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. 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 confirmation 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 defined as attendance in ≥1 CR sessions. In addition to extensive clinical and mental health data, these questionnaires also included specific questions about the patient’s participation or lack thereof in CR including the level of attendance, barriers to attendance, and perceived emotional and physical benefits ( Figure 1 ).

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

Statistical analyses were performed using JMP statistical software, version 10.0.0 (SAS, Cary, North Carolina). 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 significant.

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 benefits, 75% perceived emotional health benefits, and 45% reported still experiencing the benefits 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 ).

Patient-perceived benefits of cardiac rehabilitation (269 patients). Rehab = rehabilitation.

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

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 fit before their event. This concern was reflected 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. Health-related 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.

Table 2

Mental health surveys and exercise training in spontaneous coronary artery dissection

Variables	Overall (n=354)	Cardiac Rehabilitation		P-value
		Yes (n=269)	No (n=85)
Time from SCAD to survey, mean ± SD (months)	33.6 ± 50.6	33.4 ± 51.9	34.3 ± 46.5	0.81
Generalized Anxiety Disorder 7 score, mean ± SD	4.7 ± 4.8	4.9 ± 4.7	3.9 ± 4.9	0.03
Patient Health Questionnaire 9 score, mean ± SD	3.9 ± 3.6	4.0 ± 3.5	4.0 ± 3.8	0.71
Rand 36 Items SF Health Survey subscales, mean ± SD
Physical functioning	80.5 ± 19.9	81.1 ± 18.7	78.4 ± 23.4	0.79
Role functioning-physical	63.8 ± 41.1	63.0 ± 41.5	66.5 ± 39.6	0.50
Bodily pain	55.5 ± 7.8	55.2 ± 7.5	56.5 ± 8.9	0.36
General health	65.6 ± 20.9	65.3 ± 20.8	66.2 ± 21.2	0.73
Vitality	51.9 ± 22.5	52.4 ± 22.5	50.6 ± 22.7	0.49
Social functioning	78.9 ± 24.3	78.8 ± 24.5	79.4 ± 23.8	0.87
Role functioning-emotional	78.2 ± 35.8	78.2 ± 36.0	78.0 ± 35.5	0.83
Mental health	73.7 ± 15.7	72.9 ± 16.0	76.3 ± 14.4	0.09
Duration of aerobic exercise (minutes)
Never	45 (13%)	26 (10%)	19 (25%)
<20	31 (9%)	24 (9%)	7 (9%)
20-30	89 (26%)	69 (27%)	20 (26%)	0.01
30-60	147 (44%)	119 (46%)	28 (36%)
>60	24 (7%)	21 (8%)	3 (4%)
Frequency of aerobic exercise sessions/week
Never	50 (15%)	28 (11%)	22 (28%)
<1	30 (9%)	25 (10%)	5 (6%)
1-2	66 (19%)	55 (21%)	11 (14%)	0.002
>3	195 (57%)	154 (59%)	41 (52%)
Frequency of non-aerobic exercise/week (hours)
<1	55 (16%)	40 (16%)	15 (20%)
1	51 (15%)	41 (16%)	10 (13%)
2	81 (24%)	70 (27%)	11 (14%)	0.16
3	55 (16%)	41 (16%)	14 (18%)
>4	92 (28%)	66 (26%)	26 (34%)
Regularly do strength building exercises with resistance or weight lifting equipment	105 (30%)	86 (32%)	19 (22%)	0.09
Reasons for not exercising
Lack of appropriate facility or equipment	21 (6%)	16 (6%)	5 (6%)	0.98
No one to exercise with	37 (10%)	28 (10%)	9 (11%)	0.96
Physically unable to exercise	36 (10%)	25 (9%)	11 (13%)	0.33
Not enough time	147 (42%)	119 (44%)	28 (33%)	0.07
Don’t like exercise	49 (14%)	38 (14%)	11 (13%)	0.78
Lack of motivation	89 (25%)	69 (26%)	20 (24%)	0.69
Cost	22 (6%)	18 (7%)	4 (5%)	0.51
Other reasons	40 (11%)	28 (10%)	12 (14%)	0.35
No reason	88 (25%)	70 (26%)	18 (21%)	0.37

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