CAUTION: Long, personal story to lead into the questions. Please skip to the questions if you have zero interest in the story.
Last summer i was doing a run with intervals where i tried to push myself after listening to some stuff on David Goggins and listening to the book Endure. My body said stop, but I tried to turn off that central governor and kept pushing. I started to feel a slight twinge of pain in my chest. I had felt this pain before, but it was very intermittent and not even every time I achieved max HR. In my state of exercise delirium, I told myself that if some skeletal muscle ischemia is good for you, maybe some cardiac ischemia is as well? (Clearly a joke.). I asked my buddies if they ever felt this kind of pain at the highest levels of their HR, and they said no. So after doing the AZ IM Half, i shut things down. Iāve been doing Z2 work until I could get my cardiac work up done.
I got the results of my echocardiogram back yesterday, and was a little surprised to find that I do have some ST changes at higher heart rates on my EKG. (Indication of cardiac ischemia). My echo pictures were totally normal. My pulse and HR climbed and fell as they should, and I was pleased to find I wasnāt suffering when it was time to do the post-exercise echo as I had been told happens.
I have a follow-up with a cardiologist this Friday. But the problem I have found is this. Bread-and-butter cardiologists have really no idea what endurance athletes put themselves through. Repeat intervals of VO2 max, taking your HR into its upper limits, is not what a cardiologist thinks of when they hear āexerciseā. Additionally, the vast majority of cardiac patients are clearly unhealthy, and I felt like my previous cardiologist and his staff looked at an endurance athlete with derision, like, why in the hell are you even here?
So most cardiologists are going to sign off on my case and say, just be mindful of what you are doing and listen to your body. But thatās not helpful to the time-crunched athlete. Am I allowed to continue with HIIT or not? Can i still compete and push for PRs? Thereās a different mindset when exercise goals switch from performance to general cardiac health, eliminating Z4 and 5 and staying in Z2.
So hereās the questions:
1.) Would you go with the opinion of a well-known and respected cardiologist in your area, or would you actively pursue a cardiologist who understands endurance athletes?
2.) Would you hang up your racing career for some intermittent cardiac ischemia, or just be mindful of not pushing into Z5 often?
3.) What if the trade off was continue racing, but get repeat stress tests annually and call it quits when you start showing wall abnormalities?
4.) Could you give up racing and change your mindset to exercise for overall health and wellness and not performance?
A friend was suffering chest pain during his cycling but not at other times. Eventually had an angiogram and they discovered a coronary artery was 90% blocked. Required open heart surgery as blockage near a junction and not suitable for a stent. Heās about 3 weeks into his recovery. He is 44. I wouldnāt ignore chest pain during your cycling or other exercise, itās not normal, even at maximal HR.
I would find an excellent cardiologist with experience working with endurance athletes, and let him answer questions 2-4 for me. Good luck and let us know how it goes.
Hi,
Iām a practicing doctor but not a cardiologist.
I have previously suggested that threads like these should not be allowed on the forum. But anyway.
We couldnāt possibly answer any of these questions. You havenāt even stated your age. We donāt know your medical background. We also donāt know the nuts and bolts of the tests youāve had done.
Iād be very wary of taking advice from anyone online about this topic. I do like RecoveryRideās answer, and I agree with him.
I realize it sounds like I am asking for medical advice. I am not. I will get my medical advice from a well-respected cardiologist on Friday. I am asking a What would you do ifā¦ among other endurance athletes.
Totally understand if a written forum doesnāt allow for that kind of distinction.
#4 - Yes absolutely. There is more to life than amateur racing. Setting oneās own goals and challenging oneself within health parameters is just as admirable as owning the KOM on Mt. Ventoux. A friend of mine lost over 250 lbs cycling, talk about discipline and determination.
How long have you been involved in endurance sport?
Really #1 is the only question worth asking. I canāt imagine any sane person would say ānoā to #4. Regarding #2 and #3, Iām not sure why youād want to push it if something is actually wrong.
My reference point here: Iāve raced IM Hawaii and am still at the pointy end of the overall amateur race at 70.3s and IMs. Iāve been doing the sport 20 years and a few years back had what I thought was a heart scare. I had zero issue saying goodbye and have no doubt I could do so permanently with walks in the mountains and SUP as my exercise.
I ask about your time in the sport because I guess I can remember when I was in my early 20s thinking similarly, maybe(?), but performance in amateur sport as a trade off for running any known risk to my heart isnāt something worth considering.
Iāve gone thru something similar recently and understand your line of questioning. As for #1 - yes find a well respected cardiologist and a sports oriented one if possible. I ended up in a cardiologist office after some iffy scans then an abnormal ECG (AV block). All 4 chambers have enlarged - he was honest that their practice doesnāt see a lot of āathletesā. Suggested cutting back 30% of volume to minimize more enlargement. Seems kind of random to me and Iāll get to a sports cardio soon. I have cut way back BUT the conversation also turned to the value of aerobic exercise and to not stop completely. Thereās a delicate balance to achieve here. I asked him about Z2 vs Z4/5 and his statement was that the heart impact going from brisk walking to Z2 is greater than the impact of Z2 to Z4/5. So focus on volume reduction more than intensity reduction was the guidance - again thatās my situation and one doctor - obviously not advice for ANYONE else. Iām personally curious to know what you find out.
Thank you for the replies. This is kind of my point. Most cardiologists would look at my data and say, āyouāre fine. Just donāt push it and listen to your body.ā But thatās actually not a helpful answer to me.
42 y/o male. Started training about 10 years ago. I donāt race to win, I race for PRs. Iāve been enjoying steadily dropping my times in local sprint and Olympic triathlons until Father Time catches up. I love swimming and cycling and barely tolerate running. I occasionally do group rides and non-USAC bike events. At my fittest, I did a 4:35 El Tour de Tucson in 2019 (closed course 100 mile Gran Fondo). Iām that triathlete who can be dangerous in a peloton. My enjoyment comes in continuing to improve my best performances in a given race or ride. I want to continue to improve my performance at the sprint and Olympic distances. But of course I donāt want to be the athlete that has a sudden cardiac event during a hard effort. If itās time to be done, Iāll be done.
Just read your post about possible ischemia. When I was 60, began to get slight feelings similar to yours. Laid off training for a couple years for unrelated reasons, only to start up again and have much more significant discomfort than before, even after getting back into shape.
Long story short, I had significant blockage in my LAD and after postponing it for some time, ended up getting 2 stents. To me, the prior discomfort was just those early indications of the same problem.
I assume you got resolution of the situation by now.
Interesting newer test is the CT FFR ā¦or is it FFR CT which is a enhanced version of CT angiography.
Not only shows the blockages but give them a useful score.
Donāt believe trim and ultra fitness can overcome blockages.;
Iām on a strong statin and huge alteration in my diet. (and important, avoid any of those ācarnivoreā diet sites that are all over the place.)
@HivaOa47 Is it the āCoronary Artery Calciumā (CAC) test that is often self-pay like $99? I had one a few years ago based on family history and it was around 147, focused on the LAD being a moderate risk.
I retested a few years later when appealing an increased life insurance premium and found the CAC value doubled. I was told thatās due to the soft plaqueās hardening and being more stable and dense which raised the score. Also was told one really shouldnāt retake those scans as they are unreliable after the initial one.
Iām doing TR to reverse any long term risks that my ancestors took for granted
You did not mention your age. When I was age 64 my CAC score was 65 which was at the 52nd percentile āfor subjects of the same age, gender, and ethnicity who are free of a diagnosis of cardiovascular disease.ā
Iām guessing your first test was at a younger age. āa few years laterāā¦your score was about 300.
Age is important, but having said that, you have active build up at any age. Not off the charts, but a indication that you need to be addressing the situation.
The question isā¦not just your age, but when you were made aware of the score what changes have you made? What meds (statins) are you on and how have you changed your diet.
Any other tests? What was the latest lipid panel you had done for Total cholesterol and LDLā¦etc.
LDL is the more important number.
Those test results, your meds, and your diet are important.
Please donāt fall into the idea that doing TR (cycling) is going to make anything āreverseā.
In fact training is going to have far less impact on your cardio-vascular future than is your diet and meds.
Have you seen a cardiologist or only your primary care doctorā¦ What did he/she tell you about your score and your lipid panel testing (TC, LDL, HDL, Triglycerides)ā¦ as well as your diet.
Again, to repeat, what is your age at first test, second test (CAC, and your current age.
You are right, most doctors donāt suggest you repeat the CAC test once it shows there is a potential problem.
Yes, the soft plaque is turning into calcified plaque, BUTā¦that does not mean there isnāt new areas that are building up soft plaque in areas that are then more dangerousā¦
Take a look at this important calculator dealing with risk and your CAC score MESA Risk Score and Coronary Age Calculator".
Lastly, to repeat over and over, diet, meds, and such have more impact than cycling 200 miles a week. Also if you have it, make note of where your calcium was located. Often it can be mostly in the LAD (left anterior descendingā¦aka, āthe widow makerā
Oh yesā¦the CAC score you got was not from the CT Angiography nor the CT-FFR. Those are much more involved and very expensive.
But the $99 type CAC score is very useful and subjects you to far less radiation.
Thanks for the reply. Without revealing too much in a publicly readable forum, first test was at age 51 score 147; second test age 54 score 336. Been on statins for many years and changed doctors right before the pandemic who added a BP and LDL med. Dropped 40+ pounds (155 current) and maintaining an LDL under 70. Diet changed to maintain the weight and height of 5ā 5ā.
I had the misconception that losing the weight and cycling would improve the CAC score so I retested, not knowing it wouldnāt be accurate. Cycling has improved many things for me over the past 5 years and TR especially with some structured workouts.
I was having chest pain at times but only during really hard intervals. I ended up getting a āCTAā, and it showed that I had an undersized vessel in my heart, and I was literally exercising/training to the limit that vessel could provide blood. I found that had an internal governor and started backing down. Now, back riding hard, Ive hit that point a couple of times. Is it something? Yes. Will it cause problems? My cardiologist said no, unless it continues after I slow down. Other than that, everything else checked out perfectly, no value issues, regurg, etc, and vessels clean too. (Might get it again if I can just to see if anything has chanced)
60yr old male, 25+ yrs of local racing/training/Max HR 184. Had ablation 10yrs ago, no meds all has been good but notice that up around 170-175 I have bouts of breathlessness have to back off, but still go hard after recovery. Went into new cardiologist because mine was retiring. He immediately requested stress test, no blood work, and no review of previous stress test the year before (which was perfect). There was an 1-on the ischemic index which automatically put me in the category suggesting there is a lack of blood supply. I not been feeling well, in hind sight should have cancelled the stress test, I mentioned this after getting the results and they said it would not have impacted the stress test results. The cardiologist now wants a CCTA - which will require exposure to radiation, which I really do not want - has anyone ever requested a redo on a stress test? Iām pretty much asymptomatic, do not want CCTA, but also a little concerned. I asked doc about exercising, that I had events planned, he said full steam ahead, just back of if you get chest painā¦is the CCTA really necessary? Has anyone had doctors jump right to this?
First of all, Iām not a doctor. Just someone who has gone through a similar investigation around age 60 and eventually getting two stents 8 years ago.
It seems unusual that you had the stress test in the prior year and then another one now. Why did they do the original one as there is not much value in doing them on everyone, without even having symptoms. Donāt think anyone would suggest a āredoā because the test is not all that definitive anyway. Plus if one is positive and the next negative, which one do you assume is correct?
How long ago did you do a lipid panel ( for your Total Cholesterol, and especially your important LDL).
You might ask the new cardiologist if he could use the newer CCTA, which is FFR-CT which in some gives a more precise measure of each arteryās blood flow.
However most doctors donāt yet have access to that new test.
I suppose you could just wait and see what develops. Your doctor seems OK with that.
Ever get low radiation CAC calcium score test? Interesting but doesnāt replace a CCTA.
Longer term, driving your LDL below what is often called "normalā is beneficial. Normal bloodwork in a nation where heart disease is the leading cause of death is not comforting.
One thing I know from experience is that cycling doesnāt guarantee a healthy heartā¦
Well, it is a ridiculous requirement but if you change physicians, or are referred to a different group, they will often ārequireā some or all basic tests to be redone at their facility. Some of that is actually necessary as their equipment might be more advanced for what they are looking for. I ran into that a couple of times, and was occasionally able to get the referred provider to take the existing studies. It wasnātā exactly easy, but our local hospital isnāt a ramshackle shed in the middle of a corn field. And yeah, depending on the equipment used, the type of test might not be what they are requiring. I had 2 stress tests done within months because the basic test, I failed, didnāt have all of the telemetry the referred specialist wanted, so I did it again, and failed it again, and they had enough info to know why, and what my heart was/wasnāt doing.
But to redo things like blood tests and MRIās and x-rays is silly. To do the same MRI study just because itās on their equipment (same brand and model as the first study) was insurance abuse! āItās the same study, done the same way! NO I will NOT redo that just to give your practice more profit!ā. There are times to say noā¦
Thanks for the feedback - my last bloodwork for Lipids was 2022 - cholesterol - 177, Tryglycerides - 59, HDL Cholesteral - 91, Calculated LDL CHOL - 72, Calculated VLDL - 14.0, Risk Ratio LDL/HDL - 0.79 - always had good bloodwork -
And yeah, depending on the equipment used, the type of test might not be what they are requiring. I had 2 stress tests done within months because the basic test, I failed, didnāt have all of the telemetry the referred specialist wanted, so I did it again, and failed it again, and they had enough info to know why, and what my heart was/wasnāt doing.