinical focus has traditionally centred on diagnosis, acute management, and recurrence risk, considerably less attention has been paid to the period following hospital discharge. Emerging evidence and patient-reported experiences suggest that recovery after SCAD extends well beyond vascular healing [1,2].

Unlike atherosclerotic myocardial infarction, SCAD presents patients and clinicians with a distinct clinical profile with specific challenges, including uncertainty regarding underlying mechanisms, limited evidence-based guidance for medical treatment and physical activity after the admission for SCAD, and a lack of tailored rehabilitation pathways. A substantial proportion of patients continue to experience persistent symptoms that affect daily functioning and quality of life long after discharge [2].

Fatigue is frequently reported and remains insufficiently addressed in clinical practice. Patients frequently describe fatigue as profound, unpredictable, and disproportionate to physical exertion, often occurring during routine daily activities and in the absence of identifiable cardiac dysfunction. For individuals who were previously healthy and physically active, this loss of energy can be both unexpected and distressing [3,4].

Emerging evidence suggests that fatigue and psychological distress are highly prevalent following SCAD and may be particularly persistent compared with other forms of acute coronary syndrome in younger patients. This is likely related to the unique clinical and psychosocial profile of SCAD, including younger age, diagnostic uncertainty, and a substantial burden of post-traumatic stress and health-related anxiety [5-7].

Importantly, this recovery experience is often partially invisible. Patients may struggle to explain their symptoms to family members, employers, and sometimes healthcare professionals, which can lead to pressure to resume normal activities before they feel ready.

Patients frequently report that existing CR programmes do not meet their specific needs, particularly in relation to psychological support and individualised exercise guidance [1,8]. Furthermore, return to work – an important marker of recovery and social reintegration – has received limited attention in the literature [5].

This article proposes a clinically applicable framework for understanding SCAD recovery as a process of restoring confidence, building resilience, and supporting returning to work within an ESC-aligned cardiac rehabilitation context.

Fear and anxiety as central barriers to recovery

A defining feature of recovery after SCAD is the prominence of both fear and anxiety. While fear of recurrence is frequently described by patients, it is closely intertwined with broader anxiety responses that can persist long after the acute event [5,7,9].

For many individuals, SCAD represents an unexpected and life-threatening experience that challenges their previous sense of health and bodily integrity. This disruption often leads to heightened uncertainty and loss of control, which are key drivers of anxiety.

This uncertainty is further reinforced by a mismatch between clinical findings and lived experience. Although angiographic healing is common within months, a substantial proportion of patients continue to experience symptoms such as fatigue, chest discomfort, or palpitations. This divergence may contribute to difficulties in symptom interpretation and a persistent sense of vulnerability [1,2,5,7].

Anxiety is often closely linked to bodily awareness. Patients commonly develop hypervigilance to physical sensations, particularly chest discomfort or changes in heart rate. Given that such symptoms are relatively common after SCAD, they may trigger repeated cycles of worry and reassurance-seeking [5,10,11].

Fear of recurrence represents a specific manifestation of this broader anxiety. Patients may come to perceive physical exertion, emotional stress, or everyday activities as potential triggers for another event. As a result, physical activity – despite being a cornerstone of recovery – is often approached with caution or avoided altogether.

Over time, this fear-avoidance pattern may contribute to reduced physical capacity, diminished confidence, and delayed engagement in rehabilitation. Anxiety may also affect cognitive and emotional functioning, including concentration, sleep, and overall well-being.

Recognising anxiety as an integral component of SCAD recovery has important clinical implications. Rather than viewing fear of recurrence as an isolated concern, it should be understood within a broader framework of uncertainty and threat perception.

Managing uncertainty and regaining control in SCAD recovery

Uncertainty regarding medical management remains a central concern during SCAD recovery. Patients frequently report receiving inconsistent or conflicting information from healthcare professionals, often compounded by variable online sources, which may undermine trust and contribute to ongoing anxiety [2]. In particular, variation in pharmacological management – such as transitions between dual and single antiplatelet therapy – may be perceived as a lack of clarity or consensus, reflecting the current limited evidence base and reinforcing doubt and vulnerability [4,8,12,13].

In response to this uncertainty, many patients seek to regain a sense of control over their condition and recovery. This may involve extensive information-seeking from multiple sources, close monitoring of bodily sensations, adjustments to health behaviours, or the use of alternative or complementary approaches [2,12]. While such strategies may represent adaptive coping mechanisms, they may also perpetuate uncertainty if not supported by clear, consistent, and patient-centred communication.

Supporting patients in developing a realistic sense of control – grounded in understanding rather than avoidance – should therefore be considered an essential component of SCAD rehabilitation. In this context, cognitive-based interventions may offer a valuable strategy to address anxiety and uncertainty. Cognitive behavioural therapy (CBT) integrated into cardiac rehabilitation has been associated with reductions in anxiety and depressive symptoms, as well as improvements in heart-related quality of life and adherence to rehabilitation programs among patients with cardiac disease [14]. Although evidence specific to SCAD remains limited, the comparable psychological burden and symptom experience suggest that such approaches may be relevant in this population and warrant further investigation.

Restoring confidence as a foundation for resilience

To address the complexity of SCAD recovery, rehabilitation can be conceptualised as a process of restoring confidence across interconnected domains [1,2].

Biological confidence relates to understanding the healing process, medication, and physical capabilities. Psychological confidence involves managing emotional responses, reducing anxiety, and developing coping strategies. Social confidence encompasses the support provided by healthcare professionals, family, peers, and the workplace [5,7].

Resilience can be understood as the ability to function and engage in meaningful activities despite ongoing uncertainty. Rather than eliminating fear entirely, the goal is to enable patients to coexist with uncertainty while maintaining confidence in their ability to manage symptoms and participate in daily life [1].

In this sense, recovery involves not only regaining physical capacity but also rebuilding trust in the body and in one’s ability to interpret and respond to symptoms.

The biopsychosocial nature of healing after SCAD

Recovery following SCAD is inherently dynamic and influenced by multiple interacting factors.

From a biological perspective, patients must adapt to the healing process of the coronary artery, often accompanied by persistent symptoms such as chest discomfort and fatigue that may not align with objective findings [1].

Psychologically, many patients experience significant distress. The sudden and unexpected nature of SCAD may disrupt prior assumptions about health and vulnerability, leading to heightened vigilance and concern about recurrence [5,7].

Social factors also play a crucial role. Some patients report challenges in having their symptoms recognised or taken seriously, which may influence trust in healthcare systems and subsequent healthcare-seeking behaviour. Peer support and shared experiences can provide validation, while work-related expectations and family responsibilities may further shape recovery trajectories [2,5,15].

Taken together, these factors highlight that recovery is not linear but adaptive, shaped by time, context, and individual coping strategies.

Figure 1. From fear to function. A biopsychosocial pathway to recovery after SCAD. Cognitive behavioural therapy. Created in BioRender.

Building resilience through cardiac rehabilitation

Cardiac rehabilitation provides an important opportunity to support recovery after SCAD; however, programs must be adapted to address the specific needs of this population. Education is a central component, as providing clear, consistent, and SCAD-specific information can reduce uncertainty and enhance patient understanding [3,4,12,15].

Physical activity remains a key element of recovery, yet is frequently associated with fear, underscoring the importance of a tailored approach with gradual progression and appropriate supervision to rebuild confidence.

Fatigue management should be explicitly addressed through pacing strategies, energy conservation, and individualised planning. Additionally, fear of recurrence requires structured support, including normalisation and gradual re-engagement in activity. Psychosocial support should be integrated throughout rehabilitation, recognising emotional adjustment as a fundamental component of recovery.

Supporting return to work

Returning to work represents a key milestone in recovery, yet remains insufficiently addressed in standard rehabilitation pathways [15,16]. Fatigue, uncertainty, and fear of recurrence may influence one’s readiness to return to work, while the often invisible nature of symptoms may complicate communication with employers [5]. A structured and individualised approach is essential, including assessment of readiness, gradual reintegration, and support for workplace communication. Recognising that a patient’s return to work is a process, rather than a single event, allows for flexibility and supports sustainable reintegration.

A practical framework for SCAD rehabilitation

Recovery after SCAD can be conceptualised as a dynamic, three-phase process reflecting the gradual restoration of confidence and function. The initial phase focuses on stabilisation with emphasis on reducing uncertainty and providing clear information regarding diagnosis, treatment, and symptom interpretation. The second phase involves rebuilding, characterised by gradual re-engagement in activity, individualised exercise, and ongoing psychosocial support. The final phase focuses on reintegration, supporting the return to meaningful roles, including work, while maintaining function despite ongoing uncertainty. These phases are not strictly linear. Patients may move between stages depending on symptoms and life circumstances. This dynamic perspective allows for more individualised rehabilitation [1,12].

Impact on practice

Recovery after SCAD extends beyond vascular healing and requires a comprehensive, individualised approach. Clinicians should recognise persistent symptoms and their potential mismatch with objective findings. Anxiety and fear of recurrence should be addressed proactively  [1]. Fatigue may benefit from targeted management strategies. Cardiac rehabilitation programs should be adapted to include condition-specific education, individualised exercise, and integrated psychosocial support. Return to work should be incorporated as a key outcome supported through structured and flexible approaches. A biopsychosocial perspective is essential to bridge the gap between clinical recovery and patient experience [1,15].

Table 1. Guidelines for traditional versus SCAD-specific rehabilitation (17).

Conclusion

Recovery after SCAD is a complex and adaptive process that extends beyond biological healing. Patients must navigate persistent symptoms, uncertainty, and changes in self-perception. By integrating biological, psychological, and social perspectives, cardiac rehabilitation can support patients in rebuilding confidence, developing resilience, and returning to meaningful life roles. A more nuanced and patient-centred approach may help bridge the gap between clinical outcomes and lived experience, ultimately improving long-term care for individuals affected by SCAD.