You are skiing the same trail you’ve toured nearly every late January for the past 15 years. Conditions are just right: a cold 6 inches of powder over a firm base. There is a long hill towards the end and, as usual, you push it up that difficult half-mile or so. This time something is different. You feel real air hunger, not just the usual enthusiastic air exchange of good hard exertion. You are sweating more profusely than usual despite having shed extra layers a while back. The kicker: you have chest heaviness that, come to think of it, you have been vaguely but increasingly familiar with when exercising for the past few weeks. Trying to brush it off, you continue to push up and over the top, heeding the words of your high school cross-country coach so many years ago. As you glide silently down the velvety powder of the hard-earned downhill reward you become dismayed at how long it takes for your pounding heart and gasping to settle down. The chest pressure takes a least a couple of minutes to dissipate. Most worrisomely, you feel dead tired. You feel like lying down and just resting. How strange, normally your energy is boundless with such perfect skiing conditions.
Is something wrong? Or are you just getting old? Is it time to start “acting your age” and get used to the inexorable onset of age-related limitations? Be advised: a healthy, fit person should be able to exercise vigorously on a regular basis well into advanced age without the alarming symptoms above. Exercise intolerance should not be tolerated. This is a warning sign that something is wrong; you apparently flunked nature’s exercise tolerance test. It is time to get a medical work-up post-haste.
In the case above, the diagnosis sounds like textbook angina. Angina is an old-timey term given to constricted blood flow through one or more coronary arteries, the main providers of nutrition to heart muscle. The constriction can be a relatively stable condition caused by a slowly progressive narrowing of the arteries or it can be caused by a more dangerous sudden blockage caused by blood clots forming within diseased arteries. Both problems are caused by a disease called atherosclerosis.
Symptoms of angina can be classic as described above or can be more atypical, especially in diabetics and in women. Atypical symptoms can include nausea, back pain, or indigestion in addition to the more typical chest discomfort, fatigue, shortness of breath, or sweatiness.
Failure to identify and treat angina can result in a heart attack, the prolonged total blockage of a coronary artery in which heart muscle dies. This can be a rapidly fatal condition without state of the art treatment and monitoring. Those who survive may become disabled due to the inability of a damaged heart to perform all its duties as a blood pump.
Many risk factors for developing atherosclerosis and angina are largely well-known to the public: smoking, diabetes, obesity, inactivity, high cholesterol, family history of heart disease, and high blood pressure. Other risk factors not so well known include use of anti-inflammatory medications, hormones, and certain drugs of abuse.
Do not be one of the tragic athletes who emulate Jim Fixx, the running guru of the late 1970’s and early 1980’s who, despite his high level of aerobic conditioning, sustained a fatal heart attack immediately after his daily training on Rt. 15 in Hardwick. Apparently, he ignored obvious warning signs of heart disease under the mistaken belief that his hard-won fitness rendered him immune.
There are many athletes who routinely “reward” themselves with fat-laden treats such as steaks and large bowls of Ben & Jerry’s ice cream after hard workouts. There is no evidence that exercise mitigates the harm that over-indulgence causes. If you have any risk factors at all it is still very important to eat well. Diets with large amounts of fat and protein, animal-derived in particular, promote inflammation damaging arterial linings and impairing recovery of muscles, joints, and ligaments from the regular micro-trauma of exercise. The best nutrition research indicates that a vegan diet is probably the most healthy diet and is certainly capable of sustaining a world-class athlete in top form. Other preventative steps to take are quitting smoking, maintaining proper weight, control of high blood pressure, diabetes control, stress management, and avoiding sleep deprivation.
Other, less well-known, causes of exercise intolerance include:
- Hypertensive heart disease in which years of pushing blood against high pressures causes the cardiac muscles to hypertrophy in a pathologic way.
- Pulmonary embolus or PE. PE’s are clots which break off from a large vein, usually in the leg, and travel with blood flow to the lungs where they lodge. Tiny PE’s can be imperceptible but if they are numerous, frequent, or large enough they can wreak havoc. Repeated clots can cause constriction of blood flow through the lungs, a condition called pulmonary hypertension. This can result in significant loss of exercise capacity. In cases of large clots, death can result. PE’s can have many symptoms: shortness of breath, chest pain, fainting, or coughing up blood. Often, there are preceding symptoms of blood clots in a leg such as muscle pain, redness, and swelling. Main risk factors are extreme immobility, major trauma, genetic factors, hormone therapy, and smoking.
- Atrial fibrillation. This is an irregular, usually very rapid heart rhythm in which the atria have chaotic electrical activity, no longer providing proper pacing of the ventricles. Symptoms include a fast, irregular pulse (of course), shortness of breath, fainting, fatigue and chest pain. This becomes more likely with age but also has associated risk factors such as alcohol overuse, atherosclerosis, and thyroid over-activity.
- Anemia. This has myriad causes such as slow blood leaks from the digestive tract, blood cancers, and severe B12 deficiency.
We all are getting older and, being human, must face increasing threats of illness that stalk us. However, there is much we can do to prevent or mitigate many of these assaults on our wellbeing. Do not tolerate exercise-intolerance.
This article provided by Dr. George Terwilliger an ER physician who lives in Brattleboro and is a lifelong Vermont resident. He is an avid backcountry skier and has skied many sections of the Catamount Trail.