Cycling UK Forum

Shortest version of my situation possible:

Ive been a cyclist (primarily mountain biking) for over 20 years. But in the past 5 years or so I seem to have developed a problem where my HR will not come down after high intensity training and/or after races (sometimes accompanied by chest pain that I can only describe as angina like), it will remain very high for up to 10-20 minutes and the experience is both painful and frightening, and it happens about 1 out of 10 times I go out to do training. Ive gone to doctors for years, they tell me my tests all come back normal and I dont seem to be able to trigger one of these events during testing.

Some other cyclists I have spoken to tell me they've had similar experiences and a few of them said they were finally diagnosed with arrhythmia that forced them to drop out of racing and they can only do training now at much lower levels. My doctors advise has been similar, I should ride less, do less high intensity training, avoid racing etc, and thats not something I really want to do.

I should mention that unlike a lot of others who have afib problems all the time, ONLY get mine occasionally during high intensity exercise, it happens maybe 1 out of 10 times I go cycling. The intermittency makes it a lot harder to get a diagnosis since it has to show up on a test for doctors to really care.

Thanks for any suggestions, I'm not taking any medical advice from strangers but Im looking for others who have had similar issues and what their diagnosis and or treatments have been that helped them. Thanks.

What do you call a very high heart rate? My arrhythmia typically runs at 180-200, but the record is 260. There are several of us with heart arrhythmias on here, chronic endurance training increases your risk of developing it.

What tests did you have? I had two Bruce (treadmill) tests, two 24hr Holter monitors (ambulatory EGC recorders), a 7 day Holter, and more ECGs than you can poke a stick at, but the only times they've ever seen my arrhythmia are the other ten occasions I've fetched up at A&E in an ambulance. Arrhythmia's like that, one second you're fine, the next you aren't, and when there's nothing to see, they won't see it.

I'd been getting minor episodes for years, but it started getting much worse shortly after the first Bruce test in 2009, that seemed to be the last straw. Then one day in 2010 I had a big episode lasting about 9 hours during which I was crawling around the house on all fours, but it was still another two years before I was diagnosed in August 2012.

Some patients can continue exercising, even at Olympic level, others like me end up giving up altogether, I was a tourist not a racer but it was game over for me. In the last decade I've had numerous attempts at re-training carefully in the hope that I could regain enough fitness to resume touring, but they all ended in tears. I used to be able to continue doing a very modest amount of cycling provided I kept my heart rate below about 90-100, but nothing anywhere near what's needed for touring, then since an ill-advised attempt to retrain three years ago I've not been able to cycle at all.

Ive had all the same tests as you except for the 7 day holter test, I did a 48 hour one and all they found was PVC's which I dont think are the cause.

So my theoretical Max HR is around 180-ish, and the highest HR I have ever seen in training or racing is around 184, but when I get these episodes my HR will go slightly higher than that to around 186-188 range. The really disconcerting part is that at the time my HR is that high Im standing still, not biking, not running, just standing, and its pinned at 188 and wont come down for 10-ish minutes usually.

Im concerned with the fact that no arrhythmias have shows up yet on any of these tests, some people have told me you have to be in the middle of an episode for them to really be able to see what it is. I hope thats not the case because the only way that would happen is if I get an episode that lasts for hours and I have to go to hospital.

So are you saying that even if I get a clinical diagnosis of arrhythmia, there is nothing that can be done about it? Beta blockers? Anything?

In my case I do think the regular over training issues were a factor, I was a competitive MB racer for years and trained over 300 hours a year for almost 10 years, 20 years of training in total. However in my case I also have a bad hiatus hernia which leads to severe reflux issues and I have some evidence that it could be part of the problem as well;

"Direct inflammation of the atrium from the adjacent esophagus may contribute to these atrial arrhythmias in patients with acid reflux"
https://www.aafp.org/pubs/afp/issues/2019/0115/p78.html

So Im feeling a bit hopeless at the moment, I have switched to ebiking as that keeps my HR low, but Im not getting any cardio from that.

aegisgfx wrote: ↑16 May 2023, 4:19pm some people have told me you have to be in the middle of an episode for them to really be able to see what it is. I hope thats not the case

It is, AFAIK, when there's nothing to see, there's nothing to see, it's capricious and evanescent.An episode can terminate in the next two seconds, or days, or weeks, or never, and it can start in just the same way, you won't know until it happens, although when you're used to it you have expectations based on past experience.

aegisgfx wrote: ↑16 May 2023, 4:19pm So are you saying that even if I get a clinical diagnosis of arrhythmia, there is nothing that can be done about it? Beta blockers? Anything?

I should start by saying I'm not a doctor, just an atrial fibrillation patient who's spent a decade reading all the research he can lay his hands on in the hope of improving his situation. (It didn't, and as a result I've lost a bit of interest in reading lately.) My comments relate to my own experience of AF, not any other type of arrhythmia.

To quote my consultant, AF is treatable, not curable. It tends to be degenerative, often getting worse over time, but not always, and if it's exercise induced, de-training can help. There are numerous treatments available, each with their own categories of patients they're suitable for, and each with their own advantages and side effects. I know a bit about the ones I have experience of, but very little about the others.

One of the more common drugs is a ryhthm control drug called Flecainide which is relatively safe provided your not ishaemic, in which case it's contraindicated. It can cause cardiac arrest in some patients, and has to be prescribed in hospital, so I assume you won't get a GP offering you a packet to try without a diagnosis. Its major side effect is that it can cause another arrhythmia called atrial flutter along with other drugs of the same class. That in itself can be dangerous, so it's usually prescribed in conjunction with a rate control drug like Diltiazem or a betablocker, which keeps your heart rate to a safe level if the flec doesn't maintain normal rhythm. They both have side effects: betas make you lethargic, and exercise difficult, Dilt affects exercise less, but causes swollen feet (oedema). Oedema damages nerves and blood vessels in the long term.

Amiodarone is a powerful drug, but it's regarded as a drug of last resort.

The main alternative to drugs is an ablation. This is done by threading a catheter up into your heart from the vein in your groin, which is then used to burn the inside of your heart so that scar tissue blocks the faulty electrical pathways that cause the arrhythmia. Success rate is about 70%, and sometimes it will take 2 or 3 attempts to stop the arrhythmia. Complication rate is quite low: about 1% AIUI, but there are multiple serious ones. The advantage is that if it works, you'll be off the drugs and free of AF for as long as it takes to come back, which is typically 5+ years or so from listening to others on the AF forum, then you're in for another one, until they reach a point where they can't do any more.

There are other options such as ablate & pace, or a maze, but I don't know any details of those. I've not seen other patients on forums that have had them either, so they seem as if they're rare.

The big side effect of untreated arrhythmia is stroke. When the heart doesn't beat in the correct rhythm the blood flow can form stagnant pools and tend to clot, then if a piece of the clot breaks loose you can have an ischaemic stroke if it reaches the brain. I think it's a common way to get diagnosed in patients whose arrhythmia is asymptomatic. The actual risk of stroke depends on multiple factors, and can be as low as a normal patient, but the average of all AF patients is around five times higher than normal. Those who are at risk are put on an anticoagulant such as warfarin to control the risk, which in turn comes with an increased risk of haemhorragic stroke.

Research on the risk of AF among those with a history of exercise is relatively new, and whilst the existence of the problem is slowly becoming accepted, the magnitude of the effect is still contentious. There's been some reluctance to accept it because exercise is seen as so beneficial:- and it is, in moderation. When it comes to the continuation of exercise after diagnosis, there's very little research at all AFAIK.

Sees HR question in titles. Gets excited, might be able to help.

Walks off in disappointment

How about the reflux question, so you think mine could be caused exclusively by that?

"Direct inflammation of the atrium from the adjacent esophagus may contribute to these atrial arrhythmias in patients with acid reflux"
https://www.aafp.org/pubs/afp/issues/2019/0115/p78.html

The reason I ask is because in spite of many tests they have found nothing wrong with my heart, and Im thinking that might mean I have a more esoteric cause for my problems than just over training, one that might not be picked up on standard tests.

Also, at the time this all started about 2017 I had an out of control reflux problem that I did not know about and was completely untreated. So I find that to be an interesting coincidence.

If it is reflux causing my problems, would the standard beta drugs be of any use? Is it worth going on something like Diltiazem just to see if it helps?

Bonefishblues wrote: ↑16 May 2023, 6:28pm Sees HR question in titles. Gets excited, might be able to help.

Walks off in disappointment

Id be happy to hear any insights you have actually

aegisgfx wrote: ↑16 May 2023, 6:47pm How about the reflux question, so you think mine could be caused exclusively by that?

I don't know, you'd have to ask a doctor. Bearing in mind that you don't have a diagnosis of AF, these are the latest (2020) Guidelines for the Diagnosis & Management of AF from the European Society of Cardiology, if you follow the link to the supplementary data you'll find this table of risk factors for developing AF:
. Reflux isn't mentioned, but inflammation is.

I think your best chance of getting it diagnosed is in A&E when it occurs, but if it typically only lasts 10 mins your chances aren't good with demand for ambulances the way it is. On the other hand, a HR >150bpm is one of the criteria for direct admission to resus on the red telephone, so I would think that a HR of 180 is likely to get their attention.

aegisgfx wrote: ↑16 May 2023, 6:47pmIs it worth going on something like Diltiazem just to see if it helps?

I've stopped taking diltiazem because it's damaged my feet, I wouldn't be taking it voluntarily knowing what I know now. When you were discharged after the tests weren't you given any advice on what to do if it keeps happening?

"When you were discharged after the tests weren't you given any advice on what to do if it keeps happening?"

No, my cardiologist just asked me "why do chest pains bother you so much?"

At that point I realized they were not taking my situation seriously so Ive essentially given up on finding an answer, and I have given up exercise completely.

Incidentally the chest pains and rapid heart beat happened a dozen or more times before I started going to doctors and about 10 or 15 times after I started seeing doctors, so its never gone away and continues to be an intermittent issue, but they basically have no suggestions for me. I live in a place where they chalk up everything to 'anxiety' and move on, I will never get the help I need here.

I had a couple of instances of arrythmia. Went to GP who took it seriously as I have had a stroke in the past.

Had the 24 hour holter and a couple of ecgs but it didn't show up.

So the local hospital issued me with a Kardia device. If I have another episode I can record it immediately on the device and send the reading to the hospital via my mobile.

If your local cardiology department don't offer them for free you can buy one for £99 at Amazon.

PeterJ wrote: ↑30 May 2023, 7:16am I had a couple of instances of arrythmia. Went to GP who took it seriously as I have had a stroke in the past.

Had the 24 hour holter and a couple of ecgs but it didn't show up.

So the local hospital issued me with a Kardia device. If I have another episode I can record it immediately on the device and send the reading to the hospital via my mobile.

If your local cardiology department don't offer them for free you can buy one for £99 at Amazon.

They're very useful devices, and allowed me to record and email to the A&E doctor 'on the spot' for him to review.

aegisgfx wrote: ↑15 May 2023, 9:29pm ...
Thanks for any suggestions, I'm not taking any medical advice from strangers but Im looking for others who have had similar issues and what their diagnosis and or treatments have been that helped them.
...

Having seen how the thread has developed how would you feel about lifting that requested restriction?

Thanks

Jonathan

This just prompted me to look up my target heart rate on the British Heart Foundation site.
Age based, it came out as 74-104 bpm.
50-70% of maximum heart rate.
It didn't tell me the maximum.
148-148.5 working backwards from the percentages.
I strongly suspect that I may be going higher than that once I get exercising properly on the bike.
Possibly time to break out a HRM from the drawer.

Jdsk wrote: ↑30 May 2023, 11:07am

aegisgfx wrote: ↑15 May 2023, 9:29pm ...
Thanks for any suggestions, I'm not taking any medical advice from strangers but Im looking for others who have had similar issues and what their diagnosis and or treatments have been that helped them.
...

Having seen how the thread has developed how would you feel about lifting that requested restriction?

Thanks

Jonathan

Sure if you have medical advise, please let me know. Ive just been banned from idiot sites like reddit for not saying specifically I wasn't looking for medical advice.