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A Breakthrough Training Day, Followed by an ER Visit for Chest Pain

re: atherosclerosis

After months of doldrums with rare exceptions, my body being aggrieved by some overburden from Long-Haul COVID or whatever it might be, I had another breakthrough ride yesterday, the last one having been about a month ago.

It was as if some weight had been lifted; I left home and immediately saw power levels (watts from my power meter) 30 to 50 watts higher than had I had been seeing for weeks prior. Power with greater ease and less sense of effort that at the lower levels. And with heart rate totally consistent with what it should be in detrained state in the winter, and relatively low in absolute terms.

While riding, I pondered whether it was some karmic reward for helping an injured cyclist the day prior. But if that were true, I wondered: might I need help soon too for some unforeseen problem? Mind you, I don’t tend to think in such terms, and I am not religious. Nor do I know why my thoughts turned that way, even while riding. In retrospect... well, read on.

There remains one bothersome issue: a strange asymmetry in lung expansion—the left side expands readily but the right rib cage seems “stuck”, and the asymmetry can be seen to an observer. I believe this goes all the way back to my 2018 crash. I had this treated by medical massage therapy with good resolution back then, but it has recurred more than once. On this ride below, I was “working” my rib cage with deep breathing to force the issue (force lung expansion), so this might be a salient point in what follows.

Continues below...

2021-12-19: Breakthrough ride of 210 watts @ 127 bpm
The big drop in heart rate at the ~34 minute mark is some static electric issue I see sometimes (wool pullover)

Chest pain

As it turned out, I began experiencing chest pain that very night around 9:30 PM. I could not find sleep on my back or either side. Standing up did not help, nor did lying down, or being on my hands and knees, nor deep breathing, etc. Nothing helped. It was very annoying. After a time, some ache migrated from the left chest wall to shoulder and towards neck—low level but there.

A critical point is that this type of chest discomfort is not the first time; I’ve felt this before and for several years. I had always dismissed it as some kind of internal pain in the chest wall, probably some latent thing from my late 2018 bike crashes. I still discount it as cardiac in source, but I could be wrong. Indeed, a low-level discomfort is back as I write this at 1PM today,but it also involves my left shoulder—maybe it stems from that? But I also recognize that making too much of an assumption with such things is a really bad idea—as in dropping dead—so I am taking it seriously.

So around 10:30 PM I checked the internet which basically said of such chest pain: “get your ass into a hospital within 15 minutes’. Being a stubborn old goat, I waited two hours or so until about 11:30 PM and then called my internist (physician), who asked a few questions and then told me I should get my ass into a hospital. Well OK, I’m stubborn but not stupid.

As a side note, my small airways were acting up a bit, so around 11:00 PM I took ~300m magnesium chloride as I do when that happens. That cleared it up, but it took longer than usual, about 45 minutes to an hour. MgCl can also act as a vasodilator, so there was a double logic involved. But clearly it did not work on blood pressure in this case, read on.

Around midnight we arrived at the ER (my wife drove). Right as we arrived, I felt very hot, like I was going to sweat a lot, even though my body temperature turned out to be 97.1°F. Soon I was on a gurney getting an EKG and blood draw and basic exam, though the MD on duty never got closer than arm’s length (the RN did what little was done to examine me).

My heart rate was 63 (I normally rest at 43 bpm), and my blood pressure was about 170/110 (normally 116/68). I felt simultaneously hot and cold (temp 97.1°F). It was later seen that my body was flushed*, as if I had sunburn; the RN remarked on it. I suppose that general flushing (not hives) was associated with the hot feeling.

* A pheochromocytoma seems unlikely; sudden onset and has not occurred before, and I did not feel panic or anxiety.

Around 00:45 I felt the symptoms ease a bit, and not long after I was given some nitroglycerin, which seemed to ease things even more. By 04:00 AM, my blood pressure was down to 139/80 and HR was down to about 52 bpm.

Around 01:30 we learned that the first blood draw showed normal Troponin levels—apparently not a heart attack. But since there can be a delay in Troponin following ischemia, another blood draw was done at 03:00. Just after 04:00 that test also came back negative. So not a heart attack. Which does not preclude blockage, but it does suggest that if the pain came from impaired blood flow, there was no damage.

We checked out around 04:30 AM and I went home. By then things has subsided to only a faint feeling of discomfort and I was able to sleep some hours.

I was given a referral for a cardiac stress test, which I intend to get done ASAP.

Followup

Here mid-day today as I write this, I still have some vague left-side pain just like last night, but also pain in my shoulder joint—related? I feel otherwise normal. As I’ve had this pain before, I’m at ease letting it be what it is until the cardiac stress test. Could it be referred pain from the shoulder? It all seemed to start on the left chest wall though. Pleurisy seems ruled out.

I had a long discussion with a cardiologist friend, very helpful. We could not come up with any evidence to support blockage, but there is also no way to be sure other than a cardiac stress test. Since the ER could find no evidence of cardiac events, I am comfortable for the time being in just living with the discomfort.

Moreover, my recollection from intermittent past events is that the discomfort generally eases if I exercise.

The safe thing to do is to get an exercise cardiac stress test with echocardiogram or radioactive dye, and I’ll be scheduling that first thing tomorrow.

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