Keywords
Chest Pain; Exercise; Angina Pectoris; Asthma Exercise-Induced; Bronchial Spasm
Introduction
Chest pain is one of the most common complaints in emergency departments, and internal medicine and cardiology clinics.11 Stepinska J, Lettino M, Ahrens I,Bueno H, Garcia-Castrillo L, Khoury A, et al. Diagnosis and risk stratification of chest pain patients in the emergency department: focus on acute coronary syndromes. A position paper of the Acute Cardiovascular Care Association. Eur Heart J Acute Cardiovasc Care. 2020;9(1):76-89. Patients’ comorbidities and the clinical characterization of chest pain are cornerstones to guide symptom differentiation. Information about pain intensity, duration, localization, changes with posture/movement, and its reaction to nitroglycerin helps diagnose cardiac chest pain.11 Stepinska J, Lettino M, Ahrens I,Bueno H, Garcia-Castrillo L, Khoury A, et al. Diagnosis and risk stratification of chest pain patients in the emergency department: focus on acute coronary syndromes. A position paper of the Acute Cardiovascular Care Association. Eur Heart J Acute Cardiovasc Care. 2020;9(1):76-89. Typical angina pectoris is the presence of substernal chest pain or discomfort provoked by exertion or emotional stress, and is relieved by rest and nitroglycerin. Angina pectoris is attributed to myocardial ischemia due to the unbalance between myocardial oxygen supply and myocardial oxygen demand elicited during exercise or emotional stress.
The diagnosis and treatment workup in patients with moderate to high cardiovascular risk presenting angina pectoris is quite straight-forward.22 Cesar LA, Ferreira JF, Armaganijan D, Gowdak LH, Mansur AP, Bdanese L, et al.*Guideline for stable coronary artery disease. Arq Bras Cardiol. 2014;103(2 Suppl):1-56. Nevertheless, exertional chest pain in a young man can be challenging and yield a common but overlooked diagnosis, as in the present case report.
Case report
An 18-year-old professional, right-handed tennis player sought out a sports cardiology clinic due to several exertional chest pain episodes. In the last four months, the patient has been experiencing frequent bouts of oppressive, substernal chest pain, provoked after 20-30 minutes of running or during long tennis rallies. The pain was severe enough to make him stop exercising but usually lasted less than five minutes. These episodes were limiting the patient’s ability to train and compete. There were no complaints about syncope, pre-syncope, dyspnea, or palpitations. Past medical history was unremarkable, except for allergic rhinitis. The patient denied using any drugs, tobacco, or even nutritional supplements. There was no family history of coronary artery disease or sudden cardiac death.
Physical exam was normal, with unremarkable heart and lung auscultation. At rest, blood pressure was 120 x 70 mmHg, and the heart rate was 71 bpm. The resting electrocardiogram presented tall T waves in precordial leads that were compatible with a vagotonic pattern.
The patient was submitted to a maximal cardiopulmonary exercise test following an incremental ramp protocol on a treadmill (ATL, Inbrasport, Brazil). Oxygen uptake (VO2), carbon dioxide (VCO2), and ventilation (VE) were registered every ten seconds using a metabolic cart (Handymet, MDI, Brazil). Forced expiratory volume in one second (FEV1) was measured immediately before the exercise test and in several moments after peak exercise (immediately, 5 minutes, 10 minutes, and 15minutes) (Smart One, MIR, USA). A 12-lead electrocardiogram was continuously recorded (XCribe, Mortara, USA), and non-invasive blood pressure was measured each two-minutes
The ventilatory threshold was identified by the combination of the following methods:33 Ross RM. ATS/ACCP statement on cardiopulmonary exercise testing.Am J Respir Crit Care Med. 2003;167(2):1451. at the point of the first upward inflection of the ventilation vs. time curve, at the beginning of a consistent increase in the ventilatory equivalent for O2 (minute ventilation/oxygen consumption) without a concomitant increase in the ventilatory equivalent for carbon dioxide (minute ventilation/carbon dioxide production), and at the beginning of an increase in expired oxygen fraction. The ventilatory threshold was considered as the point identified by at least two of these three criteria.
Respiratory compensation point would have been identified at the point of the second upward inflection of the ventilation vs. time curve, which was concomitant with the beginning of a consistent increase in the ventilatory equivalent for carbon dioxide (minute ventilation/carbon dioxide production). However, the respiratory compensation point did not occur in this test. The maximum value of each variable during the final 30s of the exercise was used as peak variables.
The patient complained of mild chest pain after 8 minutes of exercising, and the test was interrupted at 10:40 min due to lightheadedness, moderately intense chest pain, and dyspnea. Chest auscultation at peak exercise revealed mild wheezing in both lungs. Symptoms disappeared in the first 5 minutes of recovery. Exercise electrocardiogram, VO2, and oxygen pulse curves were normal, excluding exercise-induced myocardial ischemia.
Peak VO2 was within normal values (95.5% of predicted, Table 1 ), but these were far below what is expected for athletes with a high aerobic component of training (>125% of predicted). Rest FEV1 was 3.76 L. There was a decrease in FEV1 during recovery, reaching a nadir of 2.67 L at 10 minutes after peak exercise. This decrease in 29% of FEV1 measured at the tenth minute of recovery is compatible with moderate exercise-induced bronchoconstriction ( Figure 1 ).44 Parsons JP, Hallstrand TS, Mastronarde JG, Kaminski DA, Rundell KW, Hull JH, et al. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med. 2013;187(9):1016-27.
Forced expiratory volume in one second (FEV1) before and after the cardiopulmonary exercise test.
After the diagnosis, the patient started treatment with the daily administration of an inhaled corticosteroid (Fluticasone) and a leukotriene receptor antagonist (montelukast), with no symptoms to date (follow-up of six months). The patient is training and competing at a local level with no discomfort.
Discussion
Exercise-induced bronchoconstriction represents the narrowing of the acute airway during exercise.44 Parsons JP, Hallstrand TS, Mastronarde JG, Kaminski DA, Rundell KW, Hull JH, et al. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med. 2013;187(9):1016-27. Although this diagnosis can be linked to asthma, it may occur in up to 70% of athletes without asthma.55 Parsons JP, Kaeding C, Phillips G, Jarjoura D, Wadley G, Mastronarde JG. Prevalence of exercise-induced bronchospasm in a cohort of varsity college athletes. Med Sci Sports Exerc. 2007;39(9):1487-92. Symptoms of exercise-induced bronchoconstriction are nonspecific, and the presence of respiratory symptoms (such as dyspnea) are not always present. As this syndrome is usually present in athletes, the inability to perform high-intensity endurance exercise is one of the most common complaints.44 Parsons JP, Hallstrand TS, Mastronarde JG, Kaminski DA, Rundell KW, Hull JH, et al. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med. 2013;187(9):1016-27. , 66 Parsons JP, Mastronarde JG. Exercise-induced asthma. Curr Opin Pulm Med. 2009;15(1):25-8. , 77 Teixeira RN, Teixeira LR, Costa LA, Martins MA, Mickleborough TD, Carvalho CR. Exercise-induced bronchoconstriction in elite long-distance runners in Brazil. J Bras Pneumol 2012;38(3):292-8.
Chest-tightness is a frequent complaint in these cases and usually leads to a full workout to rule out the risk of sudden cardiac death. One of the fundamental core competencies of the cardiologist who is taking care of an athlete is to reduce the risk of adverse cardiovascular outcomes during intense physical activity.88 Baggish AL, Battle RW, Beckerman JG, Bove AA, Lampert R, Levine BD, et al. Sports Cardiology: Core Curriculum for Providing Cardiovascular Care to Competitive Athletes and Highly Active People. J Am Coll Cardiol. 2017;70(15):1902-18. Nevertheless, once lethal causes of chest pain have been ruled out, we must remember that most chest pain in athletes is musculoskeletal or respiratory. In this context, if the diagnosis is kept unrevealed after anamnesis and physical examination, the cardiopulmonary exercise test is the gold standard to investigate exercise-induced chest discomfort in athletes.33 Ross RM. ATS/ACCP statement on cardiopulmonary exercise testing.Am J Respir Crit Care Med. 2003;167(2):1451. , 77 Teixeira RN, Teixeira LR, Costa LA, Martins MA, Mickleborough TD, Carvalho CR. Exercise-induced bronchoconstriction in elite long-distance runners in Brazil. J Bras Pneumol 2012;38(3):292-8.
Nevertheless, one must take into account that the usual cardiopulmonary testing protocol does not include FEV1 measurements after peak exercise.33 Ross RM. ATS/ACCP statement on cardiopulmonary exercise testing.Am J Respir Crit Care Med. 2003;167(2):1451. Moreover, wheezing may not be present in cases of exercise-induced bronchoconstriction.99 Suguikawa TR, Garcia CA, Martinez EZ, Vianna EO. Cough and dyspnea during bronchoconstriction: comparison of different stimuli. Cough 2009;5:6.doi: 10-1186/1745-9974-5-6 Thus, in cases where exercise-induced bronchoconstriction is being investigated, a specific testing protocol should be considered.44 Parsons JP, Hallstrand TS, Mastronarde JG, Kaminski DA, Rundell KW, Hull JH, et al. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med. 2013;187(9):1016-27. , 1010 De Fuccio MB, Nery LE, Malaguti C, Taguchi S, Dal Corso S, Neder JA. Clinical role of rapid-incremental tests in the evaluation of exercise-induced bronchoconstriction. Chest. 2005;128(4):2435-42. The protocol should include FEV1 measurements before and at several moments after exercise (minutes 0, 5, 10, 15, and 30 of recovery).44 Parsons JP, Hallstrand TS, Mastronarde JG, Kaminski DA, Rundell KW, Hull JH, et al. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med. 2013;187(9):1016-27. The severity of exercise-induced bronchoconstriction can be graded according to the maximum percent of fall in FEV1 from the pre-exercise level, as follows: mild ≥ 10% but < 25%; moderate ≥25% but < 50%; and severe ≥50%.
Conclusion
Exercise-induced bronchoconstriction should be considered a cause of chest pain elicited during exercise in athletes after ruling out other potentially lethal causes.
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Sources of FundingThere were no external funding sources for this study.
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Study AssociationThis study is not associated with any thesis or dissertation work.
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Ethics approval and consent to participateThis article does not contain any studies with human participants or animals performed by any of the authors.
References
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1Stepinska J, Lettino M, Ahrens I,Bueno H, Garcia-Castrillo L, Khoury A, et al. Diagnosis and risk stratification of chest pain patients in the emergency department: focus on acute coronary syndromes. A position paper of the Acute Cardiovascular Care Association. Eur Heart J Acute Cardiovasc Care. 2020;9(1):76-89.
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2Cesar LA, Ferreira JF, Armaganijan D, Gowdak LH, Mansur AP, Bdanese L, et al.*Guideline for stable coronary artery disease. Arq Bras Cardiol. 2014;103(2 Suppl):1-56.
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3Ross RM. ATS/ACCP statement on cardiopulmonary exercise testing.Am J Respir Crit Care Med. 2003;167(2):1451.
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4Parsons JP, Hallstrand TS, Mastronarde JG, Kaminski DA, Rundell KW, Hull JH, et al. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med. 2013;187(9):1016-27.
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5Parsons JP, Kaeding C, Phillips G, Jarjoura D, Wadley G, Mastronarde JG. Prevalence of exercise-induced bronchospasm in a cohort of varsity college athletes. Med Sci Sports Exerc. 2007;39(9):1487-92.
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6Parsons JP, Mastronarde JG. Exercise-induced asthma. Curr Opin Pulm Med. 2009;15(1):25-8.
-
7Teixeira RN, Teixeira LR, Costa LA, Martins MA, Mickleborough TD, Carvalho CR. Exercise-induced bronchoconstriction in elite long-distance runners in Brazil. J Bras Pneumol 2012;38(3):292-8.
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8Baggish AL, Battle RW, Beckerman JG, Bove AA, Lampert R, Levine BD, et al. Sports Cardiology: Core Curriculum for Providing Cardiovascular Care to Competitive Athletes and Highly Active People. J Am Coll Cardiol. 2017;70(15):1902-18.
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9Suguikawa TR, Garcia CA, Martinez EZ, Vianna EO. Cough and dyspnea during bronchoconstriction: comparison of different stimuli. Cough 2009;5:6.doi: 10-1186/1745-9974-5-6
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10De Fuccio MB, Nery LE, Malaguti C, Taguchi S, Dal Corso S, Neder JA. Clinical role of rapid-incremental tests in the evaluation of exercise-induced bronchoconstriction. Chest. 2005;128(4):2435-42.
Publication Dates
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Publication in this collection
22 Apr 2022 -
Date of issue
Nov-Dec 2022
History
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Received
18 Nov 2020 -
Reviewed
29 May 2021 -
Accepted
14 July 2021