Reyna Robles was always the first one up and the last one to bed, the
kind of person whose warmth and energy seemed effortless, possessed of
more than enough steam to come home from her full-time job, to select
recipes from her large collection of cookbooks to prepare a meal for
her husband and children, and then to take her dogs for walk and help
her kids with homework. Before bedtime, she'd fit in a good work out.
She wasn't one to complain, either, except the spring day when she
suddenly felt a pain in her chest as she exercised. It was a
cramp-like pain, not anything like the normal muscle aches Robles
expected from her body after vigorous activity. "I didn't think I
should be feeling chest pains," she said. She wasn't even 40.
She saw her doctor, who ordered an EKG. Everything was fine, Robles
was told. Nothing was wrong with her heart. But the pain kept coming
back, and that worried her. "Exercise should feel good," she
said. "It shouldn't hurt." She went back to her doctor, who
ordered more tests. Still nothing, she was told. Soon, she started
feeling the pain even when she wasn't exercising. "I intuitively
knew something wasn't right," she said. Still, none of the
doctors she saw could discern a problem. And she began to doubt
herself, "although I knew I wasn’t imagining it. It was
With no answers and no end to the pain, Robles' whole view of life
was gradually permeated by the uncertainty of her health. "I'm
normally very positive, very bubbly and cheerful," she said,
"but I felt like a shadow of my former self. All I could think
about was my chest pain." By winter, she'd become desperate for
help and went online to find it. She connected with a group of women
who had experienced similar symptoms. One of them was a patient of Jennifer
Tremmel, MD, Clinical Director of the Stanford Hospital Women's
Heart Health program, just celebrating its fifth year in service.
In Tremmel, Robles found someone whose focused interest and
knowledge of heart disease in women became the key to solving her
medical mystery. "For years, the standard medical treatment for
women with heart disease was based on what we know about heart disease
in men," Tremmel said. "That's really confounded things. In
the past 30 years, we've learned a lot about how women differ from
men, but there's a lot we still don’t know. Just getting physicians to
have a broader concept of symptoms, and what constitutes coronary
artery disease in women, is a challenge."
Robles is a classic example of the challenge, in several ways. Her
first EKG, stress test and angiogram were deemed normal. "What we
have found is that stress tests, and even angiograms, may not always
identify the problem in a woman's heart", Tremmel said. "If
a lack of blood flow through the entire thickness of the heart muscle
is needed to have a positive stress test, those patients with symptoms
from a lack of blood flow to only the inner most lining of the heart
may not be caught."
Similarly, Tremmel said, angiograms catch only blockages in large
vessels, but patients, particularly women, may have a problem like
endothelial dysfunction, which affects small vessels whose failure to
work properly can't be seen on angiography.
Robles came to Stanford as many do, having been told no abnormalities
had been found. Yet her symptoms were still there. "We decided
we'd look harder," Tremmel said. "We did all this extra
testing to see if we might find something that had been missed on her
Tremmel discovered that Robles had a physical anomaly called a
myocardial bridge, where an artery that normally sits on top of the
heart actually dives down into the heart muscle. Such bridges are not
uncommon, and most people can live their entire lives without
symptoms, but if a large portion of the artery is deeply buried, then
there's trouble. Again, however, this physical abnormality often
doesn't show up on an angiogram.
What we have found is that stress tests, and even angiograms, may not always identify the problem.
- Jennifer Tremmel, MD, Clinical Director, Women's Heart Health at Stanford
Finally, with no other options left, Tremmel began to consider a
surgery to release the artery from the muscle. "The surgery
itself isn't complicated," she said, "but it is open heart
surgery where you open the chest and expose the heart. It's a big
deal. But for patients who have a poor quality of life, and you can't
find any other way, it's a viable option."
Before the final decision was made, Tremmel wanted to do one more
test. She inserted a wire into Robles' artery, while stressing her
heart with medication, to measure the pressure and flow, on that one
particular part of her heart's anatomy. "The test proved that the
bridge was definitely the problem," Tremmel said. Tremmel’s
colleague, cardiovascular surgeon Michael
Fishbein, MD, made the repair to Robles' heart.
Less than a month after her surgery, Robles was taking small but
steady steps toward a more active life. After so many months of living
with fear and uncertainty, Robles' belief in the strength of her
repaired heart has been helped along by Tremmel's gentle
encouragements. Robles worried aloud at a recent exam about some
enthusiastic laughing she'd done with one of her daughters, so
exuberant that her chest began to hurt. Tremmel pressed her
stethoscope against Robles' chest for a close listen.
"It sounds like a happy heart," said Tremmel. "You can
laugh as much as you want."
"I'm so very grateful to her," Robles said, "and to
my whole care team at Stanford. I will never stop being grateful. I am
blessed every day. It can be difficult to find a doctor willing to
listen. Dr. Tremmel never ever gave up."
"We pride ourselves in taking the time to really figure out
what's going on," Tremmel said, "and not just saying there
are no blockages, that everything must be fine. The technique we use
in the cath lab, for instance, is available to any physician out
there, but it's really a matter of learning how to do these things and
taking the time. It is more time consuming than a simple angiogram."
Beyond accurate diagnosis, she said, "you also have to stick
with your patients. There's no magic bullet to make them feel better.
It's a multi-factorial approach of using medications that improve
symptoms, as well as encouraging lifestyle changes and stress reduction."
"The Stanford Women's Heart Health program staff includes a
psychologist," Tremmel said. "There's a great deal of
emotional stress that comes along with having these symptoms that
nobody could explain for a long time. That in itself is a huge burden.
A lot of women come to us with years of having people tell them,
'There's nothing there.' They doubt themselves and have really been
affected by that. I think addressing all these factors is