Understanding a woman's heart means knowing what to look for (2023)

Reyna Robles was always the first to get up and the last to go to bed, the kind of person whose warmth and energy seemed easy, possessing more than enough energy to come home from her full-time job, to curate her vast collection of cookbooks to cook a meal for her husband and kids, then walk the dogs and help the kids with their homework. Before bed, she would fit in a good workout.

He wasn't one to complain either, except one spring day when he suddenly felt a pain in his chest while exercising. It was a cramp-like pain, not at all like the normal muscle aches Robles expected from his body after vigorous activity. "I thought I shouldn't have chest pains," he said. She wasn't even 40 years old.

She went to the doctor, who ordered an electrocardiogram. All was well, Robles was told. There was nothing wrong with his heart. But the pain kept coming back and it worried her. "Exercise must be good," he said. "It shouldn't hurt." He went back to see his doctor, who ordered more tests. Nothing yet, they told him. Soon, he started experiencing pain even when he wasn't exercising. "Intuitively, I knew something wasn't right," he said. Still, none of the doctors he consulted could pinpoint a problem. And she began to doubt herself, “although I knew I wasn't imagining it. It was real."

deceptively normal

In Tremmel, Robles found someone whose interest in and knowledge of heart disease in women became the key to solving his medical mystery. "For years, the standard medical treatment for women with heart disease was based on what we know about heart disease in men," said Tremmel. “This is really confusing. Over the past 30 years, we've learned a lot about how women differ from men, but we still don't know much. coronary artery disease in women is a challenge.

Robles is a classic example of a challenge, in many ways. Her first EKG, stress test, and angiogram were all found to be normal. "What we found is that stress tests, and even angiograms, can't always pinpoint a woman's heart problem," said Tremmel. "If a lack of blood flow throughout the entire thickness of the heart muscle is required to obtain a positive stress test, patients with symptoms of lack of blood flow only in the innermost lining of the heart may go undetected."

Likewise, Tremmel said, angiograms only detect blockages in large vessels, but patients, particularly women, may have a problem such as endothelial dysfunction, which affects small vessels whose failure to function properly cannot be detected.

Robles came to Stanford as many do after learning that no abnormalities were found. However, symptoms of it were still there. "We decided we were going to look further," said Tremmel. "We did all these additional tests to see if we could find something that was missing from her original angiogram."

Tremmel discovered that Robles had a physical abnormality called a myocardial bridge, where an artery that normally sits at the top of the heart actually dips into the heart muscle. These shunts are not uncommon, and most people can live their entire lives without symptoms, but if a large part of the artery is buried deeply, there will be problems. Again, however, this physical abnormality often does not show up on an angiogram.

problem discovered

Finally, with no other options, Tremmel began considering surgery to free the artery from the muscle. "The surgery itself is not complicated," he said, "but it is open-heart surgery, where you open up the chest and expose the heart. It's a big problem. But for patients with poor quality of life, you can. .. If you can't find another way, it's a viable option."

Before making the final decision, Tremmel wanted to do one more test. She inserted a wire into Robles' artery, while pressing medication into his heart, to measure pressure and flow in that specific part of his heart's anatomy. "The test showed that the bridge was definitely the problem," said Tremmel. Tremmel's colleague, cardiovascular surgeonDr. Michael Fishbein, repaired Robles' heart.

Less than a month after the surgery, Robles was taking small but steady steps towards a more active life. After so many months of living in fear and uncertainty, Robles' confidence in the strength of his mended heart was bolstered by Tremmel's gentle encouragement. Robles worried aloud in a recent exam about some enthusiastic laughs she had shared with one of her daughters, so exuberant that her chest started to ache. Tremmel pressed his stethoscope against Robles' chest to listen carefully.

"Sounds like a happy heart," said Tremmel. "You can laugh all you want."

Re-entry

"I am so grateful to her," Robles said, "and to my entire care team at Stanford. I will never stop being grateful. I am blessed every day. It can be difficult to find a doctor who is willing to listen. Dr. . Tremmel never gave up.”

"We pride ourselves on taking the time to really find out what's going on," Tremmel said, "and not just saying there's no blockage, everything should be fine. The technique we use in the cath lab, for example, is available to any doctor, but it's really a matter of learning to do these things and taking time. It takes more time than just an angiogram."

In addition to an accurate diagnosis, he said, “you also need to follow up with your patients. 🇧🇷

"Stanford's women's heart health program staff includes a psychologist," said Tremmel. "There's a lot of emotional stress that comes with these symptoms that no one could explain for a long time. That in itself is a huge burden. Many women come to us with years of people telling them, 'There's nothing there. ' They doubt it. themselves and were really affected by it. I think addressing all those factors is important."