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Dr Larry Creswell

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Caution! The Six Warning Signs You Shouldn’t Ignore

February 24, 2018 By Larry Creswell, MD 16 Comments

Some readers here at the blog will remember that I once wrote a monthly column for Endurance Corner, a multisport coaching outfit. Many of the links to those articles are no longer active, as readers have pointed out.  One of the most popular Endurance Corner articles was a 2010 article entitled “Caution!  The Five Warning Signs You Shouldn’t Ignore.”  I thought I’d update the article here at the blog, and include an additional, sixth warning sign that athletes should also be aware of.

Over the years, I’ve noticed that my athlete friends seem to be very “in touch” with their bodies. They can be hyper-vigilant about the first signs of “swimmer’s elbow” or plantar fasciitis or leg muscle strain.  They’re also apt to be proactive about dealing with these problems.  Maybe that’s just because it’s sometimes easy to self-diagnose a musculoskeletal problem and easy to self-prescribe rest, ice, or analgesics.  Maybe over time, they’ve learned the lesson that early intervention can head off bigger problems later on.  That’s an important lesson, too.

I’ve also noticed, though, that my athlete friends sometimes give short shrift to some of the warning signs of potentially more worrisome problems—problems that stem from the heart or cardiovascular system. In my experience, it seems that men are worse than women.  Like I’ve mentioned in previous articles, young “healthy” men just don’t like to go to the doctor.  It’s easy to think that we’re invincible and ignore serious warning signs until they simply can’t be ignored any longer.  But just like plantar fasciitis, it’s always best to recognize and deal with any serious heart-related problem earlier rather than later.

Here’s my short list of six warning signs that you shouldn’t ignore. These are symptoms that you should discuss with your doctor.  Get reassurance if there’s really no serious problem and get thoroughly evaluated if your doctor believes there may truly be something wrong.

  1. Chest pain or discomfort. Once every few weeks I meet with a small group of third year medical students to talk about patient scenarios that involve chest surgery. One of the scenarios that we discuss deals with a young man with chest pain. I ask the medical students to come up with a list of the potential causes and I’m always amazed at how many answers are offered up. Sometimes they’re able to list 30 or more. That’s the way it is with chest pain—many, many potential causes. These include things like injuries to the chest, reflux disease of the stomach, inflammation of the joints between the ribs and breast bone, anxiety, and diseases of the esophagus, among others. The students are quick to remember the potentially life-threatening causes such as heart attack (acute myocardial infarction), collapse of one of the lungs (pneumothorax), tears (dissection) of the aorta, the large blood vessel that carries blood away from the heart, and pulmonary embolism, the condition where blood clots form and travel to the lungs. I suppose that any of these causes may be in play for an athlete with chest pain. But the particular scenario that’s most important for athletes is chest pain or discomfort that comes with exertion and is relieved by rest. This can be an indication of coronary artery disease (CAD) that is usually caused by plaque build-up in the coronary arteries that supply blood to the heart muscle itself. In its early stages, the pain can be very subtle, perhaps nothing more than a twinge. In its later stages, the pain can be crippling. The good news is that, working with your doctor, you can be evaluated to see if chest pain is due to CAD. A variety of treatments may be available depending upon your situation. Don’t ignore chest pain!
  2. Unexplained shortness of breath. As athletes, we’re all short of breath at some point—some of us earlier than others. And as athletes, we usually become accustomed to the level of shortness of breath that is associated with a given workout or level of effort. What’s worrisome is when there is some change to that pattern—when shortness of breath is unexpectedly out of proportion to what you’d ordinarily expect. That’s when the alarm bells should go off inside your head. Just like chest pain, there are a myriad of causes of shortness of breath, ranging from pulmonary or bronchial infections, to asthma (potentially made worse with exercise), to blood clots in the lungs (pulmonary embolism). For athletes, the most worrisome sign might be shortness of breath that persists after exercise stops or shortness of breath that occurs at rest. Both are signs that a heart condition may be responsible. This is a warning sign that you should report to your doctor.
  3. Loss of consciousness. Much of medical school involves learning a big vocabulary of new “medical” words. Our word for sudden, unexpected loss of consciousness is syncope. Patients will use a variety of terms like “blacking out,” “passing out,” “falling out,” or even just “lightheadedness” or “dizziness.” Again, there are many causes, such as dehydration, side effects of various medications, etc. For athletes, one common scenario is near-syncope or syncope at the end of a workout, when the exercise is stopped abruptly without a period of cooling down. Thankfully, that situation can be avoided just by remembering to have an appropriate cool-down after each workout. The most worrisome type of syncope occurs during exercise. This almost always indicates a serious underlying medical problem—and often related to the heart. All cases of syncope should be discussed with your doctor, but it’s particularly important (bordering on emergency) to be evaluated if you have syncope during exercise.
  4. Unexplained fatigue. Like shortness of breath, all athletes are familiar with fatigue. Almost regardless of the sport, fatigue just comes with the territory. It’s important to remember that, besides exercise, there are many causes of fatigue, including depression, the side effects of various medications, and anemia, among others. It’s also true that fatigue can be a symptom of underlying heart disease. Athletes become accustomed to the degree of fatigue that is associated with any particular workout or load and they should be acutely aware when there is a change to this pattern. Whenever there is a sudden change in an athlete’s pattern of fatigue or when the fatigue persists for an excessively long time, it’s important to get evaluated. Find out what’s going on.
  5. Palpitations. Of the first five of these warning signs, palpitations—the feeling of an abnormally strong, fast, or irregular heartbeat that just grabs your attention—is undoubtedly the most common among athletes. It’s an unusual problem in school-aged athletes, but is very common among middle-aged endurance athletes. In some reports, as many as 70% of adult athletes report this problem. The palpitations may occur during exercise or at rest. We could make a long list of specific arrhythmias (abnormal heartbeats) that explain palpitations in athletes. The most common problems are due to abnormal heartbeats or rhythms (like atrial fibrillation) that start in the upper chambers of the heart (atria). Most of these arrhythmias are benign and require no treatment. But if you’re bothered by frequent palpitations, it is best to find out exactly what’s causing them, because they’re sometimes a sign of underlying heart problems that do require treatment. Resist the urge to ignore this problem.
  6. Unexplained decrease in performance. I didn’t include this warning sign in my original list back in 2010, but I’m adding it here because of what I’ve learned over these past few years. By decrease in performance, I’m talking about an unexplained decrease in pace, endurance, or perhaps other measures of performance. Needless to say, there could be many reasons for such a decrement, including (poor) nutrition or hydration, various illnesses or injuries, the distractions of life outside of sports, depression, or even, simply, aging. All of those potential causes deserve attention, of course. But I’ve also seen cases where an unexplained decrease in performance, in the absence of any of the other five warning signs above, was the only indication of a serious heart condition. In situations where a decrease in performance persists despite consideration of the more innocuous causes, evaluation by your doctor with a particular eye toward hidden heart problems may be in order.

 

I realize this is a short list. But by paying attention to just these six warning signs, athletes can uncover many of the potentially serious underlying heart-related conditions that could place them at risk.  Do this for yourself and remind your athlete friends, too.

 

Related Posts:

  1. In the News:  Marathoners and  Coronary Plaque
  2. Cyclist’s Account of Atrial Fibrillation
  3. PR While Having a Heart Attack

Filed Under: Athletes & preventive care, Heart problems Tagged With: athlete, chest pain, fatigue, heart, heart disease, lightheadedness, palpitation, performance, performance decrement, symptom, syncope

Coach John Fox and Aortic Valve Replacement

November 3, 2013 By Larry Creswell, MD 5 Comments

 

NFL Broncos head coach, John Fox, will reportedly undergo aortic valve replacement (AVR) this week.  I’ve gotten some inquiries over the weekend about his situation and I thought I’d take a few minutes to write about aortic valve problems and aortic valve replacement.

This story is reminiscent of Atlanta Falcons coach, Dan Reeves, who had urgent coronary artery bypass surgery in 1998, late in his team’s 14-2 season.  For reference, Reeves made an excellent recovery, rejoined the team just 3 weeks after surgery, and went on to coach for another 5 seasons.

Aortic Valve Disease

The aortic valve is the valve that lets blood out of the heart.  The left ventricle of the heart pumps blood out through this valve into the aorta with each heart beat.  At rest, this might amount to about 5 liters per minute.  The valve ordinarily has 3 tissue thin leaflets, but some individuals are born with just 2, a condition known as bicuspid aortic valve (BAV).

There are 2 different problems with the aortic valve.  The valve can become narrowed or it can leak.  Either situation produces trouble for the heart, which then must do extra work.  When the valve is narrowed, we call the condition aortic stenosis.  When the valve leaks, we call the condition aortic regurgitation.  When there is severe aortic stenosis or regurgitation, aortic valve replacement is often the only available curative treatment.

In this country the most common cause of aortic stenosis in adult patients, by far, is build-up of calcium in the valve leaflets over many years’ time.  This progressive calcification causes the valve leaflets to become thickened.  As a result, they don’t open or close easily and eventually they become immobile.  Severe aortic stenosis most often manifests in patients 60+ years old.  In individuals with BAV, this process occurs much earlier in life, and the condition often manifests in patients in their 40’s and 50’s.  Rheumatic fever is probably the next most common cause.  The normal aortic valve opening is about the size of a half dollar.  But with severe aortic stenosis, the opening can be reduced to the size of a drinking straw.

Aortic regurgitation may occur for a variety of reasons such as:  infection (that we call endocarditis) that destroys the valve leaflets; enlargement of the aorta that stretches the leaflets apart; rheumatic fever; or trauma.

Patients with severe aortic stenosis have symptoms of shortness of breath with exertion, chest pain/discomfort, or light-headedness or blacking out (that we call syncope).  Patients with aortic regurgitation most often have symptoms of shortness of breath with exertion.  Either condition can be revealed by listening to the heart with a stethoscope because either condition produces turbulent blood flow that can be heard as a heart murmur.  The diagnosis is confirmed using ultrasound, in a test known as an echocardiogram.

Once there are symptoms, patients with severe aortic stenosis need operation.  Once the heart function suffers because of aortic regurgitation, operation is needed.  In either case, we usually plan for operation at the earliest, convenient opportunity.  Emergency operations for aortic valve problems are unusual.

In John Fox’s case, we know from reporting that he was in Charlotte, North Carolina to visit his doctor(s) about a known aortic valve problem–one that was being monitored and for which aortic valve replacement was being planned once this year’s football season was complete.  The initial news reports spoke about the possibility of a heart attack, but he apparently became light-headed while playing golf.  It’s not clear if he passed out completely.  He was taken to the hospital where additional testing was completed.  The Broncos then made the announcement that Fox would undergo surgery this coming week.

Aortic Valve Surgery

Aortic valve replacement is a very common heart operation today.  And while there are new technologies that allow for valve replacement in high-risk patients without conventional operation, the vast majority of patients undergo typical open heart surgery to replace the valve.

The patient has general anesthesia with use of a breathing tube to provide ventilation while asleep.  Access to the heart is gained by dividing all or part of the sternum and using a retractor to spread the rib cage open.  The first main part of the operation involves connecting the patient to a heart-lung bypass machine that sits at the side of the operating table and takes over the job of the patient’s own heart and lungs for a period of time.  This allows the patient’s heart to be still and empty of blood.

The next main part involves replacing the valve.  An opening is made in the aorta, the large blood vessel that carries blood away from the heart.  This allows the surgeon to look in and see the diseased valve.  In the most straightforward operation, the patient’s aortic valve is removed using scissors and any calcium-related debris is also removed.  A measuring tool is used to determine the correct size for a substitute valve which is then taken from the shelf.  Sutures are used to sew the substitute valve into the opening left behind where the patient’s valve was removed.  The opening in the aorta is then closed with sutures.

The last major part of the operation involves letting the patient’s own heart and lungs take back over again, and gradually reducing the amount of help that the heart-lung machine provides.  Once the patient’s heart is beating again, the sternum is re-approximated with wires and the overlying tissues and skin are re-approximated using sutures.  The entire operation usually takes about 3 hours.

There are several options for substitute valves.  Mechanical valves are made out of space-age materials and are designed to last forever, but patients must take blood thinning medications to prevent blood clots from forming on the prosthetic valve.  Tissue valves (eg, aortic valve “borrowed” from a pig) don’t require anticoagulants, but the valves don’t last forever.  The modern tissue valves can be expected to last 10-15 years in adult patients and then some will deteriorate; re-replacement of the valve may sometimes be needed.  In special circumstances, other more exotic options may be appropriate, but we won’t consider those options today.

Recovery from Operation

The typical patient wakes up soon after the operation.  The breathing tube and ventilator are withdrawn once the patient is wide awake and breathing on his/her own.  Most patients will spend a night in the intensive care unit and then several more days recovering in a regular hospital room.  A typical stay would be about 5-7 days.  We work hard to have patients up and walking on the first day after operation and most are walking laps around our hospital ward by the time they go home.

Many patients with AVR notice even in just the first couple days after operation that they no longer have the symptoms that led to discovery of their problem.  Particularly for aortic stenosis, the calcification of the valve happens so gradually that patient’s aren’t always aware of how much of a decrement there’s been in their exercise tolerance.

As the sternum heals, we ask that patients avoid physical activities that place stress on the sternum and shoulders (eg, pushing, pulling, reaching, etc.) for 1 month after the operation.  The sternum regains about 75% of its strength in about 1 month.  In my practice we also restrict driving for that same month.  Most any other activity is allowed and we encourage lots of walking as the preferred type of exercise.

Each patient’s situation with return-to-work is different, not only because each patient’s recovery is different but also because each patient’s job situation is different.  In Fox’s case, if all goes well, I wouldn’t be surprised to see him back at work, at least in some capacity, very quickly.

Best wishes to John Fox!

Filed Under: Current events, Heart problems Tagged With: aortic regurgitation, aortic stenosis, aortic valve, coach, football, heart, heart surgery, syncope

Syncope–Part 1

August 21, 2009 By Larry Creswell, MD 1 Comment

 

Some of you will know about professional triathlete Joanna Zeiger’s recent troubles with syncope. Her trials and tribulations with race-related dizziness are summarized in a nice article at slowtwitch.com, “Zeiger sidelined by dizziness.” Her story is typical. This week and next week, we’ll talk about the causes, medical evaluation, and treatment options for syncope.

Syncope is the medical term used to describe a brief period of loss of consciousness (either partial or complete) that is due to insufficient blood flow to the brain. This process is temporary and is followed by spontaneous recovery. Patients often use different terms such as “dizziness”, “light-headedness”, “blacking out”, “passing out”, or “falling out” to describe this problem. This is a common medical condition that affects approximately 3% of the population at some point during life. It is increasingly common as we age, affecting 6% of individuals over the age of 75. It’s not surprising, then, that this is a fairly common problem among athletes.

Syncope may occur without warning or may be preceded by warning signs that are called premonitory symptoms. Typical premonitory symptoms might include palpitations, light-headedness, grogginess, feeling warm, or experiencing nausea.

TYPES OF SYNCOPE

There are many types or causes of syncope and it can be useful to categorize the types as: 1) cardiac (heart-related), 2) non-cardiac, or 3) unknown. This framework helps the physician sort out an individual’s cause among the many possibilities and then provide any needed treatment.

Cardiac syncope

A variety of cardiac disorders can produce syncope, but cardiac causes account for the explanation in only 10% of cases. As patients age, it is more likely that a cardiac cause is responsible for their syncope. Some of the cardiac causes are potentially life-threatening, but most are less serious; all can be treated.

Life-threatening cardiac causes. Acute myocardial infarction (“heart attack”) or aortic dissection (tearing apart of the layers of the aorta) can produce syncope or other changes in the level of consciousness. Both of these conditions are usually accompanied by chest or back pain and can also be associated with shortness of breath. In these situations, syncope is the result of decreased blood pressure and/or decreased blood flow to the brain. Both of these conditions can result in sudden death and affected individuals require urgent medical attention.

Arrhythmias. The most common cardiac cause of syncope, though, is an abnormal heartbeat, or arrhythmia—either atrial (from the upper heart chamber) or ventricular (from the pumping chamber of the heart). Syncope can be the result of an abnormally fast (tachy-) or slow (brady-) arrhythmia. Bradyarrhythmias are usually found in patients with known, pre-existing heart disease, but they sometimes occur because of unwanted side effects of medicines (eg, beta-blockers for high blood pressure). It’s important to remember that the well-trained athlete typically has a baseline slow heart rate and this can sometimes confuse the picture. Syncope is more common with atrial or ventricular tachyarrhythmias, though. The atrial tachyarrhythmias include atrial fibrillation (A-fib), atrial flutter (A-flutter), and supraventricular tachycardia (SVT). These arrhythmias may be accompanied by chest discomfort, palpitations, or shortness of breath. With persistent arrhythmias, syncope often occurs when moving from the sitting to standing position (postural) due to decreased blood pressure. Ventricular tachyarrhythmias include ventricular fibrillation (V-fib) and ventricular tachycardia (V-tach). These arrhythmias are usually associated with known, pre-existing heart disease. Syncope due to ventricular tachyarrhythmias is not usually related to posture.

Cardiac bloodflow obstruction. A third set of cardiac causes of syncope are due to obstruction to blood flow in the heart. This can be due to narrowing (stenosis) of the aortic, mitral, or pulmonary valves, hypertrophic obstructive cardiomyopathy (HOCM, one of the most common causes of sudden death in athletes), or to tumors of the heart. With these conditions, syncope is often sudden, without any preceding symptoms.

Low cardiac output. The last set of cardiac causes are those due to decreased pumping function, or cardiac output, from the heart. Long-standing congestive heart failure (CHF) or leaking (regurgitant) heart valves may lead to a low blood pressure that limits blood flow to the brain.

Non-cardiac syncope

Neurocardiogenic syncope. The most common type of syncope is termed neurocardiogenic, or vasovagal syncope. The term vasovagal conveys the association of “vaso,” for vasodilation of arterial system (leading to a decrease in blood pressure) and “vagal,” for the accompanying slow heart rate (sometimes produced by decreased activity in the vagal nerves). This type of syncope usually occurs in the standing position and is usually preceded by symptoms such as light-headedness, nausea, or sweating.

Situational syncope. A variety of precipitating factors, such as emotional stress, anxiety, pain, cough, urination, or defecation can lead to syncope. In this situation, the resulting syncope is thought to be due to a reflex, sudden decrease in heart rate that produces a transient reduction in blood flow to the brain.

Orthostatic syncope. Syncope can be caused by a sudden drop in the blood pressure as we rise from a sitting to standing position. The medical terms for this situation are orthostasis, or orthostatic hypotension (reduced blood pressure). Ordinarily, the body adjusts to this change in position by increasing the heart rate and increasing motor tone in the blood vessels to keep the blood pressure constant. When these mechanisms fail, the sudden (relative) drop in heart rate and blood pressure may produce syncope. This problem can be made worse by dehydration or medications that reduce the circulating blood volume or by medications that limit the blood pressure response (eg, beta-blockers).

Neurologic syncope. One last, unusual category of causes is termed neurologic. In this situation, the syncope is caused by a sudden decrease in blood flow to the brain in conditions such as stroke, transient ischemic attack (TIA, or “near-stroke”), or seizures. In one variant, syncope is due to a sudden decrease in blood flow to the posterior portion of the brain called the cerebellum. This is often due to pre-existing vascular disease in the vertebral arteries that supply this portion of the brain. Patients with neurologic syncope often experience other neurologic symptoms such as vertigo, visual changes, or muscle movement clumsiness immediately before the syncopal event.

MEDICAL EVALUATION

Syncope can sometimes easily be explained by benign problems such as dehydration, but the majority of individuals with syncope should be evaluated carefully for an explanation. Because of the demands on the athlete’s cardiovascular system during exercise, it is particularly important for the athlete with syncope to be evaluated completely.

NEXT WEEK

Next week, we’ll talk about the medical evaluation of patients with syncope and discuss the various treatment options.

Filed Under: Heart problems Tagged With: blacking out, cardiac screening, light-headedness, sudden cardiac death, syncope

 

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