# Cycling with chest pain/angina - suggestions?



## mxhdroom (Apr 19, 2013)

Hello everyone, 

First: I'll be 59 years old in March and I've been a devoted roadie for the past 29 years. My yearly mileage fluctuates between 1000 - 3500 kilometers, and I also put in my share of gym time and some jogging. I'm about 195 lbs and for the most part, in good physical condition. My doctor agrees, for what that's worth. I have slight hypertension, but nothing alarming. 

I've been dealing with exercise-induced chest pain or angina for the best part of 16 years. On most rides (indoors or out, road or off-road) I'll start out OK but will soon experience crushing chest pains which will sometimes radiate down my left arm. It was scary when it first happened; it's now so routine I just shrug it off. It appeared suddenly on an after-dinner ride in 1999 and since then, I've undergone two stress tests, two thallium (nuclear) stress tests, ultrasounds, a catheter angiogram (the "Gold Standard" for blockage diagnosis), endoscopy, medications - you name it. All tests came back good or negative for blockage. My cholesterol numbers are great and the cardiologist I saw was very impressed with what he saw on the angiogram. Diet has an effect; if I adopt a gluten-free diet my conditions improve slightly but don't disappear. 

While I'm getting really good at ignoring the symptoms, the pain is normally too great to ride through and I end up slowing down or stopping for a minute to recover (this makes club rides difficult, which causes me anxiety and worsens the pain!). It usually comes back, but just sits there as a dull ache for the rest of the ride which makes breathing difficult. Heart rate makes no difference, although once I hit a high HR and recover, I can never get it that high again for the rest of the ride. My endurance used to be OK, but over the past year it has dramatically decreased to the point where my longest ride last year was 45 rolling kilometers (about 28 miles). Part of the problem is diet - I worry if I eat anything before riding it will exacerbate my chest pains, and so I bonk far earlier than I would otherwise. Damned if I do, damned if I don't. Every year I think "this is the year I beat this," and every year it ends up beating me. I'm now at the point where I'm contemplating selling my beloved Look 566 and buying a "grocery-getter" to ride to the corner store and no farther. 

I'm just curious if anyone else has this problem and what, if anything, you've been able to do about it. Apologies for the long post; thanks in advance for your replies and advice.

Gary


----------



## robt57 (Jul 23, 2011)

Any stress test with a treadmill and EKG yet?

Myself and a friend similar age and fitness get digestive related deferred chest pains. We realized we both had this going on at one point. The stories we traded going to the ER and getting plugged into an EKG [which was normal], oddly similar and funny. The stress at the time not so much funny.


Has your Dr. touched on that with you ever?


----------



## mxhdroom (Apr 19, 2013)

Thanks for your reply.

Yes - two "regular" tests on the treadmill with EKG and two thallium stress tests (both on the treadmill and resting) about 5 years apart. All tests came back with very good results (i.e. no reason for further follow-up). I'm on family doctor #3 (due to moves; not because I fired them!) and all have been very helpful. None of them or any of the specialists I've seen have been able to nail it down. 

It's as much frustrating as painful. 

G.


----------



## CrankyCarbon (Dec 17, 2014)

My doctor is a triathlete (recently retired from it though) and has done Ironmans.
So talking to him helps a bit.

I have a genetic issue with my stomach valve.
Doesn't sound like much, but if you exercise (even light situps) and use your stomach muscles then I run the risk of pumping whatever is in my stomach up.
And thus Acid Reflux is in the cards, in a major way.
Which give me some really heavy chest pains, which for most people are like heart attack symptoms.

Add to that some nerve issues which can shoot down the left side of my body
and you get a mixture where I sometimes have 911 dialed on my phone as I see if it's going to subside or I press CALL.

Diet-wise, If I eat foods that require more digestion and are dense, such as meats, then the symptoms are worse. OR, if I eat too much. If I eat foods that can soak up acid (breads, pastas, etc) then the symptoms can be much more easily controlled.

I've been through the tests you mentioned as a double/ triple check.

I don't really have an answer for your issues, your doctors will know best.

But with the left shooting pain. maybe if you raise your handlebars a bit, it may minimize any pressure in your wrists (to minimize any arthritis, carpel tunnel) which may further cause the pain.

Don't give up on cycling if you like it. Try to figure out exactly what is increasing the problems.

btw, no reason you can't have a fun bike along side your Look. I just got a Walmart Mongoose 4 inch 26inch monster tire bike!. Pretty kewl looking and should be fun to ride for grocery getting ==> 26" Mongoose Dolomite Men's 7-speed All-Terrain Fat Tire Mountain Bike, Navy Blue/Red - Walmart.com


----------



## Srode (Aug 19, 2012)

Did your stress tests last into the upper HR zones you normally see cycling? My last stress test they intended to stop very early vs what I ride and based on 85% of age calculated max I think. I ride regularly at HR's way over that so asked them to keep going - and they did and nothing showed up as a problem.


----------



## adjtogo (Nov 18, 2006)

mxhdroom said:


> Hello everyone,
> 
> First: I'll be 59 years old in March and I've been a devoted roadie for the past 29 years. My yearly mileage fluctuates between 1000 - 3500 kilometers, and I also put in my share of gym time and some jogging. I'm about 195 lbs and for the most part, in good physical condition. My doctor agrees, for what that's worth. I have slight hypertension, but nothing alarming.
> 
> ...


I can speak with experience, as I've had three stents placed in my Left Anterior Descending Artery AKA "The Widowmaker", one in May, 2011, January, 2013, and September, 2014.

You need to go see a cardiologist. You may need to have an angiogram dome in the cath lab where they can check to see if you have any blockages in your arteries.

I have been an avid rider for quite a while and never thought in my wildest dreams that I'd have blocked arteries. Never, I told myself, even though I have a family history of high cholesterol, diabetes, and heart disease. I had been taking Lipitor and Metformin, ate pretty healthy, so I thought, and pedaled 125-150 miles per week. None of that mattered.

In May, 2011, I was about 10 miles away from home on a 30 mile bike ride when I began to have pain between my shoulder blades. At first, I thought it was discomfort from riding, but then the pain became severe, and traveled to my shoulders, then started down my left arm, and I began feeling heaviness in the chest. At first, I thought it was from the heat and humidity, as it was in the 80's with over 90% humidity and sunny. I had already drank two water bottles of Gator Ade, so I knew I wasn't dehydrated. I slowed down, and stopped at a convenience store and went inside to cool off. The pain diminished a bit, and I refilled the bottles. I got back on the bike and hit my pace, but the pain came back. I backed off, pedaled slowly, and I mean slowly, and sang "Sweet Caroline" in my head until I got home. I ended up feeling exhausted way more than normal, so I took a nap for two hours, which I never do. I had to work that night, and I felt sluggish and went to work anyway. I made it through, although I had some heavy heart palpitations. I rested the next day and felt fine. The following day, I went out for a ride, and only made it to the warm up phase and the pain came back.

I turned around, went home, cleaned up, and went to the ER. They admitted me right away. My BP was through the roof!! They took a blood test, but no heart attack. EKG was high. After I was admitted, I spoke to a cardiologist. He was going to to a stress test, but since I was an avid rider, that test wouldn't show anything. They decided to take me to the cath lab, where they found a 90% blockage in my LAD artery. They placed a drug eluding stent. They told me, had I not been a bike rider, I would have had a heart attack, and maybe a fatal one at that. After two weeks, I was back on the bike. With this stent, they entered through my groin near my thigh, which was a painful recovery.

I eventually built up my miles and was able to ride farther and faster for a while as I had more heart capacity. In November, 2012, I noticed I was having some minor chest pain during my warm ups that were uncomfortable, but would go away after 4 or 5 miles. Then it started to hurt more and I decided to see my cardiologist. It took me to the beginning of January to get in. Basically, my BP was a little high as well as my pulse rate. He was thinking it was my position on the bike and maybe I needed to adjust it. A few days later, my wife and I got into an argument about my irresponsible 25 year old son that has been evicted twice previously. But to make this story short, I had palpitations and chest pain. I ended up in the hospital, and went to the cath lab. The original stent was 95% blocked. I had a restenosis, one stent inside the other. This time, they went through my right wrist. I wasn't able to use my right hand at all for 3 days, and within less than a week, I was back on the bike.

Things went well for several years. In August, 2014, I had reconstructive surgery on my nose. They took rib cartilage and ear cartilage and completely rebuilt my nose. I had a six week recovery period. I was given the green light to ride on September 9, 2014. The first ride was unremarkable. I rode at a casual pace and made it 22 miles. On September 10, I started my ride and began to have chest pain right away. I rode a bit further in warming up and the pain continued. I wasn't thinking blockage at the time, so I kept riding slowly. The pain never went away, and I turned around went home, cleaned up, went to the ER, and I was admitted. Next day, back to the cath lab. Yup, another blockage in the LAD artery, lower than the others, and 95%. 

So, the moral of the story, go see your cardiologist. You may have blockages or some other underlying problem. Don't let the "silent killer" take you away.


----------



## mxhdroom (Apr 19, 2013)

Thanks for all the replies. 

Just after these pains started, my doctor put me on Pantoloc for acid reflux to see if that would help. It did for a while, but not with 100% efficacy and it seemed to become less helpful as time went on. I eventually found I could control that part of it with diet (i.e. no gluten) and that is still the case. I haven't taken a Pantoloc, Tecta, or equivalent for a couple of years now, as they do have an effect on Vitamin B levels and red-blood cell production. And if I can control it with diet, why take pills?

I have seen the same cardiologist twice, and he is one of the best in the city. The first time, he was convinced I had a blockage and ordered a catheter angiogram right away. Up through the groin, and yes adjtogo, I know what you mean by a long recovery. I was black and blue from my nipples to my knees for well over a month. Anyway - it was clear. I had no blockages and, for my age, very little constriction anywhere. The cardiologist and my GP were surprised and overjoyed. My symptoms didn't go away, so I saw the same cardiologist again late last fall when he put me through another thallium stress test. All of my stress tests have been towards the top of my MHR (or at least as close as I can get it). Again, it was negative. He turned me back to my GP with a clean bill of cardiac health. 

I've told my doctor(s) that I would be satisfied if one of them would tell me: "you can't ride any more centuries or gran fondos. Stick to zone 2 stuff for an hour and be happy with what you can do." But they won't tell me that (although my wife does) and so I feel there's no physiological reason why I can't do longer and faster rides. 

And so here I am today, wondering if the Look should go to someone who can really use it. I have been doing more off-road stuff and I enjoy it. I think the concentration I put on weaving through trees and around obstacles takes my mind off of the sometimes drudgery of straight pavement miles where pain sometimes takes centre stage. My off-road rides are shorter and while intense, there's no lengthy periods of high exertion. I'ts safer too, quite frankly, other than the odd concern about grizzly bears here in the foothills of the Canadian Rockies. 

If it sounds like I'm trying to talk myself into giving up the road, perhaps I am. Regardless, keep your advice and suggestions coming in . I sincerely appreciate it. 

Gary


----------



## jspharmd (May 24, 2006)

Srode gave some good advice. When you did your stress tests, was the physical activity the same as when you experience angina on the bike? If your stress tests didn't "stress" you the same, they may not have noted the oxygen delivery/oxygen consumption mismatch you experience on the bike.

It is important to note that this stress test is a less invasive way of seeing if your coronary arteries have blockage. Since you've had an angiogram that was negative, the stress test wouldn't be super helpful. The only thing it might do is to show that, even with normal coronary arteries, you experience an oxygen delivery/consumption mismatch. They could draw blood (immediately after you begin experiencing chest pain) to see if your heart muscle (cardiac myocytes) are being injured or not. 

Your case is also complicated by the fact that you have some degree of "possible" acid reflux (which others have mentioned can mimic the pain of a myocardial infarction). 

One question about the reflux. How did you take the Pantoloc? Did you take it every day (at least once a day, if not twice a day)? Did you only take on days you rode your bike? Did you only take it before rides? How about providing a dose too. This could be very important to whether or not this medication works properly or not. Also, you know Tecta and Pantoloc are the same drug right? Have you taken any H2-antagonists? Ranitidine, Famotidine, etc.?


----------



## mxhdroom (Apr 19, 2013)

Hi jspharmd, 

The level of exertion on the treadmill was the same as when I experience the pain on the bike. While my "220-age" MHR is 161, I've never seen the high side of 153 for a couple of years and the stress test(s) got me up into that area. 

Regarding the Pantoloc/Tecta: I think my dosage was 20 mg which I took daily, regardless of whether I was exercising or not. I've not taken any H2-antagonists. Quite frankly, I don't even know what they are. Time to visit Google, obviously. My GP did give me a few Ativan to test, as we know anxiety makes the condition worse. My tests so far with Ativan before a workout have been non-conclusive. The pain still comes, but perhaps I don't care about it as much. I can't decide whether this is a good thing or not without a diagnosis of the underlying issue. 

Gary

Edit for update: Oh, OK - Zantac and the like (H2-antagonists). I've not tried them before exercise yet, but perhaps it may be worth a test.


----------



## jspharmd (May 24, 2006)

Pantoprazole (Pantoloc) 20 mg is a low dose. If you noted improvement at first, you might need a larger dose. While outside of the prescribing information, I've seen doses as large as 40 mg twice a day. These drugs, proton pump inhibitors (PPIs), have a slower onset. So, if you were only taking the pantoprazole sporadically, you might not have seen the full benefit. Zantac (and other H2-antagonists) work faster than PPIs, but they lose their effect over time (meaning if you take them every day for a week or two). 

Some clinicians will prescribe the PPI regularly (daily, or twice a day) and have patients take the H2-antagonist before an inciting event (food that causes gastroesophageal reflux), or in your case before you ride. 

I recommend talking with you primary care physician about trying to scale up the PPI and see what happens. If you do that and you try the H2-antagonist around cycling, and you still don't get any benefit, I would drop it. 

You are correct that PPIs are not benign. They care risks (like potential to cause vitamin B12 deficiency, possibly increased risk of community acquired pneumonia, etc.), so you don't want to take the medication if it isn't helping. 

Good luck with this issue, it sounds extremely frustrating.


----------

