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Forum Name: Cardiology Symptoms

Question: Exercise Struggles, Exerices Fears


 eovi7 - Wed Nov 11, 2009 1:51 pm

Hi,

I'm a 37 year old male who has had recurring chest discomfort and other heart related symptoms for about two years which include palpitations, skipped beats, chest tightness (mainly far left pectoral area), left arm pain and tightness, some lightheadness and slight dizziness, as well as shortness of breath. I have had the following tests done - numerous ekg's, stress echo (Jan 2008), echo (June 2008), holter monitor (July 2008, October 2008), CPET (April 2009), and blood work. All of the test were normal except my first holter monitor registered a slow heart rate during the late night, early morning hours so my cardiologist had me do it again in October which came out normal. My cholestrol is low (70 for 'bad', 35 for 'good', and triglycerides at 70.) My BP has had some high readings at the doctor's office (as high as 160/100; on average 140/85); but at home I consistently get readings around 110-130/70-85. My mom and brother do have hbp and are on medication but my doctor doesn't feel like it's necessary.
My doctor attributes my symptoms to anxiety since I was cleared by the cardiologist and I have been receiving therapy for the past year (twice a month basis). While this has been helpful, it also has been hard to get over the hump that anxiety is the main cause of my symptoms. I also had my breathing issues checked out with a pulmonologist where he examined me and did the spirometry test. I also asked him if I could take an exercise test and he did the CPET test for me. My spirometry test did show some lower side of normal readings and my lowest reading was 79. He gave me some albuterol and also some alvesco as a controller to take once in a while when symptoms develop. The alvesco has proven helpful and after one 10 day treatment, I have used it on occassion when I feel symptoms slowly developing. I think allergies and air quality may have something to do with this slight asthma. (Also, when I was 13, I wheezed a few times and was given an inhaler which I never used). Anyways, besides this, I have not been diagnosed with anything.
However, these symptoms still persist and the biggest difficulty is how I feel like I struggle with exercise. Before any of this happened, I had consistently and quite vigorously worked out - from running 4 to 8 miles at a time, to jump roping, doing resistance training, and other kinds of workouts - it was a big, regular part of my life. However since the symptoms began, I have become increasingly worried when I exercise. There is this tension that exists in that I want to exericise and miss it, but I am also worried if something might happen as I exercise and any symptom, feeling I have while exercising effects me. I am scanning and monitoring my body as I exercise. When I do feel symptoms, I try to push through them by telling myself that I have been checked out and that I'm okay but I still can't shake my fears not only during but after and before I exercise again. An example of this was a couple of weeks ago when I took my family for a short weekend vacation. I went to workout in the hotel gym twice while we were there. Both times, I rode an exercise bike and elliptical machine. I haven't used gym equipment for a couple of years. I used the bike first for about 25 minutes and then the elliptical for the same duration. While riding the bike, I felt slightly dizzy and a little nauseated. But I pushed through it telling myself to not be worried. When I rode the elliptical I felt better but I also experienced some of the chest tightness and discomfort that I often do. This made me think I was experiencing exercised induced angina. I fininshed my workout and then went back to my room. Had lingering symptoms for a couple of hours after workout. But it is not just when I actually work out - I feel symptomatic while at rest and also with minimal effort like walking up a flight of stairs. I can feel some palpitations and a little shortness of breath and then that worries me because I think something has to be wrong.
My question is can anxiety be the root cause of my symptoms? And has my exercise struggles become the result of my anxiety or do I have some kind of condition that is producing these symptoms therefore making me anxious? Might I have some kind of slowly progressing heart issue that wasn't revealed in the tests I have taken and should I take some other tests? Can my worry whether conscious or sub conscious during exercise actually be producing these feelings and symptoms? My anxiety therapist says that moderate to vigorous exercise can amp up the nervous system thus producing some of these symptoms and feelings in someone with an anxiety condition. While I can understand that I have a hard time fully believing that is what is going on. I'm also frustrated because I want to feel normal again and I especialy want to be able to exercise freely again without concern. Any medical suggestions you can give. Your help in this matter would be greatly appreciated as I have been pretty frustrated. Thank you.
 John Kenyon, CNA - Sat Nov 28, 2009 11:15 pm

User avatar Hello -- I can tell you that an echocardiogram plus stress echo (including of course stress test) has ruled out any structural heart disease, which is what I always look for first in athletic people. You don't have structural heart disease, which at your age is the biggest concern among athletes. You've also ruled out, to a very reasonable degree, coronary artery disease, which otherwise would be fairly well down the list except for the symptoms you describe, if they were taken out of context. Fortunately they are not out of context here. You have been very forthcoming and your post is very detailed. You consider the possibility of anxiety and I am very much inclined, given the other rule outs, to believe this is the root cause of your symptoms and of course of your concern -- concern to the degree it's beginning to be disruptive.

To answer your last questions, anxiety absolutely can account for all this, and no, it would seem, given your various negative tests, there is no occult heart disease to worry about. If there were frank heart disease it would have shown itself, and the only occult (hidden) type would have been structural abnormalities which would have shown up on both echocardiograms. You tolerate exercise well but acknowlege anxiety over the symptoms, the only question left being: Which came first? As usual, the anxious person is the last to recognize this chain of events. It's almost always this way, is classic for anxiety. The patient often will deny any stress or life situation which could be causing this, and sometimes there actually is none, but rather some long-repressed concern which finds expression at last in concerns about physical problems, usually heart-related. Since the heart is a great barometer for anxiety (especially with regard to palpitations) and so much misinformation is common in the general public about heart disease symptoms, the most likely symptoms (according to the degree of knowlege the given patient has on the subject) will tend to be noticed. The symptoms may well be actual ones, but they are not heart-related and may well be trivial but maginified because of anxious concern.

This is difficult to word in such a way as to not sound judgemental of the patient, and that's unfortunate, because anxiety, in its own way, can be quite disabling though not life-threatening. Getting the patient to the point where he can understand the cycle of anxiety and break it is the hard part.

Something happened to shift your awareness and your concern to your heart. It could have been merely some random pain or palpitation (we all have those) but in the final analysis there's usually something else, often symbolic, that sends us off suddenly on that particular tangent. We rarely recognize it, and frankly once this cycle starts, the psychological trigger is moot. The trick becomes developing awareness of what we are doing.

You've been more than adequately cleared of suspicion of any sort of heart disease. A little knowlege can be a dangerous thing, though, especially in the hands (or mind) of someone who is anxiety-prone.

What I would suggest to you is if you cannot work through this on your own that you then seek out someone who practices cognitive behavioral therapy (CBT), which is a very effective and highly successful sort of limited, interactive psychotherapy involving "homework." This is not endless "talk therapy" like regular insight therapy is, but rather a limited, goal oriented program to help one recognize the process, break the cycle, and essentially be "cured" of the problem. It may sound too easy to be true, and of course it doesn't work on 100 per cent of people, but it does have a high rate of success. If you hadn't already had all the tests you've had, medically, I wouldn't be making this suggestion,but you've had every exam I would have suggested, and you've passed with flying colors. That leaves anxiety as the default diagnosis, and it certanly fits, right down to the classic, highly detailed explanation in your post.

I hope this is helpful, and if you can work through this on your own that's great, but I also hope, if you cannot,that you're not one of those people who feels asking for help of a non-medical nature is a show of weakness. You'd be surprised how many people feel this way, or simply don't want to believe it can be anxiety and anxiety can be managed or cured. It can. We've come a long way.

Good luck to you with this. I hope you are soon back to you regular schedule of working out. Oh, and by the way, very fit people often do have unusually slow heart rates, especially at night (we are mostly all much slower when sleeping anyway). Even that was actually "normal."

Best to you. Please follow up here as needed.
 eovi7 - Tue Jan 19, 2010 2:58 pm

Thank you for your informative, helpful, and reassuring reply. It is difficult for people to understand how anxiety can make a person feel so 'stuck' and fearful as to produce these kinds of symptoms. Which is why I have also had a hard time accepting this. Thank you for helping me accept this (a bit more) as being the root cause. I have been exercising more regularly and am up to jogging around 3 to 4 miles again along with other kinds of exercise on the other days.

I did have a follow up question which I am hesitant to ask given my health and heart worry prone mind. But I will ask anyway believing that there are no 'dumb' questions when it comes to one's health. Could something like Hypertrophic Cardiomyopathy been missed given the tests and workup that I have received? I understand that an echo is most used to determine something like this. Is it possible though that an echo (along with the other tests I have taken) could have not shown this (for example if this were in the early stages, might it be missed by a cardiologist)? The reason I am asking is because some of my symptoms, especially in regards to exercise seem to have some connection to this condition. I also understand that this is not uncommon in athletes and people who are fit. While I am no athlete and currently not very fit, I have enjoyed exercise regularly and pretty intensively in the past and also been pretty fit. I wonder if my shortness of breath (which has been attributed to slight asthma) is more in line with HCM. For example, I will sometimes feel short of breath after eating too much or after going up a flight of stairs (along with palpitations). However, when I go through an actual exercise routine, I don't notice this as much. I also notice when I exercise that the beginning stages seem to be more difficult when it comes to my breathing. (I have a harder time taking in a deep breath and experience more 'irritation' in my lungs - feels like I felt when I was younger playing outside on a smoggy day (live in Los Angeles) and taking a deep breath would 'hurt'.) I also notice while I am cooling down that I feel more anxious. Sometimes my heartbeat feels like it is skipping. I also have that feeling of lightheadedness, slight dizziness sometimes during but also after my workout. Nothing serious has ever happened - I haven't fainted or fallen but there are times when I don't feel right. (I also remember one occasion a few years ago before I had taken any tests, when after playing some intensely competitive basketball for a good hour with minimal breaks, I felt pretty strong palpitations and some of that 'skipped' beat sensation afterwards for what seemed to be a good 20-30 minutes afterwards. I didn't worry to the extent I do now, but as I look back on that, I wonder if that was a first sign of something being wrong (I didn't have other symptoms like chest pain or dizziness though)).
I do believe this can all be related to my anxiety and particulary my heart fears. And while I am more prone to being more sensitive and aware of everything I am feeling, what if I am just being more sensitive to an actual heart condition that is affecting me? Anyways, I wanted to know if this is something I should be concerned with and I should pursue further with a cardiologist. Thank you for your understanding in this and for all the good things this forum provides.
 rlnc722a - Thu Jan 28, 2010 4:53 pm

Hi,

I can relate to this. I've been similar to you for 2 years now - and how you explain your heart "skips" are similar to what I experience. I often can feel one coming, odd as that seems.

I also suffer chest pain, although 5 EKGs have shown normal. I was diagnosed with Tietze's Syndrome last year, but I often find this difficult to agree with as anti inflamatories often do not work. I find it difficult to find the right kind of exercise, and am getting to the stage where if I don't start soon, the after effects I feel will not be my body - more the fact that I've become so unfit.

Does your chest pain "move" ? Does it sometimes feel like a pulling, or as if someone invisible is pull chest hair ? I can usually locate the source of the pain, and it does hurt when I touch it the source.

I'm 38 and with no history and the 5 tests mentioned above, Doctors don't really want to know and assume it's anxiety.

Do you feel similar?

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