Is this exercise-induced asthma? Or...

[scottyjames]

Thought I'd pitch this out there and see if anyone has experienced something similar.

I'm 51, fit, longtime rider/runner/skier, never smoked, never overweight, etc. A couple months ago I experienced serious chest pains while riding to work in the morning (15 miles, mostly flat). It came on over the course of several minutes; it was a sharp ache throughout my entire chest, accompanied by a really uncomfortable ache in my left arm. I'd experienced some of the arm stuff before, but never the chest. I got myself to a doc asap and was put through a bunch of cardio tests: EKG, stress test, etc. Heart is fine, no signs of blockage, no other indicators of a problem. Chest xray was clear. Stayed off the bike for about 3 weeks while all this testing was going on, and with doc's permission started up again, though without a concrete diagnosis.

Since then a pattern has emerged. When I ride in the morning, I can only push my cardiovascular system to a certain point, one that's far short of my red line. It's the same sensation as before: a slow building ache in my chest that becomes a big sharp ache (not sure how else to describe it), and that nasty sharp ache the length of my left arm. If I soft pedal it all goes away after a few minutes. But once it starts it doesn't take much effort to fire it up again. Climbing hills is almost guaranteed to set it off. It's often accompanied by light-headedness and the feeling like I have absolutely no gas in the tank -- no pop in the legs at all, which would see to be a symptom of being oxygen-deprived.

Here's the thing: Mornings are hell, but I can ride home in the afternoon with no problem at all. Nothing. I can hit the uphills as hard as I want with no discomfort in my chest or in my arm. No sense of lightheadedness or fatigue. My hospital stress test was in the afternoon, and I went deep into the red trying to trigger the beast, but no go.

Before anyone says "just ride in the afternoon," I'm way ahead of you. But the days are about to get short, and that'll no longer be an option. Morning is it. And besides, that's not really the point.

I discussed the possibility of asthma, exercise-induced and otherwise, with the doc, but he wasn't convinced: there's none of the coughing or wheezing of asthma, and I don't really feel like the problem is getting air into my lungs. I can still take a deep breath when I'm having my attacks, but the problem is that it can hurt enormously to do so. I've experimented with my wife's asthma inhaler, but so far it's had no effect. I've never experienced an attack that wasn't exercise-related.

So I'm not convinced it's asthma. I'm also not convinced that nothing's going on with my heart. Some kind of chest wall malady? Stress I don't realize I have? Bacterial infection from that river in Maine we probably shouldn't have swam in earlier this summer? Clueless at the moment, but gearing up for phase II of diagnosis. I've begun the process of getting referrals to other cardio-pulmonary experts -- I live in Boston and had my cardio work done at MGH -- for lung capacity testing, more consults, etc. Clearly this thing isn't going away on its own, and I'm not inclined to wait.

Does any of this sound familiar to anyone? What's up with the AM / PM discrepancy in my ability to tax my CV system? What questions should I be asking the medical establishment?

If you've waded through this entire dump, thanks. Any suggestions welcome.

Scott

[jmeloy]

So I've had a little of both... ex-induced asthma and concerns about the heart. I NEVER got the pain you did but my daughter who has ex-induced asthma will get it once in a while. Mine is extreme shortness of breath on exertion. My resting BP is 120-80 but when I exercise hard it would go over 200 on the top end. Treadmill test identified it.
Now on light BP med to lower my overall and breathing is much better. That left arm pain would worry me.

[christian]

Do you wear a HRM? Is your heart beat normal/steady while you exert yourself? This would have me pretty worried.

Any chance you can do another test in the AM?

[67-59]

You might also want to pursue the question of whether it's stress or anxiety related.

I started getting symptoms about a year ago -- some similar, some different from what you're experiencing. They were oddly present at some times of the day, and absent at others...even when there was no obvious difference in my activity. After ruling out the likely physical/physiological causes (TONS of cardiac, GI and other tests at the Mayo Clinic), my docs suggested stress and anxiety as possible causes. I thought they were nuts -- but it turns out they were right. I'm still working to get totally back to "normal" (whatever that means), but I have made a lot of progress, and am no longer dealing with anywhere near the level of symptoms I had last year.

Probably at least worth asking....

[slidey]

Being an asthmatic, I don't think it's asthma at all.

As for the AM/PM discrepancy, I've observed that the nasal passage is not all-clear in the mornings and it gets clearer of its own accord as the day progresses. I would try to clear the nasal passages every morning without fail, and see if it has any improvement.

How do you know your nasal passage is blocked? Block the left nostril with one hand, breathe deeply in/out of just the other one and alternate...the blockage, if present, should become apparent.

How do you clear the passage? Again, block one nostril and sniff water in, and blow through the other. Alternate. Do this a few times every morning.

Hope this helps.

Thought I'd pitch this out there and see if anyone has experienced something similar.

I'm 51, fit, longtime rider/runner/skier, never smoked, never overweight, etc. A couple months ago I experienced serious chest pains while riding to work in the morning (15 miles, mostly flat). It came on over the course of several minutes; it was a sharp ache throughout my entire chest, accompanied by a really uncomfortable ache in my left arm. I'd experienced some of the arm stuff before, but never the chest. I got myself to a doc asap and was put through a bunch of cardio tests: EKG, stress test, etc. Heart is fine, no signs of blockage, no other indicators of a problem. Chest xray was clear. Stayed off the bike for about 3 weeks while all this testing was going on, and with doc's permission started up again, though without a concrete diagnosis.

Since then a pattern has emerged. When I ride in the morning, I can only push my cardiovascular system to a certain point, one that's far short of my red line. It's the same sensation as before: a slow building ache in my chest that becomes a big sharp ache (not sure how else to describe it), and that nasty sharp ache the length of my left arm. If I soft pedal it all goes away after a few minutes. But once it starts it doesn't take much effort to fire it up again. Climbing hills is almost guaranteed to set it off. It's often accompanied by light-headedness and the feeling like I have absolutely no gas in the tank -- no pop in the legs at all, which would see to be a symptom of being oxygen-deprived.

Here's the thing: Mornings are hell, but I can ride home in the afternoon with no problem at all. Nothing. I can hit the uphills as hard as I want with no discomfort in my chest or in my arm. No sense of lightheadedness or fatigue. My hospital stress test was in the afternoon, and I went deep into the red trying to trigger the beast, but no go.

Before anyone says "just ride in the afternoon," I'm way ahead of you. But the days are about to get short, and that'll no longer be an option. Morning is it. And besides, that's not really the point.

I discussed the possibility of asthma, exercise-induced and otherwise, with the doc, but he wasn't convinced: there's none of the coughing or wheezing of asthma, and I don't really feel like the problem is getting air into my lungs. I can still take a deep breath when I'm having my attacks, but the problem is that it can hurt enormously to do so. I've experimented with my wife's asthma inhaler, but so far it's had no effect. I've never experienced an attack that wasn't exercise-related.

So I'm not convinced it's asthma. I'm also not convinced that nothing's going on with my heart. Some kind of chest wall malady? Stress I don't realize I have? Bacterial infection from that river in Maine we probably shouldn't have swam in earlier this summer? Clueless at the moment, but gearing up for phase II of diagnosis. I've begun the process of getting referrals to other cardio-pulmonary experts -- I live in Boston and had my cardio work done at MGH -- for lung capacity testing, more consults, etc. Clearly this thing isn't going away on its own, and I'm not inclined to wait.

Does any of this sound familiar to anyone? What's up with the AM / PM discrepancy in my ability to tax my CV system? What questions should I be asking the medical establishment?

If you've waded through this entire dump, thanks. Any suggestions welcome.

Scott

[Johnny P]

I had a similar feeling of not being able to climb hills, and even having to stop on climbs. It felt like I was out of breath, but the real cause was a heart issue. I had atrial flutter, which was easily diagnosed by having an EKG. Also, when I did wear a HRM, I could get very high readings (above 200 bpm).

I'm fine now after having a catheter ablation (twice). Your symptoms sound more heart related than exercised induced asthma. I would wear an HRM while riding and see if you get any unusually high readings and if they occur when the other physical sensations do.

[Louis]

Scott, I have nothing to add, other than a request that you let us know how things are going as you try to figure this out, and what the final diagnosis is (which hopefully is not too long in coming).

Good Luck
Louis

[2LeftCleats]

I would still wonder about a cardiac etiology. Sometimes stress tests lie.

Another possiblility is GERD. If you eat breakfast and ride to work, sometimes acid reflux can closely mimic heart pain. I have had the same scenario. Several neg stress tests over several years, but if I eat a banana and go for a run or ride, I sometimes get exertional pain that sounds like what others experience with cardiac pain. This might explain the difference in symptoms depending on time of day.

An arrhythmia might provoke pain, but I think it'd be more likely to cause shortness of breath at levels of exertion that wouldn't normally do so.

As others said, asthma likely would be more the breath problem than the pain problem and the inhaler should have helped.

More unlikely would be pulmonary hypertension and I wouldn't expect the variablity in symptoms.

[CNY rider]

I would still wonder about a cardiac etiology. Sometimes stress tests lie.

Another possiblility is GERD.

Yep, these things.
And do you take any meds at all, whether morning or evening?
Could you have some coronary vasospasm in the mornings for some reason?

[MattTuck]

I seem to remember from first aid merit badge that pain in the left arm is related to heart attack...

I'd get a second opinion.

[BCS]

What type of stress test did you do?

[verticaldoug]

You sound like my father. He had symptoms similar to yours. The tests came back, the doctors said they couldn't find anything. More tests, and again came back negative etc etc. However, the symptoms did not go away and in fact, worsened over time. Eventually, he had an attack which sent pain shooting down his left arm. The doctors eventually found blockage and he ended up having stents put in. The good news is that was 15 years ago and he is still going strong. Even though, you have led a much healthier lifestyle than my father, genetics play a big part in our susceptibility to disease. I'd get the referral and work with some specialists until you get your answer.

Footnote: It gave me a good reason to call Dad. Dad says he'd get attacks in the morning right after going to work. Afterwards, he'd feel like he had the flu. Initially, the doctors said it was muscle spasms or something (he's in Minnesota and it's cold in the mornings). Finally on a Saturday, he had an attack that would not subside. He went to the emergency room as a possible heart attack. The angiogram is what found the blockage.

[mjbrekke]

I'm certainly not a cardiologist, but I ran this by my wife, a hospital nurse for 30 years. To her, it sounds like classic cardiac issues. She recommends seeing a cardiologist and getting a "holter monitor" which will monitor and record your heart activity for at least 24 hours. That way, you can find out what is going on precisely at the time you are experiencing the pain.

I've had asthma for years and have been diagnosed with episodes of idiopathic (unknown cause), exercise-induced anaphylaxis (acute allergic reaction). Your symptoms don't sound like either to me. However, during the period of my life in which I was having frequent episodes, I learned that it was very important to exercise together with a partner who understands what you are dealing with and the potential issues. In my episodes I could not think rationally and would just try to push through it. Incredibly dangerous. Since you may not be getting enough oxygen to your brain, you may have similar issues. And, if you black out or fall, your cell phone may do you no good at all. A partner can monitor your behavior and symptoms better than you can, and, if there is a problem, get help.

If I were you, I wouldn't ride again until I had a clear diagnosis. A few weeks off the bike is a bargain considering the risks.

Good luck.

[slidey]

To all of you who're suggesting the cardiac angle, I have a genuine couple of questions:

Shouldn't there be consistency in repetitiveness of the symptoms at any time of the day, and not just in the AM as it is in the OP's case? Or does it have something to do with the fact that the HR in the AM is closer to the resting HR, and hence making it push to peak levels is a bigger range that one has to go through, and this big range is amplifying some hidden symptoms?

To me, the human anatomy is a black-box, and hence I'd like to know.

[thwart]

I would still wonder about a cardiac etiology. Sometimes stress tests lie.

Another possiblility is GERD. If you eat breakfast and ride to work, sometimes acid reflux can closely mimic heart pain. I have had the same scenario. Several neg stress tests over several years, but if I eat a banana and go for a run or ride, I sometimes get exertional pain that sounds like what others experience with cardiac pain. This might explain the difference in symptoms depending on time of day.

An arrhythmia might provoke pain, but I think it'd be more likely to cause shortness of breath at levels of exertion that wouldn't normally do so.

As others said, asthma likely would be more the breath problem than the pain problem and the inhaler should have helped.

More unlikely would be pulmonary hypertension and I wouldn't expect the variablity in symptoms.

This.

I'd agree with the '2nd opinion' from a cardiologist... but might start some daily Prilosec tomorrow as well.

And I'd taper the AM caffeine intake a bit.

[CaptStash]

To all of you who're suggesting the cardiac angle, I have a genuine couple of questions:

Shouldn't there be consistency in repetitiveness of the symptoms at any time of the day, and not just in the AM as it is in the OP's case? Or does it have something to do with the fact that the HR in the AM is closer to the resting HR, and hence making it push to peak levels is a bigger range that one has to go through, and this big range is amplifying some hidden symptoms?

To me, the human anatomy is a black-box, and hence I'd like to know.

Also not a doctor, but as an asthmatic, I am well aware of the fact that cooler weather causes blood flow restrictions, hence the possibility of a cardiac issue related to the cooler temperatures. As many others have noted, I have never experienced any arm pain associated with asthma, although I do sometimes experience pain in taking deep breaths.

CaptStash....

[oldpotatoe]

Do the stress test in the morning so they can view the symptoms.

[tiretrax]

As a lifelong asthmatic, I'd continue to pursue the cardiac symptoms. Get a second or third cardiologist - the sooner, the better.

[srsoltis]

I strongly suggest that you seek a second opinion or at least continue testing with your current cardiologist.

Last January I was diagnosed with a myocardial bridge. Basically, one of my coronary arteries tunnels through the heart muscle and gets fully closed every heart beat. I was likely born with the condition but symptoms only started when I turned 41. My symptoms are chest and left shoulder pain, burning in my lungs, and a general state of discomfort. It occurs when I first start exercising, usually while cycling, and typically last less than thirty minutes. Most of the time, it happens in the morning.

I'm not suggesting that you have an MB, but my experience is similar to yours. Getting a diagnosis was tricky because I was not the typical patient (i.e. less than 65 years old, a non-smoker, an athlete, etc.). Nothing showed up during a stress test or even a large number of imaging studies. However, I was able to capture an event on a Holter monitor and that gave my cardiologist enough information to order an angiogram. The angiogram was the definitive test.

In hindsight, I don't know why my doctors didn't run the Holter study sooner. My symptoms were intermittent, so static tests could not detect problems. I think the Holter study was one of the least expensive tests. I wore the Holter monitor for 48 hours and the event occurred during my third bike ride of the period with less than fifteen minutes left of the 48 hours.

Be persistent because the alternatives are not good. Also, don't push it when you are experiencing the pain and you might consider backing off on your activity until you know the cause.

[Louis]

In hindsight, I don't know why my doctors didn't run the Holter study sooner. ... I think the Holter study was one of the least expensive tests.

OT snarky comment: I think you just answered your own question.

[scottyjames]

Thanks to everyone who's weighed in on this -- I really appreciate the comments. The HRM and/or Holter ideas are right on, as is the possibility of retaking the nuclear stress/treadmill test in the morning when my symptoms actually show up. I didn't have an echocardiogram or MRI done during the first round, which ties in with the note from srsoltis -- based on further research over the past day, I'm leaning towards pericarditis (and possibly myocarditis) as the culprit, which can be diagnosed at least in part with an ecg. Whether it's the answer or not, seems like the ecg or MRI should happen regardless. But the symptoms, including left arm/shoulder pain, are fairly consistent, though not lockstep, with pericarditis -- symptoms could be triggered by exertion. Possible causes are many and include bacterial or viral infection. Oddly, no blood work was ordered during my first round of tests, so that should happen, too.

Meanwhile, I'm going to stay off the bike. So much for the ambition of taking up cyclocross racing this fall.

srsoltis: What was the AM angle with your affliction? I have my own theories for why my problem is most acute in the morning, but I'm curious to hear what you learned about that. Many thanks.

Scott

[BCS]

I strongly suggest that you seek a second opinion or at least continue testing with your current cardiologist.

Last January I was diagnosed with a myocardial bridge. Basically, one of my coronary arteries tunnels through the heart muscle and gets fully closed every heart beat. I was likely born with the condition but symptoms only started when I turned 41. My symptoms are chest and left shoulder pain, burning in my lungs, and a general state of discomfort. It occurs when I first start exercising, usually while cycling, and typically last less than thirty minutes. Most of the time, it happens in the morning.

I'm not suggesting that you have an MB, but my experience is similar to yours. Getting a diagnosis was tricky because I was not the typical patient (i.e. less than 65 years old, a non-smoker, an athlete, etc.). Nothing showed up during a stress test or even a large number of imaging studies. However, I was able to capture an event on a Holter monitor and that gave my cardiologist enough information to order an angiogram. The angiogram was the definitive test.

In hindsight, I don't know why my doctors didn't run the Holter study sooner. My symptoms were intermittent, so static tests could not detect problems. I think the Holter study was one of the least expensive tests. I wore the Holter monitor for 48 hours and the event occurred during my third bike ride of the period with less than fifteen minutes left of the 48 hours.

Be persistent because the alternatives are not good. Also, don't push it when you are experiencing the pain and you might consider backing off on your activity until you know the cause.

Myocardial bridging constricts the arteries in systole. The coronary arteries fill in diastole. That is why bridging rarely, if ever, requires mechanical intervention. A Holter is not the test of choice for evaluation of chest pain. And regarding the cost of the test, I get paid $16.00 by Medicare to do an exercise stress test at the hospital. That's sixteen big ones.

[srsoltis]

srsoltis: What was the AM angle with your affliction? I have my own theories for why my problem is most acute in the morning, but I'm curious to hear what you learned about that. Many thanks.
Scott

My condition is strikingly similar to, or may actually be, a condition called "warm-up" angina. The angina goes away after a cycle or two of activity and rest. The morning before a ride, for instance, my activity is limited until I actually start pedaling my bike. The first time I reach ~120 bpm (a relatively low intensity), I experience pain. If I stop to let my hr decrease below 100, the pain goes away and might never come back. Sometimes, it take a couple cycles. If I exercise in the afternoon, I've probably had several cycles of activity and rest and thus my heart is already conditioned and thus the events are less frequent and less severe.

If I continue riding after an event of angina, for the next hour or two, I feel tired and struggle a bit. After a couple hours, I feel better and better to the point where I actually feel very good.

I am still looking for answers, because I do not believe the MB is the direct cause of the angina. The affects of bridging should get worse as heart rate increases while mine does not. Studies have found that spasms occur at the site of MB's; I think that's more likely in my case. I keep a detailed journal of how I feel, what exercise I've done, what I eat, how much sleep, etc. The only pattern that I have found is I do not experience angina days where I take a simple, multivitamin prior to exercise. There are so many variables, though.

Diagnosis and treatment will be much easier if you keep a journal and an open mind. Although you probably don't have what I do, I hope my "case study" helps.

Best of luck,

Steve

[scottyjames]

My condition is strikingly similar to, or may actually be, a condition called "warm-up" angina...Diagnosis and treatment will be much easier if you keep a journal and an open mind. Although you probably don't have what I do, I hope my "case study" helps.

Best of luck,

Steve

It's the closest to what I'm experiencing, so this is very helpful. Funny, my wife has been pushing multivitamins on me now for a while, with limited success. I'll give that a more determined try. Do you take aspirin, too?

[srsoltis]

Myocardial bridging constricts the arteries in systole. The coronary arteries fill in diastole. That is why bridging rarely, if ever, requires mechanical intervention. A Holter is not the test of choice for evaluation of chest pain. And regarding the cost of the test, I get paid $16.00 by Medicare to do an exercise stress test at the hospital. That's sixteen big ones.

The nuclear stress test that I took was as expensive as a nice pair of wheels. Ironically, your "16 dollar" test would have yielded the same results in my case.

I'm not second guessing my cardiologist especially since he stuck with it to find the cause. In fact, he would have done the angiogram earlier, but I wasn't comfortable given the risks involved.

My Holter results showed ST depression coinciding with my chest pain. Up to the point before the the Holter, all my tests came back negative (good for me). Having the results of the Holter gave me confidence that an angiogram was a reasonable next step. Without the Holter results, I probably would have moved on to exploring possible GI causes. To me, the Holter made sense because it was a picture (although limited) for a period long enough to capture an event.

My MB is considered quite severe but stenting, myotomy, and bypassing are not viable options due to its location. Regardless, these wouldn't have been first choice treatments if they were possible.

[srsoltis]

It's the closest to what I'm experiencing, so this is very helpful. Funny, my wife has been pushing multivitamins on me now for a while, with limited success. I'll give that a more determined try. Do you take aspirin, too?

See your cardiologist again!

I have always been a bit skeptical when it comes to vitamins, but I also figure it can't hurt if taken in moderation. My diet is pretty good, except that I have a sweet tooth.

Prior to July, I would experience the angina once every couple times exercising (riding, tennis, yard work) and some weeks it happen every time or even while doing something not too physical like climbing too flights of stairs. Early July, I noticed a pattern that I would not experience angina on days that I took the multivitamin before exercise. Prior to that time, I took multivitamin sporadically but rarely more than a few per week. Since my intake has become daily, I have only experienced mild events while riding and never climbing stairs.

Coincidence? Possibly. I've read several inconclusive studies on the topic. If there is a link, my gut tells me it relates to magnesium. I am still researching the topic.

I don't take aspirin as it doesn't relate to my condition. I tried a low dose of beta blockers but stopped since they made me extremely tired. Occasionally, I take nitroglycerin just prior to exercise. I think it helps but I have experienced check pain even after taking it. There are reasons for and against taking nitro with a MB. Since I haven't had issues lately, I've backed off the nitro.

Meds cannot fix an MB, but as I stated before the MB might be an indirect cause and spasms or endothelial dysfunction triggered by the MB could be the direct cause.

[Nelson99]

I second (or third) the Holter monitor idea. If you can get them to give you one of these for 24-48hrs, you will be more likely to to catch a recording of your heart during one of your episodes. That can go a very long way toward ruling out certain causes for the symptoms you are experiencing.

I am assuming that you did not experience an episode during any of your previous tests, and therefore have great baseline information, but nothing that directly measures what is happening when you experience this pain.

Ask for a Holter monitor.

IMHO