Cardiac ischemia

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. I’ve 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 wasn’t 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 “exercise”. 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 that’s not helpful to the time-crunched athlete. Am I allowed to continue with HIIT or not? Can i still compete and push for PRs? There’s a different mindset when exercise goals switch from performance to general cardiac health, eliminating Z4 and 5 and staying in Z2.

So here’s 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. He’s about 3 weeks into his recovery. He is 44. I wouldn’t ignore chest pain during your cycling or other exercise, it’s not normal, even at maximal HR.

  1. 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.

I’m 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 couldn’t possibly answer any of these questions. You haven’t even stated your age. We don’t know your medical background. We also don’t know the nuts and bolts of the tests you’ve had done.

I’d be very wary of taking advice from anyone online about this topic. I do like RecoveryRide’s answer, and I agree with him.

Wishing you all the best.


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 if… among other endurance athletes.

Totally understand if a written forum doesn’t allow for that kind of distinction.

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#4 - Yes absolutely. There is more to life than amateur racing. Setting one’s 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 can’t imagine any sane person would say “no” to #4. Regarding #2 and #3, I’m not sure why you’d want to push it if something is actually wrong.

My reference point here: I’ve raced IM Hawaii and am still at the pointy end of the overall amateur race at 70.3s and IMs. I’ve 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 isn’t something worth considering.

I finally tracked down a “sports cardiologist” after bumping into some of the same issues you bring up here and I wish I’d done it sooner.

I would’ve thought the answer to question #1 would be obvious.

I’ve 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 doesn’t see a lot of ‘athletes’. Suggested cutting back 30% of volume to minimize more enlargement. Seems kind of random to me and I’ll 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. There’s 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 that’s my situation and one doctor - obviously not advice for ANYONE else. I’m personally curious to know what you find out.

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Thank you for the replies. This is kind of my point. Most cardiologists would look at my data and say, “you’re fine. Just don’t push it and listen to your body.” But that’s actually not a helpful answer to me.

42 y/o male. Started training about 10 years ago. I don’t race to win, I race for PRs. I’ve 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). I’m 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 don’t want to be the athlete that has a sudden cardiac event during a hard effort. If it’s time to be done, I’ll be done.