Chest Pain During Running: Cardiovascular Insights and Next Steps

Chest pain during running at a faster pace?

Recently, my father experienced chest pain while running.
He underwent several tests including a stress echocardiogram, cardiac ultrasound, and a 24-hour Holter monitor.
The doctor mentioned that there were plaques present, but it was not serious.
The doctor then asked if he wanted to take medication, rather than making a judgment on whether medication was necessary.
He was prescribed only nitroglycerin and was given a document stating "no hospitalization, no transfer, no aspirin or anticoagulants, currently no medication, informed of cardiovascular disease and stroke risk, no coronary CT scan, no emergency observation, provided sublingual tablets," which required my father's signature.
This felt quite strange to me.
I would like to consult a physician regarding the following report of my father:
Carotid ultrasound:
1.
Bilateral IMT increase with plaque at the right bifurcation (0.124 cm) and left bifurcation (0.124 cm).
2.
No stenosis of the carotid artery and vertebral artery.
3.
Total vertebral artery flow volume (131 + 52 ml/min).
4.
Mild arteriosclerosis.
Stress echocardiogram: Stage 4, borderline result, suggesting further examination.
24-hour EKG: Atrial fibrillation or wandering pacemaker rhythm should be considered.
Doppler cardiac flow study:
1.
Normal left ventricular size and systolic function.
EF = 67.8%, no left atrial thrombus.
2.
No pericardial or pleural effusion.
3.
No obvious turbulent flow, no aortic stenosis.
4.
E/A = 15.
No obvious intimacy flap in the ascending aorta and arch.
EKG: Normal sinus rhythm at 62/min, no significant ST-T changes.
Is there a significant issue with my father's report? Does he need further evaluation or medication? Thank you.

Elaine, 30~39 year old female. Ask Date: 2022/02/19

Dr. Wu Xueming reply Cardiology

According to the report you provided, there is no clear evidence of cardiovascular disease; however, if your father continues to feel unwell, I recommend considering a nuclear medicine myocardial perfusion scan or a coronary computed tomography (CT) angiography.

Reply Date: 2022/02/19

More Info

Understanding chest pain during physical activities like running is crucial, especially when it involves cardiovascular health. Your father's recent experiences with chest pain during running and the subsequent medical evaluations raise several important points regarding cardiovascular assessment and management.

Evaluation of Chest Pain
1. Medical History and Symptoms: Chest pain during exercise can be indicative of various cardiovascular issues, including angina, myocardial ischemia, or even structural heart problems. Given that your father experienced chest pain while running, it is essential to consider his overall health, family history, and any pre-existing conditions. The fact that he has undergone several tests, including a stress test (exercise electrocardiogram), echocardiogram, and 24-hour ECG monitoring, indicates a thorough approach to evaluating his heart health.

2. Test Results:
- Carotid Ultrasound: The report indicates bilateral increased intima-media thickness (IMT) with plaque formation, which is a sign of early atherosclerosis. However, there is no significant stenosis (narrowing) of the carotid arteries, which is a positive finding.

- Exercise Electrocardiogram: A Stage 4 result with borderline findings suggests that there may be some level of cardiac stress during exercise, warranting further investigation.

- 24-hour ECG: The presence of a wandering pacemaker rhythm or paroxysmal atrial fibrillation (PAf) could indicate an arrhythmia, which may contribute to symptoms during exertion.

- Doppler Echocardiogram: Normal left ventricular size and function with an ejection fraction of 67.8% is reassuring, indicating that the heart is pumping effectively.

Management and Next Steps
1. Medication Discussion: The physician's approach of asking whether your father wants to start medication, such as nitroglycerin (NTG), may reflect a shared decision-making model. This model encourages patient involvement in their treatment plan, especially when the risks and benefits of medication need to be weighed against the patient's preferences and lifestyle. The physician likely assessed that while there are signs of cardiovascular risk, the immediate need for aggressive treatment may not be warranted based on the current test results.

2. Further Investigations: Given the borderline results from the exercise ECG and the presence of plaque, it would be prudent to consider further evaluations. A coronary CT angiogram could provide more detailed information about the coronary arteries and help assess for any significant blockages that might not have been evident in the other tests. Additionally, a nuclear stress test could evaluate myocardial perfusion and help determine if there are areas of the heart that are not receiving adequate blood flow during exertion.

3. Lifestyle Modifications: Encouraging your father to engage in regular, moderate exercise is essential, but it should be done cautiously. He should listen to his body and avoid pushing himself too hard, especially if he experiences chest pain. A structured exercise program supervised by a healthcare professional, such as a cardiac rehabilitation program, may be beneficial.

4. Monitoring Symptoms: It is crucial for your father to monitor any recurring symptoms. If he experiences chest pain, shortness of breath, or other concerning symptoms, he should seek medical attention promptly. Keeping a symptom diary can help healthcare providers understand the context and triggers of his symptoms better.

5. Regular Follow-ups: Regular follow-up appointments with a cardiologist are essential to monitor his condition, especially given the findings of early atherosclerosis and potential arrhythmia. Adjustments to his treatment plan can be made based on his symptoms and any new test results.

Conclusion
In summary, while your father's test results do not indicate immediate life-threatening conditions, they do suggest a need for careful monitoring and possibly further evaluation. Engaging in shared decision-making with his healthcare provider regarding medication and lifestyle changes will be crucial in managing his cardiovascular health effectively. Regular follow-ups and being attentive to his body's signals during exercise will help ensure that he remains active and healthy while minimizing risks.

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