1B). Personal History: Have you ever experienced chest pain or discomfort with exercise?
Although cardiac causes of chest pain (Table 1) are relatively uncommon (<6%) in athletes <35 years old, underlying causal conditions include potentially life-threatening diseases such as coronary artery anomalies and hypertrophic cardiomyopathy (HCM) (5). Older athletes with exertional chest discomfort must be assumed to have atherosclerotic coronary disease until proven otherwise. Noncardiac medical and musculoskeletal causes of exertional chest pain are relevant across the age spectrum. Noncardiac medical causes are outlined in Table 2, and musculoskeletal causes are discussed in the following section (part 3). The key components of a comprehensive medical chest pain history are discussed as follows.
What Is the Quality and Location of the Chest Discomfort?
Exertional chest discomfort is the most common manifestation of myocardial ischemia, an imbalance of myocardial oxygen demand and supply. Ischemic chest pain can result from a number of cardiac conditions including coronary pathologies (i.e., coronary anomalies, atherosclerotic coronary disease) that limit myocardial blood flow and noncoronary conditions including cardiomyopathy and valvular heart disease that increase myocardial demand. Regardless of the etiology, ischemic chest discomfort is typically 1) reproducibly triggered by effort, 2) relieved by rest, 3) and typically located in the substernal and/or the left chest area. It often has an aching, pressure, or tightness quality and may radiate to the jaw, neck, and/or arm.
Nonischemic causes of chest discomfort often present with disease-specific patterns. Aortic dissection is typically described as a tearing pain that starts suddenly, often during intense isometric activity or body collision and radiates to the back. Pain caused by pericarditis is commonly noticed both at resting and during exertion and is typically worsened by lying supine and relieved by standing or sitting forward. Pleural causes of chest pain including pleurisy and pneumothorax are often sharp in nature and exacerbated by deep inspiration.
Are There Specific Provoking Factors aside from Exercise Intensity That Are Related to Your Chest Discomfort?
Exertional chest discomfort provoked by climate extremes or seasonal allergens is more likely a function of reactive airway disease and not myocardial ischemia. Exertional chest discomfort that occurs immediately after eating or dietary indiscretions may point to a gastrointestinal (GI) cause but can be ischemic. Paroxysmal symptoms of chest tightness that start and stop suddenly and are accompanied by palpitations may be due to exercise-induced arrhythmia.
When during the Course of Exercise Does Your Chest Discomfort Occur?
Chest pain caused by myocardial ischemia is typically effort dependent and occurs reproducibly at a given workload. Athletes with ischemic forms of cardiovascular disease may be able to exercise for long periods of time at low-to-moderate workloads without symptoms. Athletes with atherosclerotic coronary disease, a disease process that is increasingly relevant to youthful populations, may experience “warm-up angina,” a term used to describe symptoms that develop during the first few minutes of exercise and then abate despite continued or increased workload. Athletes with an anomalous coronary artery may experience unpredictable and irregular episodes of ischemic exertional chest discomfort. An athlete presenting with sporadic and infrequent exertional chest discomfort occurring only at near-maximal exercise intensity should be studied to rule out this diagnosis.
How Long Does It Take for Your Chest Discomfort To Resolve after Stopping Exercise?
Chest discomfort due to myocardial ischemia will typically abate within several minutes of either rest or reduced exercise intensity. In contrast, symptoms caused by reactive airway disease or gastroesophageal reflux disease (GERD) more commonly persist for many minutes to hours. Chest symptoms caused by an underlying cardiac arrhythmia typically track with the onset and termination of the arrhythmia and may suddenly resolve without changes in exercise intensity.
Have You Ever Had Syncope or Near-Syncope with Your Chest Discomfort?
Syncope or lightheadedness that occurs with exertional chest discomfort is a clinical red flag for a potentially life-threatening condition. The combination of chest discomfort and near-syncope suggests that there is transient impairment of cardiac function that is sufficient to reduce delivery of blood to the brain. Athletes with this symptom constellation should refrain from exercise until comprehensive clinical investigation is completed.
Are There Any Other Symptoms That Accompany Your Exertional Chest Discomfort?
Exertional chest discomfort caused by a paroxysmal tachyarrhythmia is often preceded and/or accompanied by the sensation of palpitations or a “racing heart.” Pulmonary causes of chest discomfort such as exercise-induced asthma or vocal cord dysfunction are commonly associated with cough, dyspnea, wheeze, or stridor that may be audible to the athlete or others. GI etiologies for chest pain such as GERD characteristically cause epigastric discomfort than may be related to the timing of food intake or dietary indiscretions. GERD may be associated with heartburn, a sour taste in the mouth, dysphagia, dry cough, hoarseness, sore throat, regurgitation of stomach contents, hoarseness, and/or nausea. Chest pain that occurs both at rest and during exertion coupled with systemic symptoms such as malaise, fever, or arthralgia should raise concern for inflammatory processes affecting the pericardium (pericarditis), the myocardium (myocarditis), or the lungs (pneumonia and pleurisy).
Has Discomfort in Your Chest Ever Caused You To Slow Down and/or Reduce Your Training Regimen?
Athletes with underlying cardiovascular diseases that cause exertional chest discomfort often learn to “avoid the symptoms.” Through trial and error, often subconsciously, they learn to complete personally meaningful levels of daily exercise but remain below their ischemic threshold. Careful review of an athlete’s training regimen and competition history can uncover this adaptation.
Has Anyone in Your Immediate or Extended Family Experienced Sudden Cardiac Death, Unexplained Death or Collapse, Been Diagnosed with an Inherited or Congenital Heart Condition, Been Restricted from Competitive Athletics, or Received an Implantable Cardiac Defibrillator?
Many important underlying causes of exertional heart disease are genetic and thus inherited. We therefore advocate careful interrogation of family history in all athletic patients with exertional chest discomfort. It is valuable to go beyond simply asking the athlete if there is any family history of heart conditions by inquiring about the specific issues. If any uncertainty is encountered in the response to these questions, further acquisition of medical records and direct communication with the family are warranted.
What Medications, Supplements, Illicit Drugs, or Performance-Enhancing Agents Do You Use?
Use of performance-enhancing agents (PEA) is increasingly common among athletes and should be queried in all athletic patients presenting for medical care. Anabolic-androgenic steroids are the most widely used PEA and have been previously shown to have deleterious cardiovascular effects causing dyslipidemia, exaggerated blood pressure response to exercise, and myocardial dysfunction (2–4). The use of erythropoietin analogs, while most commonly associated with central nervous system vascular dysfunction, can precipitate microvascular coronary artery infarction from excessive red cell mass. The use of prescription, over-the-counter, or herbal stimulants is increasingly common among competitive athletes. While their impact on cardiac health remains largely unknown, anecdotal experience suggests that their use may precipitate subjective cardiac symptoms and/or unmask previously occult cardiac disease. It is recommended that a comprehensive exertional chest pain history include direct inquiry about exposure to all of the mentioned agents.
Case Report 1: an 18-Year-Old Track Runner with Exertional Chest Tightness
An 18-year-old track runner presents with episodic chest tightness at practices. She notices this sensation most often in the middle of workouts, specifically during the recovery periods between sprint/high-intensity intervals. Her chest tightness is accompanied by the sensation that her heart is beating rapidly and forcefully. She notes some concomitant nonvertiginous lightheadedness but has not had any frank syncope. She is typically unable to resume running until these symptoms terminate, which most often occurs within 10 to 15 min of onset. Her personal and family medical history, physical examination, resting electrocardiogram (ECG), and echocardiogram results are normal. She is taken for exercise testing with the goal of simulating the demands of typical workouts. During customized treadmill exercise testing, she runs 2-min sprint intervals at her usual race pace followed by 1-min recovery intervals. She is asked to continue this sequence until her fatigue becomes prohibitive or she develops her presenting symptoms. After the eighth interval, she begins to experience chest tightness and is noted to have a narrow complex tachycardia at 200 bpm on continuous 12-lead ECG. The morphology is most consistent with a reentry-mechanism supraventricular tachycardia. Management options including conservative observation and reassurance, medical therapy with a low-dose negative chronotropic agent, and referral for consideration of an electrophysiology study +/− radiofrequency ablation are discussed. She elects to trial a suppressive medication and is prescribed a low dose of extended-release oral verapamil. She is immediately cleared for returned to practice and is asymptomatic with no perceptible decrement in running performance at 3-, 6-, and 12-month follow-up visits.
Key Points: Arrhythmias, specifically supraventricular tachycardias, are an important cause of chest discomfort. Customized exercise testing is often required to reproduce presenting symptoms and underlying pathophysiology. When arrhythmia is suspected and comprehensive laboratory-based exercise testing is unremarkable, extended ambulatory rhythm monitoring is required.
Case Report 2: 18-Year-Old Soccer Player with Exertional Chest Pain and Syncope
An 18-year-old soccer player presents with recurrent exertional chest pain and one recent episode of syncope. His chest pain symptoms only occur during the middle of his most intense workouts and reach a severity that often causes him to slow down or stop. He describes the discomfort as an ache in his upper chest that is accompanied by mild dyspnea, but no clear wheeze or cough. These symptoms reliably resolve completely after 2 to 3 min of rest. He was recently started empirically on inhaled bronchodilators without improvement in his symptoms. During a recent workout, he had a chest pain episode that culminated in witnessed syncope. Specifically, his teammates and coaching staff noted that he began to clutch his chest while running after a long pass and ultimately fell to ground where he lay motionless for approximately 30 to 45 s. He regained consciousness spontaneously and complained only of transient chest pain. His personal and family medical history, physical examination, and resting ECG results are unremarkable. Transthoracic echocardiography reveals an anomalous left main coronary artery (LMCA) arising from the right coronary sinus. Computerized tomography (CT) coronary angiography confirms this anatomy and notes that the proximal LMCA had a narrow “slit-like” ostium and a proximal course that lead between the aorta and the pulmonary artery. He is removed from athletic participation and referred for cardiac surgery in anticipation of an unroofing procedure. After an uncomplicated cardiac surgical procedure and an 8-wk recovery, he undergoes maximal, effort-limited exercise testing, during which he had no symptoms, ECG changes, or arrhythmia. He was cleared for incremental aerobic training and ball drills. At 4-month follow-up, he feels well and is cleared for return to competitive soccer.
Key Points: Exertional chest discomfort that limits effort and/or is accompanied by syncope should prompt immediate restriction from athletic participation until a diagnosis is identified. Syncope that is associated with exertion, rather than immediately following sudden cessation of activity, is of particular concern. Exertional chest discomfort and/or syncope should be considered to be of cardiac origin until proven otherwise. Transient myocardical ischemia due to coronary anomalies with high-risk anatomy is a common and life-threatening cardiac cause of exertional chest discomfort and/or syncope in young athletes. High-risk coronary anomalies, when symptomatic, may present as episodic exertional chest pain and/or syncope. The resting 12-lead ECG is most often normal among patients with coronary anomalies, and exercise stress testing may prove falsely reassuring. If clinical presentation suggests the presence of an underlying coronary anomaly, noninvasive imaging is mandatory to exclude or confirm this diagnosis. Transthoracic echocardiography is the initial imaging test of choice. Additional imaging modalities are required if echocardiography cannot accurately identify normal ostia and proximal course of both coronary arteries or to define high-risk features once an anomaly is detected. Athletes found to have an anatomically high-risk coronary anomaly should be restricted until the defect is surgically corrected.
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