Episode 30: You Have a Myocardial Bridge. Could You Die? Stanford’s Dr. Ingela Schnittger Explains.

SPEAKER_00 0:00

This Encore episode is a condensed version of the two-part discussion I had with Dr. Ingela Schnitger in episodes three and four. This is for those of you who are just discovering the podcast. I wanted to bring one of the most listened to episodes up front and a bit shorter for ease of access, and to get the most important questions you have as you begin your journey of understanding myocardial bridges answered for you.

SPEAKER_01 0:26

Myocardial bridging is very common. Depending on the tool that you use to study the heart, it's at least 20 to 25% of all people out there will have some degree of myocardial bridging. But it's a wide variability in the severity of the bridging.

SPEAKER_00 0:48

Is it possible then that many of these blocked coronary arteries resulting in sudden cardiac arrest could be as a result of a bridge that's been unrecognized?

SPEAKER_01 1:00

Yes.

SPEAKER_00 1:11

Welcome to Imperfect Heart, a place for you to join me, Jeff Holden, in conversations, discussions, and dialogue about our hearts and the impact myocardial bridges have on them. 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 with hope, knowing you're not alone and that what you're experiencing is real. My guest today is somebody you're going to come across sooner than later as you seek information on myocardial bridges. Her academic and medical accomplishments are varied and numerous. She may very well be the most outspoken advocate for all of us with myocardial bridges and is most certainly a large contributor to the fact that unroofing surgery is now being done in more and more hospitals around the country, around the globe. She received her bachelor's and doctorate degrees in medicine from Karolinska Institute in Stockholm, Sweden. She received a special fellowship in cardiovascular medicine at Stanford University in 1976. After several other residencies, both in Sweden and in the United States, she returned to residency in internal medicine at Stanford University School of Medicine. In 1980, she did her fellowship in cardiovascular medicine again with Stanford, where she currently practices as a professor of cardiovascular medicine. She has passed numerous boards, received many research grants, has had multiple academic and non-academic positions with Stanford, participated on national committees and task forces with emphasis on echocardiography and cardiology, has been published in over ten scientific journals, has spoken or appeared on many broadcast outlets, including the BBC, and has been recognized as one of the best doctors in America among many other awards. She's written and published over 130 peer-reviewed articles. She's also responsible for the myocardial bridge research team at Stanford University, where they have published 16 full peer-reviewed manuscripts, four case reports, two review articles, and many abstracts on myocardial bridges. Without her efforts, many of us would not be where we are today, myself included. It is with great pleasure and a very humble heart, an imperfect heart, that I introduce a true pioneer in the field of cardiology, Dr. Ingela Schnitger. Dr. Schnitker, thank you for affording me the opportunity to spend a little time with you to talk about myocardial bridges. You are an icon in the field and a beacon of hope for so many that are still working to get proper diagnosis of their symptoms and or working to find a surgeon to perform their unroofing. Welcome to Imperfect Heart.

SPEAKER_01 4:10

Thank you. Thank you for inviting me.

SPEAKER_00 4:13

Could you please share what it was that caused you to begin down this path of learning about myocardial bridges?

SPEAKER_01 4:20

I know. It's it's curious. I was asked to be a medical expert in the legal case where a young man had exercise-induced chest pain. He had a treadmill test that was normal. His primary care doctor reassured him. And he, however, continued to have exercise-induced chest pain. And one day, while he was running on a treadmill in a commercial gym, he had a sudden cardiac arrest. He was resuscitated but turned out to be brain dead. And the autopsy showed a myocardial bridge with a plaque upstream from the bridge that had ruptured and formed a clot around it. And he had an acute heart attack followed by an arrhythmia that caused the heart to stand still. And I was supposed to be the expert on the defendant's side, but the plaintiff's attorney who took my deposition, he knew everything about myocardial bridges, and I knew nothing. It was it was humbling, it was embarrassing, and it came to really pique my interest. What is this myocardial bridge and why is it that it wasn't diagnosed and got me started?

SPEAKER_00 5:49

Isn't it interesting that the legal and medical fields come together as they do so often? And in this case, for the greater good.

SPEAKER_03 5:59

Yeah.

SPEAKER_00 6:00

What then led you to the research at Stanford and formalizing this into a myocardial bridge team?

SPEAKER_01 6:08

Well, I'm a specialist in cardiac ultrasound, also called echocardiography. And so I interpret echocardiograms and have done so for 40 years. And so one day I'm sitting in the lab and I'm reviewing a file of a 35-year-old man who came to the lab for chest pain and had an exercise echocardiogram. And as I was looking at the pictures, I was struck by an abnormal motion of one of the walls of the heart. And I asked myself, hmm, because he reminded me of my legal case. So I asked myself, could this be a pattern of motion in a person with a myocardial bridge? Well, it turned out that he soon thereafter did have an invasive angiogram that did show a myocardial bridge. And this then started my interest in trying to study this condition. So I wanted to do invasive andograms on patients that had this pattern. And of course, I had to team up with colleagues of mine, specifically Dr. Tremel, who's an invasive cardiologist. And she and a team of fellows helped us get started on investigating the bridges in the CATH lab. And then we realized we needed intravascular ultrasound. So then we engaged our very superb intravascular ultrasound laboratory, and then eventually led to involving a cardiac surgery. So that's how we formed a team. And because the myocardial ridges are much more complicated than just meets the eye. So you need input from different specialties. And I should also say that we were working with the radiologist who did the CT scans, and they learned from us, and we learned from them what constitutes a significant myocardial bridge. So that's how we came to form a whole team. And personally, I think it's important to have this team approach because there are aspects of a bridge that even a cardiologist isn't gonna know all the intricacies in evaluating the bridges.

SPEAKER_00 8:41

It's interesting. I can't help but think back again to the gentleman on the treadmill that started this cause for research. A myocardial bridge, in essence, killed him. It caused the heart attack.

SPEAKER_01 8:55

Yes.

SPEAKER_00 8:55

And yet so many times and so frequently, we're told it's benign.

SPEAKER_01 9:00

Well, it's interesting because, as you probably know, myocardial bridging is very common. Depending on the tool that you use to study the heart, it's at least 20 to 25% of all people out there will have some degree of myocardial bridging. But it's a wide variability in the severity of the bridging. The length, the depth, how hard the band compresses the vessel, how many side branches are jailed in the tunneled segment, how hard the band presses on the heart, we have shown is correlated to the plaque buildup, then you form a plaque, then that becomes a problem. So there's so many aspects, and that makes it very challenging to sort out what bridge is likely to cause symptoms, and what kind of situation should we worry about, the heart attack situation. Okay. So there are several pieces to this, which it's not just one shoe fits all.

SPEAKER_00 10:16

And Dr. Tremble did my provocative test to identify the symptom and cause and what was happening. So thank you for hiring her. I'm very, very happy about that. As you were in the process of the research part of it, you then went to actual mechanical repair. And how did that develop? How long ago was it that you started the team at Stanford? And then at what point did you decide, hey, we can actually do repair as well? We can do the surgery on these things as well as diagnosing and understanding?

SPEAKER_01 10:52

Well, it wasn't quite so simple to say, okay, we just build a team and then we go from there. It was really sort of things that developed, right? We learn with every little project we do. But we had a surgeon involved pretty quickly after we started to diagnose the bridges as significant from a circulatory problem, a circulatory aspect. So in order to get a surgeon engaged, and in the beginning we had a couple of surgeons, but in the last eight years or so, we've had one single surgeon that does all the surgeries. But they want to have some reassurance that the bridge is actually causing a circulatory problem. Since bridges are common, and many of them do not cause a circulatory problem. The surgeon, understandably, were tentative in doing open heart surgery. You know, it's not a walk in the park, it's a major surgery. And you don't want to harm anybody. Do no harm is the number one ethnic concept we had. So the surgeons wanted to have confirmation that there was a circulatory problem. And it was challenging to prove a circulatory problem because everything that had been done up to that point was to study circulatory problems in fixed blockages, fixed coronary, call it coronary artery disease, fixed blockages. But the bridge is a very dynamic, dynamic situation. So if you study the bridge at rest, a patient on the table in the cat and ab sedated, slow heart rate, you may find nothing. So we had to move to the concept of studying a bridge under the circumstances that are real life experience, such as exercising. And it could be just walking up a flight of stairs, but a situation where you're moving. Okay. So that was the first sort of obstacle. But as we were able to prove that with a new measurement tool, we got surgeons on board.

SPEAKER_00 13:18

Why do you think that there's still such a lack of understanding about the symptoms of bridges when now you've got what 10, 12 years of history surgery, correction, diagnosis, yet it still seems to be vague in the cardiology community?

SPEAKER_01 13:39

Yes, I I agree with you. And I think first and foremost, as I mentioned, you you have to use different tools to prove that there is a circulatory problem. Okay, you have to study the artery during induced stress that we do in the CAT lab. And secondly, I think that, as you know, a majority of the patients that have a significant myocardial bridge do have endothelial dysfunction. What is endothelial dysfunction? Well, the lining of the vessel is made up of special cells called endothelial cells. And in order for the blood vessel to stay healthy and stay open all the time, those endothelial cells have to be healthy. They produce nitric oxide, they produce endothelium one that keeps the vessel open. When you bang on that vessel every minute, every second, you traumatize the endothelial lining and you have a tendency to develop spasm. Why is that important? Well, because the spasm is random. It comes at rest. It can wake a person up at night. It comes with emotional stress, it comes with physical stress too. But the problem here is that the patient, the person afflicted by this condition, had just discomfort with effort and at rest. If you go to a doctor and say you have chest pain, they're gonna say, okay, let's see, do you have any risk factors for coronary arter disease? Maybe this is scared, whatever. Maybe you end up saying, okay, well, it's pretty typical pain from the heart. But when you say you get pain watching a movie or talking to your partner or spouse or kid, then the doctor is gonna say, uh-uh, this is not typical. You're probably just a little stressed, you're you're a little bit, you know, anxious, this is not heart disease. That's a problem. So then people get discarded. So it's it's I think the symptomatology with pain, both with effort and rest, as well as it being very common condition, challenging to sort out which bridges are causing problems. And in order to study that, you have to understand that this is a dynamic situation and you have to apply different diagnostic tools.

SPEAKER_00 16:33

And I can certainly concur with the at-rest, because most of my spasms occurred initially at rest.

SPEAKER_01 16:41

Yeah.

SPEAKER_00 16:42

And I had my myocardial infarction, which it's so hard to say I had a heart attack, but I had that heart attack in the morning coming out of bed.

SPEAKER_01 16:52

Yeah.

SPEAKER_00 16:53

So nothing to do with stress or exercise. As a matter of fact, when I exercised, it was better. Right. I never had the symptoms under heavy exercise.

SPEAKER_01 17:03

So there's variability in the symptom, but I think that if you're I mean, when you go to the doctor with chest pain, whatever doctor, primary care, internal medicine, cardiologist, and you say you have chest pain, it's incumbent upon the doctor to go through the differential list, right? But to discard the patient that's ah, it's musculoskeletal. Uh-huh. Muscular pain is painful to touch. When you press on the chest, it hurts. Heart pain does not hurt from the surface. If the pain is coming from the heart, you cannot elicit the pain by pushing on the muscle. So, you know, there's a number of ways you can narrow down the potential differential diagnosis because, of course, chest pain. I mean, every patient that walks through my office door has chest pain of some sort or another. And so it's a common problem, right? So we need to do better in asking questions that might lead you down the road of, oh, wouldn't this be a myocardial bridge?

SPEAKER_00 18:14

Is there one gold standard that identifies the fact that yes, this is a myocardial bridge with enough severity to cause symptoms?

SPEAKER_01 18:24

Well, I think that the most reliable non-invasive test is the CT scan. And we have shown that you if you do a careful CT scan with controlled heart rate, you want the heart rate to be 60 or less, otherwise, you get fussy pictures when the heart moves. So you do a good CT scan, and from the CT scan, you can measure the length and you can estimate the depth, and we have developed a myocardial bridge muscle mass index. It's basically a number, and if that number hits a certain threshold, we have compared that to invasive studies. So then we can say, okay, if your muscle mass index is X, it's a very high likelihood that you have a circulatory problem in your brain. So I would say I would recommend, you know, after you do stress testing, which I can come back to, which could be positive or negative, I would say the next step is a CT scan. But then you have to have a radiologist, uh-huh, that's going to read it. Because I even have radiologists at Stanford who don't always read the bridge because they are so in the mode of thinking, it's so common, it's a normal variant, we don't need to, we don't need to bother. So I've had to say to my radiology colleagues, I only want Dr. X, Y, and C to read them because if I order a CT scan and if somebody else orders a CD scan, where the question is just pain, please pay attention.

SPEAKER_00 20:14

So it actually is a specific look that they get experience from doing more and more and more, obviously. Right, right, right. Well, certainly you've got to be extremely proud of the accomplishments to date and ongoing. What do you think needs to be done to get more of the data that you're coming up with and providing into the hands of cardiologists around the world so that we can help more people with this?

SPEAKER_01 20:41

Well, I I do think that the condition, this subject, is getting some traction. And I think it's multifactorial. I think we have published a good deal. There's actually more publications from abroad than from American institutions, sadly to say. So I think that there is an increasing awareness in the cardiology medicine community. But I also think that, you know, your work and though Facebook is also helping people to gain more understanding. And I think we get a lot of referrals from across the country and sometimes from abroad. And when I asked the person, the patient, how did you come to Stanford? They would say, Well, I struggled for many years. I eventually got the diagnosis that I have a myocardial bridge, but I was told that don't worry, it's not causing your symptoms. But then I go online and I find out that it could be a problem. So sometimes it's the patient that is pushing for more. Or consultation or second opinion. Sometimes it's the cardiologist that's saying, Oh, I see that you have a myocardial bridge, I don't know if it's causing you a symptom, I don't know enough about it, but let's send you to another institution for a second opinion. So there's two ways that they come. And I think that is sort of increasing. In the beginning, when we started our work, most of my patients were local, but now most of my patients are from out of state. And they come because they understand that they may have a problem, or their doctor, I would say, admits or acknowledged that they may have a problem. So I think I think it's happening. It's still, you know, sort of tentative in some people's mind. But I I think I think we're making progress.

SPEAKER_00 22:57

Oh, I would definitely say you're making progress. And the recognition of Stanford as the leader in the diagnosis and the process of remedy to the extent that it can be remedied is world renowned. Especially from the uh the Facebook page and how people recognize it. I even had a gentleman from India email me and ask me, what do you know about Stanford? What can you tell me? Because he can't find a doctor in India to do the surgery. So it's something to be uh extremely complimented on. And again, I think anybody listening to the show is also aware of the work that you're doing there. So thank you, thank you, thank you. Keep going.

SPEAKER_01 23:41

Sure. I think we've you know gone forward slowly and cautiously. I think I feel sort of very sorry for a surgeon that is just approached by a patient who says, I have a myocardial bridge, can you fix it? Because my surgeon, he would not take a patient to surgery unless the team says this is a problem. We have studied this individual. There's a high likelihood that he or she will improve with surgery. We need to make sure there's no other major issues. We do very careful mapping of the bridges to let the surgeon know exactly where the bridge startes, when does it end, how long is it? My surgeon, he even takes out a measurement in the operating room after he has dissected free the bridge, and he measures and he says, Okay, Ingela, I have 31 millimeters. Is that good enough? And then look at the iris members. And yeah, that's good enough. You did good, you can stop now. Because you know what? I mean, even I, as a cardiologist, have learned a lot going to the operating room. And you would think that if you open up the breastbone and you look at the heart, that it would be absolutely obvious where the bridge is. Uh-uh. No, no, because it can be covered in fat, it can be covered in the pericardium. And so you need to know exactly the location, how long it is, what your landmarks is. From the CT scan, we learn if it goes very deep, if it goes into the right ventricle, we have to go on pump before. So we decide on pump, off pump, mini thorachonomy, sternotomy, all pre-operative evaluation so that the surgery can be done with a complete dissection of the whole bridge. Sometimes there are two bridges. You have to do both, okay? And then it's safe. We haven't lost anybody, no aneurysms of the heart, strokes or heart attacks, because you very, very, very carefully do the evaluation before the patient goes to surgery. So I feel very, very sorry for the surgeon who's asked to just, oh, I have a bridge. Can you take care of it? No.

SPEAKER_00 26:26

You mentioned something I think is really key, and I know it was something that I asked that same surgeon who performed my surgery. I said, How many people didn't make it off the table?

SPEAKER_03 26:38

Yeah.

SPEAKER_00 26:38

And he looks at me and he says, none. Everybody did.

SPEAKER_01 26:42

Yeah.

SPEAKER_00 26:43

And I said, Okay, I I feel pretty good about it then. I'm not, I'm not as concerned.

SPEAKER_01 26:48

Yeah. You know, this is this is not some superficial little surgery. It's it's major. And you, as a doctor, wants to instill the confidence in the person, in the patient, that they'll do well, they'll improve, and it's it's a reasonable approach, right?

SPEAKER_00 27:13

And that was actually my second question. The first one was, how many of these have you done? And he looks at me with a little smile and he goes, Over the course of the last year, more than anybody else in the world.

SPEAKER_03 27:24

Yeah.

SPEAKER_00 27:24

And I said, Oh, okay. I almost felt like I insulted him, but how would you know? And I think the significance of that is while you when you hear something like that, you say, Wow, more than anybody else in the world, that's gotta be a lot. And at that point in time, it was 200 over a 10-year period. And I thought, Yeah, well, there's not a whole lot of this being done in the United States, is there?

SPEAKER_03 27:47

Right.

SPEAKER_00 27:48

So in some of the research that I've seen, it's been estimated that roughly 25% or more of the population could be walking around with a myocardial bridge.

unknown 27:58

Right.

SPEAKER_00 27:59

And it could even be postulated that the cause of many of these blocked coronary arteries resulting in sudden cardiac arrest could be as a result of a bridge that's unrecognized. Is that fair to say?

SPEAKER_01 28:14

Yes. It's very interesting. Uh sudden cardiac arrest is not a disease in itself. It's an event, right? And it's caused by a ventricular arrhythmia. So the heart starts to go very, very fast and almost just fibrillating, and it goes so fast that it actually doesn't mechanically pump any blood out of the heart. So a cardiac arrest can be caused by a number of different conditions. Myocardial bridge is one of them. And then there's two aspects of the bridge. Number one is a plaque that everybody that I have studied in the CAF lab has a plaque, small or medium, or large. And it's always in the same position. And it's regardless if you have any risk factors for plaque. They form plaque because of the turbulence in front of the tunneled segment. So you could either, like my legal patient, have plaque-plaque rupture and acute 100% occlusion, a heart attack, and then arrhythmia. Or you can have repetitive chest pain episodes that choke the circulation in the bridge and causes fibrosis, scar, and edema, swelling. So there are autopsy studies where people have looked at patients or people that died in a cardiac arrest. Some of them, of course, do not have a bridge, but then there's a cohort that has a bridge. And in those patients, they have found scar tissue and edema in the area subtended by the area that is confined in the bridge. And that structure is a trigger for ventricular arrhythmia. So you can have an acute heart attack, you choke the circulation 100%, you trigger neurhythmia, you can have a buildup of scar and edema inside the heart wall, the septum that triggers the arrhythmia. So it's it's tricky because you can look at autopsy studies, you can look at retrospectively cohorts of people that died in a cardiac arrest. And there are bridges there. But of course, there's several other conditions. But when it comes to the bridges, you have to look for them. Because if the pathologist isn't thinking bridge, he's not going to find the bridge. He's going to look for hypertrophic cardiomypathy, he's going to look for, you know, dilated cardiomyopathy, he's going to look for valvular heart disease, et cetera, et cetera. But there's clearly bridges in that cohort. Some of them triggered by an acute heart attack, some of them triggered by just the scar tissue, edema, that, especially with effort. I mean, you hear about football players, you know, basketball players, marathon runners that just drop. And if they have a if they have a bridge and nothing else, it does it it could be either on the concept of just edema scar or acute plaque plaque rupture. I mean, I have one one case, one patient that ran the San Francisco marathon, got chest pain, got to a local hospital, the doctor there knew how to study with an angiogram, and he had a plaque plaque rupture. And the clock flew down the LED and he had a heart attack, and he had a bridge, and he was saved.

SPEAKER_00 32:20

I want to dance and I want to scream and I want to shake people because what you just said in that description is exactly why I stress to say sooner better than later.

SPEAKER_03 32:31

Yeah.

SPEAKER_00 32:32

Because that plaque is only gonna get worse over time.

SPEAKER_03 32:36

Yeah.

SPEAKER_00 32:36

And the longer you wait, I mean it was 60, 65 years for me, which means I had the ability for that plaque to build.

SPEAKER_03 32:44

Yeah.

SPEAKER_00 32:44

And I didn't have any other conditions that would suggest that I have an issue. So that was just a wonderful, wonderful description for anybody to understand how this happens.

SPEAKER_01 32:57

Yeah, and it's interesting because there is a group in Japan that has actually looked at autopsy studies in patients with bridges and acute heart attacks. And it turns out that the plaque in the bridge patients is more vulnerable to plaque rupture and clot formation than the plaque in the same position in another person who doesn't have a bridge. So these plaques are vulnerable to fissure and rupture and adhere clot. And so, therefore, anybody that has a significant bridge should be considered for baby aspirin and also.

SPEAKER_00 33:46

Yes, yes, I take it every day now.

SPEAKER_01 33:49

And also, of course, reviewing any any existing, you know, risk factors for plaque buildup, most often it could be cholesterol because that could be quiescent and the person doesn't know. Diabetes is a risk factor, but people often know that they have diabetes. So we treat the cholesterol, we we treat with baby aspirin. If a person has symptoms and also preferably some you know diagnosis of the severity of the bridge.

SPEAKER_00 34:24

And I had the good fortune of also a bypass just to really be safe and get around that you know obstruction.

SPEAKER_01 34:31

You had a you had a bypass as well, but that's tricky. It's tricky because, yes, in your case, your plaque was deemed to be partially occluding the vessel.

SPEAKER_00 34:51

Yes.

SPEAKER_01 34:52

And so you had two problems. You had a plaque that was partially occluding the vessel, and then you had a bridge that was partially occluding. Then it's legit to do bypass pass unroofing. But please do not bypass a plaque that has not been proven flow limiting, because if you do that, the bypass will close. But you were fortunate to have a very, very, very careful evaluation that showed that your plaque was significant enough that it encroaches on the lumen. See, what happens with these plaque buildups in the bridges is that the vessel enlarges eccentrically. So the plaque doesn't encroach on the lumen until very, very late. So it it causes a half-moon area of math which changes the size and the shape of the vessel. And that's why it goes unrecognized forever in a day. Those plaques don't show up on a CT scan unless they're calcified. Most of them are not calcified.

SPEAKER_03 36:03

Right.

SPEAKER_01 36:04

They only show up on an intravascular ultrasound. They don't show up on a coronary endiogram unless they start to encroach on the lumen. But they can still be there, they can still be potentially dangerous. So it's tricky. It's very, very tricky. And you should never, ever, ever bypass a plaque that isn't flow limiting. You were very, very, very carefully evaluated, and they found that your plaque was limiting the blood flow through that area.

SPEAKER_00 36:38

You know, the goal of the podcast, Dr. Schnitger, is to inform and educate as well as to give some hope to those listening that there are solutions and there are doctors and there are cures for the symptoms in some cases. Could you walk us through what you would suggest as a proper diagnosis and course of action once I'm aware that I've got this pain? I know it's not fleeting, it's not emotionally originated, it's pretty sure it's something material. And I may even have gotten the diagnosis that it is, but it it isn't a bridge. I mean, it hasn't been diagnosed as a bridge. What steps would you suggest for somebody in that situation? Yeah, the first step, second, and then obviously conclusion.

SPEAKER_01 37:23

Well, so we assume then that a person has been evaluated in such a way you have excluded other causes of the chest pain. So you don't have GURGE, you don't have musculoskeletal pain, you don't have percarditis, and hopefully at some point you get either just a simple andogram or CT scan that shows you have a bridge, okay? Then I think if you carry that diagnosis, you don't need more testing to start to treat it medically. So all bridges should be treated medically first, okay? That's number one, that's the first line of treatment. And so you don't really need to know the intricacies of the severity of the bridge to start treating medically. And the treatment will be number one, the beta blocker, and that reduces the heart rate and the contractile force. And if the person doesn't tolerate the beta blocker, maybe a calcium channel blocker, especially if they have a tendency to spasm. So beta blocker plus minus the calcium channel blocker. And then I would really seriously consider a baby aspirin unless there's a contraindication for aspirin. And then I would check the cholesterol and make sure that the LDL, the bad guy, is better than upper limits of normal. All the patient would say, okay, my LDL is 129 and the upper limit is 130. That's good, right, Doc? And I said, uh-uh, not good enough. Okay, so you want that, if you look at the coronary or disease literature, they would say 70, okay? I may not be as strict to go down to 70, but certainly less than 100, you know, at least in the 80 range. So I would start with that. And if the person, if the patient feels better, they have less often chest pain, it is shorter lasting, they have no showstoppers. It's not like they go on a hike, and after five minutes, they have to stop because they think they're gonna die. No. So if you can reduce symptoms with those treatments, then I'm happy and the patient is usually happy. Now, then we, you know, we may increase the dose, we see them back in a while, and if they can do what they want to do in life, the quality of life is acceptable, then we stop there. If they fail to improve the quality of life, then I go on to the CAP lab and then I do the invasive studies, as we have talked about. You have to look for endothelial dysfunction, you have to stress the blood vessel to see what happens when the heart rate goes up if you have a circulatory problem. And then if they have no other issues with their coronary arteries and they test positive for a significant circulatory problem, and they failed medical management, then we start to talk about unroofing surgery. But I am very, very, very careful to point out we cannot guarantee you're gonna live longer. That's not been shown. We cannot guarantee you can never have a heart attack, that has not been shown. The surgery is done for symptom reduction, increased quality of life. And the patients that we end up having go to surgery, they on the average quoted quality of life as 25% of what they think it should be. And after surgery, after six months, they're up to 78, 80% quality of life. And most people are content with that. Some people have 100% improvement, maybe some have 70%. And it a little bit depends on whether they also have endothelial dysfunction. Endothelial dysfunction does not go away automatically with surgery. What I see clinically is that it improves with time, and I think because the vessel is not constantly traumatized, but and endothelial dysfunction tends to be easier to treat. It's not as intense, it's not as frequent, it's not as severe. And then you can often be very successful with low-dose nitrates after surgery. Okay. Nitrates before surgery is a little bit dicey because some people get worse. So it's a very, very stepwise approach. And if they come to me with just chest pain, we start at the bottom of this journey. Because, as I said, surgery is major and you want it to be safe, you want to have reasonable confidence that the person is going to improve.

SPEAKER_00 42:33

If a particular cardiologist is reticent or reluctant to address the reality of the symptoms from the myocardial bridge, and that happens to be my particular doctor, I don't mean mine in in this case, but I mean anybody who is in that situation. What steps might you suggest for those patients?

SPEAKER_01 42:52

Well, Stanford happens to have an online second opinion website, and it's now actually called Included Health. And so you can go online and apply to them, and they will help you collect your medical records. They will, you know, organize them and they will choose a physician that can review records and come up with recommendations. You're allowed five questions, okay? And so this exists not just for myocardial bridge. It can be like, you know, I have prostate cancer, should I have radiation or surgery, you know, whatever. So that's one way of going. I think that if you, as a patient, have been given this diagnosis and you have ongoing symptoms and you've not been helped with medications, then you can certainly ask your doctor for a referral. And if that particular doctor is not sensitive to your request, you can go to another cardiologist and ask for. I mean, it's not just Stanford that looks at this. I mean, I know people have gone to Mayo, to Cleveland, to Columbia, and at least get a second opinion. They may not, my understanding, do that many surgeries, but they certainly can evaluate. I think that you have to say that they have the knowledge to assess the myocardial bridge.

SPEAKER_00 44:25

As you look into, let's say, a crystal ball, really, probably not that far away, what does the future look like for both diagnosis and treatment of myocardial bridges? What do you think is starting to happen?

SPEAKER_01 44:40

As I alluded to, I think that the CT scan is an excellent non-invasive tool to get an idea of who may have a significant bridge. I think there are more work to be done to try to non-invasively look at the hemodynamic consequence of a bridge. One aspect that I think is interesting is something called strain imaging. It's an ultrasound technique. Perhaps pet imaging, different imaging techniques that can address the potential consequence of the bridge. The CT is great because it gives you an anatomic picture. And we have correlated that with invasive studies, but it's also good to have like a second tool to look at the consequence of the bridge. And I think that there are potential tools that can be researched and studied to see if we can assess that better. I think it would be interesting to look at endothelial dysfunction non-invasively. Because say that I have a patient have chest pain and we studied them in the CAV lab, they have a lot of endothelial dysfunction, and the bridge is pretty minor, okay, then the surgery is not a good option. Or they have severe microvascular dysfunction, which is the small vessel disease, and we test that in the lab. If they have a lot of microvascular dysfunction, that can be seen in people with diabetes, smoking, autoimmune disease, transplant patients have a lot of microvascular dysfunction. So there are other conditions that can limit the blood flow to the heart. So if if you can study those other conditions in a little bit more detail, non-invasively, that would be great. I don't see anything in the near future that would take surgery off the table. It's interesting because people have thought, oh, we can stent the bridge, okay? That would be cool. Ha ha, that's the problem. Because, okay, so people argue that the stent will keep the vessel open so that when the heart contracts, the bridge isn't going to be compressed as much. The problem is there is a lot of potential complications with doing that because you can actually completely compress the stent. Oh, we can build sturnier stents. Aha. But that's not going to solve all the problem because there's one more problem. And I'll tell you what one more problem is. Okay. So we have looked at a large cohort, over a hundred patients with significant myocardial bridge studied in the cat lab. That not only do they have a systemic compression, i.e., when the heart contracts, it squeezes, but then when the vessel opens, it doesn't open to the same luminal diameter as it should if it wasn't a bridge there. And so 87% of that concord of 115 patients had restrictive vessel diameter even in the relaxed phase. So if you put a stent in, it's going to prevent in the beginning, perhaps, the systemic compression, but it's not going to be all able to overcome the confinement of the vessel segment inside the bridge when the heart relaxes. So that's a problem. So I don't see, but the surgery, of course, takes away the band. So then in the relaxing phase, the vessel can expand. So I don't see anything on the near horizon that is going to take surgery off the table. Because you want one guy or gal to become a super expert because that improves the safety. I believe you had Dr. Boyd, right?

SPEAKER_00 49:27

I did, yes.

SPEAKER_01 49:28

Yes. So he's the only surgeon I referred to because he's now probably the world's most experienced. And it takes time to get there, but I would say, you know, focus your referral to one person that has a chance to gain experience and help him, help the surgeon to carefully evaluate your patient before you go to surgery.

SPEAKER_00 49:57

Thank you for that. And I know one of the things that we see now on the Facebook group as well is that some of the surgeries are being done robotically, where it's capable. So a little bit less invasive, a little bit shorter healing time, which is is good to see.

SPEAKER_01 50:13

Yes, I am aware of robotic surgery being done. I think in very experienced hands, somebody who does robotic surgery routinely, it probably can be done safely, but I think you really have to customize it to each person. It's not a surgery approach for all people because you don't want it to be longer than a certain number or deeper. You don't want it to be deep enough that it goes into the right ventricle because to control bleeding. I mean, this I'm getting pretty granular here, but it is a big topic though.

SPEAKER_00 50:58

It frequently comes up on the Facebook page. I think because people recognize the significance of the strenotomy. Well, if I can do it without all that pain and all that grief. So this is good to discuss.

SPEAKER_01 51:10

Yes, no, it's good to discuss. And we do about half of our patients are probably nini thoracotomy, which is you go in between the ribs and you don't go through the breastfall. The healing and recovery is quicker. You may just be able to spread the ribs apart and not cut a rib. So that is ideal for a certain group of patients. Again, it depends on length and depth and position of the bridge. Yes. And it also is easier if you don't have to go on the cardiopulmonary bypass machine. And why do you have to go on that one? Well, again, it depends on the location, length, and depth. So, yes, I think it's a good potential, but with the understanding that it is for a smaller cohort of patients, that it can be done safely and also completely, right? I mean, we have seen patients refer to us that have had quote unquote bridge surgery and it wasn't complete. So they still have symptoms. And then do we have a second surgery? So, yes, I think it's interesting. I think it can be done. Seek out somebody who does it for a living, i.e., robotic surgery. Be sure that the surgeon understands the anatomy of the problem.

SPEAKER_00 52:42

In your years of field in echocardiograms and cardiology and your familiarity with myocardial bridges, is there any one thing that you've seen in patients that you would say was most important in their process of leading up to and successful recovery from the surgery? You might say health, you might say faith, you might say their relationships. Is there anything that you would say was more significant than others?

SPEAKER_01 53:11

I make an effort to personally really connect with my patient that goes to surgery so they have confidence in me, confidence in the decision to go to surgery. I never tell anybody that they have to have surgery. It's a joint decision. I inform the patient about the risk and the benefit. I inform them about what to expect. We talk about the recovery, the recovery after surgery. You know, the surgical procedure, I mean, it takes six weeks to just recover from being a surgical patient. But then you have to build up your stamina. I recommend cardiac rehab. Some people can do it on their own, but some people really like the comfort and the support of a cardiac rehab facility. And I think I tell them if they have endothelial dysfunction, you're going to have pain, but it will be milder, but I will help you with it. We have medication for it. The myocardial bridge will not grow back, okay? Because that's the question. Does it grow back? No, it doesn't grow back. There could be some scar tissue there, but it doesn't envelope the vessel, okay? It's not going to push on the vessel. So, no. So you inform the patient, you comfort them, you reassure them, you talk about the recovery, which is at least six weeks from surgery. If it's a sterotomy, no front seat passenger, okay? Hold on to your pillow, okay. And then you start cardiac about six or seven weeks, and you do that for a month, and you do not go back to work too early. I would say it takes four or five months to build up your stamina to sort out any kind of chest discomfort and treatment for that. And you stay positive, don't go back to work too early, because some people who have, you know, sort of a stressful, busy kind of a work, and they come back to work, and their coworker says, Well, now you're fixed now, right? So we can just work you to death. Okay, no, no, no, no. Don't go back to work too early. Take your time. You'll get setbacks if you go back too early, okay? Be patient. So, I mean, yes, I have a pemp talk, okay. And I think, you know, as I said, many of our patients, they come from across the country. And I make sure to tell them that I will help them for several months after surgery with prescriptions, with medications, with reassurance, because their local cardiologist may be hesitant or intimidated or not knowing what to do when they develop their spasm episode. So, and I think that is critical. They know we're there for them. Eventually they'll graduate to their local doctors. But I'm very careful to sort of discuss this in a good discussion.

SPEAKER_00 56:34

So, now just a little bit different question. You've done an incredible job of the explanation of the bridges and the degrees and the understanding in so many ways, much better than I expected this was going to go. Okay, great. But there's one more thing about you. What do you do with all the stress and all the work that you've got? How does Dr. Ingela Schnitger unwind, relax, enjoy? What do you do when you're not working with the healthcare team?

SPEAKER_01 57:08

Oops, that's a personal question.

SPEAKER_00 57:12

Of course.

SPEAKER_01 57:14

I don't know. I I I guess I have to admit, I I don't have one single hobby that I engage in. I I do work a lot. I mean, I I often, you know, end up reading or writing from home on the weekends, etc. But if you really counter me on it, I like to exercise. I have my own gym. I try to exercise every day or at least five days a week, or I go hiking if I'm on out of town. I like to travel. I have family in Europe. As you may have understood, I'm born and raised in Sweden.

SPEAKER_00 57:52

Sweden, yes.

SPEAKER_01 57:53

Still have family in Sweden, family in France. So I like to spend time with family and visit them. I'm not a gardener, but I I guess that's always like if you if you think that you are going to retire one day, it's like, oh my God, what am I going to do? You know. But I'm not there. I love my job. And as long as you enjoy what you're doing, you keep doing, right?

SPEAKER_00 58:19

I totally agree. And I'm so thankful you love your job and you're still doing it. If there was one thing you would like to leave the audience with for those of us who are really engaged in taking notes on some of the things that you said, what would it be?

SPEAKER_01 58:34

Well, on this topic of chest pain, I would say don't give up. If you have chest pain, and if you have not gotten an explanation for your chest pain, and perhaps not just an explanation, some testing to support the doctor's suspicion and then hopefully some treatment. I mean, if you have GERD and you get a PPI, a proton pump inhibitor and you get better, well, that's that's great, right? But if you have chest pain and you don't get better, you don't get a diagnosis with the treatment, then maybe start to think, can this be my cartoon bridge? Another thing that I always ask my patients is, do you have any family history of heart disease? And then they tell me about valves and fibrillation and this and that. I say, Did anybody have a heart attack? Yeah, my father had a heart attack at age 38. And I said, uh-uh, that's not normal, okay? And so I asked for family history because if a family member has had what I call premature heart attack, then I said, This may be something that is afflicting you too, because you know what? Rages runs in families. I have father-son, mother-daughter, I have clusters of families like that where the kids end up having the same problem as the parent. We have tried to look at what's the genetic pattern for inheritance, and we couldn't nail it down to one gene, but there are really clusters in various families. So if you have been diagnosed with the bridge and your 13-year-old son comes and says, Dad, I get chest pain when I run track. Don't just pat them on the back and say, honey, don't run so fast. Because he may have the same problem you had.

SPEAKER_00 1:00:46

My boys are not going to be thrilled to hear that. But I will I'll be cognizant of any conditions if they say symptom of anything to make sure they act on it.

SPEAKER_03 1:00:57

Yeah.

SPEAKER_00 1:00:58

Dr. Schnicker, I cannot express my gratitude enough for you today. I am blessed to have been a benefactor of something that you started. And I am so appreciative of that, and extremely appreciative of you coming on and speaking with me today as well. So thank you, thank you, thank you.

SPEAKER_01 1:01:19

My pleasure. I enjoy talking to you. I I'm sorry, I didn't I didn't see you when you were in Stanford. I'm happy to see you're thriving. That's great.

SPEAKER_00 1:01:30

Thank you.

SPEAKER_01 1:01:31

Thank you.

SPEAKER_00 1:01:33

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. Imperfect Heart is a production of Hear Me Now Studio.