Reyna Robles was always the first one up and the last one to bed: she possessed more than enough steam to come home from her full-time job, prepare a meal for her husband and children, take her dogs for walk and help her kids with homework. Before bedtime, shed fit in a good work out.
She wasnt one to complain, either, until the spring day in 2009 when she suddenly felt a pain in her chest as she exercised. It was a cramp-like pain, not anything like the normal muscle aches Robles expected from her body after vigorous activity. I didnt think I should be feeling chest pains, she said. She wasnt even 40.
She saw her doctor, who ordered an EKG. Everything was fine, Robles was told. Nothing was wrong with her heart. But the pain kept coming back, and that worried her. Exercise should feel good, she said. It shouldnt hurt. She went back to her doctor, who ordered more tests. Still nothing, she was told. Soon, she started feeling the pain even when she wasnt exercising. I intuitively knew something wasnt right, she said. Still, none of the doctors she saw could discern a problem. And she began to doubt herself, although I knew I wasnt imagining it. It was real.
With no answers and no end to the pain, Robles whole view of life was gradually permeated by the uncertainty of her health. Im normally very positive, very bubbly and cheerful, she said, but I felt like a shadow of my former self. All I could think about was my chest pain. By winter, shed become desperate for help and went online to find it. She connected with a group of women who had experienced similar symptoms. One of them was a patient of Jennifer Tremmel, MD, assistant professor of cardiovascular medicine and clinical director of the Stanford Hospital Womens Heart Health program, just celebrating its fifth year in service.
In Tremmel, Robles found someone whose focused interest and knowledge of heart disease in women became the key to solving her medical mystery. For years, the standard medical treatment for women with heart disease was based on what we know about heart disease in men, Tremmel said. Thats really confounded things. In the past 30 years, weve learned a lot about how women differ from men, but theres a lot we still dont know. Just getting physicians to have a broader concept of symptoms, and what constitutes coronary artery disease in women, is a challenge.
Robles is a classic example of the challenge, in several ways. Her first EKG, stress test and angiogram were deemed normal. What we have found is that stress tests, and even angiograms, may not always identify the problem in a womans heart, Tremmel said. If a lack of blood flow through the entire thickness of the heart muscle is needed to have a positive stress test, those patients with symptoms from a lack of blood flow to only the inner most lining of the heart may not be caught.
Similarly, Tremmel said, angiograms catch only blockages in large vessels, but patients, particularly women, may have a problem like endothelial dysfunction, which affects small vessels whose failure to work properly cant be seen on angiography.
Robles came to Stanford as many do, having been told no abnormalities had been found.
A lot of women come to us with years of having people tell them, Theres nothing there, said Tremmel. They doubt themselves and have really been affected by that. The Stanford Womens Heart Health program includes a psychologist to help its patients address the emotional repercussions of such treatment.
And, of course, the program is committed to finding the cause of the types of symptoms that Robles was reporting. We decided wed look harder, Tremmel said. We did all this extra testing to see if we might find something that had been missed on her original angiogram.
Tremmel discovered that Robles had a physical anomaly called a myocardial bridge, where an artery that normally sits on top of the heart actually dives down into the heart muscle. Such bridges are not uncommon, and most people can live their entire lives without symptoms, but if a large portion of the artery is deeply buried, then theres trouble. Again, however, this physical abnormality often doesnt show up on an angiogram.
Not only did Robles have a myocardial bridge, but she also had endothelial dysfunction within the bridge. This dysfunction causes an artery to constrict when it should dilate.
There were a lot of physiologic dynamics going on in that bridge, Tremmel said. The first approach for Robles treatment was standard: use medications to slow the heart rate enough to allow blood to flow through the artery, even though it was squeezed inside the heart muscle. That didnt work. Nor did Robles efforts to minimize stress, another tool to reducing symptoms.
Finally, with no other options left, Tremmel began to consider a surgery to release the artery from the muscle. The surgery itself isnt complicated, she said, but it is open heart surgery where you open the chest and expose the heart. Its a big deal. But for patients who have a poor quality of life, and you cant find any other way, its a viable option.
Before the final decision was made, Tremmel wanted to do one more test. She inserted a wire into Robles artery, while stressing her heart with medication, to measure the pressure and flow, on that one particular part of her hearts anatomy. The test proved that the bridge was definitely the problem, Tremmel said. Tremmels colleague, cardiovascular surgeon Michael Fischbein, MD, made the repair in November to Robles heart.
By the start of the year,, Robles was taking small but steady steps toward a more active life. After so many months of living with fear and uncertainty, Robles belief in the strength of her repaired heart has been helped along by Tremmels gentle encouragements.
Recently, Robles worried aloud at an exam with Tremmel about some enthusiastic laughing shed done with one of her daughters so exuberant that her chest began to hurt. Tremmel pressed her stethoscope against Robles chest for a close listen.
It sounds like a happy heart, said Tremmel. You can laugh as much as you want."
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