Living With Chest Pain: Myocardial Bridges Explained

If you walk into an emergency room and report chest pain, you almost guarantee a bump to the front of the line. But my mother-in-law was told to push through her chest pain and go about her life. Why? She has a myocardial bridge.

My mother-in-law first experienced chest pain and shortness of breath with activity almost 20 years ago. After about a year, she saw a cardiologist, but all her tests came back normal, and she kept living with ongoing symptoms. Finally, in 2015, a cardiac catheterization procedure showed a myocardial bridge — heart muscle tissue surrounded and squeezed one of her heart's blood vessels (instead of it resting on top of the muscle). 

Her cardiologist started her on some medications and ordered cardiac rehab to strengthen her heart, but as her chest pain continued, she was told nothing else could be done. Then, in early 2024, her symptoms grew more severe. She experienced dizziness, worsening chest pain with activity and even episodes of chest pain at rest.

After another cardiac catheterization, her cardiologist told her the results meant she was in no danger of further complications other than her pain, and encouraged her to live with it.

As a nurse who had never heard of a myocardial bridge, this concerned me. She didn't much like the idea either and quickly found a support group online full of people who were experiencing the same symptoms but left without answers from their medical providers. 

One person in the support group was Jeff Holden, who was diagnosed with a myocardial bridge in November 2021 and now produces a podcast called "Imperfect Heart" to educate the public about the condition and provide support for those with it. I spoke with Holden, who confirmed many medical practitioners are still unfamiliar with this condition, which can make it difficult to get an accurate diagnosis and treatment.

When you have a myocardial bridge (MB), a coronary artery is partially covered by heart muscle. Just like the rest of your body, your heart muscle needs oxygen, and your coronary arteries deliver it through blood. If you have an MB, you were born with it, and although about 30% of people have this congenital anomaly, most never experience any symptoms. 

With a MB, when your heart beats, the muscle tissue can squeeze the part of your coronary artery that sits within the heart muscle during each heart beat (or contraction). Blocking flow through a blood vessel like this is a serious problem, but even though that artery gets temporarily blocked, it opens up as soon as the heart finishes that beat, and delivers its oxygen.

However, for some people, MB can lead to long-term changes in the blood vessels that reduce blood flow to the heart muscle. Newer research suggests myocardial bridges can be associated with ischemia (low oxygen delivery), chest pain, artery narrowing, higher risk of coronary artery disease near the MB site and coronary artery spasm, which can all cause symptoms like those that my mother-in-law experiences.

Most people feel no effects from a myocardial bridge, but for those who experience myocardial bridge symptoms, they can include:

• Chest pain with activity or stress
• Dizziness
• Heart palpitations
• Cardiac arrhythmias
• Shortness of breath

Studies on myocardial bridging are still fairly new, but in one study of 30 patients with a symptomatic MB, researchers found over 90% of subjects were not efficiently delivering oxygen to their heart muscle during exercise. 

If you come to your health care provider or an emergency room complaining of chest pain, they'll likely first do some tests to check that you're not experiencing a serious cardiac event like a heart attack. But to diagnose a myocardial bridge, your provider may use tests like:

• Stress test: Elevates your heart rate with exercise to recreate the conditions that cause your symptoms while your provider monitors your heart rhythm.
• Coronary angiogram: Allows your provider to see how blood flows through your arteries using dye.
• Intravascular ultrasound: Uses sound waves to create a picture of your blood vessels.
• Cardiac computed tomography angiography: Takes a detailed 3D picture of your heart and blood vessels.

Myocardial bridges are getting diagnosed more often because of more advanced imaging techniques, and diagnosis typically involves more than one test. For example, my mother-in-law passed her initial stress test, but her MB was diagnosed during a cardiac catheterization. 

Sometimes, plaque builds up to one side of an MB, which increases your risk for cardiac events like heart attack and stroke. Even though your chances of serious outcomes are slim, it may still feel frightening to know it's a possibility. 

"Nearly 40% of people will have chest pain at some point in their lives," says Samit Shah, M.D., an interventional cardiologist with Yale University School of Medicine in New Haven, Connecticut. "And when you have discomfort in your chest, it can be unsettling and it drives a lot of people to the emergency department."

Although some people with myocardial bridges have experienced serious cardiac events, research hasn't proven that myocardial bridges can cause sudden cardiac death, says Shah, who adds, "We know myocardial bridges have been recognized for almost 50 years in terms of scientific literature, but we've never been able to associate that with a quantifiable risk of sudden death."

That said, chest pain is never something to ignore. For people who have symptoms with an MB, they need a thorough and systematic workup to understand if their condition could threaten their life in any way, says Shah. But once safety is established, symptom management is key. "I think that's important for patients to understand, if somebody says I have a myocardial bridge, what does my life look like?" says Shah. Here's where treatment can help.

If you experience symptoms like chest pain with a myocardial bridge, you have several treatment options, including medications and surgery. 

As a first step, your provider may recommend certain medications to prevent artery spasm, like calcium channel blockers. Some common calcium channel blockers include amlodipine (Norvasc) and diltiazem (Cardizem). Beta blockers like atenolol (Tenormin) and metoprolol (Lopressor) keep your heart rate from getting too high and can help keep your artery open. 

My mother-in-law took beta blockers, which helped a little, but still didn't entirely stop her chest pain. If your medications don't decrease symptoms, stop working, or cause too many side effects, your provider may recommend surgery. In the past, cardiologists and surgeons have tried placing stents or performing cardiac bypass surgery, but these methods weren't really designed for this issue and may not provide lasting symptom relief. 

A newer procedure called surgical myocardial bridge unroofing can expose the buried artery by removing or moving the heart muscle covering it. According to Stanford Medicine, this method is safe and effective, and research shows it can increase blood flow to that artery and decrease or eliminate symptoms.

Some physicians aren't yet aware of this condition or its treatment options, and even for providers who treat MBs regularly, treatment paths can vary by institution, Shah says. "When somebody has symptoms that are either unappreciated or undiagnosed, but bothersome to them, they should seek further evaluation," says Shah, who is currently leading a multi-center clinical trial across the United States called DISCOVER INOCA. 

This trial, which is run by the Yale Cardiovascular Research Group, will include 500 patients with symptoms such as chest pain or shortness of breath in the absence of blockages. This includes patients with myocardial bridges, and the researchers will assess the association between MBs and vascular disease, artery spasm and symptoms over five years. Anyone interested in participating can ask for a referral from their provider to a medical facility that's enrolling patients, which can be found on clinicaltrials.gov.

Abby McCoy is an RN of 16 years who has worked with adults and pediatric patients encompassing trauma, orthopedics, home care, transplant, and case management. She has practiced nursing all over the world, from San Fransisco, CA, to Tharaka, Kenya. Read More