Exercise Fatigue and Heart Issues: A Patient's Journey

Exercise, fatigue, heart problems?

Dear Doctor,
For the past few months, I have been feeling more fatigued than usual.
I feel weak when standing and cannot walk for long periods.
Additionally, my exercise capacity has decreased significantly; I often experience an inexplicable fatigue after exercising, even when I don't feel like I've exerted myself too much.
This fatigue can last from a few hours to a few days, which is quite troubling for me.

To provide some context, my discomfort dates back to a day in November 2021 when I suddenly experienced a heart rate of around 110 beats per minute while working.
I also noticed that I felt more fatigued when climbing stairs, which led me to consult a cardiologist at Taoyuan Hospital.
I underwent several tests, including an echocardiogram (which revealed mitral valve prolapse), a resting electrocardiogram (which showed no abnormalities), a 24-hour Holter monitor (which showed no abnormalities), a chest X-ray (which showed no abnormalities), a physician's auscultation (which detected a heart murmur), and blood tests (which showed no abnormalities).
The doctor prescribed me Inderal (propranolol) to take as needed.
After taking it for a while, my palpitations significantly decreased.

However, over the past three to four months, I feel my stamina has declined even further.
I used to be able to walk without issue, but now I sometimes struggle even to stand.
Occasionally, when I get up from a seated position, I notice my heart rate increases, and if I walk for a bit, I feel weak, as if I might collapse.
It seems to be a vicious cycle; the more uncomfortable I feel, the less I move.
During the pandemic, I spent almost two years working from home without much physical activity.

In the past month, I have tried to go out for brisk walks and light jogging, but I often feel extremely fatigued afterward.
This fatigue is hard to describe; it feels different from the exhaustion of sweating or muscle soreness.
Instead, it manifests as a sense of weariness where even a few more steps make my heart race and my body feel weak.
Previously, I could walk without feeling tired, only experiencing some foot soreness at most.

Given that my previous tests showed no issues, I am unsure what to do next.
I would like to consult you about what this might indicate and what direction I should take for further evaluation and improvement.
Now that the pandemic is over, I often need to go out, but due to my decreased stamina, I hesitate to go far, fearing that any physical activity will leave me feeling weak (especially my heart).
Thank you.

Raymond, 20~29 year old female. Ask Date: 2023/03/22

Dr. Hong Yuanbin reply Internal Medicine

Based on your description, it is possible that the issue may be due to physiological or psychological factors.
I recommend starting with a visit to a family medicine specialist to check your basic health status, such as whether you have anemia or if your endocrine system is functioning normally.
If all tests come back normal, you may consider consulting a mental health specialist to explore any potential psychological factors.
Thank you for your inquiry.

Reply Date: 2023/03/22

More Info

Your situation is indeed concerning, and it’s understandable that you feel frustrated with the fatigue and discomfort you are experiencing. Based on your description, it seems you have been through a thorough evaluation, including echocardiograms, electrocardiograms (ECGs), and blood tests, which have not revealed any significant cardiac issues. However, the symptoms you describe—fatigue, palpitations, and a feeling of weakness—suggest that there may be more to explore.

Possible Causes of Your Symptoms
1. Deconditioning: Given that you mentioned a significant reduction in physical activity over the past two years, it’s possible that your body has become deconditioned. When individuals stop exercising regularly, their cardiovascular fitness can decline, leading to increased fatigue and difficulty with activities that were once manageable. This can create a cycle where the fear of exertion leads to less activity, further worsening fitness levels.

2. Anxiety and Stress: The psychological aspect of health cannot be overlooked. Anxiety can manifest physically, leading to symptoms such as palpitations, fatigue, and a feeling of being overwhelmed. If you have been under stress or anxiety, especially during the pandemic, it could contribute to your symptoms.

3. Autonomic Dysfunction: Your symptoms of feeling faint or weak upon standing could indicate issues with autonomic regulation. Conditions like postural orthostatic tachycardia syndrome (POTS) can cause symptoms of fatigue and increased heart rate with minimal exertion.

4. Potential Undiagnosed Conditions: While your tests have come back normal, there are still conditions that may not have been fully explored. For example, thyroid dysfunction, anemia, or even chronic fatigue syndrome could contribute to your symptoms.

Recommendations for Management
1. Gradual Increase in Activity: Start with low-intensity exercises, such as walking or gentle stretching, and gradually increase the duration and intensity as your body allows. It’s important to listen to your body and not push too hard too quickly.

2. Consult a Specialist: Since you have already seen a cardiologist, it may be beneficial to consult with a specialist in sports medicine or a physiotherapist who can help design a tailored exercise program that considers your current fitness level and health status.

3. Mental Health Support: If anxiety or stress is a factor, consider speaking with a mental health professional. Cognitive-behavioral therapy (CBT) or mindfulness practices can be very effective in managing anxiety and improving overall well-being.

4. Regular Monitoring: Keep track of your symptoms, including when they occur and their severity. This information can be valuable for your healthcare provider in understanding your condition better.

5. Nutrition and Hydration: Ensure you are eating a balanced diet rich in nutrients that support energy levels. Staying hydrated is also crucial, especially if you are increasing your physical activity.

6. Follow-Up Testing: If symptoms persist or worsen, discuss with your healthcare provider the possibility of further testing, such as a tilt table test for autonomic function or additional blood tests to rule out other underlying conditions.

Conclusion
Your symptoms are valid, and it’s important to address them comprehensively. While your initial cardiac evaluations have not shown significant issues, the interplay of physical conditioning, mental health, and potential undiagnosed conditions could be contributing to your current state. By taking a gradual approach to increasing activity, seeking appropriate specialist care, and addressing any psychological factors, you can work towards improving your overall health and well-being. Remember, it’s essential to communicate openly with your healthcare providers about your concerns and experiences as you navigate this journey.

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