Episode 4: You Have a Myocardial Bridge, Now What? Dr. Ingela Schnittger Suggests Next Steps (part 2 of 2 episodes)

SPEAKER_01 0:00

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.

SPEAKER_00 0:41

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. Welcome back to the second part of my discussion with Dr. Ingela Schnitker, professor of cardiovascular medicine at Stanford University Medical Center, where she not only practices, but leads a team on myocardial bridge research at the university as well. Let's not waste any time getting back to the program. 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 2:16

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 GURG, you don't have musculoskeletal pain, you don't have percarditis, and hopefully at some point you get either just a simple androgram 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, 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 say, 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, their quality of life is acceptable, then we stop there. If they fail to improve the quality of life, then I go on to the CAF 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 easy 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, you know, journey. And because, as I said, surgery is is major, and you want it to be safe, you want to have reasonable confidence that the person is going to improve it.

SPEAKER_00 7:27

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 7:46

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 my cardiovridge. 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, you know, sensitive to your request, you can go to another cardiologist and ask for a referral. 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, you know, a second opinion. They may not, my understanding, do that many surgeries, but they certainly can can evaluate. I think that you have to say that they have the knowledge to assess the myocardial bridge.

SPEAKER_00 9:21

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 9:38

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 study them in the CAF 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 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. Haha, that's the problem. That's the problem. Because, okay, so people argue that the stent will keep the vessel open so that when the heart contracts, then 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 systone 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. 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. I would recommend to any institution that wants to get into the bridges to create a team and do a careful preoperative assessment like we have outlined, and stay with one surgeon if possible, 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 14:21

I did, yes.

SPEAKER_01 14:23

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 14:52

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 15:08

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, you know, control bleeding. I mean, this I'm getting pretty granular here, but it is a big topic though.

SPEAKER_00 15:54

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 good to discuss.

SPEAKER_01 16:06

Yes, no, it's good to discuss. And we do about half of our patients are probably nine 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 and it also is easier if you don't have to go on the cardiovulmonary 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 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 17:38

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 18:07

I make an effort to personally uh 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 gonna 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 stenotomy, no front seat passenger, okay? Hold on to your pillow, okay. And then you start cardiac rehab at 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 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 21:31

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 Doctor Ingela Schnitger? Unwind, relax, enjoy. What do you do when you're not working with the healthcare team?

SPEAKER_01 22:05

Oops, that's a personal question.

SPEAKER_00 22:08

Of course.

SPEAKER_01 22:11

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 22:49

Sweden, yes.

SPEAKER_01 22:50

Still have family in Sweden, family in France. So pandemic has put a dent in that, but 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 23:19

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 23:33

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 a treatment, then maybe start to think: can this be a myocardial 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 25:45

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_01 25:57

Yeah.

SPEAKER_00 25:58

Dr. Schnecker, 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 26:19

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

SPEAKER_00 26:30

Thank you.

SPEAKER_01 26:31

Thank you.

SPEAKER_00 26:33

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. 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.