Exertional Chest Pain In A Triathlete

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HISTORY: 57 year-old male with history of CLL and bipolar disorder presented for difficulty breathing and chest pain which occurred during a triathlon 2 weeks ago. Symptoms occurred while doing an open water swim in a wetsuit, which he stated was overly tight. Reports he had sudden onset of chest “congestion”, tightness and pain. He reports this was associated with shortness of breath, wheezing and “foaming at the mouth”. Completed the event, but was swimming “from boat to boat” to be able to stop and rest during this portion of the event. Symptoms have been improving since the event, but has attempted to swim in a pool sans wetsuit since the race and feels “not back to 100%”. Has tried using his rescue albuterol inhaler with no improvement. Patient competes regularly in triathlons, reports no history of similar episodes in the past. Current training regimen includes 100 miles on bike, 3-4 miles running and 3-4 miles swimming weekly. PHYSICAL EXAM: Well appearing 57 year old male who appears his stated age. No acute distress. Heart has normal rate and regular rhythm, no murmurs, rubs or gallops. 2+ pulses throughout. Lungs are clear to auscultation bilaterally with no wheezing, stridor or rhonchi. Legs are negative for edema. Skin is warm and dry. Brisk capillary refill of both upper and lower extremities. DIFFERENTIAL DIAGNOSIS: Acute coronary syndrome, Congestive heart failure, Exercise induced asthma exacerbation, Swimming induced pulmonary edema TESTS AND RESULTS: EKG: Normal sinus rhythm, normal intervals, no ischemic findings Stress echocardiogram: Above normal (120-140%) age expected functional aerobic capacity, No significant arrhythmias noted, No evidence of myocardial ischemia and no reported ischemic symptoms, Heart rate and blood pressure responses to exercise were normal FINAL/WORKING DIAGNOSIS: Swimming induced pulmonary edema TREATMENT AND OUTCOMES: Instructed on gradual return to sport and swimming and educated on risk of recurrent episodes. So far has tolerated return to exercise well, working with endurance athlete coach to improve sport readiness for upcoming race season, goal race of Ironman California in October 2022. Planning on obtaining Cardiopulmonary Exercise Testing as patient enters into peak season training during summer 2022.

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