Episode 1: What the Hell Just Happened? I Had a Heart Attack?

SPEAKER_03 0:00

But I remember hearing the numbers and then pulling up the report and thinking, wow, like nailed it. This is this is those numbers, the amount of interruption, like how severe your arteries spasmed, how much blood supply was actually being compromised, was profound. And it made sense. I was like, this makes sense now. How this is why you develop VT. Because before that it was still very confusing. In my mind, I was like, well, maybe they won't find it. Maybe there'll be some vasospasm, but they'll still need a defibrillator. I didn't expect it to be as severe as it was, but thank God it was because it everything fell into place. It was kind of like we got there finally, right? This all makes sense. There's a path forward. And then I got more details about the nature of the bridge and opportunities for intervening to try to go for something more curative beyond just medications. And now I just I felt a sigh of relief. Like, yeah, I don't know if I, you know, did a fist pump in the air or like kicked my heels up, but I remember feeling pretty good that day. Like thankfully there was something that was reversible for you.

SPEAKER_01 1:22

We'll talk with healthcare professionals, those in related fields that support our condition, and others just like us with stories of their myocardial bridge experiences. It's my intention for this content to inform, educate, entertain, and even motivate or inspire you in your personal journey on dealing with a myocardial bridge. Most importantly, is to have you leave each episode knowing you are not alone and that what you're experiencing is real. There is hope and there are solutions. I'm even more excited to introduce you to my guest who has been with me on this journey from the beginning. He was born and raised in St. Louis, Missouri. From high school, he went directly into a combined Bachelor of Arts and Doctor of Medicine program at the University of Missouri, Kansas City. After medical school, he completed his internship and residency in internal medicine at the University of New Mexico Health Sciences Center, where he served as chief resident. He completed his cardiology fellowship at St. Louis University. And during his third year, he served as chief fellow and then took a position as assistant professor in the Division of Cardiology at St. Louis University. He then moved to the Sacramento area in 2017. He believes in using medications when the scientific data clearly supports it to prevent disease or disease recurrence. However, he acknowledges that there are gray zones and seeks to engage in discussions with patients to create a treatment plan based on their values. He draws from personal experience and patient stories to provide guidance and recommendations about lifestyle and exercise, and it's his goal to promote health and ideally reduce medications if possible. He values the time he takes with patients and often runs over designated appointment times, and I can certainly attest to that. He has an interest in heart failure, coronary artery disease, and prevention as a general cardiologist who has now assumed a leadership role at Sutter Roseville Medical Center, working on graduate education for medical residents with an emphasis in well-being. I could not be happier to have my first guest on this program, my cardiologist, my friend, Dr. Rishi Menon. So, Dr. Menon, I'm compelled to tell the story of how we met, and I'm using air quotes there because it's a bit interesting. I had been experiencing these episodes of something, unknowing to what it was. I had gone to the doctor, and this is a Monday in August, and my cardiology appointment was set for Friday of that same week. And Wednesday of that week I produce another show, and it's called Financial Sobriety. One of the hosts of that show had met you in the community at some function, and you came into the studio. So I'm thinking, this is pretty interesting. I happen to have a cardiologist in the studio. I'm really gonna have to pay attention to see where this all goes. I would never have guessed that after that first meeting in the studio, the very next day, I would have an incident. And I'll let you explain what that incident really was, but I end up in the hospital and they ask if I have a doctor. I said, of course. His name is Dr. Rishi Menon. He's my cardiologist. Is he on call today? And you know, I'll let you take it from there. I I end up in the hospital. How did I present to you? I mean, you walk in and you see me laying in the hospital bed.

SPEAKER_03 5:10

Yeah, it was remarkable. I I remember that day well. I actually don't think I was on call, but somebody had called me and said, hey, we've got this nice guy. He says he knows you. Would you mind coming to see him? And I said, Yeah, sure. And I the name sounded familiar. I was like, I think I know him. They didn't explain well exactly the relationship, but I kind of remember the name. And I think we have been using your nickname in the studio, so I don't know that I fully put it together. But I walked in and I was like, oh, this guy, what are you doing here? Because you are athletic. You do not look like the typical cardiac patient. Trevor Burrus, Jr.

SPEAKER_01 5:42

That's what I thought, too.

SPEAKER_03 5:44

A lot of people did. A lot of people did. But yeah, we got to talking and you were telling me the story about the chest discomfort that you were experiencing. The thing that alarmed us, or rather- I won't say alarmed us, but the thing that got you admitted was an abnormal blood test called a troponin. So that troponin blood test can indicate that there's been damage to the heart muscle cells. Now, what caused that damage is the real question. It's a clue, and then we have to be detectives about what was the mechanism by where that happened. Like so, for example, if you saw a large piece of concrete down the street, you don't know where that concrete came from. What happened? Was there a building being demolished? Did some was there a storm? Did something knock it off? How did that piece of concrete get there? So that's what we started with. Healthy guy who's got some evidence on his blood test that the heart muscle has been injured. And typically, with your story, with the chest discomfort that you were describing, the vast majority of the times that's gonna be what's called a heart attack, which is a sudden blockage of a coronary artery with a blood clot, typically. That's the major mechanism. So that's what I thought it was gonna be. He's coming in here, young guy, that happens. We sometimes see that.

SPEAKER_01 6:52

Not that young.

SPEAKER_03 6:53

Hard to tell, though, man. You look great. So but yeah, that's what we thought. We thought it this is likely gonna be uh typical blood clot inside a coronary causing an interruption in blood supply to the heart muscle, leading you to have heart muscle damage that showed up on a blood test. And we were gonna do the standard we did do the standard test, the angiogram, cardiac cath.

SPEAKER_01 7:14

Yeah, I know. I remember you saying, oh, it's it's probably just gonna be a stint, we'll get you in, and you might even feel better. I'm thinking, well, I felt pretty good to begin with before I ended up in here. If I feel better, this would be awesome. I'll be I'll be riding faster and longer and harder, and everything's gonna be great.

unknown 7:29

Aaron Ross Powell Yeah.

SPEAKER_01 7:30

Bionic man. Trevor Burrus, Jr. It wasn't quite the case, though. So tell me what we found after the fact.

SPEAKER_03 7:37

So what we were anticipating was that blood clot that we were talking about, or some obvious or demonstrable narrowing of the coronary. Again, typically that's with uh in the acute setting of blood clot or cholesterol. Cholesterol buildup like rust on the inside of the pipe. But we didn't see any of that. You had very normal-looking coronaries on this test. There was some slight variation on there, but nothing that we thought would explain your symptoms at that time. So no need for a stent, nothing that we thought we could fix by uh doing further procedures at that time to explain your symptoms and the lab test, the troponin elevation, which we correlated and said, okay, at some point he's probably interrupting his blood supply to his heart muscle. That's one theory. Or it could be that the heart muscle itself was directly inflamed by some other process. And we call that myocarditis, when the heart muscle is irritated or inflamed and it's damaged, not because there's an interruption in blood supply, but because something's essentially irritating or attacking it. So those are the two kind of leading theories. And we started some medications for that to see if that would help with the symptoms. Trevor Burrus, Jr.

SPEAKER_01 8:41

I recall we were on calcium channel blockers and then some differences in a variety of blood pressure medications, and clearly nothing was working. I could see the bewilderment as I would explain things to you, and as many people who are listening, the questions of stress and exercise and eating. And we did that litany to no avail of uh I eat well. I'm stressed, I would imagine, just by profession or self-induced, but nothing that would, at least in my opinion, cause that sort of discomfort. And I think I recall you saying that it was the ability to articulate the condition that helped you understand. Can you explain that a little bit more on how the benefit is from the patient to the doctor to be able to explain the condition articulately enough for them to understand that, hey, this is probably something more than stress, diet, exercise, et cetera?

SPEAKER_03 9:44

Aaron Powell Yeah, yeah. I think that's a really important point, if not the most important point. As we were talking about earlier, cardiology is always in the story. You know, the way we like to look at it as cardiologists is that the main diagnostic test is the story. And so the more information we can get about what you're experiencing and what's happening, what you're feeling, the more we can tease that out together, the more likely we are to go down the right path. And one of the key features that you can you clued in on multiple times was this kind of association with exertion. You know, when we went back to your story, it it started with exertion initially, but then it got better as you exercised, which is somewhat atypical for coronary artery disease. And then it started to happen after you exercised. So what you were exercising fine, and later on you would develop this discomfort. And the more we talked about it, and the more we realized that there was a real debility here, that it was hard to function in life, that it was this shouldn't be. You're a healthy guy, you have normal coronaries, but you clearly have an exertional limitation. That part of the story, digging in deep there, that communication that you and I had was what enabled us to go down a more objective pathway and then go from the typical things, which 90% of what we see is gonna be something like coronary disease in your in a situation where somebody presents with your symptoms, and then go to the odd things. Uh we're look- you know, zebras instead of horses, that's what we call them. You don't want to start with the zebras, you've got to check and make sure it's not a horse first. But there's something there that said we gotta keep going. This isn't just it this isn't attributable to something else. We we have to keep digging here. And I think that's what happens a lot. I think dismissed isn't the right word. I feel like there's a negative connotation with that. I think you know, in the patient-physician relationship, oftentimes people feel like they're not being heard and that's appropriate. They I don't think that they are heard. I think physicians can do better about listening and then hearing those little subtle details, but really digging more into that story and then not saying the obvious, like you know, like we were talking about this earlier. You don't need to have coronary disease to reduce the stress in your life. You don't need to have any heart condition to exercise and move a little bit more or eat better or or get to sleep on time and have you know all the healthy behaviors. But it's always troublesome when you get to that answer and you say, oh, it's just stress, because you know you're feeling something, and it can be hard to articulate. You had that gift. You had a real ability to talk that through. And I'm thinking about advice for the listeners. And uh in a way, reflecting on it or journaling about it may be helpful. Sometimes if there's a long list of it's this, it's this, it's this, and you hand it to the doctor, they'll look at it and be like, well, that doesn't make sense, that doesn't make sense, that doesn't make sense. But it's almost like if you take the time to write a narrative and think about what it is that you're gonna share with that physician, and then maybe even have open communication, like, well, I'm gonna think about this more. Is it okay if I you know not email you every day when I have the symptom necessarily, but kind of reflect on this and get back to you and maybe think more about some of the stuff that you talked about. I think that could engage, could help us all engage better.

SPEAKER_01 12:55

Aaron Ross Powell Yeah. So that dialogue of experience is certainly gonna help the doctor, cardiologist, understand a little bit better what the patient's experiencing, as well as help the patient really identify if what they're experiencing is something of significance over some period of time. And to clarify a little bit in my case, what was happening is I had been cycling. I hadn't had been cycling a great deal that particular year. It was 2020.

SPEAKER_04 13:25

Yes.

SPEAKER_01 13:25

July of 2020, I'm training for a grueling ride in the best shape I arguably have ever been for cycling. And the ride was canceled due to fire and smoke, so it didn't happen, ironically called the death ride. Which in my case might have been tragic.

SPEAKER_03 13:43

Absolutely.

SPEAKER_01 13:45

Tragic. It's you know, eight to ten hours of riding. But then I go into August and have some other competitive situations where I go out and ride and have that experience of what is this, what is this, and finally the incident that clarified at least something was going on with my heart. And I'm sure many of us, if if those of you who are listening are athletic, either distance runners or distance cyclists or uh long-term of anything, we have an elevated heart rate, you know your body pretty well. And when something's wrong, you certainly dismiss it.

SPEAKER_00 14:19

If I didn't know any better, I think it was something was my heart, but I'm in such good shape. I can't be.

SPEAKER_01 14:30

And it's something else that's causing it until you realize, okay, there is something. There's a symptom here that I can't correct through what I'm doing, and we're explaining that. So as people take the time to really document what it is for the physician to really understand what it is, we certainly hear those episodes and meetings of gaslighting and oh no, no, no, you're fine, it's nothing, it's not this, it's not that. But until you have an actual diagnosis of something, whether it be a physical malady or emotional stress, mental wellness situation that could be causing it, you don't know anything. Let's take the next step after the, as much as I hate to say it, the heart attack in in the simplest ways. It's like I can't have a heart attack, or the myocardial infarction, you know, the the occurrence of something going wrong. Now what do we do? Now we know something happened. We just don't know what it is. And we've had the discussion of what the pain is like, how frequent the occurrence is, the symptoms, the duration. What were the steps that you were evaluating post-medication? Because that really wasn't working all that well.

SPEAKER_03 15:43

Yeah, I think that's a great question. And and and there's just as a quick aside, there's this whole concept of uh a disease class called Minoca, which maybe people in the community are familiar with, myocardial infarction with normal coronary arteries. And there's a long list of different disease conditions that can cause that, that can lead to that. So basically it means you have a troponin elevation and you don't have classic coronary disease. In that list is myocarditis, vasospasm, myocardial bridging can be on there. There's lots of different things. I'm just, again, I don't want to go too far, but there's a there's that condition known as Minoca. And that really kind of underlies that or underscores that we don't fully understand what's going on when somebody has chest pain and introponent elevation. And so we've got to do more digging, we've got to do more detective work. We talked about cardiac rehab and thought, well, this would be a good way to kind of see what's going on. Let's let's put you in a safe environment where we can exercise you at least a little bit and see if we can shake something up, you know, the functional testing. And we started to see little clues in there initially. And we got to the point that we said, well, what if we had a heart monitor on him as an outpatient, just when he's living his life and he can kind of start to advance what he's doing, advance what you're doing from an exertional standpoint, but then you have the safety of us knowing that something, uh you know, if there's something was going wrong, we may catch it. Also, too, as a quick aside, an outpatient heart monitor really only monitors the rhythm. We don't get a lot of we don't get the same data that we would get from a 12-lead EKG like you would get when you come into the office or the hospital. So the stuff that we see on that monitor is different.

SPEAKER_01 17:20

And I recall as I was going through the sessions of cardiac rehab, painstakingly introductory, let's say. Okay, and you can pedal to you know a heart rate of X, and I'm I'm sitting, I could sleep on the bike. It's just killing me. And I'm thinking, well, do something. You know, and of course, my heart would never do anything. And then if it did anything, I would remember they get excited, uh not in a good way. Uh-oh, that's a triplet. I'm like, what's it- what's a triplet? Can you explain that? I could, but you're going to do a much better job. And more than a triplet's even worse.

SPEAKER_03 17:58

Yeah, and a triplet or these findings, which were generally categorized as something called ectopy, aren't inherently dangerous. It's just more clues. So a triplet is you're having normal beats, and then you get what we would call a premature ventricular contraction every third beat, or you'd have three beats of in your case, it would be there would be three beats in a row, where you'd have three kind of premature beats. Um, those are all different forms of ectopy. And again, not inherently dangerous. There's multiple reasons that could be benign. But it was another clue. And the thing that made this made us be a little bit more concerned was that you you had symptoms still. You were still not living a normal life. If you felt great and you were exercising and you had no symptoms at all, the triplet would be fairly inconsequential. But in the setting of, I just don't feel right. I can't do what I used to do, that triplet says to me, maybe there is some irritation in the myocardium. Maybe we're continuing to miss something here or something is eluding us still. And what could that be? So there's more evidence there.

SPEAKER_01 18:59

Aaron Ross Powell And I recall in the cardiac rehab, I was always anxious in a positive way, okay, it's going to do it today. They're going to get to see it. We'll be able to diagnose it. They're going to know exactly what's going on with me because we couldn't figure it out. And I would explain the pain, but it would never happen when I was being monitored. And I had gone through maybe 10, 12 different sessions of cardiac rehab, and I had a particular situation this one day, and it was great. Hey, Jeff, everything looks good. Nothing happened today. And I I would cheat. You know, they'd say, take your heart rate up to 135, and I'd be pushing it to 140, and they'd yell at me, and I'm like, I'm fine. And I would always park my car on the top of the garage roof. And that particular day, I got out and I'm, okay, everything's fine today. That's good. Maybe it's gonna go away and I won't feel the sensation. And I get to the roof, which is maybe five flights of stairs, and I'm standing in there, and all of a sudden I feel the sensation again. And it's that sensation that occurs all the time when I would start out my rides or when I'd be sitting still at the house usually early evening, and the same sensation I had that night when I ended up in the hospital with the heart attack. So I feel it, and it and it's exceptionally distressful and really painful. And I put my hands on the rail, I'm overlooking the you know, the grounds of the campus of the hospital, and it goes on for almost four minutes post a really good wired up cardiac rehab experience. And I'm like, God dang it. That's why doesn't that happen when I'm in there so they can see it? Uh and ironically, as I found out even later, those would happen, a vasospasm, which is what we would eventually diagnose those as, you don't see them. We feel them. I felt them, but they they don't manifest themselves on an EKG.

SPEAKER_03 20:56

And they can sometimes, but you don't have any chance of it's hard to correlate that without an EKG. But yeah, some some vasospasm will have electrical manifestations on EKG.

SPEAKER_01 21:07

Unfortunately, mine didn't. Right. Right? And the episode stopped. I got in the car, drove home, showered up, got to the office. I'm sitting at the office, and I get a call from you. And what did you tell me?

SPEAKER_03 21:24

So you had an alarming rhythm at that time, is something called ventricular tachycardia. And it was a short burst of it, but it was kind of like an extension of that triplet. A triplet was three beats. This was sustain it wasn't sustained, but it was much longer than three beats. And that is an alarm rhythm. That is a rhythm that says the heart muscle's not happy, something's going on here. Oftentimes it is associated with a coronary issue, or you know, if somebody had a previous heart attack and they had damaged areas of the heart, that can sometimes be a source for the ventricular tachycardia. So we said this is not normal. Like we don't normally see this on these heart. Heart monitors. We're looking for much more benign rhythms. And actually, interestingly, prior to that episode, if you look at the EKG, it did show us evidence of the heart muscle losing blood supply, a process we called ischemia. Ichemia occurs when the blood supply is interrupted either by an mechanical obstruction inside the artery or even vasospasm where it cuts off blood supply. So there was a finding of an electrical finding on that EKG that preceded the VTAC, the ventricular tachycardia. And I said, you got to get in. We got to get you down to an emergency room, a place with good resources.

SPEAKER_01 22:36

I recalled the call very distinctly because I'm sitting at my desk, everything feels fine. We're working in the studio and what one of the producers is in there getting some stuff done. And I said, okay, I'll uh I'll finish this up and and then I'll I'll head down. And the tone of your voice led me to believe that this is very serious and I'd better do it very quickly because you said, no, you're not doing anything. You're going to get down to the hospital right away, to where we have the electrophysiologist, who's one of the other hospitals in the city. And I said, okay, okay, I got it. I'll leave right away. And you said, no, you won't leave right away. Somebody will drive you down to the hospital. I'm like, oh, he's really taking this seriously. I didn't realize the significance of what this was. Uh so I had to get the producer who's like, I have to what? You you what? Uh and he drove me down, and then it was another battery of tests. Uh, and that's where we did the cardiac MRI, which was an experience in itself because you have this beautiful new machine, which was just installed. It was maybe four months old, and they get me in there, and I'm, you know, maybe 40 minutes into the process. Oh, yeah. And the machine broke. I'm thinking, are you kidding me? This isn't the most fun I've had in my life, is laying inside an MRI. And this is an open MRI, so it's a much bigger M MRI machine. And I I see all this activity going on outside of the machine. I'm thinking, something's really wrong with me, because people are running around all over and and people coming in and out of the booth, and oh no, something's wrong. Only to find that's it's not me, it's the machine. And they said we have to do it again. And unfortunately, we have to put you in the old machine, which is about the size of a straw, and you know, your nose is rubbing up against the top of the the tube. But we do get it done and and everything was fine. But the the concern was they had injected the dye already. So this all had to happen very, very quickly because it was it was all happening. The the dye, I guess, loses its efficacy in the in the transition of the information you need.

SPEAKER_03 24:55

Aaron Ross Powell Yeah, your time in the dye, because you want to you want to open the camera at the time when the dye is where you want it to be. Otherwise, you know, it's in circulation, it'll get washed out.

SPEAKER_01 25:03

Got it. So we get that done, and from there, now you have some more answers. And what do you recall from that experience once you started to talking to the electrophysiologist and the MRI? And we've already done the catheterization because you were in there with the angiogram, CT scans, did the echocardiogram. What else is left? Aaron Ross Powell Yeah.

SPEAKER_03 25:25

And b before we get to this, I got to say every time when we were working together, I was like, this guy, of course he's got to be my friend. You know? The rule is don't be friends with the doctor because you're gonna have weird stuff, you know. And then of course the MRI machine breaks down, and of course it's you know not routine coronary. I remember the first day I walked out of there thinking, oh, you know, that's interesting, he's probably gonna get a stent. I did not think it was gonna I that's what I assume uh a fair number of times, you know. And it was nothing seemed super out of the ordinary at that time. But of course, when when friend of a doctor, you're gonna have weird stuff. You're gonna keep me up at night. Trevor Burrus, Jr.

SPEAKER_01 26:00

Just think of the relationship we've built, though. It would have been a short-term relationship if we wouldn't have gotten to know you so well, and and here we are. Trevor Burrus, Jr.

SPEAKER_03 26:06

Oh, I'm so grateful. I learned and I'm just joking, you know, like I am so grateful to know you. And and I learned a lot from our experience together. One of the main things, and I know this is an aside, but hearing your experience, everything you know, about the anxiety of not having a diagnosis but knowing something's wrong, the experience of potentially being dismissed, you know, what's gonna happen? And more of this story will come out as as as we talk about other therapies and other techniques we use to try to protect you. But and even the MRI machine, what is it like to be, you know, in that MRI machine and it break down and all these experts are running around you like, is it my heart? This is a really traumatic experience.

SPEAKER_01 26:45

And I think that's giving me a heart attack.

SPEAKER_03 26:49

Yeah, exactly. Exactly. So I'm I'm grateful that you're you've been so articulate and able to express your experience. And I've learned a lot from that.

SPEAKER_01 26:57

Yeah, thank you.

SPEAKER_03 26:58

But getting back to your question, as we keep pulling at this thread, as we keep looking for clues, okay, the MRI did not demonstrate any evidence of myocarditis. And we had an electrical specialist, a ventricular tachycardia specialist down there who looked at things and agreed, you know, it was weird. It was one of those things that we said, how often do you see this on a monitor placed for you know whatever reason? How often do you see that evidence that the heart is losing blood supply? I'd never seen that on a heart monitor. And we were, you know, we were reflecting on that. And and then another specialist reviewed the images and said, you know what, maybe there's something a little bit more in here, maybe there's something subtle, the myocardial bridge. When we sat back and said, we got to really look at this. Something is going wrong here. The ventricular tachycardia, the way the EKG looked, there's something what we would call organic. There's a structural issue here. And from there, we started to look into going to a more advanced center, a place that may have a specialist who just focuses on the things that we're looking at, coronary anomalies and vasospasm. Because we had essentially rolled out myocarditis at this point.

SPEAKER_01 28:02

Which I was hoping I had. Weird, right? Like, well, I got the vaccine, and I know people get this from the vaccine. They tend to be younger than I am, obviously. And it was really late, like four months after the vaccine, but that's the problem. Clearly, that's the problem. It can't be anything else. How do you get to 65 years and not know there's an issue in there? And then I recall the doctor, the EP coming in and the electrophysiologist explaining, well, the everything looks conductivity doesn't seem to be an issue. There's nothing we can do there. It looks appropriate as it should. And you get this little thing where your artery goes into the heart, under the surface of the heart. And at the time it was to me nothing. I just, that wasn't anything because nobody was treating it as anything. And I said, Well, wait, wait, explain that to me a little bit more, how that what it is. And he goes, Well, your artery, you're born with it. It's a birth defect. It's a congenital situation. And the artery just goes into the heart instead of over it like it should. And in in just a mechanical sense in my mind, I remember thinking, well, I but I wasn't getting a full explanation of it. It was passed over, basically. Almost as, no, this this is benign. That's really not an issue. But I'm thinking, wait a minute, doesn't that thing squeeze it if it's the case? If the heart beats, and he goes, Yes, the heart squeezes it. But again, it's it's really not a situation where it would manifest itself in what we're seeing with you. We don't know what's causing those vasospasms, because that's what the diagnosis had gotten to as a lack of anything else that it could possibly be similar in symptom to what vasospasms are. We have to figure out and how do we confirm that? And I remember my naive thought was well, this is this is like a hose that's getting blocked. So why don't we just put a T in it and brunch off and go around it and make sure that that's not the issue. So that is out of the question, and then we'll figure everything else out. And he looks at me like this this almost quizzical humored look, going, we don't do that. It just doesn't work like that. And I said, Okay. And then the the next day I remember several of the doctors had all come in, we were going to have a discussion, and you were on the line as uh we all had the conversation, and that's where it was we need to look a little further. And and maybe you can explain a little bit of how that came to be. Of the thing I remember was there isn't anybody with enough specialty in Sacramento and capability and experience, and we can't get the drug to even do it if we wanted to. Aceticoline, I believe it was.

SPEAKER_03 30:46

Aaron Ross Powell That's one of the ways you can do it, yeah. There's different spasm agents for that provocative testing.

SPEAKER_01 30:52

Aaron Powell Got it. Can you explain that? Because I've seen that verbalized as something different, but it all means the same thing. For me, it was d terminology became the provocative test. Trevor Burrus, Right. Trevor Burrus And what is that?

SPEAKER_03 31:03

Aaron Ross Powell Well, essentially what a provocative test the the idea is we want to catch objectively something that we suspect clinically. So if we think that the coronary artery is spasming down, clamping down and interrupting or cutting off blood supply, one way to demonstrate that is to give an agent that's known to cause spasm or known to cause a reactive artery to spasm. So if your arteries are reactive, if we give an agent down that artery, it will spasm, and we can measure exactly how much it spasms. We meaning the specialists who do this. And you're absolutely right. It's not commonly done in cath labs across the country. And you wouldn't want somebody who maybe does it once or twice a year to do it, because it's a pretty sophisticated maneuver, and it requires a specialist who sees it all the time to know the nuances of it. So even if we had a good spasm agent here, it still makes sense to go to a place that does this routinely, that has expertise on it. And when we were talking about this, the other cardiologists, including the EP, you know, we were all putting our heads together, and the conclusion we came to was this is weird. This is not adding up, and there's some high-risk stuff here. So we have to keep digging. And the next thing that we could come up with was, well, let's explore the spasm uh more thoroughly. Because we had you on antispasm agents, and why weren't they helping you, right? You were resistant to antispasm agents, and usually we see some improvement in that, in that symptom. If that was the diagnosis, there should be some alleviation of your symptoms. Maybe not completely, but we weren't heading in that way as you had mentioned. So what else could we be missing? Let's get a person who does some slightly different advanced coronary techniques to weigh in on this.

SPEAKER_01 32:42

Aaron Ross Powell And I know that began the process of identifying first where and then secondly when, because I'm all in. It it's whatever we need to do, let's identify it because I'm in the same boat, only in a much more stressed situation, because it's it's me. And I know that many of you out there are thinking the same thing. It's me. And when it's you, that's all you focus on. When that pain is there, you know it's for real. When it's not there, you're waiting for it to happen. And when it's happening, you're thinking, Am I gonna die? Is it gonna kill me? Is it gonna be a heart attack? In my case, now that I understood VT, I said, Is it gonna send me into VT and I'm gonna pass out and lay there and not come back? Not knowing what my next gift was going to be to fix that. And I remember the conversation with EP at that point was, well, if we really can't figure it out, we're gonna stick a defibrillator in you and medical regimen that should allow you a reasonably decent life. Uh occasionally you may get defibrillated and resuscitated if you go into ventricular tachycardia. And I think, man, it just what happens if I'm on a ride or if I'm exercising somewhere, or if I'm out in the middle of nowhere and this happens? It just doesn't sound like the best solution given the circumstance. And and I do understand that there will be situations where that is the best solution. And I actually ride with a gentleman who has a defibrillator, not because of a myocardial bridge, but another heart condition. And he's living normal, he's doing what he does, and it it's never gone off. So but it's there for the security that he doesn't have to worry. And I'm thinking, okay, I don't know what this thing means. And of course, when you first get turned onto the myocardial bridge, the next step is immersion on Google. Let me find out everything I can, because that's the truth, of course, right? And and you just immerse and grab as much information you can is talk to as many people as you can. And that's that evening, I mean literally that evening, once I was told about this thing, I figured, well, maybe that's it. And so I went down that path. Then the next day, as we were having that conversation, I remember we finished up and the the solution was we were all going to do what we needed to do. Where should we try first? And I remember Cleveland Clinic came up, I remember Mayo came up, and so did Stanford. We're in Sacramento, California, which is just two hours from Stanford. So that was pretty much a no-brainer. Let's figure that out. And with a tremendous amount of gratitude and appreciation. I know you reached out to Stanford, the other docs, somebody had a relationship at Stanford. I had some personal acquaintances that had relationships with Stanford, and everybody got on board to see if I could get the provocative test done at Stanford. But before that happened, I had to get checked out of the hospital. So you want to share this. And I know many are familiar with this, but I certainly wasn't. I had no idea what was going to happen next. Trevor Burrus, Jr.

SPEAKER_03 35:56

The life vest?

SPEAKER_01 35:57

Oh, yeah.

SPEAKER_03 35:57

Oh yeah. So that's an external defibrillator. Um it is a life-saving device, uh, especially for somebody who has that electrical instability and we don't know what's going on. It would shock you. It would bring you back to life if your heart, if you had a cardiac arrest from ventricular tachycardia. But it can be a little cumbersome, as I'm sure you'll explain to the listeners. But yeah, and that's actually a great point going back to what you were talking about, your experience is man, we don't know what to do. We've got some stuff we can do. Yeah, you'll be alive, but we're not really focusing on quality at this point. And and I love how you relate that experience because we uh our number one job is to keep people alive, but there's so much more beyond that, right? What kind of life are you gonna lead? And so the moment where we're thinking, hey, let's just let's put a defibrillator in. You'll be safe, you'll be alive, that's great. You know, there are times where that may have happened. That may have been the extent of testing and the extent of the medical plan. Well, we don't know what's going on, let's just put the defibrillator in. Number one, keep them alive. But, you know, to the credit of the team taking care of you at the advanced hospital here, people were thinking. They were listening to you, they were thinking, and there's that little bit of, yeah, the majority thing here, the bigger issue is the threat to your life. Let's protect you and be done with it, right? There, that could have happened and it didn't. There was some thought that went on. And again, because of how articulate you had been. And I won't say it wasn't persistent. It was your ability to describe things and in a collaborative way, I think. Sometimes it can be a little antagonistic, like, you know, you don't believe me. Why don't you believe me? Like, don't you know what you're doing? You know, that that's that's always a hard environment to navigate for everybody. But the way you approached it and the way you were kind of like, well, could you explain this to me a little bit more? I see what you're saying, but I just have some more questions. I just think that is the real driver for ultimately getting us to the point that we're we're at now.

SPEAKER_01 37:53

Aaron Ross Powell And I recall a lot of those conversations. I was very willing. And my situation, I know everybody's situation is unique because we're human. No two cases are alike. There may be similarities. Mine was full on right away. Now we're gonna deal with it, and I've got to make decisions to a solution. And that process post-VT really took on speed. Uh obviously I stopped cardiac rehab, like I just disappeared from there. I didn't think they thought I died at first until they saw my you know my chart. Okay, he's still there, he's still he's still out in the you know in the world. But it was let's try it. I'm yes, I'll do it. You know, well let's try this, I'll do it. And the for those of you who have not experienced a life vest, it's a bulletproof jacket. It's literally what it looks like. You're putting on you know a bulletproof jacket and you're carrying around, in my case, what many of us would have affectionately called a MERS, but it weighs about nine pounds, and it's the battery pack for the vest. And you can take it off to shower. And I kept thinking, well, if you can take it off to shower, this is kind of weird. You can't wear it in the shower because it's electrical. But what if something happens in the shower? So I would take really quick showers and I get out and get the vest back on. And I remember it was the holidays that we were coming into. It was you know, a lot of people coming through the office and and all that, and I've got this encumbrance on uh what are you wearing? It's and well, let me explain it to you. And and sometimes it was just so much trouble to explain it. It's like it's it's nothing.

SPEAKER_03 39:34

Here's a link to a video. Yeah, right. Yeah.

SPEAKER_01 39:36

It's I just need it. Because I didn't talk much about what was going on because I didn't have any answers and nobody knew because I looked fine. Post LifeFest, we were successful at getting into Stanford. And through that process, we were accepted into the provocative testing from Dr. Tremel, who is world-renowned for her capability for testing and identifying myocardial bridges and vasospasms. And I recall just getting there, I was in the hospital on Thanksgiving Day because my test was going to be that Friday. So, you know, we spent Friday in there with the vest. You know, I had to wear the vest, and I go in and I think, well, I gotta take the vest off. Well, well, at least I'm in if there's any place that anything's gonna happen, I've got a catheter in me. They're gonna see everything. But you have that anxiety. And I don't even know if you know this part of the story. The nurse that was working with me to take me off the cardiac floor for the testing, because I had to go down and do an MRI, I had to do the uh echocardiogram.

SPEAKER_03 40:45

Echocardiogram.

SPEAKER_01 40:46

I had to do the echocardiogram. I keep thinking ultrasound like you're having a baby.

SPEAKER_03 40:49

It is technically an ultrasound. That's what it is. Cardiologists have to be fancy. So we call it a instead of a hard ultrasound, we call it an echocardiogram.

SPEAKER_01 40:56

And they get me into the echocardiogram, and I'm laying there and I feel the sensation. And I said to the young lady that was doing the you know, the maneuvering with the wand, so to speak, I said, it's it's okay. I said, it maybe you'll see something, because I'm thinking, this is the first time it's happened ever in a testing situation. I said, This is great. And I'm looking at it and she's looking at it and she's looking at me, and her eyes are wide open. I said, It's okay. I I mean, I'll be fine. Don't stop. Oh man. Don't stop. I'm okay. I want you to see what's up that if anything's happening, I want you to be able to get it, you know, on the echo.

SPEAKER_03 41:33

Oh my gosh.

SPEAKER_01 41:34

And she's looking at me, she keeps going, and she's going, This is like a you know, a 20-minute thing that she was doing for the echocardiogram. I said, That's what happens all the time. That's it. That's exactly what happens. You've seen it now. What do we know? Unfortunately, an echo doesn't show any of that.

SPEAKER_03 41:52

Nothing. It doesn't add a lot. No, it doesn't necessarily add a lot of shit.

SPEAKER_01 41:55

It was it was so disappointing for me because I thought, there it is, they've got it, they could see it, something's happening. And you know, unfortunately it wasn't anything, but it was uh it was good that it did happen because it was for real. And it wasn't third party from a holter monitor. It was actually in the hospital in the setting, and it was pre-provocative. And you know, that's that's what got me to that next step. So post the provocative testing, I'm I'm not quite sure how it communicated back to you with Dr. Treml.

SPEAKER_03 42:29

Oh, yeah. I looked, I reviewed her notes, I was contacted by your primary cardiologist too, who is wonderful. The whole team at Stanford is just not only are they high level with what they can do, but at how they communicate and keep everybody in the loop, you know, because they know we know each other. They know the relationship and the work we had done.

SPEAKER_01 42:45

Aaron Powell And I do want to take a second here uh as a sidebar as well. The care team here, I can't applaud enough and appreciate enough and share my gratitude to you for having the courage to say we don't know. Because I think there are instances where the cardiologist doesn't want to say I don't know. And they'll just go down the path of familiarity. And I sense for many of the people who are listening to this, they may be in a situation like that. And I think the elements that you're sharing and I can't stress the significance enough of being an advocate, you have got to be your own best advocate because if you can't communicate it, nobody can really help you and communicate it as best as you possibly can. But all of you, from obviously your office and you and the very first greeting and meeting you know, to the electrophysiologist and to everybody that touched me, it was a group effort. And it was a lot of communication, and I knew it because we kept talking all around and and the experiences and what's happening. Even the people at the cardio rehab were really. Engaged because it was unique. And what's going on with him? You know, what is this situation? Because it's definitely there. Uh, even to the episode in the hospital when I uh did go into ventricular tachycardia, because it was so unusual in the way it presented, and that's why I thought you couldn't see a vasospasm, because I would have them and they I'd buzz them because they said, Well, let us know. And I could see my monitor obviously in the in the hallway. I would buzz every time it would happen, they come running. I said, Am I having one? It's it's killing me right now. It's really hurting. Do you need some nitro? I said, It doesn't work. And they would watch me because they were concerned, and they're watching the monitor, and it just didn't manifest itself on the EKG. Because then I did have the 12 leads on, but I didn't go into VT either. So it was just the discomfort of you know the Phasmosm.

SPEAKER_03 44:51

Trevor Burrus, Jr.: And it can be it varies. Um the intensity or the severity of that spasm, you know, it varies. It it and maybe it was just below the detection threshold for something that would or below the, I guess, required amount of blood flow interruption to cause an electrical sign of that. Because that's another peculiar thing in about your story, is is there's just so many little pieces that didn't fit. And it was catching that objective evidence. Because without that objective evidence, we may still be sitting here talking about, I don't know what you're talking about. I may have told you it was just stress. You know, there has to be I wouldn't have let you. Yeah, yeah, yeah. That's right. That's right. We would have kept going. But it's that objective piece, right? It's that if you kind of keep looking, you'll see that objective piece. And that's different from somebody who really doesn't have something. Somebody who doesn't have something, you'll look, you'll be thorough, and nothing will show up. And in this era of better cardiac monitors and more things that we can do outside of the clinic in the hospital, more uh diagnostic maneuvers, especially with with um monitors, we're we're catching more and more. But I also don't want people to think even if I'm feeling something, it's always going to be, there's always going to be a pathological problem. In your case, continuing to look and then catching that objective evidence was the key. And and and you know, honestly, 10 years ago, 15 years ago, maybe we don't have the capability to catch this the way we did today. Um there's just so much more we don't know than what we do know. But yours is a really great story about that advocacy and saying, hey guys, like can you I really want to know what this is? Or I'm really I'm continuing to feel this. I understand it should have worked like this. The the vasospasm medicine should have worked, but they're not, so let's keep going.

SPEAKER_01 46:33

Aaron Powell When you got the information from Dr. Tremel, what was the the thought process there? Because for me, the identification of the vasospasms was what was critical. Because I know that's what we were trying to narrow down and say, okay, what is this that pain is? And I even remember, even though you're loaded up with painkiller and fentanyl and and all sorts of things, it got to a point where I was able to talk to her and say, that's it. I feel it. And now I don't feel it to the degree that I would feel it if I wasn't all painkilled up. But I said, Yeah, Dr. Tremble, that's it. That it's it's there right now. So I'm assuming if I'm feeling it, you've you're getting a really good dose of whatever it is, you can see whatever it is. And she said, Yeah, absolutely. We we you you are having severe vasospasms. And then immediately they induced the nitroglycerin to reverse it. Reverse it. And when you saw that, uh as well as the confirmation of the the bridge, the myocardial bridge, how how did that present to you from them?

SPEAKER_03 47:36

I received a call and we talked about it. And when I heard that, oh, they called you that day? Um, I don't believe it was that day. I think it may have been. You were still in the hospital at the time, I believe. Yeah. So it may have been the next day. Got it. But I remember hearing the numbers and then pulling up the report and thinking, wow, like nailed it. This is this is those numbers, the amount of interruption, like how severe your arteries spasmed, how much blood supply was actually being compromised, was profound. And it made sense. I was like, this makes sense now. How this is why you develop VT. Because before that, it was still very confusing. In my mind, I was like, well, maybe they won't find it. Maybe there'll be some vasospasm, but they'll still need a defibrillator. I didn't expect it to be as severe as it was, but thank God it was because it everything fell into place. It was kind of like we got there finally, right? This all makes sense. There's a path forward. And then I got more details about the nature of the bridge and opportunities for intervening to try to go for something more curative beyond just medications. And now I just I felt a sigh of relief. Like, yeah, I I don't know if I, you know, did a fist pump in the air or like kicked my heels up, but I I remember feeling pretty good that day. Like thankfully there was something that was reversible for you. Because again, you're my friend and I want to be able to sleep at night. I don't care about you, but I want to be able to sleep at night.

SPEAKER_01 48:51

Me too. Pain free.

SPEAKER_03 48:54

Exactly. And then and the trauma of it, the psychological uh component.

SPEAKER_01 48:58

Yeah, the anxiety of what might happen. Am I gonna go to sleep and wake up? I recall that as I was leaving the OR and understanding that yes, you have this, yes, you have this. She pretty much had a diagnosis of next steps right there. And here's what we're gonna do. And I'm thinking, I'm not sure about that yet. I don't know what all this means yet. I just have an understanding that we finally have gotten to a s a point where we know the symptoms are being caused by this in some way, shape, or form. And it was the vasospasms creating the pain. It wasn't the next step of could that myocardial bridge be causing the vasospasms? So I I can't thank you enough. And I mean that in so many ways. I mean I mean that in the sense of having met you in what appeared to be coincidence, but we now know was not. And having had the opportunity to get to know you a little bit better and share the things that we share, uh I I do want to address that in this situation, and I think in any health situation, in any relationship with a physician situation and as a holistic individual looking at all of it, yes there's medication, yes there's mechanical, but I know both of us believe in the fact that there's also a spiritual to some way, shape, or form that supports all of this too. And as people are trying to work their way through whatever their situation is, yes, it's medication, yes, it's mechanical, and yes, there's a spiritual part of that as well, and whatever that belief is, but you need that support. Something I didn't share with you when I was discussing this condition that we were uncertain about is I have a friend who is a cardiac nurse at the hospital, and I shared it with her, and she's like, I don't even know what you're talking about, I've never heard of this before. And she calls me back a couple days later. She goes, You are not going to believe this. I have a friend on the floor who's also a cardiac nurse who has a friend who has that thing you're talking about. That thing. I said, What, the bridge? She goes, Yes. And she had surgery on it. And she's better, she's improved. And this was just post my diagnosis at Stanford, and it gave me this incredible amount of certainly hope, but high expectation that there's a solution to this as opposed to just a moderate fix. There's actually a solution that maybe will allow me to be back to what we would consider normal. And I was able to request that friend's friend, if she'd speak with me, come to find out she's a marathon runner and had the unroofing procedure, and it was the most invigorating discussion. We spoke for two and a half hours the first time I talked to her. I'm a complete stranger. But it was that bond of similar situation in a life-threatening situation, to make it even more impactful, where she couldn't share enough about how optimistic she was about what her future was going to look like. She had just, she was about six months in post-unroofing, but how much better she felt and how she was functioning. But it wasn't just that conversation. It was the conversation and what it did for me in terms of the process of the next steps. And I hope that what we're talking about today gives people that same opportunity to look to the next steps. You know, that there is hope, that through advocacy and through process and questions and documentation, there's something that will be found in a diagnostic situation that should be able to help the majority of people who are in a quandary right now.

SPEAKER_03 53:03

I think that's a great point. And in particular, the aspect of a shared experience. So when we when people experience things that are common or uncommon, we don't have to go through these things alone. And I think there's this, there's a difficulty in reaching out or even knowing where to find these communities. And I think that's uh amazing when you share that one connection with another person who had the same uncommon presentation as you did, to realize, hey, there are people out there. And then I think that's part of the reason you're starting this podcast is to get this conversation going. You're not alone. And most things, most diseases, whatever burdens we're carrying, we're not alone, particularly when it comes to physical ailments. And so I encourage all of your listeners to look out, reach out and try to find the community that may have what you have, because you'll get ideas that are practical. You may find physicians that perhaps they have more experience in certain conditions, but you'll get that spiritual connection and you'll get that experiential connection with other people, and that alleviates some of the stress of this disease. Again, we don't have to go through anything alone.

SPEAKER_01 54:07

And interesting, too, that that spiritual connection, because there is a Facebook group, a myocardial bridge Facebook group. Uh and if you are listening to the podcast not familiar with the Facebook group, it's a private Facebook group, so you're not showing it to the ether. Uh not not any of the people in the group know that that you're concerned about the condition or that you have the condition. So it's really, really a helpful consortium and it's worldwide. And the thoughts and prayers and energy that comes from somebody, whether they're in India or France or the United States, it's real. And they sense your concern, your pain, your your grief uh in in the situation. And there's many people who may be experiencing virtually the same thing somewhere else. So I can't encourage that enough. And then obviously with our website, you can go to the website and we'll be posting more and more information as we continue to grow the program. So that was a long way saying thank you. Uh but I again my gratitude for you is is incredible. So thank you very much. Thanks for what you do too. You know, for you're literally saving lives.

SPEAKER_03 55:26

Thank you for having me on. I'm really grateful for our friendship. You know, it came at a strange cost, but I I really am so I couldn't be happier to be sitting here with you and and uh kind of going through this journey with you, man. Not just the experience you had, but you know, through life together.

SPEAKER_01 55:40

Thank you, Dr. Menon. Thank you for listening to Imperfect Heart. It's my hope that this information helped in some way to improve your situation or will help you better understand this condition. More importantly, that it gives you hope through stories that there is help and you most certainly are not alone. If you've been diagnosed with a myocardial bridge, please be sure to join the private Facebook group, Myocardial Bridge Support Group. For more information about our program or to reach me directly, visit the website, myimperfectheart.com. If you like what you heard today, please give a positive review, thumbs up, high five, whatever your app likes. And be sure to share with everyone important to you so they understand what it is you're dealing with. Please subscribe as well. Welcome each day with gratitude and positivity. The views and opinions expressed in this program are solely those of the host and the guest and are not intended to provide, nor are they a suitable substitute for professional care by a doctor, therapist, mental health professional, or other qualified medical professional. Imperfect Heart is a production of Hear Me Now Studio.